1. 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

2. 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
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 Available at:
CDC. MMWR 2009:58:

3. 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

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

5. 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

6. 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

7. 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

8. 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%

9. Influenza Vaccine Coverage All Ages, by IHS Region

10. Influenza Vaccine Coverage By Age Group All IHS Regions Combined

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

12. 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% %
Coverage varied by facility type
IHS facilities: 74.7%
Tribal facilities: 69.2%
Urban Indian facilities: 50.7%

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

14. 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)

15. 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

16. 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?