Adult Immunization: What could an ideal state program look like? Vaccination Across the Lifespan Adult Immunization: What could an ideal state program look like? March 20,2008 Susan M. Lett, M.D., M.P.H. Medical Director, Immunization Program Division of Epidemiology and Immunization Massachusetts Department of Public Health

Disclaimers The ideas presented in the presentation can be attributed only to the presenter They do not represent the official position of the Massachusetts Department of Public Health (MDPH) MDPH 3-08 MDPH February 2008

Massachusetts Adult Immunization Program Current Status

MDPH Immunization Program – September 2007 Estimated Vaccination Coverage with the 4:3:1:3:3:1* Series Among Children 19 – 35 Months of Age, 2006 National Immunization Survey MA has highest rates in nation for 3rd year in a row!!! 60 MA = 84% D.C. NATIONAL COVERAGE = 77% *4+DTP, 3+Polio, 1+MCV, 3+Hib, 3+HepB, 1 Varicella 55-59% 60-69% 70-74% 75-79% 80-85% MDPH 3-08 MDPH Immunization Program – September 2007

Influenza Vaccination Rates for MA Adults 2003, 18 –64, diabetes and asthma MA 2006 BRFSS MDPH 3-08 MDPH February 2008

Projected MA State-Supplied Vaccine for Adults – FY 08 and Staffing Universal Distribution Td 370,000 doses PPV23 95,000 Select Distribution Flu 337,000 Hep B 50,000 Hep A 18,000 MMR 20,000 Varicella 3,000 No Tdap Staffing: 1 part-time adult coordinator, 35 other staff spend approximately 10% of their time on adult immunization activities. TOTAL = 4.1 FTEs MDPH 3-08 MDPH February 2008

MA Childhood & Adult Vaccine Budgets Fed (VFC/317) $ 0 $ 69 M State $7 M $ 40 M Total $109 M MDPH 3-08

Adult Immunization Coalition Annual Adult Immunization Conference 53 member organizations Annual Adult Immunization Conference Flu clinic website 1,500 clinics; 55,000 visitors Special projects Hospital, LTC standing orders Hospital employee vaccination MDPH 3-08 MDPH February 2008

Assumptions

Assumptions (1) There is a federal Vaccines for Adults (VFA) Program for all those > 19 years of age: Covers all ACIP recommended vaccines given in all locations Regardless of insurance or residency status Timeline for funding after recommendation extremely short! MDPH 3-08 MDPH February 2008

There are no ERISA plans Assumptions (2) As a safety net, every state has 1st dollar coverage for vaccine and administration costs, regardless of place of vaccination: While awaiting federal funding For vaccines, beyond the recommendations Reimbursement should be clear and transparent There are no ERISA plans MDPH 3-08 MDPH February 2008

Assumptions (3) There is sufficient federal funding dedicated for immunization registries, including: Functionality for data exchange and interaction with electronic medical records systems personal health information records Platform for communication within and between states MDPH 3-08 MDPH February 2008

Massachusetts Adult Immunization Program Future Possibilities

Vaccination Across the Lifespan MDPH 3-08

State Adult Immunization Program (1) Build on successful strategies used in childhood immunizations and hospital standing orders Identifying partners is key Begin with demonstration projects Medical setting Nonmedical setting Identify providers and agencies who have overcome existing barriers and successfully vaccinated adults Recruit them to become champions Education and assessment are essential MDPH 3-08

State Adult Immunization Program (2) Immunization program would double in funding and size MA could have at least 13 FTEs working on adult activities Adult Immunization Coalition expansion to enhance public private partnerships Platform for all major adult initiatives Dedicated funding to staff the coalition office Subcommittee for outreach to nonEnglish-speaking, minority communities and newcomer communities In MA, 1 million (20%) do not speak English at home Subcommittee for private sector Subcommittee for public sector MDPH 3-08

Adult Immunization Coalition Objectives 1. Promote vaccination in traditional and non-traditional settings among all sectors, with traditional and non-traditional vaccinators 2. All primary care and specialty provider associations will adopt “assessment of vaccination status and offering vaccine at every visit as a standard of care” 3. Enrolling all uninsured adults in a health plan (Health Connector) 4. Immunization registry ‘roll-out’ MDPH 3-08

Expanding Adult Access to Immunizations (1) Massive enrollment of all adults in health plans to increase number with medical home MA embarked on health care reform initiative Health Connector Commonwealth Care Commonwealth Choice http://www.mahealthconnector.org/portal/site/connector/ Standing orders projects Hospitals, LTC, other settings Pharmacists pilot project Flu, PPV23, zoster Community vaccinators Partnerships STD, HIV C &T, correctional facilities Hep A & B Outreach Minority , non-English-speaking communities MDPH 3-08 MDPH February 2008

Expanding Adult Access to Immunizations (2) Massive enrollment of all providers in ‘VFA’ program (both primary care and specialties) Target OB/GYN Encourage primary care providers and specialty practices to vaccinate not refer Standing orders projects Hospitals, LTC, other settings Pharmacists pilot project Flu, PPV23, zoster Community vaccinators Partnerships STD, HIV C &T, correctional facilities Hep A & B Outreach Minority , non-English-speaking communities MDPH 3-08 MDPH February 2008

Expanding Adult Access to Immunizations (3) Standing orders projects Vaccination of women ante- and postpartum Include other family members Pharmacists projects Community vaccinators Partner with schools, worksites STD, HIV C & T, correctional facilities Outreach Standing orders projects Hospitals, LTC, other settings Pharmacists pilot project Flu, PPV23, zoster Community vaccinators Partnerships STD, HIV C &T, correctional facilities Hep A & B Outreach Minority , non-English-speaking communities MDPH 3-08 MDPH February 2008

Education Providers General Public Nursing, medical and pharmacy schools -- coordinated curriculum Mass Medical Society Faculty Grand rounds Academic detailing Webinars On-line courses Other innovative technologies General Public Multimedia approach that is audience appropriate Focus on Non-English Speaking and newcomer communities http://www2a.cdc.gov/vaccines/ed/whatworks/index.html MDPH 3-08

Assessment Expanded state-specific data from BRFSS, NIS, NHIS, CMS, MD Includes all recommended antigens ‘Immunization Site’ assessments (Adult AFIX) Providers, employers, commercial and community vaccinator, churches, etc Redefine missed opportunities Multi-generational, multi-site approach New approaches needed to effective feedback for this diverse group MDPH 3-08

Requirements for Adult Immunization Positive approaches better than negative ones But, having funding facilitates requirements, if needed Unified national recommendations and endorsement essential (ACIP,AAP, AAFP, ACOG, etc.) National standards/ regulations much more efficient than state-by-state (JCAHO, CMS, OSHA, etc.) Focus state-by-state requirements on ‘most important’ groups Healthcare workers Childcare workers/teachers Public safety and essential infrastructure MDPH 3-08

“It Takes a Village to Vaccinate Adults” Expand access to health care Empower and encourage vaccination in medical homes Support vaccination outside of medical home Use traditional and non-traditional vaccinators Use immunization registries MDPH 3-08

Contact Information Massachusetts Immunization Program 1-617-983-6800 1-888-658-2850 Website http://www.mass.gov/dph Susan M. Lett MD, MPH Medical Director, Immunization Program Division of Epidemiology and Immunization Massachusetts Department of Public Health 305 South Street Jamaica Plain MA 02467 617-983-6823 susan.lett@state.ma.us MDPH 3-08

EXTRAS MDPH 3-08

Disclosures The speaker has no financial interest or conflict with the manufacturer of any product named in this presentation The speaker will not discuss the use of vaccines in a manner not approved by the U.S. Food and Drug Administration The speaker will no specifically discuss vaccines not currently licensed by the FDA MDPH 3-08 MDPH February 2008

Flu & PPV23 Vaccination Rates in MA Long-Term Care Facilities MA DMA * 2006 – CMS MDS MDPH 3-08

Massachusetts Immunization Program Universal Vaccines Distributed for Children and Adults – Future Possibilities DTaP, DT, Td, Tdap IPV MMR Hib Meningococcal Conjugate vaccine (MCV4) Pneumococcal Conjugate 7-Valent (PCV7) Hepatitis B Varicella Influenza (TIV and LAIV) Pneumococcal Polysaccaride 23-Valent Hepatitis A Human Papillomavirus Rotavirus MMRV (Measles, Mumps, Rubella and Varicella) Zoster Vaccine MDPH 3-08

Pneumococcal Vaccination Rates for MA Adults MA BRFSS MDPH 3-08 MDPH February 2008