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
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 10-18 years of age and VFC eligible patients 16-18 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. 2018-19 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 2019 6 2
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 2018-2019 https://www.mass.gov/media/1750336/download 8 9 3
MIIS Progress Report - Data over time 2013 Total Sites: 341 Total Patients: 2011 1,539,629 Total Shots: Total Sites: 9 7,303,293 Total Patients: 3,902 Total Shots: 69,505 2015 Total Sites: 1,121 Total Patients: 4,427,623 Total Shots: 33,334,571 2017 Total Sites: 2,223 Total Patients: 6,241,144 Total Shots: 46,241,144 2018 Total Sites: 2,357 Total Patients: 6,670,758 Total Shots: 51,691,391 10 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 Email Series Self-Hosted Trainings Training Materials 12 4
Number of cases 10/16/2018 HOW ARE WE DOING? 13 Vaccine-Preventable Diseases in Massachusetts*, 2008-2018 to date 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Disease 2018 YTD Measles 2 2 3 24 0 1 8 0 1 0 1 Mumps 7 15 9 4 6 71 5 6 258 191 27 Rubella 1 1 0 0 1 0 0 0 0 1 0 Meningococcal 22 14 8 14 6 11 11 12 11 11 11 Disease Pertussis 761 362 296 280 653 348 298 253 198 383 142 Hepatitis B (acute) 63 93 87 77 76 69 33 27 35 52 31 Hib < 5 2 1 1 0 2 1 1 0 1 2 0 Tetanus 0 0 0 0 0 0 0 0 0 0 0 Diphtheria 0 0 0 0 0 0 0 0 0 0 0 Polio 0 0 0 0 0 0 0 0 0 0 0 Pneumococcal 83 81 72 40 51 24 27 20 31 21 13 Disease < 5 Varicella 1584 1415 770 606 628 475 469 356 288 383 196 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. 2018 data are preliminary and subject to change. 15 5
Mumps in Massachusetts 2016 2018 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 18-24. 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. 2018 data are preliminary and subject to change. 16 Influenza Season 2017-2018 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 17 2017-2018 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: >1010 1 st doses* (undergrad population of 2500) >575 2 nd doses* UMASS: >7600 1 st doses* (undergrad population ~23,000) > 3440 2 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 2018 18 6
Estimated Vaccination Coverage with Individual Vaccines Among Children 19-35 Months of Age in MA, NIS 2016-2017 2016 Coverage 2017 Coverage Percent difference 4+ DTP 94% 93% -1.4 3+ Polio 100% 96% -3.5 1+ MMR 99% 98% -0.3 3+ Hib 99% 94% -4.8 Hib-FS 93% 89% -3.3 3+ Hep B 97% 93% -3.9 HepB birth dose 73% 77% +3.7 1+ Var 97% 98% +0.6 3+ PCV 98% 97% -1.4 4+ PCV 95% 92% -3.2 2+ HepA 67% 57% -9.8 2+ Rotavirus 85% 80% -4.6 NIS Data, CDC MDPH 2018 19 Seasonal Influenza Vaccination Rates in Massachusetts by Age, 2017-18 Influenza Season, July 2017 May 2018 Children 6 mos 17 years Children 6 mos 4 years Children 5 12 years Children 13 17 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 2016-17 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 2016-17 MA 2017-18 US 2016-17 3 US 2017-18 4 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 2017 4 Influenza Vaccination Coverage Among Health Care Personnel United States, 2017 18 Influenza Season, MMWR, September 28, 2018 / 67(38);1050 1054 21 7
% Vaccination Coverage 10/16/2018 22 Adolescent Vaccination Coverage with Tdap, MenACWY, and HPV, Massachusetts, NIS, 13-17 years, 2008 2017 100% 90% 80% 70% 60% 50% 40% 30% 20% 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 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, 13-17 Years of Age, MA vs US, 2016 vs 2017 MA US Females Males Females Males 2016 2017 2016 2017 2016 2017 2016 2017 1+ 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
WHERE DO WE GO FROM HERE? 25 Source: World Health Organization, Measles and Rubella Surveillance Data, Access on August 31, 2018 http://www.who.int/immunization/monitoring_surveillance/burden/vpd/surveillance_type/active/measles_monthlydata/en/ 26 Religious and Medical Exemptions Among Massachusetts Kindergarten Students 1986-2017 27 % with Exemptions N=853 N=687 N=166 Year Source: Massachusetts Annual Kindergarten Immunization Survey MDPH March 2018 27 9
% 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, 2017-18 28 14 12 10 8 MA State Average: 1.35% 6 4 2 0 2017 Source: Massachusetts Annual Kindergarten Immunization Survey MDPH March 2018 28 29 30 10
Worrisome Trend of More Toddlers with No Vaccines 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% % of Children 19-35 Months with No Vaccines, United States, 2003-2017 0.0% 2003 2005 2007 2009 2011 2013 2015 2017 Source: National Immunization Survey Child Healthy People 2020 Goal: <1% 31 32 33 Vaccine Confidence Project Address targeted areas that are susceptible Answers to common myths Resources 33 11
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 2015. Report found at: http://www.hhs.gov/nvpo/nvac/reports/nvacvaccine-confidence-public-health-report-2015.pdf 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 (rebecca.vanucci@state.ma.us) or Cynthia McReynolds (cmcreynolds@mms.org) 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: https://www.cdc.gov/vaccines/parents/resources/ultimate-babyproofing-plan.html Printable version: http://mcaap.org/wp2013/wp-content/uploads/2018/04/cdc-ultimate-babyproofing-plan.pdf 36 12
14 Diseases You Almost Forgot About (Thanks to Vaccines) https://www.cdc.gov/vaccin es/parents/diseases/child/ 14-diseases.html 37 Cancers Attributable HPV per Year, U.S., 2011 2015 Cancer site Percentage of HPV cancers attributable to HPV Number of HPV cancers attributable to HPV Female Male Both Sexes Cervix 91% 10,751 0 10,751 Vagina 75% 635 0 635 Vulva 69% 2,707 0 2,707 Penis 63% 0 803 803 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, https://www.cdc.gov/cancer/hpv/statistics 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, 2004-2014 39 13
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! https://www.cdc.gov/cancer/hpv/pdf/uscs-databrief-no4-august2018-508.pdf https://www.cdc.gov/hpv/infographics/vacc-six-reasons.html 40 New HPV Materials from National HPV Roundtable http://hpvroundtable.org/action-guides/ 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). 42 14
43 Questions? Pejman Talebian Immunization Program Director Pejman.Talebian@state.ma.us 617-983-6880 Rebecca Vanucci Immunization Outreach Coordinator Rebecca.Vanucci@state.ma.us 617-983-6534 44 44 15