Post-partum Tdap Vaccination: CDPH-Stroger Collaboration, 2009

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1 Post-partum Tdap Vaccination: CDPH-Stroger Collaboration, 2009 Julie Morita, M.D. Deputy Bureau of Public Health and Safety

2 Pertussis (Whooping Cough) Highly contagious and commonly occurring -preventable disease Usually spread by coughing or sneezing while in close contact with others Many infants infected by older siblings, parents or other caregivers

3 Infants most severely affected More than half of infants < 1 year of age are hospitalized. About 1 in 5 infants will get pneumonia About 1 in 100 infants will have convulsions About 1 in 100 result in death

4 Cases Reported Pertussis by Age Group, <11 yrs yrs >18 yrs Year

5 Reported Pertussis Cases Chicago, National outbreak: increased awareness, testing

6 Vaccine Schedule DTaP 2, 4, and 6 months of age Fourth shot at 15 through 18 months of age Fifth shot at 4 through 6 years of age Protection fades over time

7 Adolescent/Adult Vaccine Licensed, 2005 Tdap Licensed for a single dose Routinely administered at year check up Catchup year olds year olds Emphasized for adults with close contact with children <12 months (parents, health care providers, childcare providers)

8 Maternal Intervention Options Preconception immunization Many medically underserved young women do not have routine healthcare visits Incomplete vaccination by provider During pregnancy: Category C, safety unknown Post-partum

9 CDPH Post-partum Tdap Initiative Federal funds, 2007 Vaccine distributed to 18 of 20 hospitals with obstetric units: 20,000 OB, pediatric and nursing departments engaged Variable success Champion needed to implement program Standing orders implemented Provider and staff education conducted

10 Stroger Hospital Received 1,200 doses, 2008 Provider education initiated Challenges associated with resources, provider - patient communication Decision support system intervention proposed Prior success with influenza vaccination

11 Clinical Decision Support System Clinical need Committee Clinicians Informaticists Intervention options Automatic order Decision support algorithm Electronic Medical Record Opt-out order Warning

12 Conditions Logic for Decision Support Rule Female, aged 14 through 45 years Prior oxytocin order Oxytocin: Medication only given to women during or after labor

13 Exclusions Conditions Logic for Decision Support Rule Female, aged 14 through 45 years Prior oxytocin order Prior Tdap order Td vaccination within 2 years Phenytoin order during admission

14 Exclusions Conditions Logic for Decision Support Rule Female, aged 14 through 45 years Prior oxytocin order Prior Tdap order Td vaccination within 2 years Phenytoin order during admission Triggers: Iron supplementation or Patient discharge order

15 Exclusions Conditions Logic for Decision Support Rule Female, aged 14 through 45 years Prior oxytocin order Prior Tdap order Td vaccination within 2 years Phenytoin order during admission Triggers: Iron supplementation or Patient discharge order Dialogue box displayed to the ordering physician

16 Order Displayed to Physicians

17 Pre-algorithm (Oct. 08 to Jan 09) Results Births (N=183) N=0 (0%)

18 Results Pre-algorithm (Oct. 08 to Jan 09) Post-algorithm (Jan 09 to April 09) Births (N=183) Births (N=248) (N=10; 4%) Oxytocin (N=238; 96%) N=0 (0%)

19 Results Pre-algorithm (Oct. 08 to Jan 09) Post-algorithm (Jan 09 to April 09) Births (N=183) Births (N=248) (N=10; 4%) Oxytocin N=0 (0%) N=0 (0%)

20 Results Pre-algorithm (Oct. 08 to Jan 09) Post-algorithm (Jan 09 to April 09) Births (N=183) Births (N=248) Oxytocin (N=238; 96%) (N=16; 7%) Iron (N=222; 93%) N=0 (0%) N=0 (0%)

21 Results Pre-algorithm (Oct. 08 to Jan 09) Post-algorithm (Jan 09 to April 09) Births (N=183) Births (N=248) Oxytocin Iron N=0 (0%) N=0 (0%) N=1 (6%) N=180 (81%)

22 Results Pre-algorithm (Oct. 08 to Jan 09) Post-algorithm (Jan 09 to April 09) Births (N=183) Births (N=248) Oxytocin Iron N=0 (0%) N=0 (0%) N=1 (6%) N=180 (81%) N=147 (59%) administered

23 Published as a model for other healthcare facilities Obstetrics & Gynecology, July 2010

24 Summary Post-partum vaccination is an important strategy for preventing infant pertussis CDPH Tdap distribution program served as a catalyst for post-partum vaccination programs Use of a computer-based clinical decision support algorithm resulted in increased postpartum vaccination Minimal intramural or extramural financial support

25 Conclusions Public Health programs play an important role in guiding prevention programs in clinical medicine Automated computer-based intervention strategies can dramatically improve processes of patient care

26 Policy Considerations Effective adult immunization programs can be implemented when adult is available Development of a federal Vaccines for Adults program (modeled after the Vaccines for Children program) would likely improve adult immunization coverage

27 Acknowledgements CDPH Maribel Chavez-Torres Pat Hoskins-Saffold Stroger Hospital Clay Caquelin Zina Jones Romina Kee Ed Lin Wendy Schmidtt William Trick

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