STATE IMMUNIZATION UPDATE Pejman Talebian, Director Immunization Program Rebecca Vanucci, Immunization Outreach Coordinator, Immunization Program

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1 STATE IMMUNIZATION UPDATE Pejman Talebian, Director Immunization Program Rebecca Vanucci, Immunization Outreach Coordinator, Immunization Program October 18, 2018 MIAP Pediatric Immunization Skills Building Conference Disclosure We, Pejman Talebian and Rebecca Vanucci, have been asked to disclose any significant relationships with commercial entities that are either providing financial support for this program or whose products or services are mentioned during my presentations. We have no relationships to disclose. We may discuss the use of vaccines in a manner not approved by the U.S. Food and Drug Administration. But in accordance with ACIP recommendations. 2 Roadmap 3 Where do we go from here? We made it! Where are we now? How are we doing? MIAP Immunization Conference 3 1

2 WHERE ARE WE NOW? 4 Vaccine Supply Massachusetts is fully universal for all routinely recommended ACIP vaccines. MDPH supplies Men B vaccine for high risk children years of age and VFC eligible patients years of age regardless of risk. High risk children currently includes full and part-time students, 18 and under, that attend one of the schools in the Five College Consortium influenza vaccine is available for sites to order. MDPH has a limited number of LAIV (FluMist) doses. 5 Hepatitis B Vaccine Shortage Orders for single antigen hep B vaccine reduced 25% except for birth facilities Recommendations during the shortage: Prioritize the birth dose Prioritize vaccination of infants born to HBsAg-positive moms or unknown status recommendations unchanged If using Pentacel (DTaP-IPV/Hib) or single antigen vaccines consider: Defering 3 rd dose of single-component HepB vaccine until later within the recommended range of 6-18 months of age for healthy infants born to HBsAg-negative mothers Transitioning to an all Pediarix (DTaP-IPV-HepB) schedule for all 3 doses in the DTaP primary series at 2, 4, and 6 months Substituting 1 or 2 doses of Pediarix for Pentacel in the DTaP primary series, as a temporary measure during the shortage If using Pediatrix can continue the infant schedule with no change Anticipate shortage lasting into early

3 Vaccine Storage and Handling As of January 1, 2018, pharmaceutical grade refrigerators are required for storage of all state-supplied pediatric vaccines Stand alone household freezers will still be acceptable for frozen vaccines MDPH will be replacing all state-supplied data loggers by early 2019 Sites will receive new data loggers for all units that store state-supplied vaccines Sites should keep their current data loggers on-hand in case of emergency 7 MA School Immunization Requirements

4 MIIS Progress Report - Data over time 2013 Total Sites: 341 Total Patients: ,539,629 Total Shots: Total Sites: 9 7,303,293 Total Patients: 3,902 Total Shots: 69, Total Sites: 1,121 Total Patients: 4,427,623 Total Shots: 33,334, Total Sites: 2,223 Total Patients: 6,241,144 Total Shots: 46,241, Total Sites: 2,357 Total Patients: 6,670,758 Total Shots: 51,691, All new MIIS User Experience All new user interface Larger font/higher contrast Customized home screen Intuitive navigation Improved workflows Redesigned Help page New My Site page and much more! 11 MIIS Curriculum Pilot Training Tracks Immunization Registry Vaccine Management School Data Quality In-Person Trainings Live Webinars Recorded Webinars Series Self-Hosted Trainings Training Materials 12 4

5 Number of cases 10/16/2018 HOW ARE WE DOING? 13 Vaccine-Preventable Diseases in Massachusetts*, to date Disease 2018 YTD Measles Mumps Rubella Meningococcal Disease Pertussis Hepatitis B (acute) Hib < Tetanus Diphtheria Polio Pneumococcal Disease < 5 Varicella Data are current as of 9/11/2018 and are subject to change. *Both confirmed and probable cases are reported for measles, mumps, rubella, and varicella to better reflect the true burden of disease. All other diseases include confirmed cases only. 14 Mumps in Massachusetts 2016: 258 cases 2017: 191 cases 2018: 27 cases Month and Year * Includes probable cases to better reflect disease burden data are preliminary and subject to change. 15 5

6 Mumps in Massachusetts to date Pediatric cases of mumps: only 5% (26/475) of all confirmed* cases in MA have been in the 17 and under age group. 400/1823 (21%) of all cases investigated were <18 years of age. 57% of confirmed* cases were ages Waning immunity following vaccination plays a role, in settings of intense close contact. Effectiveness of two doses of MMR against mumps: 88% (range of 31-95%) NEW: 3 rd dose of MMR can be used in outbreaks following consultation with MDPH. Two dose schedule sufficient for control in general population. * Includes probable cases to better reflect disease burden data are preliminary and subject to change. 16 Influenza Season Severe season for all age groups A lot of media attention Started building early but did not peak early (mid-february) Influenza A/H3N2 predominated (more flu B later in season) Moderate to low vaccine effectiveness A/H3N2 tends to impact older adults disproportionately Record year for hospitalizations for all age groups Resources taxed and stressed (hospital beds, EDs, provider offices, vaccines, antivirals, IV bags, rapid tests) One pediatric flu-related death in MA 180 pediatric deaths nationally (8/25/18) ~80% unvaccinated Outbreak of Invasive Meningococcal Disease: 5 College Consortium Began in November 2017 Three cases by March 2018 Two UMASS students One Smith College student Identification and prophylaxis of close contacts Very large vaccination efforts Smith: > st doses* (undergrad population of 2500) >575 2 nd doses* UMASS: > st doses* (undergrad population ~23,000) > nd doses* *Data are preliminary as of 8/2/18 and subject to change. Students also obtained vaccine independent of the college/university. Source: UMASS Amherst, Smith College. MIAP Conference

7 Estimated Vaccination Coverage with Individual Vaccines Among Children Months of Age in MA, NIS Coverage 2017 Coverage Percent difference 4+ DTP 94% 93% Polio 100% 96% MMR 99% 98% Hib 99% 94% -4.8 Hib-FS 93% 89% Hep B 97% 93% -3.9 HepB birth dose 73% 77% Var 97% 98% PCV 98% 97% PCV 95% 92% HepA 67% 57% Rotavirus 85% 80% -4.6 NIS Data, CDC MDPH Seasonal Influenza Vaccination Rates in Massachusetts by Age, Influenza Season, July 2017 May 2018 Children 6 mos 17 years Children 6 mos 4 years Children 5 12 years Children years MA US Ranking 74% (+1.9%) 76% (-6.5%) 74% (+2.8%) 72% (+7.9%) 58% (-1.1%)* 68% (-2.2%)* 60% (-0.4%) 47% (-1.4%) 2 (RI) 7 3 (RI, CT) 1 20 NIS Flu Parentheses denote percent-point difference in coverage from the influenza season *Statistically significant 20 Healthcare Provider Influenza Vaccination Rates Annual influenza vaccination is the best method of preventing influenza and potentially serious complications. The current Healthy People 2020 goal for influenza vaccination among healthcare personnel is 90%. The table below outlines influenza vaccination rates for different groups of healthcare workers. Vaccination rates in acute care hospitals, both nationally and in MA have surpassed the Healthy People 2020 goal and should be congratulated. However, rates for healthcare workers in general are much lower. Healthcare Personnel Setting MA MA US US All Healthcare Personnel NA 60% 1 79% 78% Acute Care Hospitals 94% 2 93% 2 92% 92% Source: 1 MA BRFSS for 2017 Calendar Year 2 Influenza Vaccination of Health Care Personnel in MA Nursing Homes and Acute Care Hospitals 3 CDC Health Care Personnel Influenza Survey, MMWR Influenza Vaccination Coverage Among Health Care Personnel United States, Influenza Season, MMWR, September 28, 2018 / 67(38);

8 % Vaccination Coverage 10/16/ Adolescent Vaccination Coverage with Tdap, MenACWY, and HPV, Massachusetts, NIS, years, % 90% 80% 70% 60% 50% 40% 30% 20% Year 96% (-1) 94% (+4) 85% (+7) 79% (+13) 67% (+5) 64% (+13) Tdap MenACWY 1 HPV - Females HPV UTD - Females* 1 HPV - Males HPV UTD - Males* Numbers in parentheses indicate a change from the previous year *HPV Up to date (UTD): 2 doses if the first dose given before the 15 th birthday and doses were separated by at least 5 months, otherwise, 3 doses NIS Data, CDC 23 Adolescent Vaccination Coverage with HPV, NIS, Years of Age, MA vs US, 2016 vs 2017 MA US Females Males Females Males HPV 78% 85% 66% 79% 65% 69% 56% 63% HPV UTD* 62% 67% 51% 64% 50% 53% 38% 44% HPV-UTD 2 doses if the first dose was given before the 15th birthday and doses were separated by five months, otherwise, 3 doses Statistically significant improvement from the previous year NIS Data, CDC 24 8

9 WHERE DO WE GO FROM HERE? 25 Source: World Health Organization, Measles and Rubella Surveillance Data, Access on August 31, Religious and Medical Exemptions Among Massachusetts Kindergarten Students % with Exemptions N=853 N=687 N=166 Year Source: Massachusetts Annual Kindergarten Immunization Survey MDPH March

10 % Exemption Rate Suffolk Essex Norfolk Bristol Middlesex Worcester Plymouth Hampden Berkshire Barnstable Hampshire Franklin Nantucket Dukes 10/16/2018 Kindergarten Total Exemption Rates by County, MA State Average: 1.35% Source: Massachusetts Annual Kindergarten Immunization Survey MDPH March

11 Worrisome Trend of More Toddlers with No Vaccines 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% % of Children Months with No Vaccines, United States, % Source: National Immunization Survey Child Healthy People 2020 Goal: <1% Vaccine Confidence Project Address targeted areas that are susceptible Answers to common myths Resources 33 11

12 34 Recommended Vaccines Providers who administer vaccines Vaccine Confidence Process that leads to vaccine licensure and recommendations National Vaccine Advisory Committee, Assessing the State of Vaccine Confidence in the United States: Recommendations from the National Vaccine Advisory Committee, December Report found at: 34 Vaccine Confidence Project 35 Target Areas of Lower Vaccine Confidence Meet with Providers, Local Public Health, School Nurses, & Advocates Develop specific training for providers Expand on general training for public Larger presentations for both providers & public Contact Rebecca Vanucci or Cynthia McReynolds if interested 35 6 Reasons Why Following the Recommended Schedule is Best 1. The immunization schedule is carefully designed to provide protection at just the right time. 2. Delaying vaccines could leave your child vulnerable to disease when she s most likely to have serious complications. 3. It s best to vaccinate before your child is exposed to dangerous diseases. 4. Your baby won t have the best protection from 14 serious diseases until she gets all the recommended doses of each vaccine. 5. Maternal antibodies and breastfeeding don t provide enough protection. 6. Not vaccinating your child on time can make someone else sick. List found at CDC Ultimate Babyproofing Website: Printable version:

13 14 Diseases You Almost Forgot About (Thanks to Vaccines) es/parents/diseases/child/ 14-diseases.html 37 Cancers Attributable HPV per Year, U.S., Cancer site Percentage of HPV cancers attributable to HPV Number of HPV cancers attributable to HPV Female Male Both Sexes Cervix 91% 10, ,751 Vagina 75% Vulva 69% 2, ,707 Penis 63% Anus* 91% 4,008 1,949 5,957 Oropharynx 70% 2,160 10,725 12,885 TOTAL 20,260 13,477 33,737 *Includes anal and rectal squamous cell carcinomas CDC, National Program of Cancer Registries and the NCI Surveillance, Epidemiology and End Results Program, and Saraiya M et al. J Natl Cancer Inst. 2015;107:djv086 Note on terminology: An HPV-associated cancer is a specific cellular type of cancer that is diagnosed in a part of the body where HPV is often found. An HPV-attributable cancer is a cancer that is probably caused by HPV. 38 HPV Cancer Incidence Massachusetts and US Change of HPV-Associated Cancer Incidence Rate, Annual Percent, Massachusetts,

14 HPV Vaccine Main Messages HPV cancers are rising Oropharyngeal cancer now surpassed cervical cancer as most common 6 different types of HPV-associated cancers HPV vaccine is safe, effective, and longlasting Over 100 million doses distributed in US Infections with HPV types that cause most HPV cancers and genital warts have dropped 71% in teenage girls We need to increase HPV rates to decrease HPV-associated cancer The 9vHPV vaccine has the potential to prevent 92% of HPV-attributable cancers, which equals 31,000 cancer cases! Your strong recommendation is vital! New HPV Materials from National HPV Roundtable 41 Take Away Messages Your strong recommendation is important! Ensure all staff are on the same page. Know your practice rates and those of your local community/school. Take advantage of educational opportunities from DPH (MIIS, Vaccine Confidence Project, HPV initiatives)

15 43 Questions? Pejman Talebian Immunization Program Director Rebecca Vanucci Immunization Outreach Coordinator