The Indiana Immunization Coalition exists to promote childhood immunization and raise community awareness about immunization issues.

The Indiana Immunization Coalition is a volunteer organization which represents over 165 agencies from many different disciplines that are concerned about the immunization of children.

Why Coalitions? T he health coalition movement is an emerging trend in the healthcare community. As society moves toward a greater focus on health and wellbeing for all citizens, the immunization coalition model will be replicated across many issues and ultimately will be the catalyst for changing the way communities look at health. Immunization Coalition Sustainability Project

Building Community Partners “It is no longer just about the public health system. It includes private health care systems, private industry, and the nonprofit community. Coalitions bridge those systems and build a healthier community.” Immunization Coalition Sustainability Project

GOALS Promote and support statewide immunization registry development and use. Develop marketing/awareness strategies for immunization issues. Provide statewide leadership to create opportunity for participation, education and collaboration on immunization issues.

IIC Beginnings Support the statewide immunization registry. Share immunization information with organizations who are concerned with the welfare of children. Developed “Best Practices” brochure for providers. Actively supported, monitored and influenced policy regarding immunization bills in the state and federal legislature. Filmed and distributed an immunization awareness Public Service Announcement featuring former First Lady Judy O’Bannon.

CHIRP Every Child By Two Registry Mentoring Grant

Shots For Tots

The Indiana Immunization Coalition Appreciation Awards recognize efforts in advocacy, registry, education and collaboration

Child health data shows a significant reduction in well baby checks and immunization visits after a child turns one year of age.

Immunize Hoosier Children 22% of Hoosier children don’t receive recommended immunizations by age 2 Indiana ranks 39th nationally in immunization for 2-year-olds Allocate $11M to expand the child vaccination program Saves $25 in additional health expense for every additional $1 spent on childhood immunizations Indiana’s Immunization Challenge Proposed Solution The Governor’s Plan for a Healthier Indiana Source: ISDH

Why Adolescent Immunization? Many adolescents are under- immunized, putting their health and their futures at risk. Many states have implemented “catch- up” requirements for Hep B, MMR#2, Dtap. New vaccines are being developed many specifically for adolescents.

Adolescent Immunization “The good news is we can now prevent so many diseases. The bad news is it’s gotten more complicated.” Dr. Anne Schuchat, U.S. Centers for Disease Control and Prevention, Immunization Programs.

Diseases Prevented by Vaccination of Children and Adolescents January 1987January 2007 Diphtheria TetanusDTP Pertussis DiphtheriaHepatitis B TetanusDTaPVaricella PertussisHPV Polio - OPV Polio – IPVPneumococcal Disease Measles MumpsMMR Rubella MeaslesInfluenza MumpsMMRRotavirus RubellaHepatitis A Hib - polysaccharideHib – conjugateMeningococcal Disease

Vaccine Recommendations by Age Group, 2003 and Diseases Maximum Vaccine Doses 2007 Disease s Maximum Vaccine Doses Children <2 years of age Children 4-6 years 7396 † Children years 2155 †† † Assumes 2 doses of influenza vaccine for 4 year olds †† Includes HPV, 3 doses for females only. For males, 4 diseases and 2 doses

Adolescent Immunization Barriers Few well child visits-approximately 60% receive primary care from a pediatrician or family physician. Others have different provider or no provider at all. No measurement or accountability system at state or local level May need to consider other points of access such as schools Vaccination Success and Stresses, Walter Orenstein, MD

VT Estimated Vaccination Coverage with the 4:3:1:3:3* Series, by Coverage Level and State National Coverage = 81% *4+DTP, 3+Polio, 1+measles-containing vaccine, 3+Hib, 3+HepB NJ CT MA NH RI DC DE MD % 70-79%  69%  90%

How is Your County Doing? Healthy People 2010 Goal Immunization rate of 90%

VACCINATE BEFORE YOU GRADUATE INDIANA 2004 ENVIRONMENT The state of Indiana passed new legislation requiring 9 th and 12 th graders receive the Hepatitis B vaccine. A new recommendation for meningococcal immunization was forecasted for the coming year as well as a new vaccine. Pertussis was being added to tetanus and strongly recommended for adolescents. HPV wasn’t on the radar.

VACCINATE BEFORE YOU GRADUATE INDIANA HEPATITIS B VACCINE LAW Law passed in 2004, effective 6/05-6/08 Affects 9 th and 12 th graders No school record audit or reporting to ISDH required No suspension of students if don’t meet the requirement An opportunity to promote Hepatitis B, other vaccines for adolescents.

VACCINATE BEFORE YOU GRADUATE INDIANA Adolescent Subcommittee The committee’s first meeting was in the spring of The committee is comprised of representatives from Indiana Immunization Coalition, Indiana State Department of Health, Indiana Department of Education, Kiwanis, School Nurse Association, Sanofi Pasteur, GlaxoSmithKline, Managed Health Centers and the Meningitis Foundation.

VACCINATE BEFORE YOU GRADUATE INDIANA Promoting Immunization through community networks is a proven means to build trust and acceptance of vaccines. Why Invest in Communication for Immunization? Silvia Waisbaord and Heidi J. Larson

VACCINATE BEFORE YOU GRADUATE INDIANA MAP IT Mobilize individuals and organizations Assess the areas of great need Plan your approach, start with a vision Implement you plan with action steps Track your progress Healthy People 2010

VACCINATE BEFORE YOU GRADUATE INDIANA PROGRAMS  Rhode Island developed a marketing campaign as well as school based clinics.  Virginia developed a marketing campaign, tool kit and held a national satellite conference.  Arizona used at risk students to develop an award winning marketing campaign.

VACCINATE BEFORE YOU GRADUATE INDIANA PLAN The vision of the Vaccinate Before You Graduate program is to develop a statewide initiative that increases adolescent immunization coverage through education, collaboration and vaccination.

VACCINATE BEFORE YOU GRADUATE INDIANA IMPLEMENTATION The committee created and implemented a model program to share with others throughout the state. The program originally focused on Meningococcal, Tetanus, Hepatitis B, Varicella and Measles Mumps and Rubella.

VACCINATE BEFORE YOU GRADUATE INDIANA PILOT PROGRAMS Hammond Vanderburgh County Vigo County

VACCINATE BEFORE YOU GRADUATE INDIANA TRACKING PROGRESS OVER TIME

VACCINATE BEFORE YOU GRADUATE INDIANA 2006 HEALTH DEPARTMENT SURVEY 66% of Health Departments participated 50% had started a Hepatitis B program for adolescents 10% had started a VBYG program 62% were collaborating with schools 84% focused the program on high schoolers

VACCINATE BEFORE YOU GRADUATE INDIANA 2007 HEALTH DEPARTMENT SURVEY 35% of Health Departments participated 63% had started a Hepatitis B program for adolescents 16% had started a VBYG program 78% were collaborating with schools 88% focused the program on high schoolers

VACCINATE BEFORE YOU GRADUATE INDIANA 2006 HEALTH DEPARTMENT SURVEY School nurses did the paperwork 61% used postcards for notification 38% conducted special clinics hours 20% conducted school clinics 10% were using VBYG materials

VACCINATE BEFORE YOU GRADUATE INDIANA 2007 HEALTH DEPARTMENT SURVEY School nurses did the paperwork 84% used postcards for notification 22% conducted special clinics hours 19% conducted school clinics 16% were using VBYG materials

VACCINATE BEFORE YOU GRADUATE INDIANA 2006 HEALTH DEPARTMENT SURVEY Difficult to complete due to vaccine shortages Difficult to offer all vaccines at school based clinics Difficulty with staffing issues to do more Great collaboration with school nurses

VACCINATE BEFORE YOU GRADUATE INDIANA 2007 HEALTH DEPARTMENT SURVEY Increase in offering other vaccines from 2% to 34% Reported reduction in school based clinics due to poor turn out. Collaboration with schools consists of schools sending out Hepatitis B letter and health departments immunizing children. Staffing issues make it difficult to do more.

VACCINATE BEFORE YOU GRADUATE INDIANA 2007 SCHOOL NURSE SURVEY Sent out required Hepatitis B letter. Eager for immunization information. Reported little contact with local health departments. Liked school based clinics.

VACCINATE BEFORE YOU GRADUATE INDIANA UNEXPECTED OUTCOMES Vaccine availability-Healthy Indiana Plan School nurse module for CHIRP

VACCINATE BEFORE YOU GRADUATE INDIANA “The campaign’s success relies in part on vaccine supply.” Dr. Anne Schuchat, U.S. Centers for Disease Control and Prevention, Immunization Programs.

VFC and Section 317 Vaccine Funding to Immunization Programs

VACCINATE BEFORE YOU GRADUATE INDIANA VACCINE AVAILABILITY January The Governor renewed his legislative proposal to increase Indiana’s tobacco excise fees and introducing the Healthy Indiana Plan. The Plan would provide smoking cessation programs, fund the children's vaccine gap and provide insurance coverage for adults.

VACCINATE BEFORE YOU GRADUATE INDIANA VACCINE AVAILABILITY May 2007—ISDH became one of the first pilot site for VMBIP (Vaccine Management Business Improvement Project). August ISDH evaluating vaccine ordering system to ensure timely delivery of vaccines.

VACCINATE BEFORE YOU GRADUATE INDIANA We may need to consider other points of access such as schools. Vaccination Success and Stresses, Walter Orenstein, MD

School Facts 22% of Indiana’s Citizens are 5 – 19 yrs. old Kindergarten to Grade 12 –Public school 1,045,702 –Private school 109,124 –Home school 23,455 * Department of Education

School Facts School vaccination laws –Vary from state to state –Indiana allows for medical and religious exemptions –Failure to vaccinate results in exclusion from school

Documentation in Schools Parents must provide documentation for first time enterers –Kindergarten –First Grade –Sixth Grade –Transfer to a new school Becomes part of official student school record Reported to state DOH and CDC

Documentation in Schools Paper Electronic School Health Records –Free-standing –“Home Grown” –Part of a larger student record management system Subject to Federal Education Reform Privacy Act (FERPA) regulations Few commonly used applications

History of Schools and Registry Unreliable source of data Use of non-clinical staff for data entry –Transfer from paper records –Legibility of record –No knowledge of the immunization schedule Didn’t question suspicious dates Didn’t question illegible dates –No supervision by nursing Limited computer skills & Internet access

School Immunization Reports Annual reporting requirements Reportable to state department of health and / or the Department of Education Due by mid-November annually School funding tied to immunization coverage rates Public health involved in this activity in some states

State Registries Working with Schools* Read Only –Arkansas –Colorado –Delaware –Georgia –Houston Harris Co. TX –Idaho –Indiana* –Maryland –Minnesota –Mississippi –Missouri –Nebraska –Nevada –New Jersey –New York State –North Carolina –North Dakota –Oregon –Rhode Island –San Antonio, TX –Tennessee –Utah –Washington –West Virginia –Wisconsin –Wyoming –Virgin Islands * AIRA Registry Profile

State Registries Working with Schools Read and Add Data** –California –Kentucky* –Louisiana –Michigan –New Mexico* –Oklahoma –Pennsylvania * Registry laws in place ** AIRA Registry Profile

Barriers Federal Education Rights and Privacy Act (FERPA) –FERPA not HIPAA regulates school information –Requires parental consent unless state law / rules specifies reporting to registry –Consent added to general student consent signed at outset of academic year

Barriers Double data entry –Multiple school applications –Cost of interfaces –Level of IT staff in schools not capable of doing interface work internally Nurse may not be entering data

Advantages Frequently first to encounter child from out of state Required to collect immunization data School nurses are active registry users → “Ultimate Win Win” Connection to families / siblings → Outreach opportunities → Source of immunization record for many Access to adolescents

Advantages Role in disease surveillance and outbreak management –Active members in community Pan Flu / BT response planning –Schools frequent site for disease outbreaks Expanded use –School based clinics –Employee health –College / University Student Health Centers

The Louisiana Experience School nurses adding data into LINKS since March 2005 –Through January 2007, schools have entered 277,782 new immunizations School nurse data “marked” in LINKS Working on bi-directional interface with school application used in 42-parish schools

LINKS facts* As of March 7, 2007 –68.9% of children < age 6 had at least two immunizations recorded –100% public providers participating –75% private providers participating –2,226,282 people of all ages –20,268,607 individual immunizations * Immunization Information Systems Use During a Public Health Emergency in the United States; Urquhart Gary, MPH; Centers for Disease Control and Prevention

After Katrina Estimated 200,000 displaced persons View only or HL7 links to other state registries allowed queries into LINKS Displaced children and adolescents enrolling in school were initially exempt from school immunization laws

Results 21,295 successful external queries were made into LINKS between August 29 and October 11, 2005 –44 states, 5 cities and Washington, D.C. Queries breakdown –30.7% for children 0-5 years old –39.6% for children 6–10 years old –30.7% for adolescents years old Houston Harris County registry alone responded to 17,000 requests for immunization records –Est. $850,000 savings in unnecessary shots

Registries and Physician Recruitment An average of 44% of private provider sites submitted data to Immunization Information Systems during the last six months of 2005 Issues surrounding private provider participation –Reluctant to add workload to staff –Won’t pay the cost for electronic transfer of data to IIS –Data quality from billing systems –Many converting to Electronic Health Records 1 of 4 using EHR; 1 of 10 using for treatment decision –Smaller practices less likely to have electronic data systems

Summary Schools hold immunization data that mirrors or exceeds what is held by private providers School nurses are motivated to work with registries → many would do double data entry Schools play a critical role in disaster, disease outbreak and Bioterrorism plans

VACCINATE BEFORE YOU GRADUATE INDIANA SCHOOL NURSE MODULE FOR CHIRP Goals: 2007 ISDH purchase School Nurse Module 2007 School Nurse Module pilot programs 2007 Freshmen records reported 2008 School Nurse Module used by all Indiana schools 2008 School nurses reviewing records of students every year.

VACCINATE BEFORE YOU GRADUATE INDIANA NATIONAL IMMUNIZATION COALITION’S TA NETWORK RECOGNITION Vaccinate Before You Graduate/Indiana was recognized by IZTA as a Promising Practice

VACCINATE BEFORE YOU GRADUATE INDIANA Vaccinate Before You Graduate information can be found on the Indiana Immunization Coalition’s website: