Texas Immunization Summit September 30, 2010 Immunizations: An Essential Resource Against Infectious Diseases H1N1

1. Texas Immunization SummitSeptember 30, 2010 “Immunizations: An Essential Resource Against Infectious Diseases & H1N1”David L. Lakey, M.D.CommissionerTexas Department of State Health Services

2. Increased Life Expectancy Driven by Public Health Improvements The public health improvements of the 20th century improved life expectancy by reducing infectious disease. The public health improvements of the late 20th and 21st century will need to reduce chronic disease by focusing on behavior change to have a comparable impact.The public health improvements of the 20th century improved life expectancy by reducing infectious disease. The public health improvements of the late 20th and 21st century will need to reduce chronic disease by focusing on behavior change to have a comparable impact.

3. Ten Great Achievements of Public Health Vaccination Motor-vehicle safety Safer workplaces Control of infectious diseases Decline in deaths from coronary heart disease and stroke Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco use as a health hazard

4. 4 Impact of Vaccines in the 20th Century A JAMA 2007 article had very different numbers in column 2 than those provided by the CDC. For example, 29,005 as the annual morbidity rate for smallpox. I called and spoke with one of the authors of the CDC study. It seems they simply picked the death totals from the year before the vaccine was produced rather than actually calculate the annual morbidity, but I have yet to receive an expected email from them confirming that this is in fact how they come up with the numbers. (Rob)A JAMA 2007 article had very different numbers in column 2 than those provided by the CDC. For example, 29,005 as the annual morbidity rate for smallpox. I called and spoke with one of the authors of the CDC study. It seems they simply picked the death totals from the year before the vaccine was produced rather than actually calculate the annual morbidity, but I have yet to receive an expected email from them confirming that this is in fact how they come up with the numbers. (Rob)

5. Number of Cases and Incidence of Hep-B, Acute in Texas 2000 - 2009

6. Number of Cases and Incidence of Hep-A in Texas, 2000 - 2009

7. For each birth cohort vaccinated in accordance with the schedule* 33,000 deaths are prevented 10.5 million cases of diseases are prevented Vaccinations have huge cost savings $10.5 billion in direct costs $42 billion in societal costs Economics of Immunizations 7

8. Global Vaccination Coverage Nevertheless … In 2002, an estimated 2.1 million people globally died of diseases preventable by widely used vaccines Around 24 million children under one year of age are not being reached with vaccines In 2003, global DTP coverage was 78%, up from 20% in 1980 8 DPT3 standard indicator for immunization program effectiveness.DPT3 standard indicator for immunization program effectiveness.

9. Vaccine Preventable Diseases: Pertussis Cases & Deaths in Texas, 1998 - 2009

10. Vaccine Preventable Diseases: Cases of Measles, Mumps and Rubella 1998 - 2009

11. Measles Returns During Jan – July 2008 , CDC received reports of 131 measles cases around the US The highest number since 1996 More than 90% of those infected had not been vaccinated Many were children whose parents chose not to have them vaccinated 15 of the patients, including four infants, were hospitalized Even though the transmission of measles was declared eliminated in the U.S. in 2000, the disease is still common in many other countries Worldwide, 10 million cases of measles occur each year The disease is a significant cause of vaccine-preventable deaths among children In 2006, there were 242,000 measles deaths worldwide Global efforts to improve vaccination coverage worldwide has had some important successes.Global efforts to improve vaccination coverage worldwide has had some important successes.

12. Texas’ Efforts and Progress in Improving Immunization Rates

13. National Immunization Survey 2008 – 2009Texas and US Rates Compared, 4:3:1:0:3:1:4 VaccineSeries Because of changes in measurement of the Hib vaccine and the vaccine shortage that occurred from December 2007 to September 2009, state coverage estimates included in the 2009 NIS were based on the series that excludes Hib, 4:3:1:0:3:1:4 Because of changes in measurement of the Hib vaccine and the vaccine shortage that occurred from December 2007 to September 2009, state coverage estimates included in the 2009 NIS were based on the series that excludes Hib, 4:3:1:0:3:1:4

14. Estimated Vaccination Coveragefor the 4:3:1:3:3:1:4* VaccineSeries Among Children 19-35 Months of Age, 2009 NIS Rest of State is 68.3 Rest of State is 68.3

15. Texas Childhood Immunization Coverage in 2008

16. 16 Coverage Levels in Texas 4+DTaP*

17. Texas’ Rank Among US States for Vaccination Coverage (Selected Vaccination Series Among Children 19-35 mo’s. of Age, 2008)

18. Texas Immunizations Texas was named the most improved state in childhood immunizations by the U.S. Centers for Disease Control and Prevention Texas increased 13.5% in childhood immunizations rates from 2004 to 2008 based on National Immunization Survey data of children 19 - 35 months of age San Antonio/Bexar County was named the most improved city/county Global efforts to improve vaccination coverage worldwide has had some important successes.Global efforts to improve vaccination coverage worldwide has had some important successes.

19. 19 Texas’ Child Vaccinations: Current Status

21. Adult Immunizations: Key Points As a Nation we do a poor job immunizing adults 2.1% of eligible adults had tetanus, diphtheria, and pertussis vaccine in the last 2 years <2% of older adults had shingles vaccine 10% of eligible adult women had the HPV vaccine 36 % of all adults are vaccinated for seasonal influenza Only 66.9 % had the pneumococcal vaccine Between 40,000 and 50,000 adults die from vaccine preventable illnesses

22. Prevalence of Adults Having Had an Influenza VaccinationAmong Adults 18+ Years (Age Adjusted) 2000 – 2009 BRFSS Texas vs. US

23. Prevalence of Adults Having Had An Influenza ShotAmong Adults 65+ Years (Age Adjusted) 2000 – 2009 BRFSS Texas vs. US

24. Prevalence of Having Had a Pneumonia Vaccine Among Adults 65+ Years (Age Adjusted) 2000 – 2009 BRFSS Texas vs. US

25. How Does Texas Rate for Adult Immunizations? Pneumococcal: 63.7% (7th lowest) Influenza: Texas Nation 18 - 49 years old 24.8% 24.1% 50 - 64 years old 42.1% 42.0% 65 years and older 71.1% 69.5% Total 35.4% 36.1%

26. Barriers to Adult Immunizations Limited Access Few requirements for adult immunizations Limited Care and Insurance Coverage Adult care does not stress primary care or prevention Limited Financing for Vaccines Lack of insurance coverage limits vaccinations Misunderstandings and Misinformation Misperceptions and myths keep adults from getting vaccinated Research and Development Ramping up discoveries and advances

27. Proven Strategies to Raise Vaccine Coverage Levels Promote the use of registries Promote reminder/recall Public education Provider education Promote the medical home concept Utilize community partners to improve in the strategies listed above These are some of the things that we do have influence on and that are proven to be consistent with higher vaccine coverage levels These are some of the things that we do have influence on and that are proven to be consistent with higher vaccine coverage levels

28. Take Home Thoughts For Public and Private Providers Screen immunization status at every visit Remind patients when next vaccines are due Keep good immunization records Maintain inventory/stock levels for all vaccines Give all needed vaccines simultaneously Don’t miss an opportunity to vaccinate 6. On Slide #20, are we telling docs to keep an accurate inventory/stock levels or an adequate inventory?  On the same slide, I am not sure what the 5th bullet means and how submitting reports on time avoids delays in receiving vaccines. Yes.  Rationale:  We want docs to keep accurate inventory/stock levels so they don’t run out of vaccine.  If they run out, they can’t vaccinate children at each opportunity. 5th bullet—same slide:  By submitting reports on time, physicians are able to comply with TVFC requirements. RECOMMEND to delete this bullet; this is meant to be explained when we present to TVFC only docs.6. On Slide #20, are we telling docs to keep an accurate inventory/stock levels or an adequate inventory?  On the same slide, I am not sure what the 5th bullet means and how submitting reports on time avoids delays in receiving vaccines. Yes.  Rationale:  We want docs to keep accurate inventory/stock levels so they don’t run out of vaccine.  If they run out, they can’t vaccinate children at each opportunity. 5th bullet—same slide:  By submitting reports on time, physicians are able to comply with TVFC requirements. RECOMMEND to delete this bullet; this is meant to be explained when we present to TVFC only docs.

30. What is ImmTrac? Established as the Texas Immunization Registry in 1996 Used as tracking and reporting tool for both vaccines and antivirals Recently expanded for adults and for community preparedness A repository of immunization histories for Texas children Consolidates immunization records from multiple sources statewide Confidential & secure Internet application Parental consent is required Only authorized entities allowed access to data

31. Why a Registry? Improve vaccine coverage levels Reduce incidence of childhood vaccine-preventable diseases Overcome barriers to vaccination Organizes vaccination records into a single source Improve vaccine tracking (reminder/recall)

32. ImmTrac Snapshot 83.2 million immunizations recorded 6.3 million Texas children 2.2 million children under age 6 91.6% of parents grant consent for their newborn babies >7,800 first responders or family members 18 years and older were immunized >6,700 active online user sites >125,000 immunization history reports generated per month >400,000 disaster-related antivirals, immunizations or medications recorded Over 18,000 antivirals entered as part of disaster response Over 1.2 million H1N1 vaccinations entered as part of disaster response

33. Immunization RecordsTotal Vaccine Doses Recorded

35. Moving Health Forward In Texas: Improving ImmTrac Goals: Consolidate vaccination records for persons with multiple providers Provide vaccination needs assessments Generate reminder/recall notices Produce official vaccination records Provide practice- and population-based vaccination coverage assessments

36. Moving Health Forward In Texas: Improving ImmTrac Strategies to Improve Provider Participation: Bring ImmTrac into Health Level 7 compliance to exchange data with medical electronic records of providers Improve software to handle complex updates of evolving vaccination requirements Integrate Vaccine Adverse Event Reporting System within ImmTrac so that all adverse reactions to vaccinations can be reported within a single system Implement a Data Analysis System to provide users with an efficient electronic tool to better manage the needs of their patients and their practices Will run complex data queries, analysis and reports

37. DSHS Receives Million Dollar ImmTrac Grant Purpose: To Link Texas Immunization Records with other Electronic Health Record Systems Grant Award: ARRA/CDC Grant of $1,039,000 $375,000 equipment $664,000 staff augmentation Timeline: September 1, 2010-August 31, 2012 Project: Identify a minimum of 6 electronic health record systems in Texas for 2-way data exchange with ImmTrac Real time or batch file Utilizing federal data exchange standards (HL7 2.5.1 standard) 

38. H1N1 Pandemic

39. Epidemiological investigation Laboratory testing Coordination Response staffing Collaborate with partners Planning Ongoing planning for and review of all response efforts Guidance for clinicians, organizations, and communities Finance Applying for federal financial assistance Distributing federal resources Distribution of response assets Antivirals Vaccines N-95 masks Communication Provide developed guidance document Working with media National Response & Plan Contributions Work with stakeholders Testify before U.S. Congress

41. Age Distribution for H1N1 Cases Compared to Texas Population (as of 5/22/10) Reported Texas hospitalized cases and deaths There have been 270 hospitalizations as of 7/31/2009, 35 deaths as of 9/1/09, of the deaths 4 among the pediatric population Majority of hospitalized patients infected with novel H1N1 virus were between 5 years and 49 years of age. Over one quarter were under the age of four. Reported Texas hospitalized cases and deaths There have been 270 hospitalizations as of 7/31/2009, 35 deaths as of 9/1/09, of the deaths 4 among the pediatric population Majority of hospitalized patients infected with novel H1N1 virus were between 5 years and 49 years of age. Over one quarter were under the age of four.

42. H1N1 Pediatric Mortality

43. Vaccine Strategy & Considerations Needed to address not only who, but also when to start, and how to deliver Based on informed decision-making Epidemiological evidence Review of past performance Guidance from CDC Input from stakeholders Planning based upon estimates of resources Responding to ever-evolving circumstances Ensure strategy can be flexed to mitigate the disease

44. Vaccination Strategies How? Private sector Local health departments Pharmacy chains Mass vaccination clinics School based clinics Occupational medicine clinics

45. Health Care Provider Vaccination Registration Total registered as of 1/22/10: 12,861 59% Private practice 13% Pharmacies 5% Hospitals 2% Schools 20% Other Vaccine apportioned to more than 10,800 providers and other health care facilities

46. ACIP 2009 H1N1 Priority Groups(CDC Advisory Committee on Immunization Practices) Pregnant women Household contacts and caregivers for children <6 months Healthcare and emergency medical Services personnel All people from 6 months to 24 years Persons age 25 to 64 years with chronic medical conditions Problem: These priority groups = 159 million

47. Target Groups in Case of Shortage Pregnant women People who live with or care for children younger than 6 months of age Health care and emergency medical services personnel with direct patient contact Children 6 months through 4 years of age Children 5 through 18 years of age who have chronic medical conditions

48. Texas’ Actual Timeline for Priority Groups Week of: October 4 – children 2-3 years of age and the health care workers that serve them October 11 – add pregnant women, 4 year olds, children 5-18 years old at high risk of complications and the health care workers that serve them October 18 – add health care workers who provider direct patient care November 1 – add children six month to one year of age, and add close contacts of infants under 6 months old November 15 – add adults at high risk of complications November 30 add all ACIP Priority Groups December 11 – opened up vaccine to general population

49. Vaccine Issues: 2009 Quantity and Type of vaccine CDC expected ~45 - 52 million doses of vaccine available by mid-October Level of vaccines reached in mid-November Texas expected 3.4 million doses, only received 1.7 million Priority populations were not served as soon as they expected Weekly CDC Vaccine Shipment Status Report Created confusion among media and public Provider registration errors Registration errors, misclassification of facility or of population served Locating vaccine providers Recalls

50. Summary Immunizations have been, and continue to be, one of the most effective public health strategies for disease prevention Improving both child and adult immunization rates must be an ongoing priority in Texas Upgrading ImmTrac to integrate with electronic health records will be an important step forward The H1N1 pandemic provided a timely reminder of the importance of vaccinations Annual vaccinations may be one of our best tools in the advent of future pandemics

52. 80th Legislature Senate Bill 11 ImmTrac expanded to include first responders and immediate family members 18 years of age or older ImmTrac also expanded to include information about persons who receive an antiviral, immunization or medication for disaster preparation or response Written consent obtained prior to inclusion in ImmTrac ImmTrac included adverse reactions to disaster-related antivirals, immunizations or medications

53. 81st Legislature Senate Bill 346 Changed ImmTrac to a lifetime registry Allowed all Texans 18 years of age and older to store immunization records in the registry Senate Bill 347 Authorized DSHS to exchange immunization records stored in ImmTrac with other state and local health departments during disaster evacuations or relocations Will assist in care for people who are displaced regardless if they are from Texas or elsewhere