Amy Groom, MPH IHS Immunization Program Manager/CDC Field Assignee Monitoring Influenza Vaccine Coverage in American Indian/Alaska Native Patients served by Indian Health Service-funded Facilities Amy Groom, MPH IHS Immunization Program Manager/CDC Field Assignee

Background American Indian/Alaska Native (AI/AN) people are at higher risk for influenza-related complications compared to U.S. Whites: Pneumonia and influenza-related mortality 1.5 to 4 times higher 1 Mortality from 2009 H1N1 influenza 4 times higher 2 2010-2011 ACIP Influenza Vaccine recommendations AI/AN people as a high risk group Influenza vaccine coverage performance indicator for IHS Coverage for 65+ year olds since 2000 Pediatric influenza coverage since 2008 IHS. Trends in Indian Health 2002-2003. Available at: http://www.ihs.gov CDC. MMWR 2009:58:1341-4.

Indian Health Service (IHS) Part of the Dept. of Health and Human Services since 1955 Federal health care provider for eligible AI/AN Member of federally recognized tribes (564) Not an entitlement program Healthcare to 1.5 million AI/AN ~60% of AI/AN Census population Highly de-centralized system IHS Funded “I/T/U” system (35 States) Indian Health Service facilities Tribal health facilities Urban Indian health facilities

Administrative Regions Indian Health Service Administrative Regions Albuquerque Portland Billings California Phoenix Oklahoma Nashville Navajo Tucson Alaska Aberdeen Bemidji User Population: 1.5 Million

IHS Electronic Health Record Resource Patient Management System (RPMS) Utilized by all IHS and most tribal and urban Indian health facilities Includes immunization component Clinical decision support (forecasting) Universal influenza forecasting incorporated for 2010 – 2011 influenza season Coverage reports 3-27 month old, 2 year old, Adolescent, Influenza (all ages) report Based on vaccines administered Reminder/recall lists and letters

Methods Patient coverage Influenza vaccine coverage report collected from facilities for vaccine administered between August 1 - Dec. 31st 2010 Includes all patients with at least 2 visits in the last 3 years Coverage in the following age/risk groups: 6 -23 months (1 and 2 doses) 2 – 4 years (1 and 2 doses) 5 – 17 years 18-49 years no high risk medical condition 18-49 years with high risk medical condition 50-64 years 65+ years

Methods , Cont. Healthcare Personnel (HCP) Coverage High risk – patients - at least 2 visits with an ICD-9 diagnosis code for high risk medical condition* (e.g. diabetes, heart disease)* Facility data aggregated at IHS Region and National levels Healthcare Personnel (HCP) Coverage Defined as all personnel working in an I/T/U facility Data collected on HCP influenza vaccination, refusals, and contraindications documented between August 1st – December 31st 2010 from each facility Data aggregated at IHS Region and National levels * As defined by ACIP

Results - Coverage among patients Data collected from 11 of the 12 IHS Regions 175 I/T/U facilities 829,704 patients (55% of IHS User population) Overall influenza vaccine coverage (all ages): 32% Range between IHS Regions, 22% - 48%

Influenza Vaccine Coverage All Ages, by IHS Region

Influenza Vaccine Coverage By Age Group All IHS Regions Combined

Influenza Vaccine Coverage 2010-2011 Season * U.S. Estimates based on CDC’s Nov. 2010 BRFSS and NIS data

Results – Coverage among HCP Data were collected from all 12 IHS Regions 181 I/T/U facilities 28,104 HCP (~ 74% of total HCP) Overall HCP coverage for all facility types: 71.3% Regional Range: 58.3% - 82.3% Coverage varied by facility type IHS facilities: 74.7% Tribal facilities: 69.2% Urban Indian facilities: 50.7%

HCP Seasonal Influenza Vaccine coverage 2008 - 2011 IHS H1N1 vaccine coverage – 61.7% U.S. H1N1 Vaccine Coverage – 37.1%

Limitations First year for IHS monitoring influenza vaccine coverage in all age groups No comparison data, except for 65+ years age group U.S. estimates not directly comparable U.S. estimates based on self report; IHS estimates based on medical record Different time periods (Nov vs. Dec)

Conclusions Overall influenza vaccine coverage among AI/AN patients served by I/T/U facilities was similar to U.S. estimates for most age groups Exception: 65+ yrs Considerable regional variation in flu coverage estimates Geographic/population differences Relatively high HCP coverage among I/T/U facilities Decrease in coverage from previous year Refusal rate remained constant

Next Steps Explore reasons for lower coverage among those 65+ years Share best practices from high performing regions (e.g. Navajo) Access to vaccine Clinics, communities, schools Walk ins, weekends and evenings Promotion of vaccine Weekly review of coverage data Reminder/recall activities Update to IHS employee immunization policy Mandatory flu vaccine?