Welcome to the California Immunization Coalition Education Hour

Transcription

1 Welcome to the California Immunization Coalition Education Hour 1

2 . Implementing a System-Wide Immunization Requirement at the University of California Webinar Objectives Describe the rationale and purpose of the UC Immunization Policy Address common questions regarding the new policy, including questions regarding the implementation timeline, exemption policy, and requirements Understand the role of providers in facilitating the implementation of this policy. Identify resources that can be used to answer questions about vaccines, vaccine safety and the new policy. 2

3 Audio Options for the Webinar Today Listen over your computer speakers Turn up your computer speakers Make sure they are not on Mute Plug in earphones or headset to computer or handheld device (phone or tablet ) All lines will be on mute during the conference You may ask questions using the Q&A Panel Technical Difficulties? Contact WebEx Technical Support:

4 Submit Written Questions at Any Time Using the Q&A Panel 1.) Type your question into the small 1) Type your question into the box at the bottom box at the bottom 3) Click Send 3) Click the Send Button 3.) Click the Send Button 2.) 2) Address Address your questions your question to All Panelists to All Panelists

5 Access the Q&A Panel From Split Screen Welcome to the Webcast! We Will Be Starting Momentarily.

6 M A R Y K N U D T S O N, D N S C, N P, F A A N E X E C U T I V E D I R E C T O R, S T U D E N T H E A L T H A N D C O U N S E L I N G U C S A N T A C R U Z B R A D B U C H M A N, M D, M B A M E D I C A L D I R E C T O R, S T U D E N T H E A L T H A N D C O U N S E L I N G, U N I V E R S I T Y O F C A L I F O R N I A O F F I C E O F T H E P R E S I D E N T A U G U S T 2 9,

7 BACKGROUND Student Health Services their mission includes public health and education of students regarding health threats and preventive care Why create a policy now? Planning began in early 2014 as response to infectious disease outbreaks on UC Campuses over past 10 years Mumps, Measles, Meningitis, Varicella, Pertussis, Active TB ACA coverage for cost of vaccines EMR systems that facilitate immunization data gathering Immunization Registry System wide use of PNC EMR by UC

8 IMPLEMENTATION PROCESS UCLA had decided to require students to enter vaccine history in EMR SHS Directors convened February 2014 and voted to pursue system wide plan to include vaccine history AND require immunizations recommended by CDPH Decision to link acknowledgement of vaccine recommendations with registration, had already missed deadlines for fall 2014, therefore efforts began with communications for fall 2015 Identified Immunization Plan Committee comprised of 5-6 SHS Directors and UCOP SHS Medical Director

9 IMMUNIZATION POLICY 3-YEAR PLAN Phase 1: Started in Fall 2015, campuses provided information to incoming students regarding immunization and TB screening recommendations, with a required acknowledgement of receipt on the admissions checklist. In addition, campuses implemented nonmandatory, student self-entry of vaccine information via the secure electronic medical record portal.

10 Immunization Policy 3-Year Plan Phase 2: Starting in Fall 2016, all campuses will implement student self-entry of vaccine and TB screening information via the secure electronic medical record portal, with a link from admissions checklist, and a stated requirement of completion prior to initial registration. This requirement would be soft, without a mandatory registration hold placement during this phase.

11 IMMUNIZATION POLICY 3-YEAR PLAN Phase 3: Starting in Fall 2017, full implementation of required student self-entry of vaccine and TB screening information via the secure Electronic medical record portal, AND SUBMISSION OF A VERIFIABLE VACCINATION RECORD, with resulting registration hold placement for failure to comply.

12 UC IMMUNIZATION POLICY California Dept of Public Health IMMUNIZATION & SCREENING RECOMMENDATIONS FOR COLLEGE STUDENTS All incoming UC Students are required to obtain these vaccines and undergo Tuberculosis screening Required Vaccination Measles, Mumps and Rubella (MMR) Varicella (chickenpox) Doses 2 doses; first dose on or after 1 st birthday 2 doses; first dose on or after 1 st birthday Tetanus, Diphtheria and Pertussis (Tdap) 1 dose after age 7. Meningococcal conjugate (serogroups A, C, Y & W- One dose on or after age 16 for all students 21 years of 135) age or younger. Screening for Tuberculosis All incoming students at higher risk for TB infection should undergo either skin or blood testing for TB infection. (Higher risk includes travel to or living in South & Central America, Africa, Asia, Eastern Europe, and the Middle East; prior positive TB test, or exposure to someone with active TB disease.)

13 EFFORTS TO DATE All campuses have linked notices regarding immunization requirement to admission and registration communications Website updates Media Meetings with UC and campus stakeholders, including: UCOP: UC President and Regents, EVC UC Health, Office of General Council, Risk Services, Legislative Affairs Campuses: Chancellors, Vice Chancellors of Student Affairs, Registrars, Graduate Deans, International Student Deans, English Language Program Administrators, IT

14 PNC IMMUNIZATION MODULE All campuses have purchased and have set up module. Immunization Plan Committee and SHS IT staff working to train each other and establish criteria for system wide reporting on compliance Program cumbersome; all data must be entered in one sitting; does not yet save and allow students to return to complete Requires complex compliance set up for reporting and coordinating holds No interface with Immunization Registry Campuses collecting student self-entered data.

15 EXEMPTION REQUESTS Task force convened to determine policy and process for exemption requests, denials and appeals UC SHS Executive Directors, Medical Directors, and UC Immunization Policy Work Group all support acceptance of waivers for medical exemptions only UC Immunization Exemption Policy still in draft revisions: Initial draft accepted only CDC-listed contraindications Later added vaccine manufacturer's insert contra-indications as acceptable Most recent addition is approval to accept treating clinician documentation that vaccination with (a) particular vaccine(s) unsafe and medically contra-indicated

16 MEDICAL EXEMPTION REQUESTS Proposed limited clinician types approved by UC to complete medical exemption requests include physicians (MD or DO), nurse practitioners (NP), or physician-assistants (PA) Specific Language for allowable documentation from a treating clinician is from CA HSC : written statement by a (physician and surgeon ) physical condition of the person or medical circumstances relating to the person are such that immunization is not considered safe, indicating the specific nature and probable duration of the medical condition or circumstances that contraindicate immunization

17 MEDICAL EXEMPTION REQUESTS Medical exemption requests are forwarded to campus SHS Medical Directors for review and decision Medical exemption requests approved if meets 1 of 3 allowable criteria [CDC, manufacturer s insert, or treating clinician documentation of other reason(s)] If ambiguous or insufficient information, will attempt to clarify submission If exemption request but does not meet criteria, it will be denied, and student will be advised of denial. Student options then include: Compliance with immunization plan requirements Submission of request for appeal to local campus medical director who will forward request to centralized UC Immunization Appeals Committee (IAC) Re-submission of exemption request -???

18 MEDICAL EXEMPTION APPEALS Immunization Exemption Policy Committee (IEPC) supports the idea of a central appeals process and Immunization Appeals Committee (IAC) 3-5 IAC members selected from IEPC members or campus Medical Directors Appeal requests will be de-identified before sending to IAC for decision Minimum of 3 members must evaluate appeal and render decision, with at least 1 member from campus of origination of appeal - decisions must be rendered within 60 calendar days of receipt Decisions relayed to campus Medical Director, who then advises student Student will be allowed to register and enroll in classes during academic term in which their appeal was submitted. If IAC denies appeal, registration for the following academic term will be blocked until compliance with requirements met

19 NEXT STEPS Complete revisions of Immunization Exemption Policy Draft and submit to UC Trouble shoot and enhance EMR set-up for immunization module & vaccination history collection at all campuses Continue communication outreach to prospective UC applicants/parents Follow-up communication to matriculants Specific outreach efforts to groups potentially more affected (out-of-state domestic students, international students, etc.) Continue to partner with CDPH, Immunization Coalition, and others to promote awareness

20 FUTURE STEPS Create immunization record validation plan Explore interface with immunization registry Your suggestions/feedback? Thank you!

21 Teen vaccines: the challenges and the role of providers MARK H. SAWYER UCSD SCHOOL OF MEDICINE RADY CHILDREN S HOSPITAL SAN DIEGO

22 Disclosures I have no financial disclosures related to this presentation 22

23 Objectives List the factors influencing our success in delivering vaccines to adolescents so that you can adopt systems in your clinic to address them Describe the role of a strong provider recommendation for vaccines so that you will understand how you can influence vaccine uptake Summarize the recent changes in vaccine recommendations for adolescents so that you provide optimal care to your patients 23

24 24 24

25 Adolescent vaccine coverage rates-united States MMWR August 26, 2016 / 65(33);

26 Challenges to delivery of vaccines to adolescents Lack of knowledge about the recommended vaccines Lack of a strong recommendation from physicians for some vaccines Need for multiple doses of some vaccines Lack of regular physician visits Vaccines with only moderate efficacy Unfounded vaccine safety concerns 26

27 What makes adolescents get vaccinated? Lindley MC, Human Vaccines and Immunotherapeutics

28 We are part of the problem Allison MA et al. Pediatrics 2016;137(2):e

29 Systems to improve vaccine coverage Immunize at every type of healthcare visit Use standing orders so that the physician does not need to take specific action unless a vaccine is contraindicated User reminder/recall systems including and text options Take advantage of community immunizers (e.g. pharmacies) Audit your own records-you may be surprised 29

30 Pertussis in California

31 Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & 31

32 Evidence of decreased protection in adolescent immunized with acellular vaccines as infants Klein NP et al. Pediatrics, 2016;137(3):e

33 Tdap recommendations Routine immunization at 11 years of age Focus immunization in households with newborns Intense effort to immunize during every pregnancy to protect infants in the first 2-3 months of life No booster recommendation for non-pregnant individuals 33

34 Meningococcal Disease, College Outbreaks, Meningococcal B Vaccine

35 Meningococcal Disease Five main strains of Neisseria meningitidis (Meningococcus): A, B, C, Y, W The quadrivalent meningococcal vaccines contain serogroup A, C, Y, W Serogroups B, C and Y circulate in the United States Serogroup B disease is common in young children and becoming more common in adolescents and adults Outbreaks of meningococcal type B at Princeton and UCSB in 2014; University of Oregon in 2015; Santa Clara University 2016 N. meningitidis causes overwhelming sepsis and meningitis with a high mortality rate (approx 10%)

36 Meningococcal serogroup ACWY vaccines MenACWY-D (Menactra) approved in 2005 MenACWY-CRM (Menveo) approved 2010 Routine immunization at 11 years of age recommended by ACIP in 2007 Routine second dose recommended at 16 years of age recommended by ACIP in 2010 ACWY vaccine also recommended at 2 months of age or older for individuals at high risk (e.g. complement deficiency, asplenia)

37 Meningococcal serogroup B vaccines First serogroup B membrane protein vaccine licensed in October MenB-FHbp (Trumenba). fhbp subfamily A/v2,3; subfamily B/v1. A 3- dose vaccine for some and now a 2-dose vaccine for some Second serogroup B membrane protein vaccine licensed in January MenB-4C (Bexero). fhbp subfamily B/v1, NhbA, NadA, Por A1.4. A 2-dose vaccine. Licensed in >30 countries Use in high-risk patients recommended by ACIP in February 2015 Permissive recommendations for use in general population in June 2015 These are different vaccines from the ACWY vaccines and different from each other. They cannot be used interchangeably

38 MacNeil-ACIP October 2014;

39 Should we immunize all adolescents to prevent a very small number of cases and deaths? MacNeil-ACIP October 2014;

40 Patel-ACIP October 2014

41 Meningococcal B Vaccines: Who should you give them to? year olds who request it Those living in dormitories or other crowded conditions? Kids whose college or other institution requires it Those who smoke or drink alcohol????

42 Three reasons you should care about HPV vaccine HPV causes lots of cancer HPV vaccine prevents cancer We are doing a terrible job of immunizing our population with HPV vaccine to prevent cancer

43 HPV infection causes lots of cancer

44 HPV vaccine-infection reduction since vaccine became availablefemales 64% reduction in prevalence of 4vHPV type infection in 14-19yo 34% reduction in yo No reduction in >24yo populations No change in prevalence of non-vaccine serotypes Achieved with only 34% 3-dose vaccine coverage Markowitz-Pediatrics 2016:137(2): e

45 HPV Immunization Recommendations Routine immunization at age years for all. Start using HPV9 All Females aged years. Can complete the series with HPV9 All Males aged years. Can complete the series with HPV9 but less benefit Men who have sex with men aged years. Can complete the series with HPV9 but less benefit MMWR 2015; 64: ; CDC.gov

46 Pneumococcal conjugate vaccine (PCV13) for older children

47 Pneumococcal Vaccines POLYSACCHARIDE-PPSV23 Pneunovax Available for decades Used in high risk populations including all adults >65 years of age Immunity wanes so some groups need a repeat dose 5 years after their first PPSV23 Only limited benefit from repeated doses PROTEIN CONJUGATE VACCINE-PCV13 Prevnar 13 Induces a better immune response Began using PCV7 routinely in young children in the 1990 s PCV13 became available in 2010 Has led to reduced disease even in unimmunized populations Licensed for adults >50 years of age in

48 Two populations should receive both PCV13 and PPSV23 HIGH RISK CHILDREN AND ADULTS Immunocompromised (e.g. HIV, malignancy) Anatomic or functional asplenia Cochlear implants CSF leaks Nephrotic syndrome ALL ADULTS 65 YEARS AND OLDER

49 Take Home Points Healthcare provider recommendations are key to getting adolescents immunized HPV vaccine coverage is suboptimal and providers have a lot to do with that Serogroup B meningococcal vaccine now available. Recommendations for use currently limited.. Pertussis remains a big problem in large part due to waning vaccine immunity. Focus on immunizing pregnant women at every pregnancy PCV13 now indicated for high-risk adolescents 49

50 Information for Health-Care Professionals NNII ( VEC ( IAC ( CDC/NIP ( AAP ( AAFP ( IVS ( Vaccine Page ( Every Child by Two ( CDPH.gov (shot for shot) PKIDS (