Universal Influenza Vaccination Challenges and Logistics: Children October 25, 2005

1. Universal Influenza VaccinationChallenges and Logistics: ChildrenOctober 25, 2005 Peter G. Szilagyi MD, MPH Professor, Department of Pediatrics Univ. of Rochester School of Medicine

2. Challenges & Logistics for Children • Where could children receive flu vaccinations? • Vaccinating in the medical home • Vaccinating outside the medical home • Other medical sites • Non-medical sites: schools, other

3. Three Age Groups Among Children • Three major age groups • Preschool: 0 -- 4.9 yrs • School age: 5 -- 17 yrs • Older teens: 18 -- 21 yrs • These age groups differ by: • Use of healthcare -- medical homes, other sites • Use of non-healthcare settings • Insurance

4. Vaccinating in the Medical Home

5. Percent of Children with a Usual Source of Healthcare (US, 2002) Analysis of 2002 MEPS Percent Facility= CHCs, PHCs, hospitals , Multi-specialty(mostly Pediatrics) Pediatricians and Family MDs are critical. Many older teens do not have medical homes

6. Average Number of Visits Per Year By Older Girls (US, 2000-02) Analysis of NAMCS and NHAMCS (2000-02) Number of Visits in USA (Millions) Younger teens: Most visits to Peds + Family MD Older teens: Peds + Family MD not as important Lots of GYN visits for girls

7. Medical Homes for ChildrenBy Major Age Group • Preschool (0-4.9yrs) • Most have a medical home • Pediatricians and Family MDs are critical • School age (5-17.9 yrs) • Most still have a medical home (Peds + Family MD) • With increased age: less Peds, more Family MD • Older adolescents (18-21 yrs) • Only 60% have a medical home • Very little Pediatrician involvement • OB/GYN’s are very important for females

8. Medical Homes for Children: Visits during Flu Vaccination Season How often do children visit their medical home during influenza vaccination season?

9. Percent of Children with > 1 Health Care Visit During Flu Vaccination Season(US, 2002) Analysis of 2002 MEPS: Visits during Oct-Dec Age Most children would need > 1 extra visit during flu vac. season

10. Percent of Children 6-23 Months Needing More Visits for Flu Vaccinations If flu vaccination season is October - December Percent Many children will need 1-2 additional healthcare visits. ‘Important to use all visits as opportunities for vaccination.

11. Challenges For Influenza Vaccinationin Medical Homes • Costs for practice & parents • Vaccine supply issues • Perceptions of MDs, nurses, parent • Office-based challenges • Identifying who still needs vaccination, who needs 2nd one • Competing priorities (acute care, other preventive measures) • Flu vaccination is during busiest time • Many patients to vaccinate in short time period Potential show-stoppers

12. Time Spent for Flu VaccinationsOlder Children with Asthma • All visits were interspersed with other visit types • Urban= twice as long • Vaccination only 2 minutes • Waiting = 80-90% of time • RN or MD exam in 10% Minutes Current processes are inefficient; New strategies are needed (e.g., vaccine-only hours)

13. Strategies for Health Providers:All consume time! • Policies and overall strategy • Develop & review practice policies & procedures before flu season • Appoint a leader & team, use toolkits (e.g., NFID), revise strategy, plan • Increase patient demand • Use patient tracking, reminder & recall (including the 2nd vaccination) • Improve office systems and efficiency • Establish influenza vaccination clinics or hours ( perhaps weekly) • Use all existing healthcare visits: Provider prompts & Standing orders • Flag charts of children needing flu shots (if not universal) • Vaccinate as long as possible (January) • Measure your flu vaccination rates (monthly audit and feedback) • Educate office staff so all providers recommend vaccination MMWR 1999;48: (RR-8)

14. Effectiveness of Patient Reminder/Recall For Influenza Vaccinations Odds Ratios(95% CI)for Intervention vs Control (RCTs) # Studies 2 11 Odds Ratio – Up to Date Szilagyi JAMA 2000

15. Vaccinating Outside the Medical Home

16. Other Medical Sites Serving Children at High Risk • Specialty Clinics • <5% of children seen there during vaccination season • Emergency Departments (EDs) • Only 3% of children during Oct – Dec 2002* • Hospitals • < 1% of children during Oct – Dec 2002* • Others (e.g., teen clinics) • Serve specific age groups * Analysis of MEPS 2002 These other healthcare sites will not capture a large percent of children.

17. Other Medical Sites Public Health Clinics • Strengths • Vaccinations are a core function • Personnel are well trained in fine points of vaccination • Linkage to registries and other systems • Challenges • Ability to handle the volume • Not uniformly functional from state-to-state

18. Non-Medical Sites:Schools • Age Groups • Preschool: 0 - 4.9 yrs Preschool (ages 3-4) • School age: 5 – 17 yrs Most children • Older Teens: 18 – 21 yrs College • Possible types of involvement • Education about influenza vaccination • Administration of vaccine • School requirements? • MD opinions of school-based vaccinations • Generally favorable, most request records (e.g., registry) • Little is published For school-aged children, schools could best capture the population

19. Non-Medical Sites:Schools (Continued) • Challenges to vaccinating in schools • Insufficient staffing to provide vaccines to large numbers • Consent and confidentiality • Follow-up (side effects, etc) • Practicality- especially if no school-based clinics • Communication- back to medical homes • Costs and reimbursement • Opposition by some parents and providers • What about parochial schools, home-schooling? Using schools as the main strategy is easier said than done

20. Other Non-Medical Sites Little is known about flu vaccinations • Preschoolers • Childcare centers (60% in child care, 13% in childcare centers) • Older Teens • Colleges (32% of 18-21yr olds) • Workplace • All Ages • Pharmacies • Public places (malls, supermarkets, etc)

21. Overall Strategies • Healthcare sites • Focus on primary care providers • Preschool: Pediatricians and Family MDs • School age: • Older teens: also OB/GYN, Internists • Consider other health sites, but large effect is unlikely • Non-healthcare sites • Schools • Childcare sites • Strong role for public health to monitor & vaccinate • Need denominators (registries, other systems) • Role of public education to increase demand

22. Gaps in Knowledge • Provider and parent perceptions of universal vaccination • Implementing best practices by age on a large scale • E.g., flu vaccination hours, reminder/recall, standing orders • Effectiveness of vaccinating in non-healthcare settings • Vaccinating challenging subgroups • Older adolescents (>16 yrs) • High-risk children not served by traditional systems • Studies of burden of disease, vaccine effectiveness (to convince providers and the public)