Transcript Slide 1

Immunization:
Challenges, What
Works
Charlene Graves, MD, FAAP
[email protected]
April 16, 2008
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
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~11,000 Children Born Each Day in US
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~230 children born in Indiana each day
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2005 - Routine Recommendation of 20+ Doses of
Vaccine by 18 months of age
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DTaP (4), Polio (3), MMR (1), Hib (3-4), Hep B (3),
Pneumococcal (4),Varicella (1), Influenza (1)
2006 
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Hepatitis A (2 doses) (late 2005)
Rotavirus (3 doses)
Take away one – MMRV
~25+ doses before 18 months
Adolescent Vaccines
7 – 18 years of age
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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:
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Hepatitis A
Hepatitis B
Polio
Measles, Mumps, Rubella
Varicella
Adult Vaccines
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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)
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Human Papillomavirus (females, through age 26)
Varicella ( all adults without evidence of immunity, high risk including medical
staff with patient contact)
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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)
(high risk adults – hemodialysis patients, occupational risks,
injection drug users, certain sex behaviors, institutional settings, )
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Hepatitis B
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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 –Q2.2007
Vaccine/Series
Indiana % 6 month
change
U.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
43133 =
91.5
431331
= 88.7
New
Hampshire
State Assessments
2004-2005
 School Age Children
 Kindergarten
(94% for all required vaccines)
 6th Grade Measles (98%)
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Day Care Children (2-5 Years)
 4:3:1:3
for 2 year olds (83%)
 Measles (95%)
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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, Indiana
1994-2006
Year
Age of Case
Country of
Origin
Japan
1994
19yo
1998
Zimbabwe
1999
8yo
12yo
15yo
8yo
1999
21yo
England
2001
Russia
2001
8mos
38yrs
10mos
2001
44yrs
China
2002
34yrs
So. Africa
2002
19yrs
Mexico
2005
33 cases
9months to 49
yrs
17yrs
Romania
2006
Phillipines
China
Ukraine
Comparison of Maximum, Minimum, and
Recent Morbidity of Selected VPDs
United 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 DISEASES
Indiana,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 Incidence
Indiana, 2006-2007
2006
2007
(preliminary)
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
721
696
64
67
Vaccine Preventable Disease
Pertussis
Invasive Strep. pneumoniae
(Pneumococcal Disease-All
cases)
under 5
years of age
Hospitalizations Due to Varicella*
Indiana 1994-2004
350
331
325
304
300
250
200
150
223
195
184
140
129 129
100
114
61
50
0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
*Source: Indiana Hospital Discharge Data
Vaccine Coverage Rates by
Race/Ethnicity/Poverty
US – 4:3:1:3:3 Series (19-35 months of age)
90
85
83
80
79
77
75
73
76
75
73
71
70
83
81
80
77
75
82
81
79
77
68
67
65
60
2000
US
Asian
2003
White- Non
2004
Hispanic
Black - Non
2005
Below Pov.
Vaccine in Indiana
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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
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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
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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?
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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)
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Insufficient evidence
 Provider
education alone
 Community-wide education alone
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Recommended
 School,
child care, college attendance requirements
 Vaccination programs in schools
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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
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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
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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
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Reminders
(Fiks, et.al, Pediatrics, October 2007)
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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
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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
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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
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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
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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
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Provider Education
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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
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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
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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
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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
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Vaccine shortages
 Hepatitis A vaccine
 Hib
vaccine
 Pneumococcal conjugate vaccine (in past)
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Vaccine cost/financing
 HPV,
rotavirus, zoster vaccines
 Access to state-funded vaccines
 Under-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”
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The Autism Issue – When Science
is Ignored
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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
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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)
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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
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vaccine – ? school clinics once a
month from October – March
 Health fairs, shopping malls, churches
 Influenza
Improve Immunization Coverage Go For It!