1. Justice, Law & Crime Policy George Mason University Immunization Obstacles at the Local Level: How Juvenile Facilities and County Public Health Perceive the Problems (Results of JRFC Pretesting) Anne S. Douds Catherine A. Gallagher Holly R. Stevens Kimberly Mehlman

2. Justice, Law & Crime Policy George Mason University Background The Juvenile Residential Facility Census (JRFC) Administered every other October since 2000 Facility-level data Companion to CJRP Modules on Health care Mental health services Education Substance abuse services Deaths and injuries Facility characteristics

3. Justice, Law & Crime Policy George Mason University Hepatitis B Question Series: 2004

4. Justice, Law & Crime Policy George Mason University Conclusions from JRFC 2004 Hepatitis Series 23,179 juveniles in 986 facilities were NOT provided hepatitis B vaccination either on- or off-site Large gap between policy to provide (65%) and actual practice (42%) Especially for large state-owned and operated long-term facilities Facilities that are able to provide vaccines on-site are significantly more likely to have reported providing at least one dose of hepatitis B vaccination in reference period Many juveniles receive hepatitis B vaccinations outside the facility

5. Justice, Law & Crime Policy George Mason University CDC Study of VFC Participation Sample from JRFC/CJRP contained all facilities with the highest odds of being enrolled in the VFC program (n=178) Criteria: (1)Are state owned and operated; and (2)Housed over 35 young people on the JRFC 2004 reference day (3)Detention centers meeting criteria 1 and 2 and in which a minimum of 50% of the juveniles were in residency for at least a period of 30 days prior to the reference day of the CJRP 2003 Results: Approximately 80% of these facilities were enrolled in VFC (Builes et al., 2006)

6. Justice, Law & Crime Policy George Mason University 2006 JRFC Collaborative project between OJJDP, GMU, CDC Primary Goals: Increase the number of vaccines covered on JRFC instrument Assess feasibility of adding data points to JRFC without compromising longitudinal integrity of instrument Gather data related to vaccine delivery and participation in VFC Intended Result: New data points (along with other JRFC/CJRP and linked data) should allow us to model where, when and how to work with JJRFs to increase vaccine delivery and use of VFC resources

7. Justice, Law & Crime Policy George Mason University Methods Design: Iterative qualitative pretesting techniques –Unstructured interviews (JJRFs) –Structured interviews (JJRFs and County Public Health Organizations –Forms design (JJRF for JRFC) Sample: Purposive –10 states –3 to 5 facilities per state –23 County public health organizations within pretest areas Respondents: –Central reporters (state-level or multiple facility) –Facility administrators/respondents –Health care providers (on- and off-site) –Data analysts NOTE: Confidentiality and objectivity

8. Justice, Law & Crime Policy George Mason University Obstacles at JJRF Level Vaccines are beyond the scope and purpose of facility Availability and costs Consent Records HIPAA Never heard of VFC

9. Justice, Law & Crime Policy George Mason University Theme 1: Vaccines Outside Facility Scope and Purpose Who Expressed This Obstacle: preadjudicatory, local and private facilities Underlying Rationale: emergency care only, not their job Issues Involved: high turnover, short stay, legal status of child, other obstacles noted below Implications: juveniles not receiving shots, VFC not used

10. Justice, Law & Crime Policy George Mason University Theme 1: Vaccines Outside Facility Scope and Purpose Recommendations Institutional paradigm shift Decision-making algorithm* Public relations and education * Currently the subject of a proposed joint endeavor between the CDC and George Mason University.

11. Justice, Law & Crime Policy George Mason University Theme 2: Costs Who Expressed This Obstacle: local and private facilities Underlying Rationale :“Many kids don’t have insurance and vaccines are costly” “County public health doesn’t provide this vaccine to us” Issues Involved: unaware of VFC or how shots can be obtained Implications: undervaccination, underutilization of VFC

12. Justice, Law & Crime Policy George Mason University Theme 2: Costs Role of County Public Health Qualitative telephone interviews with all county public health organizations serving the pretest sites N=21 (several sites served by same entity)* Method *(3 more surveys returned this week)

13. Justice, Law & Crime Policy George Mason University Theme 2: Costs Relevant Results From County Public Health Survey 11 (52%) aware of JRF within its service area 7 (33.3%) interacted with JJRFs -5 provide vaccines directly to JJRF residents -2 are intermediaries for VFC shot delivery All are VFC providers 20 (95%) understood VFC program 4 (19%) travel to JJRFs to deliver shots 15 (71.4%) charge fee for shots ($5 - $45), waived for low income patients (N = 21)

14. Justice, Law & Crime Policy George Mason University Theme 2: Costs “Who Pays for Vaccines?” Results from Facility Pretesting State (n=6)Local (n=11)Private (n=6) Funds from this Facility’s Budget696 County Public Health261 State Public Health200 Medicaid001 Private Insurance016 Parent/Guardian046 Other000

15. Justice, Law & Crime Policy George Mason University Theme 2: Costs Recommendations Strategy to improve relationships between VFC, county public health agencies, and JJRFs Plan to capitalize on public health resources

16. Justice, Law & Crime Policy George Mason University Theme 3: Consent Who Expressed This Obstacle: pre-adjudicatory facilities, those without legal custody, private facilities Underlying Rationale: perceive lack of authority, fear of legal action, believes it is school responsibility Issues Involved -At facility level: misperception of law, general reluctance -At county public health level: misperception of law Implications: shots not given, VFC not used, justification seems persuasive

17. Justice, Law & Crime Policy George Mason University Theme 3: Consent Results of Facility Pretesting Who provides consent to administer immunizations at this facility? State (n=6)Local (n=11)Private (n=6) Parent076 Child024 Facility Health Professional025 Probation officer/case worker024 Other085

18. Justice, Law & Crime Policy George Mason University Theme 3: Consent Results From County Public Health Survey “They’re wards of the state, why would we need consent?” “We are obligated to try to get consent, not to actually get it.” “If the state requires them, then we give them, no matter what.”

19. Justice, Law & Crime Policy George Mason University Theme 3: Consent Recommendations Consent from residents over age of majority (potential VFC problem) Education on custody and its meaning for consent Legislative of systematic judicial actions for vaccination purposes during periods of temporary custody Legal research on the obstacles that consent really present Study judicial amenability to immunization provision in orders Explore how VFC programs have broached the consent issue in other settings Analyze data coming back from JRFC 2006 on consent requests

20. Justice, Law & Crime Policy George Mason University Theme 4: Records “ We cannot locate accurate immunization records” Who Expressed This Obstacle: All JJRFs Public health: 8 request meds from parents all times; 2 sometimes. 9 request meds from schools 2 access registries Of 7 who serve juveniles, 3 request meds from facilities Underlying Rationale: schools, parents, registries, consent, privacy Issues Involved: registry access and maintenance, high turnover Implications: under and over immunization

21. Justice, Law & Crime Policy George Mason University Theme 4: Records Access: Results From Facilities State (n=6)Local (n=11)Private (n=6) Receive, Request, or Access Immunization Records No092 Yes624 State (n=6)Local (n=2)Private (n=4) For whom does this facility receive, request or access immunization records ALL623 At least 7 days 000 7-15 days000 Attends school 001

22. Justice, Law & Crime Policy George Mason University Theme 4: Records Recommendations Macro-level efforts to improve and coordinate existing registries into up-to-date automated systems Improved connectivity between local and state public health registries Decision-making algorithm Legislate exceptions to records requirement

23. Justice, Law & Crime Policy George Mason University Theme 5: HIPAA Who Expressed This Obstacle: pre-adjudicatory, private, local Underlying Rationale: related to records problem Issues Involved: misunderstanding of law Implications

24. Justice, Law & Crime Policy George Mason University Theme 5: HIPAA Recommendations Legal research on HIPPA provisions relevant to immunization Waiver form given to all young people entering detention facilities at or beyond age of majority Judicial order for access at initial hearing Education campaign to inform JJRFs of relevant HIPAA exemptions and exceptions

25. Justice, Law & Crime Policy George Mason University Theme 6: Passing the Buck JJRFs All expressed this obstacle Schools, parents, county public health Do not view preventive health care as their responsibility Believe that laws require shots for school, so school responsible County Public Health All indicated that JJRFs are primarily responsible View themselves as supplementing JJRF None expressed that school responsible

26. Justice, Law & Crime Policy George Mason University Theme 6: Passing the Buck Recommendations Institutional paradigm shift Model relationships between onsite schools, offsite schools, county public health, and relevant state law provisions Legislation with teeth for lack of compliance with immunization laws Educate county school systems on availability of VFC for these young people

27. Justice, Law & Crime Policy George Mason University Theme 7: Never Heard of VFC Program JJRFs All, but most local and private Explains why cost is misunderstood Increases reluctance to give shots, budget issues Implications County Public Health All county public health agencies identified themselves as VFC providers All but 1 knew what VFC was

28. Justice, Law & Crime Policy George Mason University Theme 7: Never Heard of VFC Program JJRF Responses State (n=6)Local (n=11)Private (n=6) Have you ever heard of the Vaccines For Children (VFC) Program? No485 Not Sure/Maybe 120 Yes111 Does VFC pay for vaccines administered at this facility? No396 Not Sure/Maybe 320 Yes000

29. Justice, Law & Crime Policy George Mason University Theme 7: Never heard of the VFC program Recommendations Education provided by VFC state coordinators at the facility level Education through state campaigns attached to immunizations laws Education on alternative resources

30. Justice, Law & Crime Policy George Mason University Conclusions Discussion Questions

31. Justice, Law & Crime Policy George Mason University DISCUSSION State Facilities (n=6) Type of Vaccine A. Any vaccines provided?B. Which young person receive doses? C. Any doses provided? NO YES ALL SOME YESNO Don’t Know IN & OUT INOUTAt Risk No Record Other MMR6066 Td/Tdap606642 IPV6066 Varicella510111 Influenza6056 Meningococcal6 Hepatitis A51011 Hepatitis B1505314