immunization: challenges, what works charlene graves, md, faap [email protected] april 16, 2008
TRANSCRIPT
Today’s Topics
Immunization coverage data Vaccine –preventable disease What works Best practices (evidence based) Threats Vaccine safety/the autism issue Suggestions
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.)
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
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
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)
How Are We Doing? NIS Estimates, Q3/2006 –Q2.2007Vaccine/Series Indiana % 6 month
changeU.S.% 6 month
change
4:3:1:3:3 79.7 Inc. 0.2 80.4 Dec. 0.2
4:3:1:3:3:1 76.5 Inc. 0.6 77.5 Inc. 0.5
1+ varicella
90.6 90.0
3+ PCV 91.2 88.9
New Hampshire
43133 = 91.5
431331 = 88.7
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
MMWR March 21,2008
Measles Cases, Indiana1994-2006
Year Age of Case Country of Origin
1994 19yo Japan
1998 8yo 12yo 15yo
Zimbabwe
1999 8yo Phillipines
1999 21yo England
2001 8mos 38yrs
Russia
2001 10mos China
2001 44yrs China
2002 34yrs So. Africa
2002 19yrs Mexico
2005 33 cases 9months to 49 yrs
Romania
2006 17yrs Ukraine
Comparison of Maximum, Minimum, and Recent Morbidity of Selected VPDsUnited States
Disease Max. Cases Min. Cases 2004*
Measles 894,134(1921) 37 (2004) 37
Polio 21,269 (1952) 0 (1999) 0
Tetanus 1,560 (1948) 20 (2003) 34
Rubella 57,686 (1969) 7 (2003) 10
Pertussis 265,269(1934) 1,010 (1976) 25,827
*Data from 2004 are the latest published by CDC
VACCINE-PREVENTABLE DISEASESIndiana,1949-2005
DISEASE YEAR NUMBER 2005 %CHANGE
Diphtheria 1949 394 0 -100%
Tetanus 1964 16 0 -100%
Pertussis 1955 1,966 396 -80%
Measles 1954 22,643 33 ->99%
Mumps 1964 6,853 1 ->99%
Rubella 1964 13,037 0 -100 %
Vaccine Preventable Disease IncidenceIndiana, 2006-2007
Vaccine Preventable Disease
2006 2007(preliminary)
Pertussis 280 66
Diphtheria 0 0
Tetanus 2 0
Measles 1 0
Mumps 10 3
Rubella 0 0
Hepatitis B 81 62
Hepatitis A 47 27
Invasive Meningococcal Disease
25 31
Invasive Haemophilus influenzae (All Cases)
81 74
under 5 years of age
9 6
type b under 5 years of age
1 1
Invasive Strep. pneumoniae(Pneumococcal Disease-All cases)
721 696
under 5 years of age
64 67
Hospitalizations Due to Varicella*Indiana 1994-2004
325
223195
331304
140
184
129 129114
61
0
50
100
150
200
250
300
350
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
*Source: Indiana Hospital Discharge Data
Vaccine Coverage Rates by Race/Ethnicity/PovertyUS – 4:3:1:3:3 Series (19-35 months of age)
73
7981 81
71
79
8381
76
83 83 82
68
77
80 79
68
7375
79
67
7577 77
60
65
70
75
80
85
90
2000 2003 2004 2005
US Asian White- Non Hispanic Black - Non Below Pov.
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
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
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 ????
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
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
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
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
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%)
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%
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
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
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
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
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
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
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
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
Threats to Success
Vaccine shortagesHepatitis A vaccineHib vaccinePneumococcal conjugate vaccine (in past)
Vaccine cost/financingHPV, rotavirus, zoster vaccinesAccess to state-funded vaccinesUnder-insurance (Waxman legislation)
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”
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)
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
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)
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
Improve Immunization Coverage -Go For It!