Indiana’s Immunization Successes and Challenges
By Anne Schuchat, MD, RADM, US Public Health Service, Assistant Surgeon General, and Director, National Center for Immunization and Respiratory Diseases, U.S. Centers for Disease Control and Prevention; and Thomas A. Felger, MD, Health Officer, St. Joseph County, and Past President, Indiana Academy of Family Physicians
We are proud to say that our nation’s childhood immunization program can celebrate tremendous successes. Childhood immunization programs have led to dramatic declines in the rates of vaccine-preventable diseases such as measles, polio, and haemophilus influenzae serotype b, with significant reductions in morbidity and mortality. Routine childhood immunization in just one birth cohort in the U.S. prevents about 20 million cases of disease and about 42,000 deaths. It also saves about $13.5 billion in direct costs (1).
Through immunization, we can protect young children from 14 vaccine-preventable diseases before age two. The hard work and dedication of healthcare professionals like you means vaccines are getting to the children who need them. The National Immunization Survey has consistently shown that childhood immunization rates for vaccines routinely recommended for children remain at or near record levels.
Part of our success is due to the Vaccines for Children (VFC) program, which marks its 20th anniversary in 2014. The VFC program has contributed directly to a substantial increase in childhood immunization coverage levels, as well as made a significant contribution to the elimination of disparities in vaccination coverage among young children.
Looking forward, however, we still have significant challenges, especially in Indiana. The most significant childhood immunization gaps are protecting preteens from future cervical and other cancers, and young children from pertussis.
Each year in Indiana alone, about 250 women are diagnosed and about 85 women die from cervical cancer (2). Yet, according to NIS data, only 48% of girls and 17% of boys ages 13-17 in Indiana receive the first dose in the three dose series of HPV vaccine (3). Series completion rates are also unacceptably low; only 78% of girls who begin the series get all three shots. Completion rates are much worse for boys. Compared to other adolescent vaccines, coverage rates of HPV vaccine are extremely low and don’t appear to be improving. Because we have high coverage rates for both Tdap and MCV4, we know that Indiana’s adolescents are seeing healthcare professionals, and have opportunities to be vaccinated against HPV. This is especially concerning because HPV is so common that nearly all sexually active men and women get it at some point in their lives.
A simple way to assess your own compliance with HPV recommendations is to review your vaccine ordering patterns. HPV inventory should be at least a 2:1 ratio to Tdap vaccine. A ratio of less than 2:1 indicates room for improvement with your HPV vaccination rates.
The HPV vaccines are a safe and effective method of preventing cervical and other cancers, especially when the vaccine is given as recommended: to both girls and boys at 11 to 12 years of age, prior to the initiation of sexual activity. The vaccine prevents infection with HPV types 16 and 18 that are responsible for 7 out of 10 cases of cervical cancer, anogenital and oropharyngeal cancers. Ongoing reviews of vaccine safety by the CDC and the Institutes of Medicine continue to demonstrate the safety of HPV vaccines (4).
Among toddlers, we are also seeing low rates of another vaccine series, the 4th dose of diphtheria, tetanus, and acellular pertussis (DTaP) vaccine. Indiana has low rates of completion for the DTaP series by 18 months. Only 77% of Indiana’s young children are receiving the recommended 4th dose of DTaP vaccine, whereas 92% receive 3 doses (5). While the first three doses of DTaP vaccine, at ages 2, 4, and 6 months of age, build up high levels of protection against pertussis; the booster doses at 15-18 months and at 4-6 years are necessary to maintain that protection. Indiana has seen high rates of pertussis over the past two years, including one pertussis death last year. We need your help to increase protection against pertussis by ensuring all children in your practice are fully immunized according to the recommended schedule.
We ask that your practice assess its policies and procedures related to vaccine series initiation and completion and implement these evidenced-based strategies for increasing vaccine rates:
- Strongly recommend all vaccines according to CDC’s recommended immunization schedule, including starting and finishing series on time. Healthcare professional recommendation is the strongest predictor of a patient’s vaccination status.
- Use every opportunity – including sick visits and sports physicals – to assess patients’ immunization status and administer catch up doses. Most children with minor illnesses, such as a cold, can still be vaccinated, but children who are moderately or severely ill should usually wait until they recover. Additional information can be found in Epidemiology and Prevention of Vaccine Preventable Diseases (http://www.cdc.gov/vaccines/pubs/pinkbook/index.html).
- Recommend HPV vaccine the same way you recommend Tdap and MCV4. Your strong recommendation for all of the adolescent vaccines together is the most successful way to let parents know they are safe and effective, and reduces vaccine hesitance.
- Schedule toddlers for appointments at age 15-18 months. Send reminder cards before the appointment, and follow up when appointments are missed.
- Utilize the reminder/recall function in CHIRP to notify parents when their child is due for each dose of vaccine.
- Sign patients up for MyVaxIndiana, the immunization registry’s patient access portal, to help parents check if their child is up to date with recommended vaccines.
If your practice is not currently utilizing Indiana’s Immunization Information System (CHIRP), we encourage you to enroll in the program. The registry will be mandated in July 2015 for all providers who immunize patients 18 years of age and younger.
Healthcare Professional Resources to Improve Immunization Rates:
- Provider Resources of Vaccine Conversations with Parents. This suite of materials was developed by AAFP, American Academy of Pediatrics, and the U.S. Centers for Disease Control and Prevention (CDC). It is designed to help you address parents’ questions and concerns about their child’s vaccines: www.cdc.gov/vaccines/conversations
- Current version of the recommended immunization schedules: www.cdc.gov/vaccines/schedules
- CDC’s vaccine website for parents: www.cdc.gov/vaccines/parents
- HPV Vaccine Resources for Healthcare Professionals: www.cdc.gov/vaccines/youarethekey
- Immunization Action Coalition Talking About Vaccines: http://www.immunize.org/concerns/
- Starting the Conversation: Talking to Patients about the Link between HPV and Cancer: http://www.in.gov/isdh/files/HPV_Providers_Final.pdf
Indiana is proud to serve as the kick-off site for the 20th anniversary celebration of National Infant Immunization Week (NIIW), April 26 - May 3, 2014. During this week, Dr. Anne Schuchat will be participating in Indiana’s NIIW events to focus attention on the goals and successes of Indiana’s immunization program.
- Zhou, Fangjun. (2011, March 29). Updated economic evaluation of the routine childhood immunization schedule in the United States. Presentation at the National Immunization Conference , Washington, DC. Available at: https://cdc.confex.com/cdc/nic2011/webprogram/Paper26209.html
- ICC, Indiana State Department of Health and the American Cancer Society Great Lakes Division; Indiana Cancer Facts and Figures 2012. March, 2012. Available at http://indianacancer.org/resources-for-indiana-cancer-consortium-members/indianacancerfactsandfigures2012/.
- CDC. National Immunization Survey (NIS)-Teen Data Tables. Available: http://www.cdc.gov/vaccines/who/teens/vaccinationcoverage.html#survey-data
- CDC. Human papillomavirus vaccination coverage among adolescent girls, 2007-2012, and postlicensure vaccine safety monitoring, 2006-2013 – United States. MMWR 2013; 62(29): 591-95.
- CDC. National Immunization Survey (NIS) – Children (19-35 Months) Tables. Available: http://www.cdc.gov/vaccines/stats-surv/nis/default.htm#nis