1. Adult Immunization in Michigan: Using the Standards to Increase Coverage P. Ann Ryan, D.O., Ph.D. August 15th, 2016

2. Disclosure Statements
Presenter has no conflicts to disclose.
No commercial support was obtained for this activity. 
The presenter will not discuss the use of vaccines in a manner not approved by the U.S. Food and Drug Administration (FDA)
Presenter may discuss off-label use of a product that is in accordance with Advisory Committee on Immunization Practices (ACIP) recommendations

3. Outline Disease Burden and Impact of Vaccination
Adult Coverage Levels - U.S. and MI
Adult Immunization Standards
Immunization Disparities
Call to Action for Adult Providers

4. Disease Burden & Impact of Vaccination
Vaccine-preventable diseases (VPDs) still exist

5. Vaccine-Preventable Diseases in the United States
Newsworthy
In the United States, approximately 42,000 adults die each year of vaccine-preventable diseases.1
Coverage Gaps
Adult coverage is alarmingly low. For the majority of vaccines, coverage is well below 50 percent.2
Navigation
Adult clients may be recommended up to 13 vaccines.3
Sources:

6. Burden of Disease Among U.S. Adults
Hepatitis B1
3,350 acute cases reported 2010
Human Papillomavirus (HPV)2
Estimated 79 million Americans currently infected
14 million new infections/year in the US
Zoster (also known as shingles)3
About 1 million cases of zoster annually U.S.
Sources:
CDC. Viral Hepatitis Surveillance United States, National Center for HIV/AIDS, Viral Hepatitis, STD& TB Prevention/Division of Viral Hepatitis.
CDC. Pink Book.
CDC. Prevention of Herpes Zoster. MMWR (RR-5): 1-30.

7. Burden of Disease Among U.S. Adults (cont.)
Influenza disease burden varies year to year
Average of 226,000 hospitalizations annually with >75% among adults1
3,000-49,000 deaths annually, >90% among adults2
Invasive pneumococcal disease (IPD)3
39,750 total cases and 4,000 total deaths in 2010
Pertussis (also known as whooping cough)4
~28,000 cases per year for 2013 and 2014
~9,000 among adults
Sources:
Thompson WW, et al. Influenza-Associated Hospitalizations in the United States. JAMA 2004; 292:
CDC. Estimates of deaths associated with seasonal influenza – United States, MMWR. 2010;59(33):
CDC. Active Bacterial Core Surveillance.
CDC. Notifiable Diseases and Mortality Tables. MMWR (51&52): ND-719 – ND 732.

8. Whole-Person Care: High Risk Case Study 1
Adults with diabetes (both type 1 and type 2) are at higher risk for serious problems from certain vaccine- preventable diseases:
Some illnesses, like influenza, can raise blood glucose to dangerously high levels
People with diabetes have higher rates of hepatitis B than the rest of the population
Outbreaks of hepatitis B associated with blood glucose monitoring procedures have happened among people with diabetes
People with diabetes are at increased risk for death from pneumonia (lung infection), bacteremia (blood infection) and meningitis (infection of the lining of the brain and spinal cord)

9. Whole-Person Care: High Risk Case Study 2
Adults with asthma or COPD are at higher risk for serious problems from certain vaccine-preventable diseases:
Adults with COPD or asthma are more likely to get complications from the flu
COPD and asthma cause your airways to swell and become blocked with mucus, which can make it hard to breathe.
Certain vaccine-preventable diseases can also increase swelling of your airways and lungs. The combination of the two can lead to pneumonia and other serious respiratory illnesses
Cigarette smoking also places adults at high risk for pneumococcal disease

10. Vaccination Coverage Rates Among Adults
United States and Michigan

11. Adult Influenza Vaccination Coverage, by Age, United States (Influenza Season)
Data Source: 2011, 2012, 2013 and 2014 NHIS
= Healthy People 2020 target

12. Adult Immunization Coverage, Selected Vaccines by Age and High-risk Status, United States
2013
2012
2013
2012
2013
2012
Data Source: 2012, 2013 and 2014 NHIS
= Healthy People 2020 target

13. Adult Immunization Coverage, Selected Vaccines by Age, Sex, and High-risk Status, United States
2014
2013
2012
2014
2013
2012
2014
2013
2012
Coverage rate (%)
Data Source: 2012, 2013 and 2014 NHIS
= Healthy People 2020 target

14. Adult Tdap Vaccination Coverage by Age and High-risk Status, United States
2014
2014
2014
Data Source: NHIS

15. HEDIS Quality Measures for Vaccination
HEDIS includes three quality measures for two vaccines in the adult populations
Remember to incorporate all ACIP recommended vaccines for adults in your routine assessments of adults
Vaccine-preventable diseases are disruptive to the operations of your health centers and the wellbeing of your underserved populations

16. Why we need the Standards
Adult vaccination rates are extremely low
Most adults are not aware that they need vaccines
Immunization disparities exist
Health Care Personnel (HCP) recommendation is the strongest predictor of whether patients get vaccinated

17. Adult Immunization Standards
Make immunizations a standard of adult patient care in your practice

18. Adult Standards: 1. Assess 2. Recommend 3. Administer or 4. Refer 5
Adult Standards: 1. Assess 2. Recommend 3. Administer or 4. Refer 5. Document

19. Step 1: Vaccine Needs Assessment
Assess immunization status of all patients at every clinical encounter
Implement protocols and policies
Ensure patients’ vaccine needs are routinely reviewed
Ensure patients get reminders about vaccines they need

20. Routine Health Care Visits, U.S.
82.1% of U.S. adults had contact with a HCP in the past year1
1.0 billion physician office visits2
332.2 visits per 100 persons2
55.5% of visits made to primary care physicians2
Cough most frequent principal illness-related reason for visit2
Essential hypertension most commonly diagnosed condition2
We know that patients are coming in; use this as an opportunity to assess for needed vaccines.
Source:
1. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012,
2. National Ambulatory Medical Care Survey: 2010 Summary Tables,

21. Implementing Routine Vaccine Assessment
Utilize vaccine questionnaires
Helps identify vaccine need
Grabs patient’s attention regarding immunization history
Screening for vaccines
Contraindications & precautions
Screening forms can be found at

22. Implementing Routine Vaccine Assessment
Implement standing orders and protocols
Incorporate assessment and administration of vaccines as you would routine vitals
The Community Preventive Services Task Force recommends standing orders for vaccinations based on strong evidence of effectiveness in improving vaccination rates:
In adults and children
When used alone or when combined with additional interventions
Across a range of settings and populations
Source:

23. More Tools to Help with Assessment
The Task Force recommends client reminder and recall interventions based on strong evidence of effectiveness in improving vaccination rates
Send patient reminders
Utilize Electronic Health Records (EHRs) to distribute patient reminders via postcards, letters, text message or automated phone calls
MCIR can be used to send letters to overdue patients
Utilize HCP prompts
Next dose reminders may be generated by an EHR
Source:

24. Step 2: Give a Strong Recommendation
Using SHARE Tool:
Share tailored reasons why vaccination is right for the patient
Highlight positive experiences
Address questions & concerns
Remind patients that vaccines protect them and their loved ones
Explain the costs of getting sick
Your recommendation is a critical factor in whether your patients get the vaccines they need

25. Provider Side of Messaging
HCP commonly discuss with their patients:
Consequences of not being vaccinated
Safety and efficacy
Possible side effects
Benefits
HCP believe that vaccination is the adult’s choice and are reluctant to be “pushy”
Unless they perceive the VPD to be potentially very serious
Source: Adult Immunization: The Consumer Perspective and CDC Communication Efforts, Presentation at the 2014 National Adult and Influenza Immunization Summit

26. Patient Side of Messaging
Adults:
Favor simple and to-the-point messages
React positively to messages that stress prevention or encourage vaccination as a way have control over their health (proactive)
Prefer empowering messages - ones that provide information that can help them make an informed decision
Value references to HCP - messages that urge them to talk to their HCP to determine which vaccines are right for them
Remember that a strong recommendation prompts most patients to get immunized.
Source: Adult Immunization: The Consumer Perspective and CDC Communication Efforts, Presentation at the 2014 National Adult and Influenza Immunization Summit

27. Examples of Targeted Messages: CDC
What You Need to Know About
Heart Disease and Adult Vaccines
“I have too much to do to risk getting sick, so I’m getting vaccinated”
Source:

28. Addressing Common Questions
Patients vary in their level of knowledge
Questions may include:
What vaccines do I need?
Is vaccination necessary?
Am I at risk for contracting these diseases?
Do vaccines work?
Are there any risks in receiving vaccines?
Fact sheets are available to help address common questions at:
Apply resources when addressing common questions and give a strong provider recommendation

29. Step 3: Vaccine Administration
Have all vaccines available at clinic site
Preferred practice
Stock and offer all vaccines recommended by the ACIP

30. Visits Based on Provider Specialty
Adults are being seen in a variety of settings.
Opportunity for vaccine administration:
General/Family Medicine
70.4 visits/100 persons
OB/GYN
63.7 visits/100 persons
Internal Medicine
46.1 visits/100 persons
Source: National Ambulatory Medical Care Survey: 2010 Summary Tables,

31. Recommendation & Offer Do Make a Difference
= Received Influenza Vaccine
Reported a provider recommendation and offer
Reported a provider recommendation but no offer
Reported neither provider recommendation nor offer
Source: Ding H, et al. Influenza Vaccination Coverage Among Pregnant Women — United States, 2014–15 Influenza Season. MMWR. 2015;64(36):

32. Adult Immunization Schedules

33. Recommended Adult Vaccines

34. Resources for Vaccine Administration
Quick Looks HCP offer:
Vaccine types/brands available
Indications for use
Recommended schedule and minimum intervals
Recommendations for persons at high risk
Revaccination guidelines
Vaccine administration, including needle length
Storage and handling
Special situations
Contraindications and Precautions
Documentation
Vaccine Information Statement (VIS)
 health care professionals  quick looks and other resources

35. Helping Adult Clients Pay for Vaccines
Healthy Michigan Plan – no co-payments or cost- sharing for all ACIP-recommended vaccines
Adult Medicaid (ages 19 through 64 years) – all ACIP- recommended vaccines
Coverage extended to all ACIP-recommended vaccines given in pharmacies to individuals 19 years and older
Adult Medicare (beginning at age 65 years)
Part B – annual flu, pcv13, ppsv23, and hepatitis B (for high-risk)
Part D – Zoster, MMR, Tdap; coverage varies by plan
Example of update in coverage policy
Blue Cross Blue Shield & Blue Care Network cover HPV, MMR, Tdap in pharmacies

36. Step 4: Vaccine Referral
Refer patients to providers in the area that offer vaccines not stocked at your clinical site
Be prepared to give an informed referral for vaccines not stocked
Follow up
Confirm vaccines were received

37. The Immunization Neighborhood: Partners in Health
Faith-Based Groups
Community Health Centers
Community Groups
Hospitals
Local Health Departments
Pharmacies
Health Systems
Government Agencies
College Health
Private Providers
Occupational Health
Health Professional Groups
Goal: To Promote and Increase Adult Immunization Rates

40. Michigan Vaccine Replacement Program (MI-VRP)
Public vaccines (purchased by MDHHS) administered through:
Federally Qualified Health Centers (FQHCs)
Tribal Health Centers
Migrant Health Centers
Local Health Department (LHD) clinics
Available to adults ages 19 years and older who have no insurance or who have insurance that doesn’t cover any of the cost of the vaccine
Very specific eligibility criteria
Limited vaccines offered:
Tdap, Td, MMR, Hep A, Hep B, and Zoster
Added July 2016: HPV9, PCV13, and PPS23

41. Step 5: Vaccine Documentation
Document all administered & historical vaccine doses into the MCIR
Help your office, patients, and patients’ other providers know which vaccines your patients have received

42. *Data current as of February, 2016
MCIR is for adults, too!
Expanded to include adults in 2006
Strongly recommend reporting for adult vaccinations
Some private health plans and Medicaid require documentation of adult vaccines in MCIR
6.6 million adults have a MCIR record*
54.8 million individual vaccines have been recorded in MCIR for adult patients*
*Data current as of February, 2016

43. Working Toward a Better MCIR for Adults
Provider Side
MDHHS Side
Enter adult immunization data in a timely manner
Direct, transfer, HL7
(2-way messaging)
Review every adult’s MCIR record at each encounter
Update system to comply to HL7 specifications
Enhance vaccine forecasting for adult vaccines
Priority: PCV13 and PPSV23
Provide staff training on use of MCIR
Move toward 2-way HL7 interface

44. Immunization Disparities
Decrease barriers and missed opportunities in Community Health Centers

45. Racial/Ethnic Vaccination Disparities (influenza coverage)
When compared with non-Hispanic, white adults:
Vaccination Group
% Vaccinated Whites
Disparity, Blacks
Disparity, Hispanics
Disparity, Asians
Influenza, ≥19 yrs. 47
-10
-14 -2
Influenza, yrs. 33 -3 -6
Influenza, yrs. 50 -9
Influenza, 65 yrs. 73
-12 -1
Influenza, HCP ≥19 yrs. 68
-17
+10
Data Source: NHIS

46. Racial/Ethnic Vaccination Disparities (non-influenza coverage)
When compared with non-Hispanic, white adults:
Vaccination Group
% Vaccinated Whites
Disparity, Blacks
Disparity, Hispanics
Disparity, Asians
Pneumo., HR yrs. 21 -1 -5 -7
Pneumo., ≥65 yrs. 65
-15
-20
-17
Tetanus, yrs. 69
-16
Tetanus, yrs. 70
Tetanus, ≥65 yrs. 61
-18
-12
-14
Tdap, ≥19 yrs. 24
-11 -8
Tdap, yrs. 26
-13
Tdap, ≥65 yrs. 16 -9
Hep A, yrs. 13 -2 -3 +3
Hep B, yrs. 36 -6
Herpes Zoster, ≥60 yrs. 32
HPV, Females yrs. 46
-24
Tdap, HCP ≥19 yrs.
-22
Hep B, HCP ≥19 yrs. 63 +5
Data Source: NHIS

47. Disparities In U.S. Adult Immunization Rates
Lower vaccine coverage among:
Hispanics and African Americans compared to non-Hispanic Caucasians
Uninsured
Lower incomes
Improved frequency of provider vaccine assessment and recommendations may help reduce disparities
For newly insured adults
ACA requires non-grandfathered private plans to include coverage for ACIP- recommended vaccines
Especially important to conduct assessment among newly insured
Source:
Lu, P-J, et al. Racial and Ethnic Disparities in Vaccination Coverage Among Adult Populations in the U.S. Am J Prev Med 2015; 49(6):S412–S425

48. Call to Action
All adult providers

49. Call to Action: Implement the Standards for Adult Immunization Practice Today!
Turn missed opportunities for vaccination into vaccination successes
Routinely assess adult immunization status at every visit
Implement office protocols and policies to enhance vaccination
Be a good neighbor in the immunization community
Document all vaccines administered in MCIR
Know your referral partners and neighbors

50. The Standards (Booster Shot)
Assess
Recommend
Administer
Refer
Document
Make immunizations a standard of adult patient care in your practice to ensure your adults and communities are fully protected!

51. End of Presentation, Time for:
Question and Answer
Thank you for your support!

52. Need a Refresher on Adult Vaccine Recommendations?
Available adult immunization modules:
Adult and pediatric influenza vaccinations
Adult immunizations (19 years and older)
Family Medicine immunizations (vaccines across the lifespan)
Giving immunizations: Vaccine Administration and Pain Management
Health Care Provider recommendations
HPV immunizations
Pediatric immunizations (birth to 18 years of age)
Vaccines and women’s health (obstetrics and gynecology)
Vaccine Management: Storage and Handling
Immunization Nurse Education Modules:
Contact Carlene Lockwood at or
Physician Peer Education Modules:
Contact Connie Demars at or
Source::

53. Thank you for your participation in today’s event!
For questions related to this session, contact: Jackie Chandler, MS Outreach Coordinator Michigan Department of Health & Human Services
Thank you for your participation in today’s event!