1. Rotavirus Vaccine: use in Wisconsin, effects on primary care visits, hospitalizations, and laboratory detections Jonathan L. Temte, MD/PhD Associate Professor of Family Medicine & Advisory Committee on Immunization Practices Stephanie L. Schauer, Richard T. Heffernan, Jeffrey P. Davis Wisconsin Division of Public Health Carol J. Kirk, Peter A. Shult Wisconsin State Laboratory of Hygiene Thomas R. Maerz Wisconsin Immunization Registry

2. “my bowels are troubled, my liver is poured upon the earth " Lamentations 2:11

3. Rotavirus  The most common cause of severe diarrhea among children  Results in hospitalization of approximately 55,000 children each year in the United States  Causes the death of over 600,000 children annually worldwide…  Vaccines that become routine in the U.S. become cheap in the developing world

4. RotaShield Licensed 8-31-1998 RotaShied Withdrawn October 1999 RotaTeq Licensed February 2006 ACIP Recommendation June 2006 Wisconsin VFC Distribution September 2006 RotavirusVaccine Timeline

5. Study Objective and Approaches  Objectives: Assess the uptake of this vaccine and evaluate correlates of effectiveness on rotavirus morbidity within one state  Design: Secondary data analysis of existing data sets  Setting: Wisconsin from January 2002 through December 2008  Participants: Anonymous patient interactions as extracted from the Wisconsin Immunization Registry, hospital discharge diagnosis surveillance, a network of 27 specimen testing sites, and a primary care clinical data warehouse

6. Data Sources  Wisconsin Immunization Registry  UW- Department of Family Medicine’s Clinical Data Warehouse  Wisconsin State Laboratory of Hygiene Network of virus labs Passive surveillance of rotavirus  Wisconsin Department of Health and Family Services Hospital discharge diagnosis reporting

7. Wisconsin Immunization Registry (WIR)  Computerized Internet database application  Records and tracks immunization dates of Wisconsin's children and adults  Tool for assuring that children and adults: receive immunizations according to recommended schedules prevent over-immunizing  1,100 immunization providers and 2,650 schools  27 million immunizations  3.7 million clients

8. Use of RotaTeq Wisconsin birth cohort = 67,000 ~ 3800 doses per week to provide 100% coverage ~ 63% Coverage by late 2007

9. Clinical Data Warehouse  Existing warehouse of patient data Demographic information ICD-9 codes CPT codes EPIC EMR Data  Extensive universe of Primary Care data Approximately 176,624 unique patients  3.2% of Wisconsin’s total population Approximately 312,663 visits per year  Easily accessible for queries

10. DFM Acute Diarrheal Illness Rate of ADI Visits per 1000 per week ( 2001-2008) (denominator = 2.5 million visits) Focus on 2006-2008

11.  Slight decline in total visits for ADI  50% decline in ADI visits for <1 year old children  25% decline in ADI visits for 1-4 year old children

12.  No change in ADI visits for patients 5–24 years  No change in ADI visits for patients 25-64 years  25% decline in ADI visits for 65+year old adults

13. Wisconsin State Laboratory of Hygiene  Coordinates the Wisconsin Clinical Laboratory Network in the state to ensure timely and effective response to clinical laboratory and public health needs emergency preparedness disease surveillance laboratory diagnostics training and education communications  Laboratory Surveillance Reports webpage access to the current laboratory-based surveillance reports and graphs generated as a testing reports provided by Wisconsin laboratories current and historical graphs

14. 2004-2005

15. 2005-2006

16. 2006-2007

17. 2007-2008

18. 2008-2009

19. Wisconsin Department of Health and Family Services

20. Weekly Rotavirus Hospitalizations Wisconsin 2000–2008 2001 2002 2003 2004 2005 2006 2007 2008 Vaccine uptake 84% decline in Rotavirus Hospitalizations

21. Conclusions  Implementation of an immunization policy resulted in rapid uptake of vaccine  There is evidence for overall reduction in target syndrome in target population  Vaccine use is correlated with rapid declines in detections of rotavirus  Hospitalizations from the pathogen have rapidly and significantly declined  There is evidence for effects of herd immunity