ASTHO IMMUNIZATION RESOURCE GUIDE This Publication Was Supported by Cooperative Agreement Number 5U38HM000454-05 from the Centers for Disease Control and Prevention

ASTHO IMMUNIZATION RESOURCE GUIDE This publication was supported by cooperative agreement number 5U38HM000454-05 from the Centers for Disease Control and Prevention. Its contents are solely the responsibilities of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. table of contents

Introduction...... 2

Section 1: Overview...... 4

Section 2: Vaccine Finance...... 6

Section 3: The Patient Protection and Affordable Care Act...... 11

Section 4: Childhood and Adolescent Vaccination...... 17

Section 5: Adult Vaccination...... 28

Section 6: Healthcare Provider Vaccination...... 33

Section 7: Infrastructure...... 40

Section 8: Immunization Information Systems and Meaningful Use...... 44

Section 9: Communication...... 55

Note: Words in bolded or colored text throughout document are active hyperlinks to click for more information. introduction

Vaccinations offer a wide range of benefits. This Association of State and Territorial They prevent disease and disability in a Health Officials (ASTHO) Immunization cost-effective way and thwart financial Resource Guide was created to collect and emotional tolls. F( or example, for each innovative best practices and information dollar spent on childhood vaccines, more to help our members and partners than $10.20 is saved in direct costs.) consider potential methods to increase access to vaccines and rates of vaccination. However, best practices to develop, We hope this guide serves as a valuable implement, and promote programs resource to help tackle your specific and policies that support immunization challenges and needs, and encourages need to be communicated more widely. collaboration among you, the public health Sharing of these best practices and other officials and advocates who work tirelessly relevant information is critical to maximize to improve the health of our nation. opportunities for success—namely, sustaining high vaccine coverage levels Let’s work together to ensure states and in children and adolescents, increasing territories help every person become and coverage rates in adults, and incorporating remain properly vaccinated. new vaccines into the routinely recommended immunization schedule.

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OVERVIEW

With many vaccines, immunization rates are on the rise vaccines and well below Healthy People 2020 in the United States. CDC has noted that vaccination targets. And children under six years of age coverage has remained above the national Healthy do not meet 2020 goals for inclusion in immunization People 2020 target of 90 percent for children for information systems. certain vaccines; 2011 vaccination coverage among Despite these challenges, innovations across the adolescents aged 13 to 17 was up from prior years, states and territories are making marked differences and nearly 70 percent of adults over the age of 65 receive immunization against influenza. in ensuring the population is immunized. For example, Hawaii public health officials have conducted622 Yet, with resource constraints, changing policies, school-located influenza vaccination clinics to increased burden on healthcare professionals, and immunize more than 53,000 school-aged children and more, we still face challenges in meeting goals and adolescents. Rhode Island runs the Immunize for Life unlocking potential to increase vaccination rates and program, which has significantly increased vaccine efficiencies. For example, the increase in HPV coverage coverage among pediatric and adult populations. And among adolescent females is lagging (those protected Utah has leveraged the Meals-on-Wheels program to from HPV-related cancers by the complete series engage and learn from a difficult-to-reach population. ranges from 56.8 percent to as low as 15.5 percent, This is where we should place our focus—on examples depending on the state). Adult vaccination coverage of what’s being done well that can be replicated. remains low for most routinely recommended

4 | ASTHO | IMMUNIZATION RESOURCE GUIDE vaccine finance

Several federal funding sources enable vaccine are underinsured and receive vaccines at federally delivery to the American population. Public health qualified health centers or rural health clinics. officials leverage these funding streams, along with state funds, to manage immunization programs and At the state level, funding practices are unique to administer and pay for vaccines critical to the health and each state. Policies range from “universal”—where all well-being of the country. recommended routine pediatric vaccines are supplied to children regardless of insurance status—to “VFC”— At the federal level, CDC’s Section 317 Immunization where the program supplies all routinely recommended Program allocates funding for immunization pediatric vaccines to participating private providers operations and infrastructure necessary to implement to vaccinate VFC-eligible children only. Other policies comprehensive immunization programs at the federal, include varying levels of coverage for pediatric state, and local levels. The majority of funds have populations and the types of vaccines administered. been dedicated to routine childhood programs, with The best practices in this section detail innovative smaller allocations for adults and adolescents.In 2012, Section 317 policy was updated to reflect increasing examples of how states are leveraging and maximizing insurance coverage of vaccines. Also federally funded these funding sources. is the Vaccines for Children (VFC) program, which provides vaccines at no cost to children 18 years or younger who are Medicaid-enrolled, have no health insurance, are American Indian or Alaska Native, or

6 | ASTHO | IMMUNIZATION RESOURCE GUIDE vaccine finance

Private Provider Vaccine Supply Policies: How States Use Their Funds

Policy/Coverage Routine Pediatric Vaccines Provided Insurance Status Covered Universal Purchase All All Universal Purchase Select Many All VFC & Under-insured All VFC-Eligible and Under-insured VFC & Under-insured Select Many VFC-Eligible and Under-insured VFC All VFC-Eligible

CHILDHOOD VACCINE FINANCING/SUPPLY POLICY FOR PRIVATE PROVIDERS

Universal Purchase (N=6, 12%) Universal Purchase Select (N=6, 12%) VFC & Underinsured (N=10. 20%) VFC & Underinsured Select (N=2, 4%) VFC (N=26, 52%) *Information current as of January 2011

Source: Association of Immunization Managers

ASTHO | IMMUNIZATION RESOURCE GUIDE | 7 featured best practices

Changing to a State-Supplied Vaccine Policy

(North Dakota, 2011) $1,632.70 in 2011. Meanwhile, Section 317 funding decreased from $2.2 million In the last decade, North Dakota has in 2006 to less than $1 million in 2012. seen multiple policy changes affecting Common vaccine-preventable illnesses immunization funding. Prior to 2004, were also on the rise. Data released in the North Dakota Department of Health the winter of 2012/2013 showed that provided all vaccines recommended by pertussis cases increased steadily from the Advisory Committee on Immunization 2008 (25 cases) to 2011 (70 cases), while (ACIP) to enrolled public and private in 2012, most dramatically of all, there providers, using VFC and Section 317 were 215 reported cases. Flu cases also funds, as part of a universal model. Due increased from the previous flu season. to resource challenges and increases in the number of vaccines recommended This change was not without challenges. by ACIP, the state reduced coverage to The department of health faced immunizations listed through the VFC oppositionfrom third-party stakeholders. program. Through legislation SB2276( ) Extra time and resources were dedicated passed in spring 2011, North Dakota to advocating this policy change. But in the returned to universal status for local end, the state’s return to universal status public health units, while private providers supported increased vaccination rates. remained VFC only. Provisions to bring According to CDC, the state achieved a insurance companies into the cost sharing/ 79.8 percent primary series vaccination funding pool were eventually dismissed rate in children aged 19 to 35 months in from the bill. 2010; that jumped to 83.5 percent in 2011. Resource constraints made policy changes inevitable. Costs to vaccinate a child from birth through 18 years of age increased dramatically, from $44.71 in 1985 and to

8 | ASTHO | IMMUNIZATION RESOURCE GUIDE vaccine finance

Making State-Supplied Vaccines their market share. Vermont will Available for All Children Aged evaluate the pilot program in 2014 0–35 Months (Alaska, 2013) to determine its next steps. One key learning thus far was the importance In 2012, Alaska’s Division of Public of partnering with insurers from the Health introduced new state-supplied beginning to ensure support and buy-in. vaccine guidelines that grant eligibility From a provider perspective, the pilot to all children aged 0-35 months. program has been helpful in reducing This was made possible in part by reimbursement paperwork and storage $4.3 million in annual funding from requirements for separation of vaccines a state bill to purchase vaccines for funded by different sources, given all underinsured children. Alaska’s VacTrAK vaccines now came from the same database and CDC assessment tools funding source. were valuable in sharing information critical to securing these funds. The Evaluating Funding Mechanisms new guidelines stressed that providers for Childhood Immunization must still vaccinate every eligible Programs in New England States child, even if parents cannot pay (New England, 2013) administration fees, and parents do not need to prove eligibility status. To As the number of recommended roll out this policy change, the Alaska vaccines and the cost involved increase, Immunization Program held weekly states are adapting to maintain teleconferences for one month to stable funding for immunizations. discuss vaccine eligibility, maintained a New Hampshire-based Kidsvax.org helpline, and worked with stakeholders put together a report on childhood to evaluate vaccine financing through a immunization programs in New dose-based assessment to protect even England states to assess their funding more children. mechanisms. Overall, New England states run either a universal supply Covering Financing of model or universal select to provide Immunizations for Children immunizations to providers free of and Adults (Vermont, 2009) charge. A primary consideration when In 2009, Vermont introduced a pilot evaluating the implementation of a program that changed the way the universal program is dividing costs state paid for vaccinations for both equally across the payers providing or children and adults. The state created administering health benefit plans. New its own fund to buy vaccines directly England states clearly delineate who from CDC for distribution to providers the payers are and their assessed fees, free of charge using pooled state, among other details, to address this federal, and insurer funds. Insurers potential concern. This resource also funded the pool at a level based on includes detailed statute language.

ASTHO | IMMUNIZATION RESOURCE GUIDE | 9 vaccine finance

Promoting Key Talking • Rhode Island’s legislation requiring Points on Paying for Vaccines the state health department to (United States, 2013) purchase influenza vaccine and distribute it to physicians enrolled in Healthy States, an initiative of the Immunize for Life. Council of State Governments, drafted talking points exploring the difference • Vermont’s distribution of free in how vaccines for children and adults pneumonia and Tdap vaccines are funded. While vaccines for children to healthcare providers for adult are funded by both private and public immunization. sources, federal and state governments • Oregon’s use of third-party billing play a lesser role in absorbing the cost for child immunizations in public of adult vaccinations; most are covered clinics to fund additional free privately (e.g., private insurance, vaccinations. self-pay, vaccine manufacturers). • North Dakota’s support of local Importantly, there is a call to action health departments to bill insurance section that outlines succinct ways companies to increase revenue for state legislators can help increase publicly funded adult vaccines and immunization rates. A few state other immunization projects. programs are also highlighted, including:

10 | ASTHO | IMMUNIZATION RESOURCE GUIDE the patient protection and affordable care act

In March 2010, President Obama signed 1, 2013, states had the opportunity to the Patient Protection and Affordable qualify for an additional percentage point Care Act (ACA) into law. The law makes in their Medicaid matching rate if the state preventive care, including immunization, covered preventive services recommended more accessible and affordable for by the United States Preventive many Americans. Services Task Force and immunizations recommended by ACIP, without charging ACA includes a number of beneficial cost-sharing for these services. ACA provisions for immunizations. All new requires states to pay for primary care (non-grandfathered) health plans are physician services, including immunization, required to cover all ACIP recommended at levels equal to at least 100 percent of routine vaccinations as of 2010. Medicare Part B payment rates in 2013 A major impact of ACA is expanding and 2014. Medicaid coverage expansions Medicaid, one of several important through ACA for low-income adults will provisions that the federal government result in increased immunization coverage and the states jointly finance. The impact for newly eligible enrollees. of this expansion varies state by state, and as such, states are each evaluating its potential—with 28 as of July 2013 moving toward expansion. Beginning Jan.

ASTHO | IMMUNIZATION RESOURCE GUIDE | 11 the patient protection and affordable care act

With the anticipated increase in the state and local level, made possible the number of people who have by the Billables Project for Health access to insurance coverage for Department Immunization Services immunizations, the CDC funded Reimbursement. state pilot programs to explore and implement third-party billing systems While it is too soon to understand the to collect insurance payments for full impact of ACA, this case study on those seeking immunizations at public an innovative approach from Arkansas health clinics. There are a number of shows its potential benefit for the examples of these billing systems at population.

BEYOND THE PLEDGES: WHERE THE STATES STAND ON MEDICAID (29 STATES MOVING TOWARD EXPANSION)

View Estimated Uninsured Post-ACA

NH VT MA CT RI DE MD

Not Participating 15 Leaning Toward Not Participating 7 Alternative Expansion Model 1 Considering Alternative Model 4 Participating 21 Leaning Toward Participating 3

*Information current as of October 2013

Source: The Advisory Board (as of October 2013)

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Enumerating the Economic Impact of ACA on Arkansas

(2013) federal poverty level, five percent above the mandated rate, giving With ACA’s passage, the RAND coverage to more than 200,000 of Corporation projected that, by 2016, the currently uninsured. Uniquely, 400,000 more Arkansans would have the federal government will pay for health insurance and about 1,100 Arkansas to expand health coverage fewer people would die (or as many to low-income residents through the as 2,300 fewer, including those with state’s insurance exchange, rather than non-group coverage). Additionally, net its Medicaid program. Since Arkansas federal payments to Arkansas would was one of the few states that would come to $430 million every year; the immediately benefit financially from state’s GDP would see a net increase the ACA, the compromise was reached of $550 million, after increased costs fairly quickly. According to the New for Arkansas resulting from ACA are York Times, other states should subtracted; and 6,200 more jobs would consider that this “approach might be be created. As Arkansas is “one of the somewhat more expensive,” as it is also poorest states in the union,” according likely that private insurers will charge to the RAND Corporation report, higher rates than Medicaid, costing Medicaid expansion and insurance federal taxpayers more money and/or subsidies for lower and medium Leaning Toward Not Participating 7 reducing the amount of care given-per- Alternative Expansion Model 1 income people “disproportionately dollar-spent. Considering Alternative Model 4 benefit” the state.

In February 2013, it was announced that Arkansas will cover Arkansans between zero and 138 percent of the

ASTHO | IMMUNIZATION RESOURCE GUIDE | 13 the patient protection and affordable care act

Following this agreement, the U.S. Department private health plans. In the first year alone, 11 of Health and Human Services announced that local LPHAs participated in the program, which other states seeking to use federal funds to included both billing of the vaccine itself and the shift Medicaid-eligible residents into private administration of the vaccinations in their health plans would have to obtain a waiver to new systems. do so. Based on the program’s success in the first Overall, healthcare coverage expansions year and an increase in funding, RIZO was able to will reduce mortality and the amount of double in size, supporting up to 28 LPHAs. Its uncompensated care ($340 million in Arkansas achievements included the development of a in 2010 alone). Choosing not to expand coverage mentoring model to transfer billing knowledge, would result in a direct net loss of $670 million. robust data collection by jurisdiction, The RAND Corporation noted the economic proof that LPHAs can bill for immunization impact in West Virginia and Mississippi are successfully, and strengthened relationships projected to be similar, with further evaluation between public health officials and payers. needed in other states. Several best practices were recommended: The provider application process should be Developing Better Systems streamlined; billing 101 processes should be to Bill Insurers: Project RIZO documented and made available online; and monthly reports help monitor progress and track results. To provide additional support, state-level (Colorado, 2011) mentors were designated to assist local officials. The Colorado Department of Public Health and Environment’s Immunization Program Project RIZO and 37 similar programs in the created the pilot Project Reimbursement United States obtained funding as part of the Immunization Opportunity (RIZO) to help local ACA’s Prevention and Public Health Fund and public health agencies (LHPA), regardless of the American Recovery and Reinvestment Act geography or experience, develop better of 2009. For more information, see the CDC’s systems to bill health insurance plans. Project Billables Project for Health Department RIZO supported the development of an Immunization Services Reimbursement. infrastructure for LPHAs to bill for the vaccination of patients insured by Medicaid, Medicare, the state program Child Health Plan Plus, and

14 | ASTHO | IMMUNIZATION RESOURCE GUIDE the patient protection and affordable care act

Taking a Holistic Look to Build an Based on the research conducted, the steering Effective Billing Infrastructure: committee determined that many LHDs were New York State Strategic Plan already billing for services, but there was room for improvement. Findings suggested three (New York, 2012) foundational pieces for a successful billing practice: information system capacity, third- To assist 57 local health departments (LHDs) party relationships, and workforce capacity and in billing third-party payers, Immunization capability. In addition, five basic requirements Billing by Local Health Departments: New York are needed by LHDs to bill effectively: collecting State Strategic Plan created an approach to insurance information from patients, determining immunization service billing that generated their payer mix, establishing and implementing additional revenue and used local public health an out-of-pocket patient fee process, promoting resources efficiently. New York’s LHDs provide medical homes, and submitting claims to public a small, but significant, percentage of state insurance programs. If requirements are met, residents’ annual immunizations. the plan outlined five options to improve upon A strategic planning process was funded by the LHDs’ billing practices, with a cost/benefit analysis American Recovery and Reinvestment Act to included to support decision-making. identify barriers and opportunities. Critical to Partnership with and support from the New York the success of the plan was the engagement of State Department of Health, as well as other a broad group of stakeholders within local and stakeholders such as the CDC and insurers, state-level government as part of a steering help LHDs successfully phase in new processes committee, as was assessing the capacity of and systems. LHDs to bill for immunization services—providing foundational knowledge on which to build recommendations.

FIGURE 3 from the plan: ELEMENTS FOR SUCCESSFUL IMMUNIZATION BILLING PRACTICE

REVENUE CYCLE

FRONT END INTERMEDIATE BACK END • Scheduling & Information • Charge Data Capture • Claims Processing • Registration Forms • Medical Coding • Explanation of Benefits • Insurance Verification • NYSIIS Data Entry • Remittance Posting • VFC Eligibility • Claims Follow-up • Fee Determination • Adjustments • Sliding Fee Scale • Patient Balance Collection

BILLING FOUNDATIONS

1. Information System Capacity

2. Third Party Relationships

3. Workforce Capacity

ASTHO | IMMUNIZATION RESOURCE GUIDE | 15 the patient protection and affordable care act

Centralizing Billing in Arizona: Delivering Key Insights and 10- Pilot Program Delivers Cost- Fold Return with Public Health Effectiveness (Arizona, 2011) Billing Project (California, 2012) Fifteen Arizona county health Kern County, California, implemented departments (CHDs) offer a new immunization billing project that immunizations. The state decided to updated their fee schedule, initiated introduce a centralized billing system private insurance contracts, handled for these CHDs due to public health provider credentialing, enhanced immunization budget cuts, the growing insurance verification, improved population, and an increasing number coding and medical documentation, of publicly and privately insured children and developed better public health seeking immunization from CHDs. staff placement at clinics. Critical American Recovery and Reinvestment to success was allocating funding Act funds allowed for the creation for Kern County’s upfront costs in of the Cost Recovery Program pilot purchasing an electronic patient care project to create a cost-effective billing management system and hiring staff solution that would help CHDs reach to properly implement the system for more patients with more services. The all vaccines. After hiring an insurance pilot was implemented in Maricopa specialist, the county saw a 10-fold County, which had about 126,000 increase in total revenue collected annual immunization visits, with 36 from one six-month period to the next. percent of patients on Medicaid and Kern County developed a toolkit to 56 percent of patients not covered by share their learnings, and, with the any health insurance. The pilot found California Department of Public Health, the centralized billing system was cost supported zseven other counties that effective and helped secure necessary served as California pilot sites. insurance reimbursement fees, which were not collected prior to the pilot program.

16 | ASTHO | IMMUNIZATION RESOURCE GUIDE childhood and adolescent vaccination

Overall, childhood and adolescent Children in the United States are required vaccination is on the rise. For example, to receive a number of vaccines prior to for children aged 19 to 35 months, entering school, but may receive medical, national vaccination coverage for rotovirus religious, or philosophic exemptions increased from 59.2 percent to 67.3 depending on state laws. In 2011, the percent from 2010 to 2011. Increases median exemption rate was 1.8 percent for were also seen in the birth dose of kindergarteners. A New England Journal hepatitis B, at least two doses of hepatitis of Medicine study details how the strength A and the rotavirus vaccine. For vaccines of the exemption policy plays a key role. recommended before the inception of As an example, nonmedical exemptions in the National Immunization Survey in states with easy exemption policies were 1994 (e.g., MMR, DTaP), coverage has 2.31 times as high as rates in states with remained stable since the mid-1990s. And difficult exemption policies. in adolescents, for instance, the average annual percentage point increase from The following best practices explore 2007 to 2010 was 12.8 for at least one innovative programming to increase dose of Tdap. vaccination coverage for children and adolescents.

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VACCINE EXEMPTION POLICIES

States Allowing Religious Exemptions Stated Allowing Medical Exemptions Only States Allowing Personal Belief Exemptions *Information current as of July 25, 2012

Source: Johns Hopkins Bloomberg School of Public Health

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Protecting Infants from Pertussis by Activating Parents and Caregivers

(Kansas, 2011) through a voucher. From January to June 2010, 208 out of 248 new mothers (83.9 Pertussis, commonly known as percent) were vaccinated after giving whooping cough, is highly contagious birth, surpassing the goal by almost four and a particular threat to newborns up percentage points. However, only 42 to six months of age, who accounted caregivers (16.9 percent) were vaccinated. for approximately 25 percent of all Reasons for non-vaccination included time, cases from 1997 to 2000. Across age lost vouchers, and fear of needles. groups, cases from 1994 to 2004 rose dramatically, with parents (56 percent It was noted that caregivers were in 2007) serving as the largest source nearly twice as likely to have received a of infection to others, over siblings (16 vaccine when fees were eliminated, no percent), grandparents (6 percent), and appointments were needed, and a visiting other sources (22 percent). That is why nurse was provided. When caregivers cocooning—the process of vaccinating began to receive vaccinations in-hospital an infant’s family and close contacts just after June 2010, there was a dramatic rise after birth—is a valuable approach to in vaccination rates, peaking to nearly preventing infants from contracting the 90 percent in November. A challenge disease. with in-hospital vaccination was patient processing, since the caregiver had to be Kansas launched a cocooning pilot admitted to the hospital for vaccination. program in four hospitals, the goals of Overall, this underscored the critical which were to increase awareness for importance of vaccinating as soon as providers and families, to immunize 80 possible, ideally before leaving the percent of postpartum patients during hospital, to maximize those protected. discharge, and to immunize one primary caregiver of the new mother’s choice

20 | ASTHO | IMMUNIZATION RESOURCE GUIDE childhood and adolescent vaccination

A report from the Immunize Kansas first state to have all birthing hospitals Kids program gave additional cocooning against pertussis. Starting considerations, noting that in 2006, Nevada began offering Tdap cocooning alone is insufficient as a vaccinations and influenza vaccines pertussis prevention strategy and to staff and new parents and worked recommending prenatal vaccination to enter these records into its online (after 20 weeks gestation). Nevada WebIZ immunization database, which as of August 2013 had more than 2.2 million records. RRMC, for Making Strides in Protecting example, saw a significant rise in Tdap the Community from Pertussis doses administered compared with the in Nevada number of deliveries from 2006 (2,986 doses of Tdap, 4,903 deliveries) to 2010 (Nevada, 2011-2012) (3,559 doses of Tdap, 4,643 deliveries) as a result of the program. With incidence on the rise, Nevada launched a proactive effort to prevent The effort met some obstacles along pertussis, or whooping cough, in 2006; the way. These challenges revolved the program remains exemplary in around getting nursing, pharmacy, and its depth and comprehensiveness. Its infection control leadership buy-in holistic approach protects healthcare to support the increased workload, workers (HCWs) and residents, obtaining stakeholders’ Agreement particularly in the birthing hospital, to Participate for use of Section 317 school, and community settings, in funds, conducting site visits, and an effort to increase immunization educating participants about the CDC’s and reduce illness across the state. recommendations for safe vaccine Cocooning refers to the practice storage and handling. of immunizing those around at-risk populations to protect them, in this The extremely successful program case, infants; Nevada was unique in won one of three 2012 AIM Bull’s- implementing on the postpartum and Eye Awards for Innovation and antepartum levels. Excellence in Immunization. The budget for 2012 was just under To immunize HCWs, Nevada focused $800,000 for Tdap doses and program on hospitals with birthing facilities or management. In July 2013, Nevada’s emergency rooms, distributing 1,791 governor announced an additional $1 Tdap vaccines to 32 of 34 relevant million in state funding. It was noted hospitals. The protection extended that Nevada’s pertussis incidence rate to parents of newborns through was 4.08/100,000, compared with a cocooning program in birthing 13.4/100,000 nationally. hospitals. In fact, Renown Regional Medical Center (RRMC) was the first full-scope hospital to cocoon in the United States, and Nevada was the

ASTHO | IMMUNIZATION RESOURCE GUIDE | 21 childhood and adolescent vaccination

Implementing one of the suggests that there were fewer flu cases Nation’s First School-Located from 2007 to 2010 than in the previous Influenza Clinics three-year intervals, suggesting a potential causal link with Stop Flu at School. The (Hawaii, 2011) 2007-2010 flu-like trends ranged from more than 1 percent to under 3 percent, In response to new ACIP guidelines calling while in other years the range was from for all U.S. children aged five to 18 years about 1 percent to about 6 percent. to receive an annual influenza vaccine, the state of Hawaii set up school-based clinics Researchers conductinga preliminary for K-8 students. This Stop Flu at School case study determined that, to achieve program originated from a three-school the same number of vaccinations as the pilot in 2006-2007. Spanning four school program in just its first year, 42,532 visits years from 2007 to 2011 in its statewide to physicians’ offices would have been mode, the program administered more necessary—assuming the existing health than 265,000 student vaccinations and infrastructure was capable of handling the more than 85,000 faculty vaccinations, volume. In addition, the convenience of with 88 to 91 percent of schools in-school vaccinations saved the indirect participating each year. Expenses from costs of parents’ time away from work the first year (more than $3.33 million) to transport their children to physicians’ were higher due to upfront costs for offices. Research suggests that the cost materials and procedure development; per vaccine is also lower in mass clinics total program costs were more than $8.83 than in an individual physician’s office million across four years, with primary setting. Researchers noted the program support (in the range of 80 to 90 percent) may not be easily transferable to states from federal grants. with larger populations, though it did offer other valuable benefits, such as building While the effort fell slightly short of the infrastructure and procedures to manage goal of a 50 percent student vaccination outbreaks (such as H1N1 in 2009). rate, rates of 49 percent in the first two years and 48 percent in the third and fourth years were increases from years prior (44 percent). Data going back to 1999

A school-based vaccination program’s “effectiveness extends to the household, and … a high-efficiency immunization program that requires minimal time from parents provides economic benefit.” Health Affairs

22 | ASTHO | IMMUNIZATION RESOURCE GUIDE childhood and adolescent vaccination

Determining Factors Associated Eighty-eight percent of middle schools with Tdap and Meningococcal responded, approximately 67 percent Vaccination Coverage Among of which were rural and 88 percent of Middle School Students which were public. Half had a state- law-compliant policy, and 28 percent reported having a school nurse. The (North Dakota, 2010) highest MCV coverage appeared in Meningococcal meningitis is a serious rural middle schools, schools that disease that is fatal in 10 to 14 percent have a state-law-compliant policy, and of cases. In the United States, cases of schools that have a nurse to determine pertussis, or whooping cough, are on up-to-date status. Simply having a the rise, with 17,000 reported in 2009. nurse in the school, however, did Both diseases are vaccine-preventable. not imply higher MCV4 or Tdap coverage rates. In 2005 and 2006, ACIP recommended the meningococcal vaccine, MCV4, While key insights were gleaned from and the pertussis vaccine, Tdap, for all the new survey questions to improve pre-adolescents aged 11 to 12 years. middle school immunization rates, As a result, North Dakota required there is still room for improvement. both vaccines for middle school entry; According to the 2012 survey, only state law instructed school officials 66.42 percent of seventh graders to exclude students who declined received the MCV4 vaccine and 68.20 vaccinations and were unable to percent received Tdap. For additional demonstrate proof of vaccination information, see the2012 North within 30 days of enrollment. Despite Dakota School Immunization the mandates, many North Dakota Survey Results. students attended school without the required vaccinations. In 2009, only 66 percent of 13 to 17 year olds received Evaluating AFIX to Increase MCV4 and 72 percent received Tdap. Immunization Rates To explore what factors affected middle school immunization rates, the (North Carolina, 2012) annual school immunization survey In 2011, North Carolina assessed added three new questions in 2010: Is its adolescent AFIX (Assessment, there a school nurse assigned to the Feedback, Incentive, and eXchange) school? What is the school’s policy program to determine whether it was regarding students who are not up to more effective to conduct adolescent date with required immunizations? AFIX visits via webinar or in person. It Who in the school determines which was the first time the North Carolina students are up to date? Immunization Program N( CIP) conducted a formal program analysis, and the first time AFIX visits, of any type, were conducted via webinar.

ASTHO | IMMUNIZATION RESOURCE GUIDE | 23 childhood and adolescent vaccination

To be part of the assessment, a family Implementing State or pediatric practice had to be an Requirements for Adolescent active member of NCIP and the North Vaccines: Lessons Learned Carolina Immunization Registry and (Indiana, 2011) service at least 200 adolescents aged 11-18; local health departments were Indiana law required the Indiana not included in the study. Eligible State Department of Health to adopt practices were put into one of three rules mandating that school-age groups: in-person AFIX visits, webinar children younger than 19 receive visits, and a no-visit control group. The additional immunizations against goal for these assessment visits was to meningitis, varicella, and pertussis. increase awareness and utilization of For the 2010-2011 school year, Tdap, adolescent vaccines and improve the MCV4, and varicella vaccines were state’s adolescent vaccination rates. required for all students in grades 6-12. In 2010, local Indiana health The evaluation concluded that the departments administered 1,355 adolescent AFIX program was effective doses of varicella, 2,284 of Tdap, at raising vaccination rates and that and 2,283 of MCV4, supported by webinars were a “cost-effective and the state health department. The efficient” method for implementing best practices identified included visits. The webinar group proved to collaborating through a multicounty be slightly more effective in improving immunization task force; making adolescent rates, with an 8.7 percent the most of walk-in clinic days change in percentage between the by extending hours of operation, baseline and follow-up, as compared especially prior to the school year with the in-person group’s 7.5 percent start; utilizing volunteer staff, student improvement in rates. The control nurses, and other health department group improved just 3.8 percentage staff to manage traffic flow during points. In addition, webinars were less busy periods; and photocopying expensive per visit ($50.35 vs. $75.52 in immunization records as back up. An person). Overall, program delivery and important lesson learned was that management were straightforward; parents did not make getting their the biggest challenge was scheduling child immunized a priority until the (and rescheduling) the webinars. possibility that they couldn’t attend school became real. While there were challenges overall, the prior year’s H1N1 epidemic and funding from the federal, state, and local levels helped ensure maximum preparedness with resources and capacity/management expertise.

24 | ASTHO | IMMUNIZATION RESOURCE GUIDE childhood and adolescent vaccination

Building Physician Support for Building a Cross-Channel Vaccination of Adolescents in Adolescent Immunization Schools: A Survey of Colorado Platform in Michigan Pediatricians and Family (Michigan, 2011) Physicians (Colorado, 2011) The Michigan Department of In 2011, a survey of Colorado family Community Health (MDCH) made physicians and pediatricians measured a focused effort to increase the physician support for school-located vaccination of adolescentsby adolescent vaccinations. The research requiring all sixth-grade students noted that while the majority of receive the Tdap and meningococcal adolescent vaccines were administered vaccines beginning in 2010, as by primary care providers, financial well as through a cross-channel barriers were making it difficult for engagement program. Elements those healthcare professionals to included a website and poster administer all needed vaccinations aimed at adolescents and parents, Prior research and survey data and a provider toolkit. While there suggested making vaccinations was solid, varied awareness and use available at local schools to address this of each material by each audience, growing problem. Overall, 80 percent an overwhelming 90.2 percent of of surveyed physicians believed that adolescents who participated in a school-located vaccinations would survey got information about vaccines increase vaccination rates. However, from MDCH, demonstrating the 50 percent of physicians also believed impact and authority of public health that if their patients received school- officials. Research also showed the located vaccinations, it could result in greatest barrier to getting vaccinated increased difficulty ordering vaccines remained patients’ and parents’ and negative financial impact, either lack of knowledge of diseases and from wasted vaccines or patients not vaccines. Other key insights also attending well-child visits. The majority emerged: targeted messages are (71 percent) also believed the practice critical to reaching different audiences would make it difficult to maintain effectively; audiences should be accurate patient records. Increased diverse, including parents, adolescents, efforts to understand and address and supporters; partnerships can physician concerns surrounding school- support increased success; and located vaccinations could result in healthcare providers should serve great physician participation in future as role models and immunization programs. This was seen as a critical advocates. component for success, given the link between physician participation and sustainability in school-located vaccination programs.

ASTHO | IMMUNIZATION RESOURCE GUIDE | 25 childhood and adolescent vaccination

Improving Adolescent significant numbers of cancer Immunization Rates with diagnoses and deaths in South Dakota Friendly Competition could potentially be avoided. (North Carolina, 2011) Spreading the Word, Not The North Carolina Community the Disease: An Online and Health Center Association provided Community-Based Program an overview of the Adolescent (Ohio, 2011) Immunization Competition held to With Ohio’s adolescent immunization increase meningococcal vaccination rates below the national average across rates. Community health centers the Tdap, MCV4, and HPV vaccines, and across the state participated through significant population gaps in coverage, the AFIX process of assessment reports the “Spread the Word, Not the Disease. for initial and follow-up rates, feedback Get Vaccinated” campaign set out to through data, incentives, and exchange raise teens’ and parents’ immunization of best practices. Recruitment was awareness and provide continuing done through an informational education to healthcare providers. The webinar, clinical newsletters, and department and followup via email. Adolescent utilized social media posters embedded with a QR code to immunization rates improved 26 reach teens and parents; a percent overall during the month of mobile site and microsite were built to provide in- April. Success was credited to the AFIX depth information and downloadable process on the provider side, as well as information sheets for parents and direct followup with parents, including providers. The digital components letters and front-desk-initiated were supported by a PSA and a locker phone calls. magnet with a built-in immunization Getting Vaccinated schedule. At the time of reporting, the to Prevent Cancer PSA had received more than 60 million (South Dakota, 2011) views, and there was a steady increase in “likes” and followers on Facebook The South Dakota Department and Twitter, respectively. The Ohio of Health created a parent- and Department of Health noted that all adolescent-friendly information materials were easily customizable, summary outlining the signs and which was beneficial to the program. symptoms of human papillomavirus Obstacles that others may face in (HPV) and urging boys and girls aged running a similar program were 11 to 26 years to get vaccinated. The also noted, including internal policies brief, yet impactful report provided regarding social media, technology, and a detailed look at the toll of cancer staffing limitations. in South Dakota; seven percent of all cancers diagnosed in South Dakota, and 526 cancer-related deaths from 2001 to 2008, may have been caused by HPV. If HPV was prevented,

26 | ASTHO | IMMUNIZATION RESOURCE GUIDE childhood and adolescent vaccination

Providing Guidance on School- Training Presentation by the Based Vaccination Clinics State of Hawaii on Immunization (New York, 2009) and Examination Requirements CDC and the New York State for School Entry (Hawaii, 2013) Department of Health (NYSDOH) To reduce illness and the spread of were concerned that the 2009 disease, Hawaii requires physical H1N1 influenza virus could result exams, tuberculosis exams, and in a particularly widespread and immunizations for all incoming school- severe influenza season. In response, aged students. The only exemptions the New York State Education for these requirements are medical Department and NYSDOH’s Bureau or religious, neither of which apply of Immunization compiled a guide to the tuberculosis exam. The report, on school-based vaccination clinics created in an effort to maximize to provide information for schools student compliance, details more partnering with vaccination providers specific requirements, forms that to conduct H1N1 influenza vaccination need to be completed—including clinics. Coordinating vaccination what to look for to ensure accuracy of students with schools improved and completeness—and reporting efficiency and reduced costs from a processes. public health perspective, increased access to students to provide more vaccinations, decreased burden on local healthcare providers, and reduced school absenteeism for both vaccinated and unvaccinated students. The report details practical steps on acquiring consent forms, providing education materials, and managing a vaccination day, to support effective implementation.

ASTHO | IMMUNIZATION RESOURCE GUIDE | 27 adult vaccination

While vaccinations are recommended a pneumococcal vaccination; the Healthy throughout the lifespan, adult vaccination People 2020 target is 60 percent. Creative coverage remains low for most routinely approaches to adult immunization are recommended vaccines and well below necessary to change the current trend. Healthy People 2020 targets. For example, The examples in this section aim to share only 16.6 percent of high-risk persons programming successes in reaching the aged 18 to 64 in 2009 had ever received adult population.

To see the CDC’s Recommended Immunizations for Adults by age, visit http://www.cdc.gov/vaccines/schedules/downloads/adult/ adult-schedule-easy-read.pdf

28 | ASTHO | IMMUNIZATION RESOURCE GUIDE featured best practices

Assessing the Zoster, Pneumococcal, and Influenza Vaccines with Meals-on-Wheels Recipients

(Utah, 2011) percent to 32 percent. The data showed that 82 percent of Meals-on-Wheels respondents In 2007, a subcommittee of the Utah Adult received the flu vaccine during the 2007-2008 Immunization Coalition was formed to flu season, which decreased to 76 percent promote use of the zoster and pneumococcal during the 2009-2010 season. A similar vaccines. The subcommittee partnered decrease was seen with the pneumococcal with Utah’s Meals-on-Wheels program vaccine, with a 72 percent immunization to engage and understand a homebound rate in 2008, compared with 68 percent in population that was mostly elderly, low 2010. Zoster rates were low at 7 percent in income, and likely to be at high risk for health 2008 and 9 percent in 2010. complications. To reach this population, the subcommittee leveraged an existing Refining survey questions to hone in on the survey, adding information about the zoster best results presented a challenge, as did and pneumococcal vaccines. Aging service securing the participation of aging directors directors were invited to participate in and immunization coordinators statewide. reviewing survey outcomes, as were regional Logistics of survey distribution and collection, immunization program coordinators, who as well as vaccination followup, especially in were asked to support follow-up vaccination urban areas, also strained resources. But, the of respondents. overall effort was worthwhile: The cost was minimal (printing and postage), the survey Over the course of two years, the number of design was refined to be more effective, and districts participating increased by 50 percent, the efforts provided a baseline for awareness with 100 percent participation by 2010. The and vaccination rates in the high-risk group. survey return rate also increased from 24

ASTHO | IMMUNIZATION RESOURCE GUIDE | 29 adult vaccination

Highlighting Demonstrated and engagement activity, the efforts of the six Promising Practices that Improve members made a marked collective impact. Older Adult Vaccination Rates As a result, influenza vaccination rates for (United States, 2012) high-risk adults increased four percentage points, from 53 percent in 2010-2011 to 57 The National Adult Vaccination Program, percent during the 2012-2013 season. led by the Gerontological Society of America, has focused on improving the Seeking to Vaccinate Uninsured immunization rates of older adults. This and Underinsured Adults—and population is at risk for impaired immune Succeeding (Minnesota, 2013) response, medical comorbidities, and more, With no federal program to cover uninsured which can make them more vulnerable and underinsured adults, the Minnesota to vaccine-preventable diseases. A paper Department of Health (MDH) set out to in Policy Aging Report identified four key stabilize vaccine availability for adults by interventions to improve rates: those that awarding vaccines to selected facilities target access, consumer demand, provider through a three-year program, from January systems change, and policy. By focusing 2011 to September 2013. Section 317 on these strategies, supported by a well- discretionary funds were used to purchase planned quality improvement approach the vaccine. They received more than 160 and systematic reviews to measure applications requesting a total of $10 million effectiveness, stakeholders can make a of vaccines; 109 clinics (156 total sites) were marked difference. The paper provided awarded approximately $1.5 million worth more detailed recommendations as well, of vaccine. In year one (2011), hepatitis A, such as rewarding providers for increasing hepatitis B, HPV, MCV4, MMR, PPSV23, Td, their immunization rates and encouraging Tdap, and Varicella were offered. In years the elderly to get immunized at places they two and three, influenza and zoster were already frequent (e.g., the pharmacy). added, respectively. Five key MDH program Harnessing Collective Resources to elements were developed to amplify vaccine Increase Influenza Vaccination Rates uptake: a needs assessment, patient and in High-Risk Adults provider educational resources, resources (Massachusetts, 2013) for the Minnesota Immunization Information Connection, an adult assessment report, and During the 2011-2012 influenza season, the a reminder-recall pilot project. Massachusetts Adult Immunization Coalition worked to increase the influenza vaccination Increasing Influenza Vaccination rates of high-risk adults aged 18 to 64. Among Pregnant Women Coalition members engaged the community (Rhode Island, 2011) through public service announcements, Pregnant women are at increased risk of postcards, e-newsletters, education classes, complications related to influenza. CDC and other key awareness efforts. While recommends that pregnant women get each stakeholder (insurers, public health vaccinated during influenza season; however, officials, and associations) created its own the coverage rate is still low. During the

30 | ASTHO | IMMUNIZATION RESOURCE GUIDE adult vaccination

2009-2010 influenza season, the Rhode increasing education and awareness efforts Island Department of Health explored about benefits of the registry. Ongoing influenza vaccine coverage among communication and education were key, pregnant women within the state to with WSPA staff reaching out to pharmacy identify barriers and facilitators of leadership, sending out emails, faxes, and vaccination during pregnancy. After other materials, and providing education analyzing Pregnancy Risk Assessment to individual pharmacists. At the time of Monitoring System data from 2004-2010, the report, the number of pharmacy user the state found a dramatic increase in agreements for vaccinations had gone from vaccination among pregnant women, from 10 to 27 (chains and local), representing 22 percent in 2004 to 66 percent in 2010, 59 percent of all community pharmacies with the biggest increases occurring in the in Washington. Within six months of 2009-10 season. Seventy-three percent program implementation, one large chain of women who were vaccinated received went from 828 immunizations to 147,055. a healthcare provider’s recommendation. As for smaller pharmacies, 42 percent of Thirty-three percent noted that they did community pharmacies are now reporting not get vaccinated because they were their immunizations to the registry. concerned about vaccine safety for their babies, and 29 percent were worried about Partnering to Increase their own safety. To encourage women to Adult Immunization get vaccinated, the report recommended (Pennsylvania, 2011) educating concerned women about the To increase adult immunizations, the benefits of vaccination. Pennsylvania Department of Health’s Division of Immunizations created an adult Reaching Out to Pharmacists immunization referral program with the Results in Increased Use of Pennsylvania Pharmacists Association Registries (Washington, 2011) and the Pennsylvania Academy of Family In January 2012, the Washington State Physicians. The program identified Department of Health set out to expand and created a list of all pharmacists in the role of pharmacies in providing adult Pennsylvania licensed to immunize. The list vaccines, partnering with the Washington was sent to physicians who, if they did not State Pharmacy Association (WSPA). provide vaccines themselves, could send They received funding from the Adult adults to the pharmacy with prescriptions Immunization Prevention and Public Health to be vaccinated. The program’s benefits Fund Grant, and, with those funds, focused included an increased number of adults on achieving their goal by increasing getting vaccinated, utilizing pharmacists pharmacists’ use of the Washington as alternative vaccinators and ensuring State Immunization Information System. the maintenance of pharmacists’ skills. Program coordinators from the health Pennsylvania noted this program can be department engaged pharmacists directly, easily used by other states, one obstacle

ASTHO | IMMUNIZATION RESOURCE GUIDE | 31 adult vaccination possibly being a lack of third-party by infected adults whose vaccinations reimbursement for vaccines and are not up to date. To address the the administration fees. However, epidemic, the state put $300,000 Pennsylvania was able to resolve this toward increased public awareness and issue through collaboration with their outreach efforts and increased vaccine state insurance department. supply. Provider education focused on recognition of clinical presentation, Increasing Immunization Rates appropriate testing, treatment, and Through OB/GYN Practices prevention. In addition, the health (United States, 2013) department established an incident The American College of Obstetricians command center to coordinate and Gynecologists, in partnership surveillance and response activities. with CDC and ASTHO, launched an Overall, 140 percent more adults were effort to inspire OB/GYN members vaccinated compared with the prior to recommend vaccinations for year (82,453 vs. 34,171 doses). women. Their action plan included Maximizing the Workplace as an development of a website that provides toolkits, immunization alerts, Opportunity for Immunization facts, and vaccine safety information, (Minnesota, 2013) as well as direct mailings to 35,000 OB/ To understand the needs and GYNs on the seasonal influenza and opportunities to vaccinate Tdap vaccines. Through the efforts Minnesotans in the workplace of this program, 19 percent of OB/ setting, the Minnesota Department of GYNs were giving more vaccine doses, Health convened an advisory group, 86 percent of practices identified a conducted a literature review, and vaccine coordinator, and 41 percent reviewed results of two surveys—one were actively working on an office with small businesses (fewer than vaccine program. 250 employees) and one with larger companies. The surveys showed that Using Emergency Resources a majority of all businesses offered to Prevent the Spread of the influenza vaccine (54 percent of Whooping Cough small businesses and 87 percent of (Washington, 2012) large businesses), but only 8 percent Washington state declared a pertussis of small companies and 32 percent of epidemic in April 2012. The number of their larger counterparts offered Tdap. cases had skyrocketed from about 100 Primary barriers for small employers in 2011 to more than 1,100 in 2012, the were employees on varying shifts worst outbreak in Washington since and some rarely at the worksite; large the 1940s. Then Gov. Chris Gregoire employers found time and effort, stressed the need for both children coordination of logistics, and employee and adults to be vaccinated, as the downtime as key detractors. disease is most commonly passed on

32 | ASTHO | IMMUNIZATION RESOURCE GUIDE healthcare provider vaccination

Healthcare Provider Vaccination

Immunization policies, mandates, and Successful healthcare provider vaccination exemptions for healthcare workers vary programs protect individuals who are from state to state. For example, 18 states critical to improving the health of the have no immunization requirements for population across the United States and hospital employees. Of states that do, the its territories. Importantly, successful hepatitis B vaccine is most often offered or healthcare provider vaccination programs required; three states have full influenza protect patients, as well as individuals who mandates. In addition, seven states outline are critical to improving the health of the specific exemption policies for hospital population across the United States and its employees for medical, religious, and territories. This section details some of the philosophical reasons. Twenty states have most effective examples. no requirements for ambulatory care healthcare professionals; among states that have requirements, five states specify exemption policies.

ASTHO | IMMUNIZATION RESOURCE GUIDE | 33 featured best practices

Sharing What Works with Vaccination Clinics for State Employees

(Arkansas, Arizona, Indiana, The other states specifically targeted Utah, 2010) employees in certain areas of the government. The first clinics held in Vaccination clinics are critical in protecting Indiana focused on members of the the health of state employees and the Indiana General Assembly and the health public they serve. The practices of four department. Subsequently, state legislators states in implementing H1N1 clinics in and the health department had their own January 2010 were studied; their methods clinics to expand the offering to a broader differed greatly depending on their group of state employees. Utah held resources and needs. two H1N1 clinics for its state employees, Location was a key driving factor for the first of which was held for health Arkansas and Arizona. The majority of the department employees and their families, Arkansas state employee immunization with proof of insurance. clinics were centralized in government Regardless of approach, the vaccination buildings in Pulaski County, home to the clinics attracted large numbers of state state capital of Little Rock. Arizona aimed employees, potentially due to their central for a broader reach, reaching various locations, accessibility within or near government buildings across the entire employees’ workplaces, and willingness state through a partnership with Benefit to vaccinate family members. In Utah, for Options Wellness, a health insurance and example, more than 1,900 employees and wellness program provider. their family members were vaccinated through these programs.

34 | ASTHO | IMMUNIZATION RESOURCE GUIDE healthcare provider vaccination

Learning From a Strong The challenge helped Maryland public Healthcare Personnel health officials understand that most Immunization Effort healthcare professionals know that vaccinations work. And with a yearlong (Maryland, 2011) program garnering support from senior-most staff and peer-to-peer The Maryland Healthcare Personnel champions, combined with incentives Immunization Initiative (MHCPII), a (large or small), grants, and technical partnership between the Maryland assistance, public health officials could Partnership for Prevention and the build stronger programs to ensure Maryland Department of Health more healthcare personnel were and Mental Hygiene’s Center for successfully vaccinated. Immunization, was created to increase heathcare personnel immunization Providing Data, Examples, rates for recommended vaccines. Templates, and More: Funded by both organizations, the Maryland Healthcare Personnel initiative provides grants, technical Immunization Initiative Toolkit assistance, and resources to support (Maryland, 2010-2011) campaigns and collects data on In 2011, the Maryland Partnership facility-specific vaccination rates. The for Prevention and the Maryland grants funded a variety of projects, Department of Health and Mental including purchasing vaccines, creating Hygiene co-sponsored the Maryland educational materials, and employing Healthcare Personnel Immunization additional staff members. Grantees Initiative toolkit, which aimed to raise and program participants include local awareness, both locally and nationally, health departments, long-term-care about the importance of vaccination facilities, private medical providers, among healthcare professionals. assisted living facilities, and colleges and The toolkit, produced annually since universities. 2005, highlighted several campaigns Among other programs, MHCPII that have successfully boosted developed a toolkit and implemented vaccination among healthcare the Best Practices Challenge, a professionals and provided a check yearlong effort offering grants to list of components utilized by some identify best practices in healthcare of those programs. These included personnel vaccinations. A six-year sponsoring a kick-off event, making review of program activities showed vaccines available to employees on that the most successful facilities all shifts, offering free vaccines toall had common factors, including free employees, and administering vaccines vaccinations onsite, standing vaccine under a standard order protocol (which orders, declination forms to be signed includes requesting staff who decline by vaccine refusers, more than two vaccination sign a declination form that methods for administering vaccinations, includes their reason for not getting more than three methods for promoting vaccinated)—all to increase awareness them, and incentive programs. and vaccination rates.

ASTHO | IMMUNIZATION RESOURCE GUIDE | 35 healthcare provider vaccination

Succeeding with Mandatory The Hospital of the University of Immunization Programs in a Pennsylvania adopted a mandated Healthcare Setting influenza vaccination program in 2011 and saw vaccination rates nearly (Pennsylvania, 2012) double from 54 percent in 2008- 2009 to 99.3 percent post-mandate. In 2011, the Pennsylvania Department The program was established as a of Health released a series of case condition of employment and included studies reporting the positive results all employees, volunteers, students, of several mandatory vaccination and vendors. The hospital provided programs for healthcare employees, a myriad of opportunities to receive in an effort to help others learn vaccines, making them available in all from successes with immunization inpatient units, clinics, and nonclinical mandates. The Children’s Hospital of sites, as well as a walk-in clinic. Philadelphia’s mandated influenza Adding to the success were a detailed vaccination program, during the 2009- exemption process and a strong 2010 season, achieved 100 percent tracking system. In addition, employees participation from its 9,500-person who received vaccinations were given community. Presented as a safety stickers verifying their status, which imperative, the program succeeded were worn with pride. because the hospital defined its target population early and clearly publicized Similar successes in significantly the vaccinations. The local managers increasing vaccination participation provided followup, action plans, and a through mandates are detailed for the robust tracking system to make sure Main Line Health System, the Abington every employee was up to date. Memorial Hospital, and the Geisinger Health System as well.

UNIVERSITY OF PENNSYLVANIA HOSPITAL WORKERS

90% FEEL OBLIGATED TO BECOME VACCINATED 85% THINK VACCINATION SHOULD BE MANDATORY

36 | ASTHO | IMMUNIZATION RESOURCE GUIDE healthcare provider vaccination

Facilitating Mandates to in March 2013, after the widespread Immunize Healthcare Personnel influenza season was declared over. In a Providence Journal article, ES IU (Rhode Island, 2013) noted “the [state health] department agreed to continue to meet with us The Rhode Island Flu Task Force formed to study the issue further and work in August 2011 with approximately 50 towards a compromise. Our hope members, including epidemiologists, is to reach a resolution that helps physicians, nurses, public health to increase vaccination rates while professionals, pharmacists, college and also protecting healthcare workers’ university personnel, and healthcare rights.” That resolution centered on facility administrators. The healthcare the requirement of surgical masks for worker influenza vaccination rate in those not vaccinated. Rhode Island was 65 percent when the group was formed, which sparked Despite the roadblocks, the Rhode a focus on ensuring those who Island Department of Health reported administer vaccinations were up to positive results from the mandate, with date themselves. a 22 percent increase in the healthcare worker immunization rate from the The resulting initiative, launched in previous season (from 65 percent to 87 October 2012, was called “one of the percent) and a 10 percent increase in country’s broadest, most ambitious the general public’s immunization rate measures” to vaccinate healthcare from the previous season. workers by the 2013 Immunization Excellence Awards. The task force drafted regulations requiring that all Educating Child Care healthcare workers be vaccinated, unless they had a medical exemption. Providers Gets Results Later, the rules were amended to add that those not vaccinated were (Washington, 2011) required to wear surgical masks when In 2011, the Immunization Action working with patients. Coalition of Washington partnered with the Snohomish Health District Some obstacles arose during this to create a curriculum and provide a process, including a lawsuit from two free distance learning course for child unions, SEIU and ACLU. According care providers titled “Immunizations: to the ACLU website, the union Protecting Child Care Providers and believed the requirement would Children.” “actually do very little to promote patient healthcare,” while significantly The coursework included information undermining “notions of informed on how immunizations work, vaccine- consent” and eroding “the use of other preventable diseases, vaccine safety, and more effective infection control and requirements in the child care practices.” SEIU dropped its lawsuit setting. Course completion earned

ASTHO | IMMUNIZATION RESOURCE GUIDE | 37 healthcare provider vaccination participants two free continuing vaccines free and widely accessible; education credits, feedback on their mandating education about the risk of course assignment, and a certificate of severe illness to healthcare providers, completion. patients, and their families; providing a live-attenuated influenza vaccine The course dramatically changed option; and offering incentives. Of some people’s views and actions note, mandatory signed declination, and doubled attendance to 574 identified as a strategy that is growing participants by its second year. Of in popularity, was found to have the 460 participants who completed modest success (from 2007 to 2010) evaluations, 16.5 percent said they in increasing influenza vaccination were going to get an influenza shot among healthcare professionals. Most for the first time specifically because studies found that mandatory signed of what they learned in the course. declination may not be effective as a Overall, 70.4 percent reported they stand-alone strategy. would get an influenza shot. Tripling Staff Immunization The most popular response to an open-ended question about what Rates: An Approach participants liked best about the (Texas, 2012) training was what they learned about Nix Health is a hospital system located vaccine-preventable diseases and in San Antonio, Texas. Many Nix Health immunizations. Approximately 98 employees did not get vaccinated percent of respondents said they against influenza because of fears of would recommend the training to contracting the virus. Education and someone else. outreach initiatives led by a registered nurse focused on dispelling that myth Understanding and Addressing and quelling the fears associated Why Healthcare Professionals with it. Nurses provided vaccine to Don’t Get Vaccinated employees using immunization carts (California, 2011) that traveled throughout the facility. In March 2011, the California The program resulted in an increase Department of Public Health’s of employee vaccinations from 35 Healthcare Associated Infections percent in 2005 to 76 percent in Program initiated a review to increase 2010. The number of sick employees the vaccination rate of healthcare dropped by 85 percent within the professionals across the state. The same timeframe. In 2012, Nix Health group explored the reasoning behind achieved an immunization rate of 99 low influenza vaccination rates, which percent. included access, cost, perceived risk of infection, and perceived low efficacy. The group provided several strategies to boost influenza vaccinations among healthcare providers, such as making

38 | ASTHO | IMMUNIZATION RESOURCE GUIDE ASTHO | IMMUNIZATION RESOURCE GUIDE | 39 infrastructure

State health agencies’ ability to quickly departments to community health centers, detect and respond to infectious diseases private providers, and pharmacists. The depends on having a strong infrastructure use of private providers, public health, in place. Infrastructure is the foundation community health centers, and pharmacies for planning, delivering, and evaluating for vaccines can vary greatly state by state. public health. State health agencies For adults, the doctor’s office is the most require effective and efficient systems for common place to receive the influenza preventing infectious disease morbidity vaccine (as seen in 2010-2011), with stores and mortality, ensuring control of (e.g., supermarkets, drug stores) and outbreaks and vigilance against diminishing workplaces the next most common. diseases, and preventing and responding to reemerging and emerging infectious Given the significant amount of collaboration required, creating an disease threats. Advisory committees infrastructure to manage this environment have been effective in developing infrastructure policies to support such is a true undertaking. systems. This section details examples of how states Immunizations are provided and built programs to maximize the delivery of administered by a broad range of critical services within funding parameters. stakeholders, from state and local health

40 | ASTHO | IMMUNIZATION RESOURCE GUIDE infrastructure

Investing in local health departments leads to enormous ‘bang for the buck’ now and in the future. Michigan Association for Local Public Health

ASTHO | IMMUNIZATION RESOURCE GUIDE | 41 featured best practices

Proving the Return on Investment of Vaccination

(Michigan, 2013) in 2009 for the state; influenza vaccinations had an $11 to $1 ROI, with $91 to $141 saved A 2013 report by the Michigan Association per vaccination in direct medical costs. In for Local Public Health (MALPH) explored Michigan, more than 487,990 doses of these key health investments and the value of vaccines were administered by local health public health services. The report discussed departments in 2012. Importantly, these the vital role immunizations play in keeping local health departments recorded childhood the community safe and healthy, as well as immunizations in the state registry, so that the role of local public health departments children who had not received the necessary in educating the public on vaccinations, vaccinations could be easily identified. tracking and reporting the number of people vaccinated, and distributing vaccinations The report also discussed the local for emergency outbreaks. Public health health departments’ speedy and efficient officials’ crucial responsibilities in fighting emergency administration of H1N1 and eradicating deadly infectious diseases vaccinations during the 2009 outbreak. More included public education, administration, than 1,483,000 people in Michigan received technical support, and surveillance and the H1N1 vaccine. To pay for the vaccines, reporting for childhood vaccinations, local health departments received $19 million influenza vaccinations, and emergency NH1 1 in federal emergency funds. Each vaccination vaccinations. cost an average of $13. According to the study, “In 2009, every dollar local health The data showed immunization to be of departments spent on H1N1 vaccinations significant value. MALPH found that the ROI provided up to $11 dollars in direct and for childhood immunizations was $22 for indirect savings.” every $1, with a total savings of $88 million

42 | ASTHO | IMMUNIZATION RESOURCE GUIDE infrastructure

Implementing program, Vermont collects money from Vaccine Accountability: insurance companies based on the share A Comprehensive Effort of Vermont residents they cover. This (Washington, 2012) has reduced overall costs for vaccines, lessened administrative burdens for Washington is a universal vaccine providers, and made it easier for people purchase state, utilizing state, Vaccines to get vaccinated, no matter their for Children Program, and Section 317 insurance status. funds to provide free vaccines to all children under the age of 19. In receiving Approaching an Infrastructure publicly funded vaccines, providers sign at the Statewide Level: Nevada an agreement stating they will abide 2013 - 2017 Five Year Strategic by state and federal accountability Plan (Nevada, 2013) requirements. To monitor progress, state The Nevada State Immunization and local health department staff require Program, funded by CDC, has four monthly reporting from providers and sections: VFC, Special Projects, Perinatal conduct site visits to ensure compliance Hepatitis B Prevention, and Nevada and offer resources to aid in meeting WebIZ, the statewide immunization standards. This model document registry. Ranked 40th among all details different aspects of the state’s states in the immunization of children accountability program, including annual aged 19 to 35 months, the program training requirements for fraud and developed a strategic plan to bring abuse, data tools to ensure immunization rates for this population to at least the of eligible children, and procedures to national average, to improve adolescent vaccine returns for excise credits. immunization rates, and to improve Instituting a New Approach: adult rates for influenza and Tdap Vaccine Purchasing Pool Pilot vaccinations. The program’s approach Program (Vermont, 2011) focused on prioritizing children aged 19 to 35 months, looking at strategic plans Vermont launched its Vaccine Purchasing of other VFC states, recruiting more VFC Pool pilot program in 2009 to provide providers, identifying an immunization universal access to recommended champion, partnering with other public immunizations. The pool allows the health programs, obtaining a CDC health department to buy both adult and public health advisor, and encouraging pediatric vaccines at the lowest possible health plans to promote vaccinations price, administered to anyone who gets to their members. In addition, parent care in Vermont from Vermont-licensed and provider focus groups provided providers. Very detailed implementation insightful recommendations for the procedures on such topics as healthcare plan, from creating a public vaccination practice participation, immunization record portal for parents to improving registry, and insurer participation and the insurance companies’ vaccination fee assessment are presented for reimbursement. providers, Vermont’s immunization registry, and insurers. To fund the

ASTHO | IMMUNIZATION RESOURCE GUIDE | 43 immunization information systems and meaningful use

Doctors’ and hospitals’ use of health infor- effective immunization strategies at the mation technology has more than doubled program and provider levels. Use of IIS since 2012. As of June 2013, more than is on the rise. For example, 19.2 million 309,000 healthcare providers received U.S. children under the age of six (84 payment for participating in the Medicare percent) had data entered into an IIS in and Medicaid Electronic Health Record 2011. That number drops to 53 percent Incentive Programs. This meansmore than for adolescents and 24 percent for adults. half of those eligible to participate have The policy environment supports the demonstrated meaningful use of electronic use of an IIS, with 27 states authorizing health records. an IIS and 14 mandating reporting.

Specific to vaccinations, an immunization The following best practices demonstrate information system (IIS) collects and ways states have achieved successful consolidates vaccination data from uptake of electronic health records and IIS. provider sites, providing important tools and information to design and sustain

44 | ASTHO | IMMUNIZATION RESOURCE GUIDE featured best practices

Improving Data Quality with the Arizona State Immunization Information System (ASIIS)

(Arizona, 2011) through a visit to one pilot site, the ASIIS staff organized the large client list of that Since 1998, Arizona has required reporting site into smaller, more manageable lists; of all vaccines administered to children children under 36 months of age were from birth to 18 years of age through targeted first. This approach was critical ASIIS. ASIIS operates on input from about to success, and ASIIS staff’s offer to code 1,100 provider sites, with 4.3 million records for the provider site further records, using a variety of reporting facilitated cooperation. In less than three methods. Faced with out-of-date records, months, duplicate records were identified duplications, and incomplete records, the and corrections made. OM GE coding also Arizona Department of Health Services supported better completion rates. focused a pilot on its Sentinel Site, seven counties comprised of 185,000 children To identify duplicate records, ASIIS took under age 18, to improve data quality multiple approaches, building off of statewide. its already robust algorithm. Looking for probable matches, criteria such as The Sentinel Site region is a predominantly name, guardian name, mother’s maiden rural area, with little patient changeover name, and address were used. Searching due to limited provider options, and smaller date of birth ranges made outputs many paper reporting sites that do not more digestible. And, looking at factors enter data into ASIIS or track the MOGE such as Social Security numbers and (Moved or Gone Elsewhere) status of their baby identifiers not only helped reduce clients. After finding a significant amount duplication, but also yielded valuable of potentially “non-active” clients (4,500)

46 | ASTHO | IMMUNIZATION RESOURCE GUIDE immunization information systems and meaningful use

opportunities to clean data and ensure Program challenges included migrating birth dose Hepatitis B vaccine records data from the older systems to the were up to date, respectively. While new CIIS system, especially information the process is time consuming process, regarding payor source in relation limiting lists to a manageable size was a to eligibility/funding sources, and a success factor in de-duplication. Other disconnect between the CIIS and VFC lessons learned included the need to sites. This was further compounded automate the generation of tracking by electronic reporting issues, such reports and the importance of working as electronic health records that did with reports most likely to match first. not capture the funding source or VFC eligibility, or disconnects between provider records and clinic workflow.

Implementing Dose-Level While challenging, the review of the Accountability: processes and systems led to overall Opportunities and Challenges process improvement, greater program integration, a formalized evaluation (Colorado, 2012) process, and more open dialogue. Moving forward, CIIS learned that Colorado’s Immunization Information at the very start of entering and System (CIIS) tracks vaccinations across integrating data into CIIS, dose-level 1,600 clinics, hospitals, schools, and accountability needs to be defined and health plans. CIIS administrators set out IIS training for VFC staff must occur. to improve data reporting and dose- In addition, benchmarking data and level accountability for Vaccines for potential programmatic issues need Children providers, who had 70 percent to be examined early, IIS data need to participation rates, compared with 100 be comprehended prior to provider percent participation from public and outreach, communications materials community health providers. Dose- should be crafted jointly by CIIS and level accountability was defined as VFC provider representatives to support eligibility of the patient and the funding understanding, and there should be source used to pay for vaccination at general acceptance of a long, iterative the time of the vaccination. process. To support a stronger system, CIIS administrators issued a CIIS managers recommended inventory benchmarking survey to providers management training, greater and conducted a data review to proactive engagement with providers, determine completeness of the data. and adding electronic health record They found that only 12 out of 126 questions into doctor-patient visits. VFC providers interested in using CIIS for benchmarking had sufficient data.

ASTHO | IMMUNIZATION RESOURCE GUIDE | 47 immunization information systems and meaningful use

Valuing Data in a Disaster: LHCQF worked to integrate LINKS to Louisiana Immunization other provider electronic systems by Network for Kids Statewide July 2012. A hub was developed to link LINKS with the statewide HIE, giving (Louisiana, 2012) providers the option of submitting data to LINKS directly or through the The Louisiana Health Care Quality HIE. Ongoing collaboration from a Forum (LHCQF), a private nonprofit, broad range of stakeholders ensured was formed in the wake of Hurricanes engagement, uniformity of message, Katrina and Rita to address the and forward progress. Efforts are healthcare issues that arose after the ongoing to raise further awareness of storms. LHCQF received funds from LINKS and the opportunities it presents the Office of the National Coordinator for more efficient data management. for Health Information Technology to The program demonstrates why become both a source and a repository integrated electronic health records for Louisiana health information are preferred over older information technology, as well as to develop a systems. health information exchange (HIE).

Before LHCQF existed, the Louisiana Immunization Network for Kids Reducing Vaccine-Preventable Statewide (LINKS) was already in Disease Through Immunization place. LINKS used a simple web-based Registries system to input data, with potential to extend its scope to service all (Michigan, 2012) Louisiana residents, not just children. This program remained functional The Michigan Department of after Katrina, due to backup servers, Community Health’s Division of and was used to help access data Immunization sponsors the Michigan for displaced persons all over the Care Improvement Registry (MCIR), country, saving time, money, and created in 1998 to collect reliable needless vaccinations. Additional immunization information and make it functionality was developed in the accessible to authorized users online. years after Katrina to handle vaccine The online database brings together inventories, ordering, immunization immunization records from multiple data from school nurses, and mass providers, helping to prevent vaccine- events (e.g., the H1N1 pandemic). preventable diseases and over- and under-vaccination, while ensuring providers have access to current patient information.

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As a partner, Michigan’s Health health information exchange and CDC. Information Technology Regional As of spring 2012, approximately 2,167 Extension Center (M-CEITA) providers had tested immunization coordinates and assists with provider data submission. upgrades to electronic health records to facilitate increased use of electronic MCIR credits strong relationships with recordkeeping. A collaboration of the vendor and provider communities MCIR, Medicaid and M-CEITA ensures as key to ensuring success. The intra- state organizational cooperation providers achieve Meaningful Use Stage 1. has helped ensure consistent and effective messaging, and proactive To streamline data collection and communication with vendors and increase submissions, MCIR and providers facilitated participation Medicaid set up a one-stop shop in MCIR. website for providers to test their ability to submit data for any of the three public health measures (electronic lab reporting, syndromic surveillance data, and immunization data). The site was funded by the state Medicaid health IT plan, with additional support from the state’s

“Overall, education, having the right message, and getting it out to the provider and vendor community are the most important,” to ensure the successful achievement of Meaningful Use Stage 1. MCIR

ASTHO | IMMUNIZATION RESOURCE GUIDE | 49 immunization information systems and meaningful use

Using Barcode Scanning Benefitting New York State Technology to Improve Data Health Plans with IIS Data Quality and Efficiency During (New York, 2011) Mass Vaccination Events The New York State Immunization (Wyoming, 2012) Information System N( YSIIS) has The Wyoming Immunization Section been statewide since 2008, with the (WIS) received a CDC grant to enhance exception of New York City. The New the integration of its barcode scanning York State Department of Health functionality into the Wyoming conducted a survey to evaluate Immunization Registry to improve its performance; 11 health plans data quality and the efficiency participated that were not using the of patient-level data during mass system directly (only analyzing data vaccination events. WIS partnered extracted from it). NYSIIS found the with the Wyoming Department of following key benefits may be helpful Transportation to access the two- to communicate when garnering dimensional barcodes on drivers’ support and increased participation: licenses and obtain demographic data • A high level of ease in matching that could be easily cross-referenced clients whose immunization data in the database or used to create a sets were supplied by health plans. new patient record. A broad range Facilitation of outreach of of healthcare providers tested the • members, management of care, functionality, with public health in-house analysis of rates of officials advising, training, monitoring, coverage, and finding gaps in care. and evaluating along the way. At the time of the report, no other state had • Complementary to a pay-for- implemented this technology in a performance program. clinical setting. Benefits included: • Saving time and money. • Reduced costs by saving time on Supporting Better Identification data entry (one provider estimated and Management of Perinatal time was reduced by two-thirds). Hepatitis B Cases • Reduced the burden on staffing (Georgia, 2011) resources. The Georgia Department of Public • Improved accuracy of patient Health created a perinatal hepatitis records. B case management system to • Discovery of other methods improve the identification of hepatitis to improve effectiveness and B infected women and the case efficiency. management of exposed infants. Prior to 2011, hepatitis B lab reports were

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entered manually, pregnancy was with real-time data exchange from vital determined through a separate call to records and Georgia’s Immunization the provider, and then case managers Registry (GRITS), thus reducing burden followed up. A new system was created related to data entry, redundancy, to link mothers’ and infants’ electronic and transcription errors. Additionally, records. Now, infant records, including local health departments can access electronic birth certificate information, the system and document their case are located in the state electronic management activities, and state and notifiable disease surveillance system local departments can jointly view case (SendSS). The web-based perinatal status. module allows for a paperless system

ASTHO | IMMUNIZATION RESOURCE GUIDE | 51 General trends and insights into health information exchange

Identifying the Landscape and characteristics and community Path Forward for the Health needs. Information Exchange Roadmap • Government funds should not be (United States, 2012) depended on to sustain a program; budget and project how funding In April 2012, the National eHealth will be utilized. Collaborative released the Health Information Exchange Roadmap • Value-based (as opposed to volume-based) care models require to provide a “landscape and path widespread, robust HIE. forward” for increased HIE adoption. Although HIE is still in its infancy, it has • Key areas for development include the potential to change and improve business models for sustainability, the way healthcare is administered quantifiable measures of success, and managed. This was brought to best practices for phasing HIE life through nine different programs services, and governance and exchanging health information online, stakeholder engagement. including HealthBridge, which uses standards-based HIE as an intermediary Revealing Secrets of Heath for immunization reporting from Information Exchange Success HealthBridge participants to CDC. These (United States, 2011) programs demonstrated key lessons: In 2011, the National eHealth • The guiding principle in achieving Collaborative conducted a study of 12 widespread HIE use should be enterprises that were seen as leading in to focus on what is best for the the HIE space. In addition to providing patient. profiles on each enterprise, the study identified overarching themes and • Building trust with stakeholders solution trends that have led to HIE and ongoing alignment is necessary success, including aligning stakeholders to delivery. with HIE priorities; maintaining a • There is no one-size-fits-all consistent brand identity and role as approach; determine what model a trusted, neutral entity; and valuing works based on local market an understanding of clinical workflows and managing change. The report of health information exchange. also identified several keys to future Companies that have succeeded in success. Ensuring growth potential was implementing these programs named paramount, with the report noting standardized legal practices and that all 12 successful enterprises were operating systems across partners as poised to grow in and outside of their essential components of an effective respective markets. The strategy for HIE initiative. success was summarized as “innovation, continuous learning, and business Delivering Better Care discipline with the end goal of improving Through Sharing Electronic quality, care coordination, and cost Medical Records effectiveness of healthcare.” (United States, 2012) Breaking Down the Barriers with The Health Affairs Blog featured the one-year anniversary of the Health Information Exchange Care Connectivity Consortium, (United States, 2010) a partnership of five top health An April 2010 article in The Wall Street systems (Intermountain Healthcare, Journal profiled an initiative from three Geisinger Health System, Group Health Colorado health systems to create Cooperative, Kaiser Permanente, and an electronic health record exchange Mayo Clinic) aimed at increasing access program for the exchange of medical to and efficiency of electronic patient records and data of more than a million information. The initiative, described by Colorado residents. Although it was the blog as a “landmark collaboration,” noted that programs such as these was said to be significant because of have consistently improved patient its goal to secure sharing of patient care, at the time of the article, their information regardless of the vendor adoption rate was very low, with 10 used to create the electronic medical percent of hospitals nationwide and records (referred to as “vendor-agnostic less than 7 percent of physicians’ offices modalities”). The consortium was utilizing full-fledged electronic records. praised for its willingness to test data Stephen Lieber, CEO of the Healthcare sharing across proprietary systems with Information and Management Systems its own funds. The article noted that all Society, said that by 2015, “Americans five members view the funding as an ought to be able to expect there will investment because increased access to be a relatively widespread exchange electronic medical records resulted in of health information in a safe and better patient care, lower overall costs, secure way.” Privacy concerns and and fewer medical mistakes. interoperability were named as two hurdles for nationwide adoption communication

Communication is a critical component 2010 California pertussis outbreak, where to ensuring the public understands the there were 9,477 confirmed, probable, importance of vaccination and takes action and suspect cases. The coalition set out to protect themselves and their loved to educate drivers of public opinion, ones. With the number of information legislative staffers, providers, and media, sources expanding exponentially due as well as to support public health officials’ to the explosion of online resources media and marketing efforts. Traditional and social media, the rising influence of and social media were both used, which peer-to-peer communication, and a 24/7 supported the enactment of a mandatory dialogue representing all points of view, the vaccination law for students in grades seven communications environment has never to 12 for 2011; since 2012, the mandate been more challenging. has been narrowed to seventh graders. Success in reaching target audiences was In addition to ASTHO’s communications credited to consistent messaging, statewide toolkit, the examples in this section cut media events during the school year in through the communications clutter to collaboration with the department of reach their target audience effectively and education, multichannel outputs (e.g., PSAs, increase vaccination rates. web banners, billboards), and working with Delivering on Communication professional associations. Strategies and Partnerships During Using CDC Content: Low-Tech, California’s Pertussis Epidemic Quick-to-Implement Tools for Web (California, 2011) Sites (United States, 2011) The California Immunization Coalition, CDC has noted that it is far easier for a statewide nonprofit engaged in state and local health professionals to advocacy and education, presented its utilize free CDC resources, especially communications strategies from the

ASTHO | IMMUNIZATION RESOURCE GUIDE | 55 communication web-based communications, than to • Enable easy file sharing among the develop separate materials and tools team with a central email account. with their own limited resources. • Hold a facilitated brainstorm CDC’s materials are simple to use and session(s) to map out strategy and can easily be integrated into existing execution. resources. In particular, CDC presents Maximize productivity with smaller, all its resources and instructions • in very user-friendly language, to focused teams and clear roles. leverage on an organization’s own • Be creative and unique with a fun web site. This content syndication and catchy platform/tagline. is already being used and tested in • Focus on achievable goals with a 47 states, including content to inform collaborative group. the public about immunization options, Track results and manage centrally guide health professionals on reaching • with existing digital tools. their audiences, and facilitate website development (e.g., web buttons, RSS Delivering Plain Talk on Complex feeds, widgets). Topics (Washington, 2011) Showing How to Succeed The Washington State Department at Social Media of Health shared best practice (United States, 2011) communication tips based on its experience engaging with the public. The Immunization Action Coalition This was brought to life with examples created a “Real Guys Immunize” of effective and ineffective word campaign in 24 hours to encourage choices commonly used related discussion around the role of men in to immunization, such as “germ” their family’s health. The topic was vs. “pathogen” or “tracking and determined after a crowdsourcing monitoring” vs. “surveillance.” The exercise with health communication department emphasized several key professionals from the California tips in both developing programs and Department of Public Health, drafting content: Immunization Branch, GAVI Alliance, Colorado Children’s Immunization • Partner with an in-house Coalition and BC/DC Ideas. The social communications expert. media awareness campaign took place • Leverage relationships with just before Father’s Day and the World relevant people and organizations. Cup and delivered engagement across multiple platforms. Facebook fans went • Plan early and seek ongoing peer up 224 percent, Twitter followers 138 and target audience feedback. percent; content received 800 YouTube • Be aware of your audience. views and 5,461 webpage views. The • Be concise in your message (think coalition credits its results to several sound bites and elevator speeches). key learnings:

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• Imagine you are speaking to the toolkit’s objectives were to help schools reader when writing. prepare for and organize school-based • Be careful with your word choice, influenza clinics, inform parents and favoring simpler and fewer words. students about the benefits of school- based clinics, and clearly state the Talking to Parents About importance of vaccinating children Vaccines: Communications Tips against influenza. Materials ranged from (California, 2012) recruitment and announcement letters to promotional posters and signage In January 2012, the Los Angeles County and a frequently asked questions Department of Public Health released document. The toolkit’s documents a set of guidelines to help healthcare are customizable and printable, so that providers discuss vaccinations with users can insert relevant information parents, particularly those considering about their school, partners, and clinic not vaccinating their children. The dates. guidelines, part of the county’s Immunization program, identified Reaching and Engaging “effective, empathetic communication” Diverse Communities: as a critical component in engaging Flu Vaccine for Everyone! unsure parents. The resource provided (Massachusetts, 2011) seven tips for healthcare professionals to create an open and honest dialogue The Massachusetts Department of with parents, including “take time to Public Health created the Flu Vaccine listen,” “solicit and answer questions,” for Everyone! Flu Outreach Guide to and “use a mix of science and personal help public health officials reach racial, experience.” Model supporting ethnic, and linguistic groups that are resources listed included those from the commonly difficult to access. Many American Academy of Pediatrics, the of these groups are underserved California Immunization Coalition, The and have greater vaccination needs Children’s Hospital of Philadelphia, compared with the general population. CDC, Every Child By Two, and the To be effective, the guide encourages Immunization Action Coalition. public health officials to tailor specific communications and work with the Implementing a School-Based community organizations and leaders Flu Clinic: Promotional Toolkit who regularly reach these populations. (New Hampshire, 2013) These include libraries, local politicians, spiritual leaders, business owners/ The New Hampshire Immunization leaders, local community groups and Program’s Vaccinate for Life! campaign social workers, and mentors (e.g., compiled the 2013 School-Based coaches, PTA leaders). A supporting Flu Clinic Promotional Toolkit, made strategy recommends holding available on the New Hampshire large public events and leaving Department of Health and Human assumptions about these groups Services’ website, for schools to utilize behind when engaging (which is why in their communication efforts. The

ASTHO | IMMUNIZATION RESOURCE GUIDE | 57 communication engaging community leaders is so educational games, videos and an important). The guide also included immunization rap song, along with communications templates and helpful supporting educational materials for partners’ contact information. parents. The Preteen Vaccine Week Kit also includes immunization factoids, Providing a Range of promotional tools, and classroom Tools/Publications on activities for sixth and seventh grade Immunization Services teachers. It is estimated that the 2011 (Massachusetts, 2005-2012) Preteen Vaccine Week efforts helped to Masspro, a private company that support the immunization of 3 million focuses on promoting healthcare students during the 2011-2012 school quality, provides a variety of year. immunization tools and publications Informing Providers and to facilitate adult immunization in Patients: HPV Resource Guide community, hospital, home health, nursing home, and physician practice (Oregon, 2013) settings, as well as underserved The Oregon Immunization Program populations. Topics range from the created an HPV Resource Guide for informational (e.g., vaccine-preventable providers and patients that centralized diseases) to the actionable (e.g., how to information and resources on HPV set up clinics). There are more than 40 and cervical cancer. Its depth of resources, including presentations from information—from basic overviews to past events, toolkits, and education and Q&As, audience-specific resources, training resources. Funding to develop and calls to action—leveraged existing these materials came from the Centers resources from organizations such for Medicare and Medicaid Services, as CDC and HHS and the Oregon the Massachusetts Department of Immunization Program’s own content. Public Health, and educational grants By ensuring materials would address from pharmaceutical firms. a broad audience, including both men and women, with some content in Reaching Adolescents: Preteen Spanish as well as English, the guide was Vaccine Week Campaign Kit created for the broadest set of patients, (California, 2012) with private and public providers, To promote vaccination against schools, and community clinics in mind. pertussis, California holds an annual Preteen Vaccine Week in February. The California Department of Public Health recommends that all Californians aged 10 and older get Tdap; state law requires all incoming seventh graders receive the shot before starting school. Preteen Vaccine Week resources were created to engage tweens directly, including an interactive website with

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