Strategies for Public Health Programs to Improve Adult

Strategies for Public Health Programs to Improve Adult Immunization

Goals of Presentation • Provide information on • • Adult immunization schedule Burden of vaccine preventable diseases Adult immunization coverage rates Barriers and opportunities in adult immunization • Discuss adult immunization practice standards • Identify strategies by health departments to increase adult immunizations 2

http: //www. cdc. gov/vaccines/schedules/index. html

http: //www. cdc. gov/vaccines/hcp/acip-recs/index. html

Burden of Disease Among U. S. Adults for Diseases with Vaccines Available q Influenza § § disease burden varies year to year Millions of cases and average of 226, 000 hospitalizations annually with >75% among adults 3, 000 -49, 000 deaths annually, >90% among adults 2 q Invasive pneumococcal disease (IPD)1 § 39, 750 total cases and 4, 000 total deaths in 2010 • 86% of IPD cases and nearly all IPD deaths among adults q Pertussis (whooping cough)3 § >28, 000 total reported cases 2013 and 2014 • ~9, 000 among adults q Hepatitis B 4 § 3, 350 acute cases reported 2010 • 35, 000 estimated cases q Zoster (shingles)5 § About 1 million cases of zoster annually U. S. 1. 2. 3. 4. 5. CDC. Active Bacterial Core Surveillance. http: //www. cdc. gov/abcs/reports-findings/survreports/spneu 10. pdf. CDC. Estimates of deaths associated with seasonal influenza – United States, 1976 -2007. MMWR. 2010; 59(33): 1057 -1062. CDC. Notifiable Diseases and Mortality Tables. MMWR 2013. 61(51&52): ND-719 – ND 732. CDC. Viral Hepatitis Surveillance United States, 2010. National Center for HIV/AIDS, Viral Hepatitis, STD& TB Prevention/Division of Viral Hepatitis. CDC. Prevention of Herpes Zoster. MMWR 2008. 57(RR-5): 1 -30. 9

Adult Immunization Coverage Estimates from National Health Interview Survey, 2014 CDC estimates vaccination coverage levels for adult immunizations using data from the National Health Interview Survey (NHIS) q 2014 data analyses published in February 4, 2016 MMWR q NHIS is an annual in-home survey of U. S. non-institutionalized civilian population q Collects detailed health survey of one adult per family in each household sampled q Provides national coverage estimates q Final sample of adult component: q Response rate: 58. 9% • N = 36, 324 • q Sample for estimating influenza coverage, 2013 -14 season: Response rate: 61. 2% (2013); 58. 9% (2014) § N = 32, 296 §

NOTE: Additional tables for this figure available at http: //stacks. cdc. gov/view/cdc/37407. Abbreviations: HPV = human papillomavirus; HR = high risk; Td = tetanus-diphtheria toxoid; Tdap = tetanus, diphtheria, and acellular pertussis vaccine. * Influenza vaccination coverage for 2010 is coverage from the 2009– 10 season, 2011 is coverage from the 2010– 11 season, 2012 is coverage from the 2011– 12 season, 2013 is coverage from the 2012– 13 season, and 2014 is coverage from the 2013– 14 season. Interviews from August through June of each season were used to estimate coverage from July through May using Kaplan Meier survival analysis. Tdap vaccination coverage data among adults aged ≥ 65 years are available beginning in the NHIS 2012 survey. The 2010 HPV vaccination coverage estimate among males is suppressed due to relative standard error >30%. † Adults were considered at high risk for pneumococcal disease if they had ever been told by a doctor or other health professional that they had diabetes, emphysema, chronic obstructive pulmonary disease (beginning in 2012), coronary heart disease, angina, heart attack, or other heart condition; had a diagnosis of cancer during the previous 12 months (excluding nonmelanoma skin cancer); had ever been told by a doctor or other health professional that they had lymphoma, leukemia, or blood cancer; had been told by a doctor or other health professional that they had chronic bronchitis or weak or failing kidneys during the preceding 12 months; had an asthma episode or attack during the preceding 12 months; or they were current smokers.

Adult Vaccination Coverage Selected Vaccines with Increases from 2011 to 2014 2013 2012 2011 Zoster, ≥ 60 yrs 2014 2013 2012 2011 HPV (≥ 1 dose), Women 19 -26 yrs 2014 2013 2012 2011 Tdap, 19 -64 yrs 2014 2013 2012 2011 Tdap, HCP 19 -64 yrs 0 Data Source: NHIS 2011 -2014 10 20 30 40 50

Hepatitis B Vaccination Coverage by Age and High-risk Status, United States, 2014 Hep. B (≥ 3 doses), ≥ 19 yrs 25 Hep. B (≥ 3 doses), Travel Endemic Area 31 (-2. 6) 21 Hep. B (≥ 3 doses), No Endemic Area Travel Hep. B (≥ 3 doses), Chronic Liver Disease 30 Hep. B (≥ 3 doses), HCP ≥ 19 yrs 61 Hep. B (≥ 3 doses), 19 -49 yrs 32 Hep. B (≥ 3 doses), Diabetes 19 -59 yrs 24 Hep. B (≥ 3 doses), Diabetes ≥ 60 yrs 14 0 10 20 30 40 50 60 70 80 90 % Vaccinated HP 2020 Target: 90% Hep. B Healthcare Personnel (HCP) Data Source: 2014 NHIS

Hepatitis B Vaccination (≥ 3 doses) for Adults Living with Diabetes, 2010– 2013 100 90 Coverage rate (%) 80 70 60 50 40 30 20 10 0 19 -59 yrs 2010 2011 2012 2013 Age Source: National Health Interview Surveys 2014 ≥ 60 yrs

Adult Immunization Rates Still Low HPV (≥ 1 dose), Women 19 -26 yrs 2014 2013 HPV (≥ 1 dose), Men 19 -26 yrs 2012 2011 Tdap, HCP 19 -64 yrs Hep B ≥ 3 doses, HCP ≥ 19 yrs 0 10 20 30 40 50 60 Coverage rate (%) Source: National Health Interview Surveys 70 80 90 100 : Healthy People 2020 target

Adult Tetanus-containing Vaccination Coverage by Age and High-risk Status, United States Td past 10 yrs, 19 -49 yrs 63 Td past 10 yrs, 50 -64 yrs 65 Td past 10 yrs, ≥ 65 yrs 58 Tdap past 9 yrs, ≥ 19 yrs 20 (+2. 9) Tdap past 9 yrs, Living with infant <1 yr, ≥ 19 yrs 32 Tdap past 9 yrs, HCP ≥ 19 yrs 42 0 Data Source: 2013 NHIS 10 20 30 40 50 60 70 80 90 % Vaccinated

Influenza Vaccination Coverage Among Adults 2011 -12, 2012 -13, and 2013 -14 Seasons, United States 2011 -12 (%) 2012 -13 (%) Persons > 18 yrs 38. 8 41. 5 42. 4 3. 6 Persons 18 -49 yrs, all 28. 6 31. 1 32. 3 3. 7 Persons 18 -49 yrs, high risk 36. 8 39. 8 38. 7 1. 9 Persons 50 -64 yrs 42. 7 45. 1 45. 3 2. 6 Persons ≥ 65 yrs 64. 9 66. 2 65. 0 0. 1 Group 2013 -14 Difference (%)* (%) * Estimates of the percentage of people vaccinated are based on interviews conducted beginning September (BRFSS) or October (NIS) 2013 through June 2014 and reported vaccinations from July 2013 through May 2014. For California, BRFSS interview data were only available for September-December 2013 and thus estimates for persons ≥ 18 years only reflect vaccinations during July-November 2013. For Mississippi, sample size was insufficient from interviews conducted April-June 2014 to estimate vaccinations past the end of February, 2014 for persons ≥ 18 years. http: //www. cdc. gov/fluvaxview/index. htm

Influenza Vaccination Coverage Among U. S. Adults 2011 -12 through 2014 -15 Seasons Group 2011 -12 (%) 2012 -13 (%) 2013 -14 (%) 2014 -15 (%) Persons > 18 yrs 38. 8 41. 5 42. 4 43. 6 Persons 18 -49 yrs, all 28. 6 31. 1 32. 3 35. 5 Persons 18 -49 yrs, high risk 36. 8 39. 8 38. 7 39. 3 Persons 50 -64 yrs 42. 7 45. 1 45. 3 47. 0 Persons ≥ 65 yrs 64. 9 66. 2 65. 0 66. 7 Health People Target 70% for all adults Estimates of the percentage of people vaccinated are based on interviews conducted beginning September (BRFSS) or October (NIS) 2013 through June 2014 and reported vaccinations from July 2013 through May 2014. For California, BRFSS interview data were only available for September-December 2013 and thus estimates for persons ≥ 18 years only reflect vaccinations during July-November 2013. For Mississippi, sample size was insufficient from interviews conducted April-June 2014 to estimate vaccinations past the end of February, 2014 for persons ≥ 18 years. http: //www. cdc. gov/fluvaxview/index. htm

Disparities in Adult Immunization • Lower immunization coverage rates among 1 • African Americans and Hispanics • Uninsured • Lower income • Reduce disparities by • Providers assessing for and recommending vaccination • Key is incorporating vaccination needs assessment into routine patient clinic flow • Promote immunization for people newly insured through Affordable Care Act 1. Lu, P-J, et al. Am J Prev Med 2015 20

Reasons for Low Adult Immunization Rates • Adults not aware of vaccines they need • Healthcare providers for adults busy and often have • Competing priorities • Incomplete vaccination history • Not all providers stock all vaccines for adults • Adults frequently see multiple providers, so vaccine history recordkeeping difficult • Reimbursement for vaccines confusing, unclear 21

Opportunities for Adult Immunization • Adults not aware of vaccines they need… but most patients will accept vaccines if recommended by trusted healthcare provider • Healthcare providers for adults are busy and have competing priorities… but healthcare providers think immunizations are important for their patients • Not all providers stock all vaccines for adults… but access to vaccines is increasing • Adults frequently see multiple providers and recordkeeping is difficult… but state vaccine registries include adult immunizations 22

Seize Opportunities to Improve Adult Immunization • Affordable Care Act (ACA) • More adults insured • Requires insurance for adults and children to include vaccination • Improved access to vaccines through public and private insurance • Since nearly all children covered through Vaccines for Children or private insurance, more of available Section 317 vaccine purchase funds can be used to vaccinate uninsured adults 23

Use of Section 317 Funds by Health Departments • Utilization of Section 317 vaccine purchase funds for adult immunization in 2015 among 55 immunization programs • 23 state or city immunization programs allocated 100% of Section 317 vaccine purchase funds for adults • 32 immunization programs allocated an average of 74% of Section 317 vaccine purchase funds for adults (4 programs used only state funds for adults) • [Optional: Add state’s use of 317 funds for adult immunization activities] Source: Program Operations Branch, Immunization Services Division, NCIRD, CDC 24

Adult Immunization Priorities • Strategies for Health Departments to Increase Adult Immunizations 1 by National Adult Immunization Coordinators’ Partnership (NAICP), 2014 • Based on Standards for Adult Immunization Practice 2, National Vaccine Advisory Committee, 2014 1. Available at: www. izsummitpartners. org/wp-content/uploads/2014/09/adult-tips. pdf 2. Public Health Reports, March–April 2014. Available at: www. publichealthreports. org/issueopen. cfm? article. ID=3145 25

Vaccination Coverage by Provider Recommendation and/or Offer Influenza vaccination before and during pregnancy overall and by provider recommendation and offer* for influenza vaccination among women pregnant anytime between October 2012 -January 2013, Internet Panel Survey, 2012 -13 Influenza Season Coverage estimates (%) 100 90 80 70. 5 70 60 50. 5 46. 3 50 40 30 16. 1 20 10 0 n = 1, 702 Overall n = 895 n = 270 n = 455 Reported a provider recommendation Reportedand a provider offer recommendation. Reported but no offer no provider recommendation *Women who didn't visit a provider since August 2012 (n=27) or women who didn't know whether they received provider recommendation or offer (n=55) were excluded from this analysis.

What are Standards for Adult Immunization Practice? • All providers, including those who don’t provide vaccine services, have role in ensuring patients up-to-date on vaccines • Call to action for ALL healthcare professionals to: • • Assess immunization status of all patients at every clinical encounter Strongly recommend vaccines that patients need Administer needed vaccines or refer to a provider who can immunize Document vaccines received by patients in state vaccine registries www. cdc. gov/vaccines/hcp/patient-ed/adults/for-practice/standards/index. html www. cdc. gov/vaccines/hcp/patient-ed/adults/for-patients/index. html □ Assess nd e m m o c e □R efer R r o r e t s □ Admini nt □ Docume 27

Organizations Supporting Standards for Adult Immunization Practice • • • • Association of Immunization Managers (AIM) National Association of County & City Health Officials (NACCHO) Association of State & Territorial Health Officials (ASTHO) Centers for Disease Control and Prevention (CDC) American Academy of Pediatrics (AAP) American Academy of Physician Assistants (AAPA) American Academy of Family Physicians (AAFP) American College of Obstetricians and Gynecologists (ACOG) American College of Physicians (ACP) American Pharmacists Association (APh. A) Immunization Action Coalition (IAC) Infectious Diseases Society of America (IDSA) National Foundation for Infectious Diseases (NFID) Others To add your organization to those supporting the standards, go to… http: //www. izsummitpartners. org/support-adult-standards/ 28

Strategies for Health Departments to Improve Adult Immunizations • Determine community needs and vaccination capacity • Identify and address barriers to adult vaccination • Provide outreach and education to providers and the public • Develop and maintain partnerships with key stakeholders www. izsummitpartners. org/wp-content/uploads/2014/09/adult-tips. pdf 29

Determine Community Needs and Vaccination Capacity • Designate adult immunization coordinator who spends >50% of time on adult immunization activities • Work with other health department services or clinics, stakeholders to assess community vaccination needs • Develop and maintain adult immunization coalition • Include adult immunization activities in immunization program’s priorities and planning • Devise and apply targeted strategies to address disparities in immunization coverage and access to vaccines www. izsummitpartners. org/wp-content/uploads/2014/09/adult-tips. pdf 30

Identify and Address Barriers to Adult Immunization • Use available 317 funds to purchase vaccines for uninsured adults • Assist health department in becoming in-network provider • Develop reminder/recall functionality in state vaccine registry • Assist providers in utilizing patient assistance programs offered by vaccine manufacturers for uninsured adults www. izsummitpartners. org/wp-content/uploads/2014/09/adult-tips. pdf 31

Provide Outreach and Education to Providers and Public • Promote Standards for Adult Immunization Practice, adult immunization schedule, and other updates to partners, e. g. , state chapters of medical, nursing, and pharmacy professional organizations • Urge use of state vaccine registry among adult vaccine providers • Provide annual state-level adult immunization coverage rates to vaccine providers • Distribute patient education and provider materials www. izsummitpartners. org/wp-content/uploads/2014/09/adult-tips. pdf www. cdc. gov/vaccines/adultstandards www. cdc. gov/vaccines/adultpatiented 32

Develop and Maintain Partnerships with Key Stakeholders • Partner with pharmacies and community vaccinators to increase access to vaccines • Establish relationships with employers to promote vaccines to employees • Collaborate with community and faith-based leaders to promote immunizations for adults • Collaborate with clinical public health programs, e. g. , STD, substance abuse, chronic disease, to incorporate vaccine assessment and administration into their routine practices www. izsummitpartners. org/wp-content/uploads/2014/09/adult-tips. pdf 33

Using Adult Vaccination Records to Improve Programs • Include adult vaccination records in state vaccine registries (immunization information systems, or IIS) • Use IIS to develop programmatic initiatives to improve adult immunization coverage and reduce disparities • Ensure IIS meets new standards of interoperability with electronic health records (EHR) to track adult immunization records • Examples of activities at local health department • Expand access to and provide training for IIS to adult healthcare providers • Share information with providers on how to enroll and use IIS, produce recruitment materials • Disseminate vaccine coverage data in IIS to providers and public; identify and address gaps in coverage • Collaborate with state IIS managers to improve interoperability 34

Summary • Background and issues in adult immunization • • Adult immunization schedule Burden of vaccine preventable diseases Adult immunization coverage rates Barriers and opportunities in adult immunization • Promote adult immunization practice standards • Assess, recommend, administer or refer, document (in IIS) • Strategies for health departments to increase adult immunizations • • Determine community needs and capacity Identify and reduce barriers Provide outreach and education to providers and public Continue to develop partnerships, promote use of IIS 35

Resources • [Insert state immunization program] • [Insert state immunization program URL] • National Association of County & City Health Officials • www. naccho. org/topics/HPDP/immunization/ • Association of State and Territorial Health Officials • www. astho. org/Programs/Immunization/ • Association of Immunization Managers • www. immunizationmanagers. org/ • American Immunization Registry Association • www. immregistries. org/ • Centers for Disease Control and Prevention (CDC) • www. cdc. gov/vaccines/hcp/adults • www. cdc. gov/vaccines/adults/index. html • Immunization Action Coalition (IAC) • www. immunize. org/ • National Foundation for Infectious Diseases (NFID) • www. adultvaccination. org/ • American College of Physicians • http: //immunization. acponline. org/ 36

Thank You • [Insert] state health department adult immunization coordinator, IIS manager 37

EXTRA SLIDES 38

Call to Action for Public Health • Determine community needs, vaccination capacity, and barriers to adult immunization • Provide access to all ACIP-recommended vaccinations for insured and uninsured adults and work towards becoming in-network provider for immunization services for insured adults • Partner with immunization stakeholders and support activities and policies to improve awareness of adult vaccine recommendations, increase vaccination rates, and reduce barriers • Ensure professional competencies in immunizations Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice Public Health Reports, March–April 2014. Available at: www. publichealthreports. org/issueopen. cfm? article. ID=3145 39

Call to Action for Public Health (2) Routinely collect, analyze, and disseminate immunization coverage data Provide outreach and education to providers and public Work to decrease disparities in immunization coverage and access Increase immunization registry access and use by adult vaccine providers Develop capacity to bill for immunization of insured people Ensure preparedness for identifying and responding to outbreaks of vaccine -preventable diseases • Promote adherence to applicable laws, regulations, and standards among adult immunization stakeholders • • • Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice Public Health Reports, March–April 2014. Available at: www. publichealthreports. org/issueopen. cfm? article. ID=3145 40

What are your community needs, capacity, barriers? • Work towards decreasing disparities in immunization access based on race/ethnicity, insurance status, poverty, location (e. g. , rural, medically underserved), other factors • Examples of activities at local health department – Conduct needs assessment and use data in program planning – Understand populations within community, e. g. , diversity and insurance status 41

Promote system-based changes • Develop policies and regulations that promote vaccination and reduce immunization barriers for adult patients and their providers. • Examples of activities at local health department – Work with providers in your area to do IIS onboarding, educate and improve awareness – Collaborate with existing public health clinical services (e. g. , STI, HIV, TB programs, substance abuse treatment service, chronic disease programs) to include to do assessment – Educate state legislatures and board of health regarding potential barriers – Incorporate vaccine assessments into routine care 42

Effective Public Outreach • Increase public awareness and knowledge of adult immunizations through appropriate venues to – Community organizations, business and civic groups – Advocacy groups, e. g. , mental health services, diabetes education, correctional facilities • Examples of activities at local health department – Provide culturally-competent communications and outreach, including social media and ethnic media – Work with organizations associated with targeted population groups, e. g. , Hispanic and Asian-Pacific organizations – Collaborate with healthcare coalitions to reach high-risk adults 43

Outreach to Healthcare Providers • Provide outreach and training to healthcare providers – Professional organizations, e. g. , medical, pharmacy, nursing – Healthcare networks and systems • Increase healthcare providers’ awareness and knowledge of adult immunizations and training opportunities • Examples of activities at local health department – Share local adult immunization coverage information – Distribute communications and outreach materials – Assist providers with IIS on boarding and use of IIS 44

General Communication • Disseminate information on vaccines and vaccine preventable disease outbreaks through press releases, social media, news articles, other channels • Examples of activities at local health department – Communicate information on vaccine shortages, recalls, safety concerns – Ensure professional competency by providing and supporting education to providers about immunizations – Distribute information to provider groups on ACIP recommendations – Local access TV programs-newsletters – Identify local champions/celebrities 45

Education and Training • Assist providers implement systems changes to routinely assess adult vaccination, develop protocols for standing orders, other changes to incorporate routine vaccine needs assessment into patient flow • Examples of activities at local health department – Integrate services to deliver adult pneumococcal vaccinations in HIV Clinics or chronic disease programs – Provide examples of best practices to providers and collaborate with them to implement changes – Share successful practices with other health departments and providers; submit for recognition at immunization coalition, NACCHO Model Practices, National Adult and Influenza Immunization Summit 46

Adult Immunization and Public Health Preparedness • Ensure preparedness for outbreaks of vaccine-preventable diseases—create, maintain, practice emergency plans for vaccine distribution and recordkeeping • Participate in surveillance of state reportable disease system • Maintain preparedness to investigate and control outbreaks • Examples of activities at local health department – Participate in and help develop pandemic preparedness plans and exercises, ensure inclusion of adult vaccination, vaccine storage and handling practices, accountability – Improve access to vaccines for adults 47

What More Can We Do? • Provide ACIP-recommended vaccines to insured and uninsured adults • Become in-network provider for immunization services for insured adults • Actively engage providers to disseminate vaccine recommendations, storage and handling, administration • Examples of activities at local health department – Stock and dispense ACIP-recommended vaccines – Develop billing capacity to become in-network provider – Provide education, training, technical assistance to providers: healthcare systems, education institutions, professional organizations, individuals 48