1. Successful Strategies that Prevent Vaccine Wastage Cherry Boardman, R.N., M.S.N. Becky Burkhart, M.Ed. Kathy Fredrickson, M.S., M.P.H. Arizona Immunization Program Office

2. Background The Arizona Vaccines for Children (VFC) Program began operating in 1994. Over 800 clinic sites participate in the program today. More than 1.8 million doses of vaccine are distributed annually.

3. Program Funding Federal and state funds are used to purchase vaccine for children birth through 18 years of age. Arizona state funds are available to vaccinate underinsured children in clinics other than Federally Qualified Health Centers.

4. Topic Vaccine wastage is a problem for all immunization programs. Arizona has developed successful strategies to keep wastage low. These strategies can be successfully used by all projects.

5. Setting Arizona did not track vaccine wastage during the first two years of the program’s startup. Strategies needed to be implemented to track the wastage. Each year, strategies are improved or added to prevent wastage. Now the wastage rate is below 2.5%.

7. Strategies to Prevent Wastage Communicating program requirements to providers –Vaccine program operations guide –Annual provider site visits –Required monthly reports Multiple educational opportunities: –In provider offices –Classroom setting –Conferences Frequent communication: –Newsletters –Blast Faxes –Mailings –Phone Support Active and involved immunization partners

8. Arizona VFC Program Enrollment Arizona’s Medicaid program requires Medicaid providers to enroll in the Arizona VFC program. Providers must initially enroll, then re- enroll annually to receive vaccine.

9. Enrollment Agreement The Enrollment Agreement stipulates the program requirements that the provider must follow in order to receive vaccine. Providers agree to reimburse the Immunization Program for vaccine wastage.

10. 2007 Arizona Vaccines For Children (VFC) Program Provider Enrollment Agreement I agree to the following conditions, on behalf of myself and all practitioners, nurses and other staff associated with this medical office, group practice, healthcare maintenance organization, community/migrant/rural clinic, or other entity of which I am the physician-in-chief or equivalent, in order to participate in the Arizona VFC program and receive other federal or state procured vaccine provided to my facility at no cost: 11. I shall reimburse ADHS for the value of vaccine that has expired or wasted, in excess of 5% of the total doses distributed, based on the total number of doses I have received during the previous contract year. This agreement is for the calendar year 2007 and will become effective when signed and received by the Arizona Department of Health Services, Vaccine Center, 150 N. 18th Avenue, Suite 120, Phoenix, Arizona 85007-3233.

11. Recouping Funds Invoices are sent to providers annually when wastage exceeds 5%. An account was created to receive checks. Wastage reimbursement funds are used to purchase additional vaccine. Wasted and expired vaccines are returned to the manufacturers quarterly to recoup the cost of the excise tax.

12. Vaccine Ordering Protocols New VFC Providers: –Must receive an orientation in-service before ordering vaccine. –Must submit a temperature log showing 5 days of “good” refrigerator/freezer temperatures before vaccine will be shipped.

13. Vaccine Ordering Protocols-cont. Required Provider Monthly Reports: –Current vaccine inventory –Doses administered –Temperature logs for all units storing vaccine  Provider must return all vaccine if logs contain out of range temperatures.  Provider must submit 5 days of “good” refrigerator/freezer temperatures before replacement vaccine will be shipped to them.

14. Ordering Pediatric DT Annually, Arizona had wasted 8,000-9,000 doses (packaged in 10 x 1 dose vials) of pediatric diphtheria-tetanus (DT). Providers were required to stock DT but rarely used the vaccine. DT is now distributed one dose at a time from the state vaccine depot at the provider’s request.

15. Returning Viable Or Wasted Vaccine All vaccine must be returned to the Immunization program. Providers are instructed to return viable vaccine three (3) months prior to expiration. Courier pick up service is provided in the Maricopa County Phoenix area. Field representatives will pick up viable vaccine in other Arizona counties when possible. Providers may return wasted or expired vaccines via regular mail.

16. Return & Adjustment Form Providers use form to return viable and wasted vaccine. VACMAN wastage codes are listed on the form. Providers are not charged for wastage in the following circumstances: –Power outage –Refrigeration failure  Provider must provide purchase or repair receipt.

17. Educational Opportunities In Provider Offices New Provider In-services orient new providers to the VFC program. In-services are provided as needed for existing provider’s new staff. Providers receive annual Quality Assurance Reviews –Conducted by Vaccine Center staff or a contractor.

18. Provider Training Highlights Proper vaccine storage and handling techniques. Material provider’s receive initially and as needed: –All vaccine ordering and reporting forms –Vaccine Information Statements (VIS) –Thermometers Importance of monitoring and recording refrigerator/freezer temperatures twice daily. Stress importance of taking action if temperatures are out of range. Importance of notifying state of 3 months before vaccine expires. How to pack and return viable vaccine.

19. Educational Opportunities Classroom Setting Educational Opportunities Classroom Setting Quarterly Immunization Services meetings for public providers “Learn at Lunch” programs –Conducted in collaboration with AIPO staff and The Arizona Partnership for Immunizations (TAPI) –Classes offered throughout Arizona. –Topics covered: office practices, vaccine administration, immunization standards, vaccine storage and handling, and immunization registry training. –Over 300 participants from 200 provider offices attend annually. Quarterly updates to EPSDT Coordinators

20. Educational Opportunities Conferences Two annual conferences provide presentations by Arizona and national immunization experts. Multiple workshops provide a wide variety of immunization topics. Manufacturers are encouraged to distribute vaccine information at the conferences.

21. Communications AIPO newsletter, “Immunications” –Produced quarterly –Wide variety of immunization articles. Blast Faxes –Provide most current new vaccine information, or to introduce new policies or forms. –Sent 10-12 times per year Mailings –Provide updated forms, VIS, changes to provider Manuel, etc.. Extensive phone support is given to all providers.

22. Summary Provider offices are very busy so keeping the provider’s focus on proper vaccine management decreases wastage. Successful vaccine management strategies are: –Enrollment Agreement charging for excessive wastage; –Communicating program requirements to providers; –Extensive provider education; –Regular onsite quality assurance visits –Frequent communication to providers via newsletters, faxes, and telephone support.

24. Presented by: The Arizona Immunization Program Office 150 N. 18 th Avenue, Suite 120 Phoenix AZ 85007-3233 (602) 364-3642 phone (602) 364-3276 fax Email address: boardmc@azdhs.gov