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 Vaccines 7 – 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, 1 st year college students living in dorms, military recruits, prolonged contact in endemic areas)

8. How Are We Doing? NIS Estimates, Q3/2006 –Q2.2007 Vaccine/Series Indiana % 6 month change U.S.% 6 month change 4:3:1:3:3 79.7Inc. 0.2 80.4Dec. 0.2 4:3:1:3:3:1 76.5Inc. 0.6 77.5Inc. 0.5 1+ varicella 90.6 90.0 3+ PCV 91.2 88.9 New Hampshire 43133 = 91.5 431331 = 88.7

9. State Assessments 2004-2005 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, Indiana 1994-2006

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

14. VACCINE-PREVENTABLE DISEASES Indiana,1949-2005

15. Vaccine Preventable Disease Incidence Indiana, 2006-2007 Vaccine Preventable Disease20062007 (preliminary) Pertussis28066 Diphtheria00 Tetanus20 Measles10 Mumps103 Rubella00 Hepatitis B8162 Hepatitis A4727 Invasive Meningococcal Disease2531 Invasive Haemophilus influenzae (All Cases) 8174 under 5 years of age 96 type b under 5 years of age 11 Invasive Strep. pneumoniae (Pneumococcal Disease-All cases) 721696 under 5 years of age 6467

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

17. Vaccine Coverage Rates by Race/Ethnicity/Poverty US – 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 pricethan 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 checklist in 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!