Indiana Immunization Task Force Progress Report Report Published December 2009 Progress Report Published May 31, 2012 2344 Broadway Street, Indianapolis, IN 46205 Tel: 317-628-7116 Email: director@vaccinateindiana.org www.vaccinateindiana.org 1
INTRODUCTION The Indiana Immunization Task Force consisted of a group of concerned Hoosiers who volunteered their time and effort to develop a strategic plan to improve immunization rates in Indiana. The Task Force evolved as an outcome of the Indiana Immunization Summit held in September 2008. It was a partnership between the Indiana Immunization Coalition and the Indiana Chapter of the American Academy of Pediatrics. The Summit brought together representatives from numerous Indiana organizations and agencies for a one-day meeting to examine policy and advocacy issues that could begin to improve immunization coverage rates in Indiana. Of the more than 70 people attending the Summit, 40 people volunteered to participate in the Task Force. The Task Force met monthly from November 2008 to December 2009 to create an immunization strategic plan for Indiana. The vision of the Task Force was to increase awareness of the importance of immunizations for Hoosiers. The mission of the Task Force was to decrease vaccinepreventable diseases by increasing Hoosier immunization coverage rates through education, advocacy, and partnership. The strategic plan was adopted by the Indiana Immunization Coalition after the Indiana Immunization Task Force was voluntarily disbanded in 2009. A set of goals, with some selected measurable objectives, were developed for the Indiana Immunization Strategic Plan. This progress report describes the status of these objectives two years after publication of the Plan in December of 2009. The following pages provide data and detailed information on each aspect of the Plan. Through ideas brought forth from the Task Force Education Committee, an additional accomplishment was the creation of the Vaccinate Indiana website (August 2009). Acknowledgments to the Indiana State Department of Health (ISDH) Immunization Division for its contribution to some of the data provided in this progress report. Section 1. IMMUNIZATION DATA BY AGE GROUPS Childhood Immunization Data The National Immunization Survey (NIS) administered annually by the CDC measures vaccine coverage rates for 19-35 month old children, commonly known as vaccine coverage rates of 2 year olds. This data provides a chronological overview of Indiana s immunization coverage rates for 2- year-old children compared to the coverage rates for other states (the state ranking listed below shows Indiana compared to the state with the highest coverage rate) and to the U.S. as a whole. 2
NIS data for each calendar year is published in the Morbidity and Mortality Weekly Report the following year (i.e. 2009 data is published in the late summer or early fall of 2010). Each year the coverage of specified vaccines is noted, as well as certain vaccine series. The vaccine series measured (in doses received) are 4 DTaP, 3 polio, 1 MMR, 3 Hib, 3 hepatitis B, 1 varicella, and 4 pneumococcal conjugate vaccine (4:3:1:3:3:1:4). Vaccines included in the vaccine series measurements can vary slightly from year to year. National Immunization Survey, Indiana and U.S. Coverage Rates for 19-35 months of age Year State Ranking IN. Rate U.S. Rate Vaccine Series 2010* 28 th 71.6% 72.7% 4:3:1:3:1:4 (Hib excluded) 2009* 36 th 67.3% 70.5% 4:3:1:3:1:4 (Hib excluded) 6 th 71.1% 65.7% 4:3:1:3:3:1:4 (Hib included) 2008 24th 75.5% 76.1% 4:3:1:3:3:1 2007 38th 74.0% 77.4% 4:3:1:3:3:1 2006 27th 75.9% 77.0% 4:3:1:3:3:1 2005 38th 78.1% 80.8% 4:3:1:3:3 2004 33rd 79.0% 80.9% 4:3:1:3:3 2003 26th 79.0% 79.4% 4:3:1:3:3 2002 38th 76.0% 79.4% 4:3:1:3:3 2001 29th 71.1% 73.7% 4:3:1:3:3 * Due to the ongoing shortage of the Hib vaccine that occurred in 2009, CDC made adjustment in the vaccine series affecting children for the 2009 and 2010 measurements. Adolescent Immunization Data In recent years, the CDC also began to use the NIS to measure vaccination coverage rates in adolescents. Individual state data on these coverage rates first became available in 2009 (reflecting 2008 data). Vaccines included are Tdap (tetanus/diphtheria/pertussis), meningococcal conjugate, and HPV (human papillomavirus). National Immunization Survey, Adolescent Immunization Coverage Rates (13-17 year olds) Vaccine IN 2010 US 2010 IN 2009 US 2009 IN 2008 US 2008 Tdap 72.3% 68.7% 44.4% 55.6% 31.2% 40.8% Mening 70.6% 62.7% 41.7% 53.6% 31.8% 41.8% HPV, 1 dose 37.0% 48.7% 37.1% 44.3% 26.1% 37.2% HPV, 3 doses 24.8% 32.0% 3
Comment: Major improvement in the Tdap vaccine and Meningococcal conjugate vaccine coverage levels in 2010 largely reflect the new school entry requirement for all Indiana 6 th -12 th graders to be immunized with these two vaccines beginning with the 2010-11 school year. Also see Objective A.4. Adult Immunization Data Note: Adult immunization coverage rates are usually measured for senior citizen coverage of annual influenza vaccine and if a pneumococcal vaccination has ever been received. Data for Indiana persons age 65 years or older are presented below. This data is obtained from annual Behavioral Risk Factor Surveys done by the CDC. Also see Objective A.5 below. Age 65 years or older 2010 2009 2008 Influenza, current year 66.4% 67.7% 68.6% Pneumococcal, ever 68.8% 66.3% 68.5% Note: U.S. data for 2010 shows a 67.5% coverage rate for current year influenza vaccine and a 68.8% coverage rate for having had a pneumococcal vaccination. Section 2. STATE PLAN OBJECTIVES Adults: 1. Increase Access to Immunizations Obj. A. Identify FP, IM, OB providers and educate on importance of providing immunizations Outcome: Health care providers are educated on the importance of providing immunizations through many activities of local health departments, the ISDH Immunization Program, the Indiana Immunization Coalition and a variety of professional and non-profit organizations. Obj. B. Implement state-funded vaccines up to age 19 to allow more 317 funds for adult vaccines Outcome: Since 2011, the ISDH Immunization Program began collecting data on the number of doses administered from the VFC Program, but that data is not yet available. As of May 31, 2012, no additional information or data is available. Obj. C. Remove barriers to accessing vaccines (example: HPV vaccine to age 26 with reimbursement by Medicaid) Outcome: An exact measure of the proportion of 317 fund used for adult vaccines is unavailable, but it is estimated that approximately 25% is used to purchase vaccines for adults. As of May 31, 2012, no additional information or data is available. 4
Children and Adolescents: Obj. A. Provide more vaccines for uninsured, Medicaid-eligible, and the underinsured A1. Policy changes and incentives at both the state and national level. Outcome: As of 2010, 84 sites have a Delegation of Authority on file and 14 sites are without a signed Delegation of Authority. Some counties have two (2) sites and both of those sites may be listed. See Objective A.4 for impact of new school entry vaccine requirements. 2. Improve Immunization Coverage Rates (THE 80% PLAN) Obj. A. Improve specific immunization coverage rates: A.1. Two year olds (19-35 months of age) for the 4:3:1:3:3:1 series (4 DTaP, 3 polio, 1 MMR, 3 Hib, 3 Hep B, 1 varicella) to 80% by Dec. 2011. (Baseline: 2008 NIS, Indiana = 75.5 +/-6.1%) Outcome: Measurement for this vaccine series cannot be tracked after 2008, as the subsequent NIS series was for the 4:3:1:3:1:4 series (i.e. pneumococcal vaccine coverage rate is now included in the series measurement.) See Objective A.3 below for results related to the current NIS vaccine series being measured. A.2. Two year olds (19-35 months of age) for pneumococcal conjugate vaccine (4 doses) to 80% by Dec 2011. (Baseline 2008 NIS, Indiana = 79.5 +/- 6.0%) Outcome: 2 year old children 2010 (MMWR 9/2/11) 2009 (MMWR 9/17/10) 2008 IN US IN US IN US Pneumococcal conjugate vaccine, 4 doses 80.2% 83.3% 78.6% 80.1% 79.5% Interpretation: Objective of 80% coverage by December 2011 has been accomplished, although Indiana remains below the national coverage rate. A.3. Two year olds (19-35 months) to 80% for the 4:3:1:3:3:1:4 series (Series per A.1 above + 4 pneumococcal conjugate vaccine doses. (Baseline: 2008 NIS, Indiana = 70.3 +/-6.6%) 5
Outcome: 4:3:1:3:3:1:4 vaccine series in 2 year olds 2010 2009 2008 IN US IN US IN US Hib vaccine excluded 71.6% 72.7% 67.3% 70.5% X X Hib vaccine included N/A N/A 71.1% ** 65.7% ** 70.3% ** Dr. Duwve, NIS data Interpretation: Results for 2009 and 2010 adjusted for the Hib vaccine shortage which lasted over one year. Indiana continues to be on the lower end of coverage rates for 2009 and 2010 when Hib vaccine is excluded and behind the U.S. as a whole for this vaccine series, although 2009 coverage rates with Hib vaccine included surpassed the U.S. rate. The vaccine series noted in this objective is far from the desired coverage rate of 80%. A.4. Adolescents for Tdap and meningococcal conjugate (MCV4) vaccines to 40% by Dec. 2010 and 80% by Dec. 2011** (Baseline: 2008 NIS, Indiana, data for 13-17 year olds: Tdap = 31.2%, MCV4 = 31.8%) Outcome: Indiana school entry requirement for 6 th -12 th grades for Tdap and MCV4 began in the 2010-11 school year. IN 2010 US 2010 IN 2009 US 2009 IN 2008 US 2008 Tdap 72.3% 68.7% 44.4% 55.6% 31.2% 40.8% Mening 70.6% 62.7% 41.7% 53.6% 31.8% 41.8% Interpretation: The tremendous impact of the new school entry requirement is demonstrated by an almost 30% gain in coverage rates from 2009 to 2010, but does not yet meet the desired objective of 80% coverage. Prior to the new school entry requirements, an increase in coverage rates of 10-12% for both vaccines occurred from 2008 to 2009. This means the objective of 40% coverage by December 2010 was met, although Indiana lagged behind the U.S. as a whole. 6
A.5. Adults (age 65 and older) for current influenza vaccine to 80% and for pneumococcal vaccine, to 80% by Dec. 2011. (Baseline: 2008, BRFSS for Indiana: influenza vaccine within past year = 68.6%[65.6-71.7]; pneumococcal vaccine = 68.5% [ 65.4-71.6]) Outcome: 2010 2009 2008 Influenza, current year 66.4% 67.7% 68.6% Pneumococcal, ever 68.8% 66.3% 68.5% Interpretation: Senior citizen coverage rates for these two vaccines remain stagnant over a 3-year period. A.6. Increase seasonal influenza vaccine coverage rates in children and adolescents. (Baseline: selected states composite, 24.0% [21.8-26.4%] for 2008-09) a. Children age 6 mos. -17 yrs to 40% by December 2011. Outcome: Children age 6 mo. 17 yrs Influenza vaccine, at least one dose ** Estimated by CDC 2010-11** (MMWR 6/30/11) IN US 67.4% 68.6% 2009-10 ** (MMWR 4/30/10) IN US 46.2% 40.0% 2008-09 24.0 % ** [proxy, composite of selected states] Interpretation: The desired influenza vaccine coverage rates of 40% or higher were achieved in the 2009-10 influenza season. An increase of approximately 20% in the coverage rate was accomplished from the 2009-10 to 2010-11 seasons. b. Children age 6 mos 23 mos to 80% by December 2011. (Baseline: selected states composite, 40.9% [31.3-51.6%]for 2008-09. Also NIS Indiana data for 2007-08 was 42.4% [34.2-51.0%] for at least 1 dose) Outcome: Data published by CDC does not include this specific age category, so follow-up data is difficult to obtain. Obj. B. Data/reports from NIS, CHIRP and CASA-AFIX on coverage rates regularly disseminated to providers, with ISDH field staff assisting providers in use of methods to improve immunization coverage, e.g., reminder/recall and others 7
Outcome: ISDH provides reports generated from CoCASA post-assessments to health care providers. Several reports are available, including vaccination coverage rates, number of missed opportunities, and suggestions on how to improve coverage rates. The ISDH Immunization Program is studying how to provide data to providers from the National Immunization Survey or CHIRP. As of May 31, 2012, no additional information or data is available. 3. Reduce the Cost to Pediatric Providers of Financing Vaccines Obj. A. Identify family practice and pediatric providers who don t vaccinate in their offices and identify reasons why. Note: Only anecdotal information is available, although the high cost of new vaccines and limited reimbursement by insurers for the cost of administration of vaccines are important factors that affect family physicians and pediatricians as to whether immunizations are provided in the office setting. A1. Educate these providers about opportunities for vaccination for their practice. Outcome: No data is available on efforts to educate health care providers who do not vaccinate in their office practice. Obj. B. Disseminate information to providers on: (1) group purchasing programs, (2) methods to improve vaccine financing and reimbursement available from professional organizations and other sources Outcome: Pediatricians/practices can access information from the American Academy of Pediatrics website (www.aap.org or http://pediatrics.aappublications.org/content/124/supplement_5.toc) on methods to study their vaccination costs and methods to improve reimbursement. 4. Expand Immunization Education Obj. A. On the burden of vaccine preventable diseases Outcome: ISDH Data on Reported Cases of Vaccine-Preventable Disease (selected diseases) 2008 2009 2010 Pertussis 271 392 744 Measles 0 0 0 Invasive Meningococcal Disease 27 34 33 Invasive Haemophilus influenza, 1 2 0 type b, under 5 years of age Invasive Pneumococcal Disease, 77 (8.4% of all cases) 82 (10% of all cases) 51 (6.5% of all cases) under age 5 years Varicella 2009 is the 1 st year of reporting 463 356 8
Interpretation: Many sources of information on vaccine-preventable diseases are available, through the Centers for Disease Control and Prevention (CDC), the Immunization Action Coalition, the National Foundation for Infectious Diseases, the ISDH, the Indiana Immunization Coalition, and professional organizations of health care providers. The Indiana Hospital Association, with assistance by the Indiana Immunization Coalition and ISDH, created an immunization tool kit in 2010 which is available at http://www.ihaconnect.org/issues/publichealth/default.aspx Obj. B. On the importance of up-to-date vaccination and methods to improve immunization coverage rates Outcome: See answer above to Objective 4.A. 5. Expand the use of CHIRP, the State Immunization Registry Obj. A. Use by private and public providers. Outcome: Measurement of the annual growth in CHIRP-enrolled providers (number and percentage) is not available as a query is not written to obtain this information. The ISDH Immunization Program is obtaining data to find the total number of patients with complete immunization data in CHIRP. As of May 31, 2012, no additional information or data is available. Obj. B. By schools and child care centers Outcome: As of May 31, 2012, no additional information or data is available. 9
SUMMARY Much progress has been made with teenagers in improving vaccination coverage rates, largely due to the Indiana school entry requirements beginning in the 2010-2011 school year that all 6 th -12 th graders receive Tdap vaccine and meningococcal conjugate vaccine. Indiana does not fare as well when it comes to entering the top tier of states for immunization coverage levels of 2 year old children. Indiana is consistently in the bottom half of all states on the NIS annual surveys for this category. For most measurements in 2009, Indiana s status for vaccine series or specific vaccine coverage rates in this age group decreased slightly, although some showed improvement in 2010. It should be noted that influenza vaccination coverage rates for children age 6 months to 17 years of age have improved, since the 2010 recommendation that everyone 6 months of age or older should receive an annual influenza vaccination. The effect of the 2009-2010 H1N1 (swine flu) pandemic that caused an increased incidence of severe influenza disease (requiring hospitalization) in children and pregnant women may have helped families to realize the importance of influenza vaccination. For Hoosier seniors, coverage rates for seasonal influenza vaccine and a one-time pneumococcal vaccine remain fairly stagnant. Several measurable objectives in the Immunization Strategic Plan have been accomplished: 1) 4 doses of pneumococcal conjugate vaccine in Indiana 2-year-old children reached the 80% level in 2009. 2) Indiana adolescent Tdap and meningococcal conjugate vaccine coverage levels reached 40% in 2009 and appear to likely obtain 80% coverage rates in 2011. 3) Hoosier children ages 6 months to 17 years accomplished 40% coverage rates for influenza vaccine in the 2009-2010 influenza season and increased about 20% for the next season. Ongoing efforts must be continued by all parties involved to ensure the protection of Hoosiers from vaccine-preventable infections. 10
NEXT STEPS As noted in this progress report, some improvements have been made in coverage rates for several vaccines, but much more remains to be done. Ongoing education on the importance of vaccination to the general public, health care providers, healthcare personnel, and policy makers must continue. Reimbursement of health care providers for the cost of vaccines, time and effort involved in vaccine administration continues to be an issue of concern. Health care providers should not be forced to lose money in their practice because of inadequate reimbursement by insurers. The safety net provided by local health department vaccination programs is experiencing major changes in 2011 and 2012. The need for expanded use of Tdap vaccine in adults has become a major concern, as noted by the tremendous increase in the number of reported cases of pertussis in 2010 in Indiana and across the United States. A one-time Tdap vaccination is now recommended for adults 65 years and older, all adults in contact with young infants/children, as well as pregnant women after the 20 th week of gestation. Hospitals should implement policies that all birth mothers receive a Tdap vaccine before being discharged home and that Tdap vaccine should replace the use of Td vaccine for treatment of wounds in the emergency department. The Indiana Immunization Coalition is honored to be a major participant in improving the health of Hoosiers through immunization. These materials were created by the Indiana Immunization Coalition, Inc. and were funded by the Indiana State Department of Health through a grant from the Centers for Disease Control and Prevention (Award No: 5H23IP522522-10). 11