Federal and State Vaccines For Children (VFC) Updates

Objectives

• NCIRD Goals and Objectives• Federal Vaccines For Children Program• Texas Vaccines For Children Program• Coverage Levels- Pediatric• Coverage Levels- Teen• Influenza Update

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National Center For Immunization and Respiratory Diseases (NCIRD)

NCIRD Goals and PrioritiesStrengthen domestic

immunization program

Accelerate development and introduction of new

vaccines

Innovate through improved use of technology and

systems

Protect Americans from influenza threats

Improve prevention, detection and response of

respiratory diseases

Nourish a culture that makes NCIRD the

Healthiest Organization

NCIRD Goals and PrioritiesStrengthen domestic immunization program• Strengthen collaboration and coordination with immunization awardees

• Improve lagging immunization coverage across the life span

• Address rural and urban disparities• Evaluate system barriers to maternal immunization

• Integrate vaccine registries as a core component of the public health immunization program

NCIRD Goals and PrioritiesAccelerate development and introduction of new vaccines• Implement and evaluate the new zoster vaccine• Develop the evidence base to support decision making for priority vaccines under development

• Evaluate new platforms for study of viral and bacterial disease vaccines

• Maximize the impact of current and future vaccines for pertussis control

NCIRD Goals and PrioritiesInnovate through improved use of technology and systems• Evolve methods for monitoring national, state and local immunization coverage

• Improve usability and availability of vaccination coverage and surveillance data

• Improve integration of epidemiology and laboratory data including genomic sequencing data

• Modernize NCIRDs approach for online content

NCIRD Goals and PrioritiesProtect Americans from influenza threats• Determine the comparative effectiveness of influenza vaccines

• Reshape global surveillance to detect novel influenza viruses with pandemic potential

• Improve pandemic preparedness in the US through exercises and evaluation of non-vaccine interventions (antivirals, RPDs)

• Improve selection and production of influenza vaccine viruses

NCIRD Goals and PrioritiesImprove prevention, detection and response of respiratory diseases• Develop and implement an integrated global health strategy

• Improve rapid diagnostics for legionella from environmental samples

• Diversify partnerships for prevention and control of respiratory diseases

• Optimize use of respiratory diagnostics with domestic and global public health partners

NCIRD Goals and PrioritiesNourish a culture that makes NCIRD the Healthiest Organization• Implement a comprehensive strategy that develops and strengthens the NCIRD workforce

• Ensure capacity for continuous evaluation and improvement of operations

• Improve internal communications throughout NCIRD

• Cultivate an open, inclusive and diverse work environment

Vaccines For Children (VFC) Program

Vaccines for Children: 25 years of protecting America’s children

CDC estimates that vaccination of children born between 1994 and 2018:• Prevent 419 million illnesses• Prevent 26.8 million hospitalizations• Help avoid 936,000 early deaths• Save nearly $406 billion in direct

costs and $1.88 trillion in total society costs

• Every dollar spent in childhood vaccination ultimately saves $10.10.

Childhood Immunization Provides Big Savings

VFC Program History

• Congress created the VFC program in response to the 1989–1991 measles outbreak in the United States, at a time when vaccination coverage was low. The measles epidemic resulted in tens of thousands of cases and hundreds of deaths

• The VFC program was created as part of the Omnibus Budget Reconciliation Act of 1993. It was established as a new entitlement program required to be a part of each state’s Medicaid plan. The VFC program is a Title XIX Medicaid program.

VFC Program History• Section 1928 of the Social Security Act (42 U.S.C.§1396S) provides the legal authority for the VFC program by requiring each state to establish a program for pediatric vaccine distribution to registered providers. It provides authority for purchase of vaccines for administration to eligible children using federal Medicaid and state funds (including 317).

• VFC was officially implemented in October 1994 as part of the President’s Childhood Immunization Initiative.

• The VFC program is available in all 50 states, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands.

VFC Program Funding

• Funding for the VFC program is approved annually by the Office of Management and Budget (OMB)

• The funds are allocated through the Centers for Medicare and Medicaid Services (CMS) to CDC

• The CDC awards VFC funding through a cooperative agreement to 61 state, local, and territorial immunization programs.

VFC Program Oversight• The VFC program is administered at the national level by CDC through its National Center for Immunization and Respiratory Diseases (NCIRD).

• CDC is the lead agency responsible for VFC policy development and national program oversight.

• CDC’s immunization program awardees manage and implement a VFC program in their state, city, or territory.

• NCIRD’s Immunization Services Division (ISD) provides technical assistance to awardees.

VFC Program Highlights

• VFC benefits an estimated 40 million children

• Approximately 38,000 enrolled health care providers

• 61 VFC state, local, and territorial immunization program awardees

• Approximately 79 million VFC vaccine doses distributed in 2018

Vaccines Licensed and Added As General Recommendations• Pediatric Vaccine

• Pertussis (1914)• Diphtheria (1926)• Tetanus (1938)• Polio (OPV-1955) and (IPV-2000)• Measles (1963)• Mumps (1967)• Rubella (1969)• Hib (infant)- (1989)• Hepatitis B- (1991)• Varicella (1996)*• Pneumococcal Conjugate (2001)*• Pneumococcal Polysaccharide (2002)*• Influenza (2002)*• Hepatitis A (2006)*• Rotavirus (1998-1999)*

DTP (1948)DTaP (1997)*

• Adolescent Vaccine• Tdap (2006)*• Meningococcal (2005)*

• Men B (2016)*• HPV (2011)*

First Annual Pediatric Schedule: 1994First Adult Immunization Schedule: 2002First Catch-up Pediatric Schedule: 2003First Separate Adolescent Schedule: 2007First Catch-up Adolescent Schedule: 2007

* Vaccines added since start of VFC Program

1994 ‘First’ Immunization Schedule

Vaccines Available to Infants, Children and Adolescents (1994 and 2019)

• 1994 (9)• Measles• Rubella• Mumps• Diphtheria• Tetanus• Pertussis• Polio• Hib (infant)• Hepatitis B

• 2019 (16) • Measles• Rubella• Mumps• Diphtheria• Tetanus• Pertussis• Polio• Hib (infant)• Hepatitis B

• Varicella• Pneumococcal

Disease• Influenza• Hepatitis A• Meningococcal

• MCV4• Men B

• Rotavirus• HPV

2019 Immunization Schedule

TEXAS Vaccines For Children (TVFC) Program

Difference Between Federal and Texas VFC Programs

Federal VFC Program Includes• Medicaid• Uninsured• Underinsured children seen at a FQHC/RHC or

DSHS Regional or Local Health Department Clinic• American Indian/Alaskan NativeTexas VFC Program (expansion of Federal VFC Program)• CHIP• Underinsured children served in private sector

Texas VFC- 2020 (Children 0-18 years)

Total Texas Population (0-18) 8,368,518 Percent

1. Children enrolled in the Medicaid 2,946,397 35.21%2. Children that are American Indians/Alaska Natives 147,934 1.77%3. Children without health insurance 904,655 10.81%

Underinsured and VFC Eligible4. Children served in Federally Qualified Health Centers 159,011 1.90%5. Children served by Delegated Authority 4,432 0.05%

Sub-total FEDERAL VFC Eligible 4,162,429 49.74%

6. Children underinsured in private sector* 56,520 0.68%

7. Children with CHIP* 378,971 4.53%Sub-total Additional State (TVFC) Eligible 435,491 5.20%

TOTAL FEDERAL (VFC) & STATE (TVFC) Eligible 4,597,920 54.94%8. Privately Insured (does not include private CHIP) 3,770,598 45.06%

*Additional 435,491 (5.2%) Non-VFC Eligible Children (CHIP and Underinsured) are Texas VFC Eligible

Children 0-18 VFC and Non-VFC Eligibility By Category

Medicaid eligible35%

American Indians/Alaska

Natives2%

Uninsured11%

FQHC2%

Delegated Authority (DA)

0%

CHIP (private insured S-CHIP)

4%

Underinsured at non-DA sites

1%

Fully, privately insured45%

Goals of Texas Vaccines For Children Program

• Ordering vaccines in the appropriate quantities (per provider profiles)

• Storing and handling vaccines appropriately (minimizing transfers and borrowing)

• Screening clients for VFC Program eligibility (documentation critical)

• Recruit/enroll new provider’s and sites• Continue to strive to increase children

and adolescent immunization rates

DSHS Health Service Regions

Texas VFC and Adult Safety Net (ASN) Providers By Region (October, 2019)

Region Total Sites Pedi Pedi/Adult Adult OnlySAMHD 161 127 29 5

1 149 119 28 22 90 64 26 03 585 524 48 134 154 125 24 55 94 71 22 16 217 178 38 17 333 231 92 108 168 125 42 19 100 78 20 210 131 106 18 711 436 363 64 9

COH 296 256 36 4COH-Harris County 210 195 13 2

TOTAL 3,124 2,562 500 62

TVFC and ASN Providers 2015, 2017 and 2019

Region June 2015 August 2017 April 2019 October 2019HSR 1 163 158 145 149HSR 2 103 90 93 90HSR 3 663 597 563 585HSR 4 168 166 162 154HSR 5 115 98 93 94HSR 6 400 201 204 217HSR 7 354 339 332 333HSR 8 180 165 164 168HSR 9 104 107 101 100HSR 10 129 130 125 131HSR 11 466 439 428 436

COH 347 488 493 506SAMHD 174 160 157 161Total 3,366 3,138 3,060 3,124

Initiated TVFC Provider Recruitment Campaign 3/2019

TVFC Recruitment Resources

CDC National Immunization Survey

Childhood Coverage Levels

2017 NIS-Childhood Overview

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• The 2017 survey assessed children who were born between January 2014 and May 2016.

• The NIS-Child uses a random-digit–dialed sample of telephone numbers followed by a mail survey of the children’s vaccination providers to collect immunization information.

• NIS-Child results can be compared to the Healthy People 2020 (HP 2020) goals for immunization coverage among children.

• For 2017, coverage rates were reported for US, Texas, and the selected jurisdictions of Bexar County, City of Houston, Dallas, Travis, and El Paso County.

2017 NIS-Childhood Overview

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The following vaccine doses routinely recommended for children 19-35 months were measured in the 2016 NIS-Child:• Diphtheria and tetanus toxoids and acellular pertussis vaccine

(DTaP/DT/DTP)• Poliovirus vaccine (Polio)• Measles or Measles-Mumps-Rubella vaccine (MMR)• Haemophilus influenzae type b vaccine (Hib)• Hepatitis B vaccine (HepB)• Varicella vaccine (Var)• Pneumococcal conjugate vaccine (PCV)• Rotavirus vaccine (ROT)• Hepatitis A vaccine (HepA)• Influenza vaccine (reported separately through NIS-Flu)• 4:3:1:3:3:1:4* series

*4+ DTaP, 3+ polio, 1+ MMR, 3 or 4 doses Hib, depending on vaccine type, 3+ HepB, 1+ Var, and 4+ PCV

2017 NIS-Childhood Results

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VaccineU.S. National Average 2017

Texas 2015

Texas 2016

Texas 2017

≥4 doses of DTaP 83.2% 82.1% 81.3% 81.2%≥3 doses of Polio 92.7% 92.5% 90.1% 93.1%≥1 dose of MMR 91.5% 92.5% 89.8% 90.3%Hib† 80.7% 80.4% 80.0% 80.9%≥3 doses of HepB 91.4% 90.7% 88.3% 90.1%HepB birth dose§ 73.6% 76.4% 75.2% 76.3%≥1 dose of Var 91.0% 92.3% 90.4% 89.1%≥4 doses of PCV 82.4% 83.3% 82.4% 83.0%≥2 doses of HepA 59.7% 64.6% 60.5% 62.7%Rotavirus¶ 73.2% 75.7% 72.7% 76.0%

4:3:1:3†:3:1:4 series* 70.4% 71.2% 69.5% 67.8%

*4+ DTaP, 3+ polio, 1+ MMR, 3 or 4 doses Hib, depending on vaccine type, 3+ HepB, 1+ Var, and 4+ PCV

2017 NIS- Childhood Results (Texas Sites)

36*4+ DTaP, 3+ polio, 1+ MMR, 3 or 4 doses Hib, depending on vaccine type, 3+ HepB, 1+ Var, and 4+ PCV

70.4% 67.8%74.3% 75.6%

66.2% 65.6% 66.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

US Texas City of Houston Bexar County El Paso County Dallas County Travis County

Cove

rage

Est

imat

e

Childhood Immunization DisparitiesIn spite of high national childhood immunization coverage rates:

• We see lower coverage for some vaccines requiring doses in the second year of life, such as DTaP, Hib, and PCV.

• For most vaccines, coverage among children living below the federal poverty level is lower than coverage among those living at or above the federal poverty level.

• Coverage is lower among children on Medicaid and much lower among uninsured children.

• CDC is currently working to identify reasons for disparities and evidence-based interventions. 14

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CDC National Immunization Survey

Teen Coverage Levels

2018 NIS-Teen Overview

• Conducted annually by CDC, assesses immunization levels among teens 13-17 years of age

• Population-based, random-digit–dial sample of phone numbers followed by reviewing the child’s vaccination record from the provider

• Provides a “Report Card” on national and state estimates

• Assesses coverage of 3 key recommended teen vaccines (including breakdown of number of doses by gender for HPV)

2018 National Immunization Survey-Teen Results

• In Texas, a statistically significant increase was observed for ≥1 dose HPV and HPV UTD coverage in Texas adolescents. These increases were due to statistically significant increases in ≥1 dose HPV and HPV UTD coverage among males from 2016 to 2017.

• In 2016, 44.3 percent of males in Texas had initiated the HPV series, and in 2017 coverage increased to 55.2 percent and now 55.5% for 2018.

• In 2016, 26.5 percent of males in Texas had completed the HPV series. In 2017, 36.0 percent had completed the HPV series. In 2018, 39.4% had completed the series.

VaccineU.S. National Average 2018

Texas 2017 Texas 2018

≥1 dose of Tdap 88.9% 83.2% 83.4%

≥1 dose MenACWY 86.6% 85.1% 86.7%

≥1 dose HPV 68.1% 57.8% 59.9%

HPV Up-To-Date (UTD) 51.1% 39.7% 43.5%

≥1 HPV, females 69.9% 60.4% 64.6%

HPV UTD, females 53.7% 43.5% 47.8%

≥1 dose HPV, males 66.3% 55.2% 55.5%

HPV UTD, males 48.7% 36.0% 39.4%

≥2 doses MMR 91.9% 84.7% 83.1%

≥2 dose VAR 89.6% 82.9% 82.0%

2018 National Immunization Survey-Teen Results

2018 National Immunization Survey-Teen Results

• > 1 doses of Tdap over past 5 years• 2014: 88.2%• 2015: 85.1%• 2016: 85.0%• 2017: 83.2%• 2018: 83.4%

• > 1 doses MCV4 over past 5 years• 2014: 88.6%• 2015: 89.6%• 2016: 85.5%• 2017: 85.1%• 2018: 86.7%

Additional Adolescent Immunizations

• 16-18 year old has additional vaccine recommendations• MCV4 dose 2 (prior to 19 for college requirement)

• Men B dose 1 and dose 2• HPV 3 dose catch-up/completion• Annual Influenza

• Opportunities to target age group prior to 19 year critical to successful completion of all adolescent vaccines

Challenges for NIS Teen

• Tdap and MCV coverage levels are maintaining, but not improving

• Influenza rates continue to be low• HPV rates increasing, but below national average

• Reducing missed opportunities• Improving strong provider recommendation for adolescent vaccines

• Educating parents and addressing any concerns about safety and necessity of adolescent vaccines

Reducing Missed Opportunities • Eliminating missed opportunities could increase vaccination coverage by up to 20%

• Top reasons • Lack of simultaneous administration

• Nurses or physicians may be hesitant • Unaware child (or adult) needs additional vaccines

• Invalid contraindications• Inappropriate or not updated clinic policies (lack of standing orders)

ANSWER= ADDITIONAL PROVIDER AND PUBLIC EDUCATION

Immunization Training for Clinicians• You Call the Shots: Web-based modules

that discuss vaccine-preventable diseases (VPDs) and explain the latest recommendations for vaccine use. CE/CME credit offered.

• Current Issues in Immunization Net Conference (CIINC): Live 1-hour audio and visual presentations with on-demand replays. Offered 4-5 times per year. CE/CME credit offered.

• Pink Book Webinar Series: Online series of 15 1-hour webinars. Provides an overview of the principles of vaccination, general recommendations, immunization strategies for providers, and specific information about VPDs and vaccines. CE/CME credit offered.

• Webcasts: Topics include HPV, pertussis, flu, vaccine storage and handling, and more. CE credits offered.

www.cdc.gov/vaccines/ed/index.html

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Provider Resources for Vaccine Conversations with Parents

• Talking to Parents about Vaccines• Understanding Vaccines and Vaccine Safety

• How Vaccines Work• The Recommended Childhood Immunization Schedule• Ensuring the Safety of U.S. Vaccines• Understanding MMR Vaccine Safety• Understanding Thimerosal, Mercury, and Vaccine Safety • The Advisory Committee on Immunization Practices

• Diseases and the Vaccines that Prevent Them • If You Choose Not to Vaccinate, Understand the Risk and

Your Responsibilities

www.cdc.gov/vaccines/conversations46

Childhood Immunization Materials to Share with Parents

www.cdc.gov/vaccines/parents/resources

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Infant Immunization FAQs• Written for parents of

children ages 0-2• English and Spanish• HTML and PDF• Co-branded with AAP

and AAFP

www.cdc.gov/vaccines/parents/parent-questions.html

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DSHS VFC Flu Update

2016-2017 Flu Program

2016-17 Flu Doses Final Report

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1,381,521Doses

Administered

2,008,210Doses

Ordered

4,807,252TVFC

Eligible Children

28.7% Vaccinated3,424,731 Missed opportunities

2017-2018 Flu Program

2017-18 Flu Doses Final Report

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33.6% Vaccinated2,991,649 Missed opportunities

1,513,326Doses

Administered

1,831,890Doses

Ordered

4,504,975TVFC

Eligible Children

2018-2019 Flu Program

2018-19 DSHS Flu Summary

• 100% of all vaccines were allocated to Texas from CDC (by early November, 2018)

• Open ordering for all providers began in November, 2018• Total providers who ordered and received 100% of pre-booked vaccines= 67%

• Total Doses Ordered by Texas: 1,984,880• Total Doses Shipped to Providers: 1,645,460 • Total Doses Administered by Providers: 1,476,529 • Total Doses Expired/Wasted

• Doses expired/wasted by providers: 168,931• Doses expired at CDC on Texas ‘shelf’: 339,420• TOTAL doses wasted/expired/not ordered: 508,351

2018-19 Flu Doses Report

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34.3% Vaccinated3,101,219 Missed opportunities

1,476,529Doses

Administered

1,968,600

Doses Ordered

4,577,748

TVFC Eligible Children

2019-2020 Flu Program

2019 Texas Target Population (TVFC)

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•Total (0-18) Population: 8,258,118•Total TVFC Eligible Children (0-18): 4,577,748•Total doses ordered by TVFC Providers: 1,740,430

Age Projected TVFC Eligibility

Percent of Age Group TVFC Eligible

0-1 285,277 62%1-2 517,033 57%3-6 1,000,199 56%7-18 2,775,239 55%

2019-2020 Flu Pre-Book By Region

Region Total Sites Complete % Complete01 139 126 90.6%02 93 88 94.6%03 561 539 96.1%04 151 147 97.4%05 88 81 92.0%06 380 360 94.7%07 325 310 95.4%08 156 150 96.2%09 98 96 98.0%10 118 108 91.5%11 423 377 89.1%

00- Bexar County 150 148 98.7%25- City of Houston 307 279 90.9%

TOTAL 2,989 2,809 94.0%2018-2019 Texas Pre-book: 90%

2019-20 DSHS Flu Allocation Process

• Texas began allocating flu doses on Monday, 9/16/2019 (+25% received by DSHS)

• Doses are allocated to each provider as available on a weekly basis

• Notifications of available doses are sent out on Monday and doses must be accepted by provider (all or partial) by Friday (noon)

• Doses not accepted each week will be re-allocated the following week to other providers

• Instructions are provided in TVFC allocation provider notifications

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2019-20 DSHS Flu Allocation Notice

Based on your pre-booked influenza vaccine request, you have doses of influenza vaccine available to order in the Electronic Vaccine Inventory (EVI) system. This may only be part of your order for the season; if so, the remainder will be allocated as it becomes available. Please review the detailed instructions on the flu ordering process below.

You will now have until Friday at noon to accept the allocation amount. It is very important that you go into EVI as soon as possible once receiving this notification. Any doses not accepted by Friday at noon will be returned to the overall influenza allocation pool. We request that the listed amounts of flu vaccine that have been allocated be accepted – please do not decrease your weekly allocation unless storage capacity at your facility is an issue.

Please assure that there will be enough free refrigerator space for the doses you accept and that someone will be available during your scheduled delivery hours to receive this shipment. 63

Allocation as of 10/20/2019

Texas has received and allocated to providers over 1,431,320 doses of flu vaccine this week (82% of pre-book amounts)

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Manufacturer Doses Ordered (Pre-booked)

Texas Doses Available % Available

GSK 975,810 961,060 98.5%

Sanofi 625,520 331,310 52.9%

Seqirus USA, Inc. 104,250 104,250 100.00%

AstraZeneca 34,850 34,850 100.00%TOTAL 1,740,430 1,431,320 82.3%

TVFC Provider Flu Dashboard

TVFC Provider Flu Dashboard

• Specifically designed for each TVFC provider• Highlights TVFC provider reported data including eligible TVFC clients, flu doses ordered and flu doses administered during season (updated monthly)

• Provides coverage data for each provider (TVFC clients/flu doses administered)

• Calculates county and state coverage levels based on provider utilization data

• Provides updated current influenza activity across the state

Presenter

Presentation Notes

After several different phases of design, we finally decided on one.

Presenter

Presentation Notes

After several different phases of design, we finally decided on one.

Texas Flu Coverage Levels 2015-2019

TEXAS 2015-16 2016-17 2017-18 2018-2019

Persons >6 months 47.9 43.5 37.6 47.9

6 months to 4 years 71.8 71.9 65.4 72.6

5 years to 12 years 63 59.8 60.9 63.9

13 to 17 years 50.2 50.3 48.1 51.96 months to 17

years 62.1 60.3 58.0 61.8Adults > 18 43.2 37.9 30.7 43.2Adults 18-64 38.7 32.9 26.0 37.7Adults 65+ 65.1 62.1 52.6 67.5

https://www.cdc.gov/flu/fluvaxview/index.htm

Barriers to Vaccination in Texas• High uninsured 0-18 population percent • Lack of provider participation in TVFC Program• Complicated schedules• Missed opportunities• Vaccine cost (inventory) and reimbursement• Other Barriers (identified by NVAC)

• Delays in scheduling appointments (recall system)• Lack of using benefits of registry (ImmTrac2) • Requiring a well-care visit for immunization only visits• Long waiting periods in the office• Lack of culturally and age-appropriate educational

materials

DSHS Strategies to Increase Immunization Rates

• Promoting the Medical Home• Systematic, methodical understanding of and development and implementation for provider, public, and parent education

• Increasing access points of TVFC and Adult vaccinations

• Promoting the Use of the Statewide Immunization Registry and Disaster Preparedness Tracking and Reporting System, ImmTrac2

Thank youMark Ritter, MHA

CDC Senior Public Health AdvisorMark.ritter@dshs.texas.gov

DSHS Immunization Unitwww.ImmunizeTexas.com

1-800-252-9152 72