Childhood Immunizations: Practice Barriers

and Solutions September 18, 2013

Peter G. Szilagyi, MD, MPH Professor of Pediatrics

University of Rochester School of Medicine and Dentistry

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Agenda Item Time

Welcome and Introductions

Janet Gingold, MD, MPH

5 min

• Burden of childhood vaccine-

preventable disease

• Strategies to improve immunization

rates

• Challenges and methods to

overcome challenges

• Useful immunization resources

Peter G. Szilagyi, MD, MPH

45 min

Questions and Answers 10 min

Housekeeping

All phones are muted until Q&A at end

Type questions during the presentation into the chat

box and send to Janet Gingold or everyone or wait

to ask over phone during Q&A

3

Attendance Tracker for CME & MOC Within 1-2 days of the webinar, please submit a

spreadsheet containing the following information

about the webinar participants from your practice:

Please send this spreadsheet to Liz Rice-Conboy at

ericeconboy@aap.org. An evaluation survey will be

sent out via REDCap. Liz will email a PDF of the

CME Certificate directly to each participant.

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Full name

(as it will

appear on

your CME

Certificate)

Email address

(you will be sent

a webinar

evaluation after

the webinar)

Designation

(as it will

appear on

your CME

Certificate)

Full Address (only if

this differs from the

address of the

Project leader’s

address)

CME Designation The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for

Continuing Medical Education (ACCME) to provide continuing medical education for

physicians.

The AAP designates this live activity for a maximum of 1.00 AMA PRA Category 1

Credit(s)™. Physicians should claim only the credit commensurate with the extent of their

participation in the activity.

This activity is acceptable for a maximum of 1.00 AAP credits. These credits can be

applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of

the American Academy of Pediatrics.

The American Academy of Physician Assistants (AAPA) accepts certificates of

participation for educational activities certified for AMA PRA Category 1 Credit™ from

organizations accredited by ACCME. Physician assistants may receive a maximum of

1.00 hours of Category 1 credit for completing this program.

This program is accredited for 1.00 NAPNAP CE contact hours of which 0.25 contain

pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners

(NAPNAP) Continuing Education Guidelines.

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Speaker’s background Peter Szilagyi is a Professor of Pediatrics at the University of

Rochester School of Medicine and Dentistry and division chief of the

Division of General Pediatrics at the University of Rochester. He

directs a large research operation in the Robert J Haggerty Health

Services Research Laboratory. His studies to improve the quality of

care and outcomes for vulnerable children have led to important

changes in immunization delivery, child health care financing and

care of children with chronic conditions. For example, in the field of

immunizations his studies have contributed to the Vaccines for

Children Program and the focus on the medical home for vaccine

delivery; in the field of healthcare financing his studies have

contributed to the formation and continuation of the SCHIP program.

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Locally, Dr. Szilagyi spends substantial time each week mentoring faculty and fellows,

directs the General Academic Pediatric Fellowship Program. He directs a city-wide

outreach program that has reduced disparities in immunizations, and is Chair of the

Board of Directors of the Monroe Plan, the largest Medicaid Managed Care and SCHIP

plan in Upstate NY which serves >200,000 members. In 2010 he was the first recipient of

the Dr. David Satcher Award for community health improvement, a Rochester-based

award.

Comparison of Immunization Quality

Improvement Dissemination Strategies (CIzQIDS)

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CME Disclosure

I have no relevant financial relationships with the

manufacturer(s) of any commercial product(s) and/or

provider of commercial services discussed in this CME

activity.

I do not intend to discuss an unapproved/investigative

use of a commercial product/device in my presentation.

Learning Objectives

After completing this course, you should be able to:

a) Understand the burden of childhood vaccine-

preventable disease

b) Identify strategies and methods to improving

immunization rates and confront practice system

barriers

c) Recognize useful immunization resources

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Recommended childhood

immunization schedule 2013

Recommended childhood

immunization schedule 2013

Vaccinations recommended to prevent 13 childhood diseases!

The next 3 slides are from Ann

Schuchat (CDC)

Assistant Surgeon General

Director, National Center for Immunization and

Respiratory Diseases

Texas Immunization Summit 2012 – Houston, Texas

September 27, 2012

State of the Nation is Strong

Most vaccine-preventable diseases at record lows

Achieved & sustained high childhood immunization

Reduced disparities in childhood coverage

Introduced multiple new vaccines

Improved influenza vaccine supply

From Ann

Schuchat

* Target is 80% for Rotavirus and 60% for Hepatitis A

† DTP/DTaP (3+) is not a Healthy People 2020 objective. DTaP (4) is used to assess Healthy People 2020 objectives.

§ Reflects 3+ doses through 2008, and Full Series (3 or 4 doses depending on type of vaccine received) 2009 and later

¶ 2 or 3 doses, depending on the type of rotavirus vaccine received

Note: Children in the USIS and NHIS were 24-35 months of age. Children in the NIS were 19-35 months of age.

Source: USIS (1967-1985), NHIS (1991-1993) CDC, NCHS and NCIRD, and NIS (1994-2011), CDC, NIP, NCHS and NCIRD; No data from 1986-1990 due to cancellation of USIS because of budget reductions.

Increasing Vaccine-Specific Coverage Rates Among Preschool-Aged Children: 1967 - 2011

0

20

40

60

80

100

1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012

Percent

Hep A

(2+)

DTP / DTaP(3+)†

MMR(1+)

Hib§

HP 2020 Target*

Hep B

(3+)

Polio (3+)

Varicella (1+)

PCV

(4+)

RV¶

<1% of toddlers received zero doses of vaccines

From Ann

Schuchat

Estimated Return on Investment

of Childhood Vaccines

For each birth cohort vaccinated against 13 diseases

in accordance with the schedule for DTaP, Hib, IPV,

MMR, hep B, Varicella, Hepatitis A, Pneumo-7, and

Rotavirus vaccines: 42,000 lives are saved

20M cases of disease are prevented

13.5 billion dollars in direct costs are saved

68.8 billion dollars in direct plus indirect (societal) costs are saved

For each dollar invested in these vaccinations, $10.20 is saved

Fangjun Zhou et al – National Immunization Conference 2011 Workshop D2

https://cdc.confex.com/cdc/nic2011/webprogram/meeting.html

Preliminary results of updated analysis from Zhou et al, Arch of Ped and Adolesc Med 2005

14

From Ann

Schuchat

Seasonal Influenza Vaccination

Coverage—Last 3 Years

0

10

20

30

40

50

60

70

80

90

100

2009-10 2010-11 2011-12

Children (6m - 17y)

Adults (18+ yrs)

Estimated US influenza vaccination coverage

(BRFSS & NIS), 2011-2012 season

http://www.cdc.gov/flu/professionals/vaccination/coverage_1011estimates.htm

Age Groups % 95% CI

Children

6 mos–17 yrs 51.5 (±1.0)

6–23 mos 74.6 (±2.5)

2–4 yrs 63.3 (±2.3)

5–12 yrs 54.2 (±1.4)

13–17 yrs 33.7 (±1.6)

Adults

18-64 yrs 33.1 (±0.6)

65+ yrs 64.9 (±0.8)

Some child vaccine-preventable

disease still occurs in the US

Measles (outbreaks)

Pertussis (>40,000 cases in 2012)

Influenza (20,000 hospitalizations in children)

But overall we are doing very well!

Pertussis Cases in USA

2000 7867

2001 7580

2002 9771

2003 11651

2004 25827

2005 25619

2006 15631

2007 10454

2008 13278

2009 16858

2010 27550

2011 18719

2012* 41,880

Outline

Burden of childhood vaccine-preventable

disease

Strategies to improve immunization rates

Challenges and methods to overcome challenges

Useful immunization resources

System

Provider

Patient

-No access -Extra visit -Fear -Costs

-Missed opportunities -No reminder/recall -No QA- practice rates -Ordering vaccines

-Vaccine shortages

-No tracking system

-Financing (despite VFC)

-Scattering of care

Barriers to Vaccinations

System

Provider Patient

-No access -Extra visit -Fear -Costs

-Missed opportunities -No reminder/recall -No QA- practice rates -Ordering vaccines

-Vaccine shortages

-No tracking system

-Financing (despite VFC)

-Scattering of care

Barriers to Influenza Vaccinations

Vaccine -Need to vaccinate annually

-Short time window to vaccinate

So what works?

To improve childhood immunizations

Review of the literature and experience

System

Provider Patient

-No access -Extra visit -Fear -Costs

-Missed opportunities -No reminder/recall -No QA- practice rates -Ordering vaccines

-Vaccine shortages

-No tracking system

-Financing (despite VFC)

-Scattering of care

Barriers to Influenza Vaccinations

Vaccine -Need to vaccinate annually

-Short time window to vaccinate

Practice-based interventions to

improve childhood vaccination rates

Intervention Experience Across the US

Patient Reminder-Recall Some practices use it (phone, autodialer, cards)

Clearly helps (5-10%), Challenge for the poor

Provider prompts or standing

orders (to reduce missed

opportunities)

Feasible, fits potentially with EMRs

Not well studied, small benefits

Patient education (provider

recommendations)

“Necessary but not sufficient;” by itself unclear

benefit although clearly needed

Audit-feedback Small benefits

Vaccine champion in office (for

QI changes, policies)

Not studied well but clearly helps

Interweaving vaccinations with

WCC visits

A critical component of success

Summary: Many interventions help, combination of >1 intervention the best

Practice-based interventions to

improve influenza vaccination rates

Intervention Experience Across the US

Patient Reminder-Recall Many practices use it (autodialer phone, cards)

Clearly helps (5-10%)

Flu Vaccine Clinics (e.g.,

Saturdays)

Some benefit; variable success

Relatively small numbers

Patient education (provider

recommendations)

“Necessary but not sufficient;” by itself unclear

benefit although clearly needed

Don’t stop vaccinating too

soon

Not much data, small benefits

Summary: Many interventions help, but won’t raise rates to >80%

System

Provider Patient

-No access -Extra visit -Fear -Costs

-Missed opportunities -No reminder/recall -No QA- practice rates -Ordering vaccines

-Vaccine shortages

-No tracking system

-Financing (despite VFC)

-Scattering of care

Barriers to Influenza Vaccinations

Vaccine -Need to vaccinate annually

-Short time window to vaccinate

Patient-based interventions to

improve childhood vaccination rates

Intervention Experience Across the US

Provide a medical home Clearly important

Not always possible (so alternative sites needed)

Provide access to those without

medical homes (PHCs)

Some evidence, more experience

Educate the public

(benefit of vaccines, fear, side-

effects, myths)

Very important to “increase demand”

Best if combined with other strategies

Needs to be culturally sensitive

Varies by vaccine (eg flu, MMR [autism])

Address costs (also under

“System”)

Not well studied other than VFC

Need to address costs for visit, vaccines, and

indirect costs

Summary: Big role for public health and professional organizations

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System

Provider Patient

-No access -Extra visit -Fear -Costs

-Missed opportunities -No reminder/recall -No QA- practice rates -Ordering vaccines

-Vaccine shortages

-No tracking system

-Financing (despite VFC)

-Scattering of care

Barriers to Influenza Vaccinations

Vaccine -Need to vaccinate annually

-Short time window to vaccinate

System-based interventions to

improve childhood vaccination rates

Intervention Experience Across the US

Provide a tracking system

(immunization registries

Important, can improve rates if combined with

interventions. Inter-changeability with EMRs key

Reduce out-of-pocket costs

VFC is critical, more self-insured plans, ACA

Provide health insurance to all

children

Strong evidence. ACA should help

Provide appropriate

reimbursement

Important for flu and newer vaccines

VFC coverage and national recs. should match

School entry requirements-

laws

Very powerful policy lever

Summary: Build upon current systems and programs. Communicate!

“Hot” research topics

Evaluate interventions – especially in real

world (T3-T4 research)

EMR-based interventions

Influenza vaccine (since rates are low)

Using QI to improve vaccination rates

Vaccine communication and education

With the public

With professionals

Outline

Burden of childhood vaccine-preventable

disease

Strategies to improve immunization rates

Challenges and methods to overcome challenges

Useful immunization resources

New Tools for Clinicians and Parents

Provider Resources for Vaccine Conversations

with Parents

www.cdc.gov/vaccines/conversations

Health Care Professional Home Page

www.cdc.gov/vaccines/hcp

“Get the Picture” Childhood Video

www.youtube.com/user/CDCStreamingHealth

Public awareness campaign launched Niiw 2012

Radio,TV , print PSAs From Ann

Schuchat

Immunization Action Coalition

http://www.immunize.org/

American Academy of Pediatrics (AAP)

http://www2.aap.org/immunization/

Teaching Immunization Delivery and

Evaluation (TIDE)

http://tide.musc.edu/

Task Force on Community Preventive Services http://www.thecommunityguide.org/vaccines/index.html

CDC Immunization Information http://www.cdc.gov/vaccines/ed/default.htm

Summary

Vaccine-preventable diseases still exist for children

E.g., flu, pneumococcal, measles, pertussis, Hepatitis A)

Vaccination rates are high, preventing morbidity!

Barriers to vaccinations do exist:

Provider + Patient + System + vaccine-specific

What works: Strategies to overcome the barriers

Resources: many exist (provided)

Childhood vaccines are a major benefit!

Extra Slides:

Disease Burden

CDC/National Center for Immunization & Respiratory Diseases

Comparison of 20th Century Annual Morbidity and Current Morbidity: Vaccine-Preventable Diseases

Disease

20th Century

Annual Morbidity†

2011

Reported Cases † †

Percent

Decrease

Smallpox 29,005 0 100%

Diphtheria 21,053 0 100%

Measles 530,217 222 > 99%

Mumps 162,344 404 > 99%

Pertussis 200,752 18,719 91%

Polio (paralytic) 16,316 0 100%

Rubella 47,745 4 > 99%

Congenital Rubella Syndrome 152 0 100%

Tetanus 580 36 94%

Haemophilus influenzae 20,000 14* > 99% †Source: JAMA. 2007;298(18):2155-2163 † † Source: CDC. MMWR August 17, 2012;61(32);624-637. (final 2011 data)

* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 14 cases of Hib are estimated to

have occurred among the 226 reports of Hi (< 5 years of age) with unknown serotype.

Measles, United States, 2011

Geographic Distribution of Cases (n=222)

43

= 1 case

MMWR April 20, 2012

Measles Outbreaks*, U.S., 2011

112/222 (50%) annual cases were

outbreak-associated

17 total outbreaks

Median outbreak size was 6 (range: 3 – 21)

44% of outbreak-associated cases occurred

in unvaccinated philosophical belief

exemptors

44

*Outbreak = 3 or more epidemiologically linked cases MMWR April 20, 2012

Whooping cough cases reach epidemic

levels in much of Washington All teens and adults need a whooping cough booster

April 3, 2012 July 20, 2012

Burden of influenza in the US

Annual Burden-All Ages

200,000 hospitalizations 20,000 in children

36,000 deaths 46-153 per year in children

Hundreds of thousands of outpatient visits

During 3m peak flu season, 20-75% of ARI visits

Complications mostly in: <2y, elderly, chronic disease

Rates of Visits Per 1,000

Age Hospital ED Outpt.

0-4.9y* 0.4-0.9 6-27 50-95

5-12y** One-quarter to one-half

of above

NVSN Studies:

* Poehling et al NEJM, 2006

** From NVSN

Influenza-related morbidity & mortality

among healthy people

Glezen WP. Emerging infections: pandemic influenza. Epidemiol Rev. 1996; 18(1),64-76.

<5 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 > 65

Pneumonia-Influenza Mortality

120

80

40

0

Age (Years)

80

40

0

30

20

10

0

Per 100,000

Hospitalizations

Rates

Medically Attended Illness

20

60

Has not changed much since then