Building a Better Tomorrow

1. Building a Better Tomorrow (Rah, Rah, Vaccines!) Christoph Diasio MD FAAP Sandhills Pediatrics Southern Pines NC

2. Disclosures • I do not intend to discuss any unapproved uses of vaccines. • I do not have any financial interests in vaccine companies.

3. The value of vaccines • One of the greatest achievements of human beings in our time on Earth • Responsible for a greater reduction of suffering than anything except modern sanitation • We have the best thing imaginable, an almost magic shield against horrors, and some parents don’t want it because of what they read on the INTERNET ??

4. Why do I care? • To be the parent/physician/nurse to a child is think about the potential of that life • I watched children die and suffer horribly from vaccine preventable diseases and we have the tools to prevent this

5. Julie • Otherwise healthy 2 yo girl from Mississippi • Seen by PCP, dx pneumonia, appropriate abx  worse, admitted c approp. inpatient abx.  worse, flown to us at LeBonheur Children’s (Memphis) • 6 chest tubes, oscillator vent.

6. Julie • Original blood culture- Strep pneumoniae (sensitive to EVERY abx tested) • From Mississippi, so they had not started PCV7 yet. • Likely a preventable illness • Survived! A HUGE save!

7. Seriously, you want to believe Jenny McCarthy? • How do I argue with a media personality? • Lots of ways to approach the anti-vax/vax hesitant. Start by asking why? • The most effective technique is to explain to them that “my children and every child of the staff in this clinic is UTD on the _standard_ schedule”

8. Dr Bob • The Starbucks theory of Vaccinology • If it is different for my unique child, it must be better! (does the half-caf., twist of lemon, frappucino _really_ taste that much better?) • Modern vaccine schedule is NOT an accident- the conclusion of literally 100’s of person-years of research and evidence • Dr Bob- It’s just his opinion

9. History context • Smallpox was an unbelievable scourge of humanity • So awful that people would voluntarily infect themselves (variolation) with smallpox hoping for a milder case • Cowpox/Edward Jenner- major success but rapid pushback against compulsory vaccination

10. Polio • Killed and crippled 1000’s of children in America alone • Cutter lab incident- in rush to distribute vaccine post the initial Salk trial, manufacturing error led to infected children from the vaccine • Modern genesis of anti-vax themes in America • Govt is hiding info • Conspiracy btw docs/pharma/gov’t

11. Disparate timing of flu vaccine delivery VFC vs private • Section on Practice mgt of AAP listserv • #1 topic is flu vaccine- delays in delivery, cost, wastage etc • Last season multiple complaints on listserv about delays in VFC vax • webbased convenience sample survey done • Significant variation btw delivery of 1st shipment private vs VFC vaccine BY STATE • Presented poster at National Immunization Conf. in DC

12. Disparate Timing In the Delivery of Influenza Vaccine In Pediatric Offices • Tuesday, March 29, 2011 • Elizabeth Sobczyk, MSW, MPH , Manager, Immunization Initiatives, American Academy of Pediatrics • Christoph Diasio, MD, FAAP , Pediatrician, Sandhills Pediatrics, Inc • Background:  Children who receive Vaccines for Children (VFC) influenza vaccine are less likely to be immunized than their privately insured counterparts. There is also evidence that administering vaccine in September and October saves $6-9 million annually. Due to additional distribution steps, VFC vaccine may be shipped later than privately purchased vaccine. Delays in VFC vaccine delivery create a disparity of care and place an extra burden on pediatric practices. • Objectives:  To assess the difference in the timing of VFC and privately purchased influenza vaccine delivery to private pediatric offices. • Methods:  In November 2010, a geographically diverse convenience sample of approximately 800 pediatricians was asked to complete a web-based survey.  Physicians were ask to provide the exact date of delivery for their first shipment of VFC and privately purchased influenza vaccine. • Results:  Fifty-seven pediatricians in 24 states completed the survey. The difference between mean first delivery date of VFC and private multidose vaccine is 4 weeks; between VFC and private preservative free vials is 4.5 weeks; between VFC and private FluMist is 6 weeks. Although many states only had 1 respondent, several state-level observations were made. Five states (IL, PA, NY, NJ, and MD) received VFC influenza vaccine 6-12 weeks later than privately purchased vaccine.  Three states (TN, NC and WA) did not report similar relative delays. North Carolina received VFC vaccine as early as privately purchased vaccine but in small shipments. • Conclusions:  In this limited sample, the delivery of VFC vaccine lagged behind that of privately purchased vaccines, yet state-level variability exists. This variability appears to be, in part, due to state-level ordering and distribution practices, creating disparity in care. States who distribute vaccine efficiently should share best practices with other VFC grantees.

13. Flu vax delivery • Some states 9 weeks disparity! • (In NC ours arrived before private vax!) • Conclusion was state-level ordering practices are responsible • Federal system- CDC grants vax to states who determine who gets what when • Effective state govt is good!

14. Flu disease can be bad • 6 yo presented to ER- looked slightly dry, ER doc calls for admission • On arrival to floor, arrests • Code unsuccessful

15. How do we get to scale for flu vax? • Huge challenge! Vaccinate almost entire patient population, but have private and VFC stock, and you won’t know when you will get what!

16. Ideas we tried Saturday flu only clinic • Tent in parking lot- exam rooms with a nurse per room • Night clinics • Express lane clinics • 1 nurse who only gives flu vax all day long • Add-on flu vax form

18. Online scheduling • We gave over 8000 doses of flu vaccine last year- if even a fraction of those appts are made via internet, decreases call volume

23. Measure what you do, and improve! • Can’t manage what you can’t measure! • P-lan • D-o • S-tudy • A-ct • Continuous Quality improvement • What works well in your clinic? What are the barriers? Experiment and innovate!

28. Storage • Vaccines are worth a lot of money! • Need a temp. monitor/alarm system that measures liquid/glass bead temp in fridge (less swing than air temp c opening door) • Consider a “purpose built vaccine fridge/freezer” non-household fridge - you get what you pay for! Need insurance to replace loss in case of fire, fridge death, fridge freezes vax, or HUMAN ERROR (door left open) -ask insurance co rep. “what could happen to make your company not pay my claim” and file that email away somewhere safe…. -may need a fridge maintenance contract!

29. A real vaccine fridge

33. Varicella is NOT benign! • Many parents (and some docs) think of varicella as a “benign rite of childhood” • Pre-vaccine, 4 million cases with 100 deaths/yr • Superinfection with bacteria can be deadly • M-R-S-A widely prevalent now!

34. Superinfected Varicella

35. VPDs are horrible • Keep fighting the good fight • Vaccination is the best way to protect tomorrow Keep building a better tomorrow!