Immunization: Challenges, What Works

1. Immunization: Challenges, What Works Charlene Graves, MD, FAAP CGraves1203@aol.com April 16, 2008

2. Today’s Topics • Immunization coverage data • Vaccine –preventable disease • What works • Best practices (evidence based) • Threats • Vaccine safety/the autism issue • Suggestions

3. Goal • To ensure that all recommended vaccines are delivered in a timely, cost-effective manner to a population. (Ideally, vaccine administration occurs through a person’s medical home.)

4. Childhood Vaccines • ~11,000 Children Born Each Day in US • ~230 children born in Indiana each day • 2005 - Routine Recommendation of 20+ Doses of Vaccine by 18 months of age • DTaP (4), Polio (3), MMR (1), Hib (3-4), Hep B (3), Pneumococcal (4),Varicella (1), Influenza (1) • 2006 - • Hepatitis A (2 doses) (late 2005) • Rotavirus (3 doses) • Take away one – MMRV • ~25+ doses before 18 months

5. Adolescent Vaccines7 – 18 years of age • Tetanus, Diphtheria, Pertussis (TdaP booster at 11-12) • Human Papillomavirus (females, 3 doses @11-12) • Meningococcal (11-12 years of age) • Influenza annually • Pneumococcal (high risk persons) • The following vaccines should be administered if not previously immunized or not immune: • Hepatitis A • Hepatitis B • Polio • Measles, Mumps, Rubella • Varicella

6. Adult Vaccines • Tdap(recommended as a one-time booster) • Influenza(over 50 years and high risk for any age) • Pneumococcal (recommended for anyone 65 years or older and younger persons with high risk conditions) • Shingles(anyone 60 years and older) (licensed May, 2006) • Human Papillomavirus (females, through age 26) • Varicella( all adults without evidence of immunity, high risk including medical staff with patient contact) • Td( every 10 years, or 3 dose primary if not received as a child) • MMR(born 1957 or later) • Hepatitis A(high risk persons – clotting factor disorders, liver disease, travel to endemic areas, men who have sex with men) • Hepatitis B(high risk adults – hemodialysis patients, occupational risks, injection drug users, certain sex behaviors, institutional settings, ) • Meningococcal(medical disorders, 1st year college students living in dorms, military recruits, prolonged contact in endemic areas)

8. How Are We Doing? NIS Estimates, Q3/2006 –Q2.2007

9. State Assessments2004-2005 • School Age Children • Kindergarten (94% for all required vaccines) • 6th Grade Measles (98%) • Day Care Children (2-5 Years) • 4:3:1:3 for 2 year olds (83%) • Measles (95%) • College Students • Two Doses Measles (94%) • One Dose of Mumps and Rubella (94%) • Td (94%) Available at ISDH website www.IN.gov.isdh and click on Data and Statistics

10. MMWR March 21,2008

12. Measles Cases, Indiana1994-2006

13. Comparison of Maximum, Minimum, and Recent Morbidity of Selected VPDsUnited States *Data from 2004 are the latest published by CDC

14. VACCINE-PREVENTABLE DISEASESIndiana,1949-2005

15. Vaccine Preventable Disease Incidence Indiana, 2006-2007

16. Hospitalizations Due to Varicella*Indiana 1994-2004 *Source: Indiana Hospital Discharge Data

17. Vaccine Coverage Rates by Race/Ethnicity/PovertyUS – 4:3:1:3:3 Series (19-35 months of age)

18. Vaccine in Indiana • Public Vaccine - Indiana • ~ 40% of all vaccine administered in Indiana is purchased with tax funds • 1,280,000+ doses of vaccine distributed in 2005 • $27,000,000+ of vaccine purchased in 2005 • Federal Funds: VFC, 317 • State Funds non-existent • Private • ~ 60% purchased privately in Indiana • purchased at a higher price than public health

19. Factors Needed for Success • Enough vaccines • Enough resources • Enough information for families and health care providers • Enough access to affordable vaccines • Enough convenience for families • Enough registries/databases/tracking mechanisms

20. So What Works? • Reminder/recall systems • Registries and provider alerts • Partnerships and teamwork • Measuring what we do • Monitoring immunization status on every visit • Standing orders • Education ????

21. Evidence-based Strategies – Task Force on Community Preventive Services (MMWR 1999) • Insufficient evidence • Provider education alone • Community-wide education alone • Recommended • School, child care, college attendance requirements • Vaccination programs in schools • Strongly recommended • Reducing out-of-pocket costs of vaccines • Multi-component interventions that include education

22. Strategies for Health Care Providers • Standing orders for vaccination • Chart reminders and computerized reminders • Measurement of coverage rates • Performance feedback • Outreach to the under-immunized • Patient and provider education

23. Standing Orders • Consistently effective • Influenza vaccine to inpatients – 40% vaccinated compared to 10% in control (Crouse, 1994) • Other studies: flu and pneumococcal vaccination in Emergency Departments, nursing homes, outpatient clinics show similar results

24. Record Reminders • Effective, efficient, inexpensive • If computerized, there is an initial expense • Visual cue – stickers, checklist, similar • Requires chart/record review BEFORE the patient visit

25. Reminders (Fiks, et.al, Pediatrics, October 2007) • Electronic health record clinical alerts • 1 year intervention at 4 urban primary care centers in Philadelphia – 15,928 visits • Increased 24-month old coverage rates from 81.7% to 90.1% • Increased opportunities to immunize for well visits (76.2% to 90.3%) and sick visits (11.3% to 32.0%)

26. More on Reminders • Health maintenance checklistin chart (Rodney, 1983) • Tetanus vaccination increased from 3.2% to 19.8% • Pneumococcal vaccination increased from 1.6% to 14.6%

27. Performance feedback • CoCASA and AFIX • HEDIS and similar assessments • Pay for performance initiatives • Review data with providers • Increase compliance with desired end results • Can build in incentives, so is a motivator

28. Outreach to the Underimmunized • Identify “pockets of need” • Consider home visits (also existing home health care delivery services) • Mail, telephone reminders • Special events (health fairs or similar) • Partner with churches, schools, community organizations

29. Expanding Access to Immunization • Convenient hours of service for patient • Non-traditional settings • Globally – mass vaccination days/weeks • Vaccines for Children (VFC) Program • State-purchased vaccine available • Need access for the under-insured

30. Patient Education • Use information sheets (or VIS) as patient checks in for a visit, leaves hospital, etc • Include screening questions with it • Consider literacy level • Use of videos, posters (IN on Time) • Bilingual information • Personal health record

31. Provider Education • Immunization A to Z presentations • Tailor information to practice site • Re-educate as new members of the health care provider team come aboard • Encourage reminder/recall • Institute visual cues on patient charts • Internal medicine doctors in particular need

32. Quality Improvement • Set a measurable objective and design an intervention • Compare pre- and post-implementation of intervention • Develop a method to track results • Assess successes (or failures) • Revise intervention accordingly • Re-measure

33. The Marion County Health Department – CDC Award Winner for “Most Improved” Urban Area • Multifactorial contributors: • Standing orders and reminder/recall • All immunizations needed at every visit • Accelerated schedule – IN on Time • Walk-in Immunizations: 10 AM to 6 PM three days a week, 10 AM to 4 PM the other 2 days • Varicella vaccine requirement for child care, school entry • AFIX site visits to all private providers each year

34. The Marion County Experience – Outreach Programming • 3 outreach workers -1 is bilingual in Spanish. Focus on underimmunized. • Home visits, phone calls, post cards: R/R • All 80 school based clinics immunize • Health fairs (30+ annually), major back-to-school clinics with community partners • Partner with Indy Parks Dept., Children’s Museum, others • CHOP videos in clinic waiting rooms

35. Threats to Success • Vaccine shortages • Hepatitis A vaccine • Hib vaccine • Pneumococcal conjugate vaccine (in past) • Vaccine cost/financing • HPV, rotavirus, zoster vaccines • Access to state-funded vaccines • Under-insurance (Waxman legislation)

36. Families Choosing Not to Vaccinate • MMR/Thimerosal/autism concerns • Vaccine skeptics (personal belief exemptions) • Puts others at risk of disease • Balance risk of disease vs. risk of vaccine • Example: chickenpox, and even measles, “parties”

37. The Autism Issue – When Science is Ignored • Autistic Spectrum Disorders occur in 6/1000 (or 1 in 150) children. Genetics and environment play a role. Immunizations DO NOT! • No relationship between MMR vaccine and autism (10 studies). No relationship between thimerosal and autism (6 studies) • Parental misperceptions persist – recent survey: 54% re immunizations, 53% re genetics • Vaccine Injury Compensation Board recent ruling (Poling case)

38. Tools in Our Arsenal in Combating Threats • Educate, educate, educate • Maintain Indiana law regarding exemptions from required immunizations • Expand school, day care, college vaccination requirements • Access and convenience important • Require vaccinations, change policies • Immigrants, refugees to U.S. • U.S. travelers going abroad

39. What Can You Do? • Expand access to immunizations – convenience for patients is a key • Support laws/policies that address the under-insured • Adopt 1 or 2 quality improvement projects for your community (+ one in your practice)

40. What Can You Do? • Be creative – think “outside the box” • Expand partnerships and networking • Share your ideas, learn from others • Use non-traditional sites more • Influenza vaccine – ? school clinics once a month from October – March • Health fairs, shopping malls, churches

41. Improve Immunization Coverage -Go For It!