Post on 24-Mar-2021
1/9/2019
1
Nor th Dakota Immunizat ion Pract ices Dur ing the COVID-
19 Pandemic Response M a r y W o i n a r o w i c z , N D I I S M a n a g e r
A b b i B e r g , V F C / Q I M a n a g e rM o l l y H o w e l l , I m m u n i z a t i o n P r o g r a m M a n a g e r
May 13, 2019 1
2
North Dakota Vaccine Doses Administered According to NDIIS
124,401
106,863
95,000
100,000
105,000
110,000
115,000
120,000
125,000
130,000
doses administered
2019 2020
14.1% decrease
*Doses administered data as of the end of week 18 (2019 week end = May 4th; 2020 week end = May 2nd)
3
36,281
30,246
27,000
28,000
29,000
30,000
31,000
32,000
33,000
34,000
35,000
36,000
37,000
Jan - April 2019 Jan - April 2020
17% decrease in vaccine ordering
North Dakota Total Doses Ordered from the VFC Program
1
2
3
1/9/2019
2
4
https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e2.htm
5,385
7,402
6,864
6,175
5,4745,855
7,4027,189 7,186
7,009
6,413
7,528
8,321
7,286 7,1907,379 7,266
7,077
5,354
8,031
7,5087,117
6,937 7,026
6,5116,857 6,953 6,934 6,965
5,179
4,097
3,184
3,812
4,446
4,981 4,971
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
WEEK_1 WEEK_2 WEEK_3 WEEK_4 WEEK_5 WEEK_6 WEEK_7 WEEK_8 WEEK_9 WEEK_10 WEEK_11 WEEK_12 WEEK_13 WEEK_14 WEEK_15 WEEK_16 WEEK_17 WEEK_18
ND Total Doses Administered by Week According to NDIIS
2019 2020
0
1,000
2,000
3,000
4,000
5,000
6,000
WEEK_1 WEEK_2 WEEK_3 WEEK_4 WEEK_5 WEEK_6 WEEK_7 WEEK_8 WEEK_9 WEEK_10 WEEK_11 WEEK_12 WEEK_13 WEEK_14 WEEK_15 WEEK_16 WEEK_17 WEEK_18
ND Weekly Doses Administered to Kids <= 18 years According to NDIIS
2019 2020
4
5
6
1/9/2019
3
0
500
1,000
1,500
2,000
2,500
3,000
3,500
WEEK_1 WEEK_2 WEEK_3 WEEK_4 WEEK_5 WEEK_6 WEEK_7 WEEK_8 WEEK_9 WEEK_10 WEEK_11 WEEK_12 WEEK_13 WEEK_14 WEEK_15 WEEK_16 WEEK_17 WEEK_18
ND Weekly Doses Administered to Adults >= 19 years According to the NDIIS
County % decreaseSlope 100%Burke 74%Foster 73%Pembina 70%Grand Forks 68%Cavalier 68%Divide 67%Oliver 67%Rolette 62%Bottineau 62%Benson 57%McLean 56%Nelson 56%Sargent 53%Dunn 51%Bowman 50%Emmons 50%Renville 50%Sheridan 50%
9
Vaccine Coverage Ratesdecreases from week 1 to week 18
infant 4:3:1:3:3:1:4
series11.6% decrease
teen HPV up-to-date
0.2% decrease
teen1 dose Tdap
2.3% decrease
teen 1 dose MCV42.5% decrease teen HPV
series start1.9% decrease
infant4 doses DTaP
11.2% decrease
infant3 doses polio7.5% decrease
infant1 dose MMR
1.9% decrease
infant3 doses hep B7.2% decrease
infantHib up-to-date10.1% decrease
infant1 dose varicella1.9% decrease
infant4 doses PCV
1.8% decrease
infant2 doses hep A14.6% decrease
7
8
9
1/9/2019
4
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
WEEK_1 WEEK_2 WEEK_3 WEEK_4 WEEK_5 WEEK_6 WEEK_7 WEEK_8 WEEK_9 WEEK_10 WEEK_11 WEEK_12 WEEK_13 WEEK_14 WEEK_15 WEEK_16 WEEK_17 WEEK_18
Immunization rates by week for infants 19-35 months at the end of each week
4:3:1:3:3:1:4 series 4 DTaP 3 Polio 1 MMR 3 Hep B Hib UTD 1 VAR 4 PCV 2 Hep A
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
WEEK_1 WEEK_2 WEEK_3 WEEK_4 WEEK_5 WEEK_6 WEEK_7 WEEK_8 WEEK_9 WEEK_10 WEEK_11 WEEK_12 WEEK_13 WEEK_14 WEEK_15 WEEK_16 WEEK_17 WEEK_18
Immunization rates by week for teens 13-15 and 16-18 at the end of each week
1 TDAP 1 MCV4 2 MCV4 HPV Start HPV UTD
* Rates for 1 Tdap, 1 MCV4, HPV start and HPV UTD include kids in the 13-15 year age group.** Rates for 2 MCV4 include only kids in the 16-18 year age group.
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
WEEK_1 WEEK_2 WEEK_3 WEEK_4 WEEK_5 WEEK_6 WEEK_7 WEEK_8 WEEK_9 WEEK_10 WEEK_11 WEEK_12 WEEK_13 WEEK_14 WEEK_15 WEEK_16 WEEK_17 WEEK_18
Immunization rates by week for adults 19 years of age and older by the end of each week
1 TDAP* Zoster Startⱡ Zoster UTDⱡⱡ 1 PCV13¥ 1 PPSV23€
*Rate is based on adults 19 years of age and older who have at least one documented dose of Tdap vaccine in their NDIIS record.ⱡ Rate is based on adults 50 years of age and older who have at least one documented dose of Shingrix® vaccine in their NDIIS record.ⱡⱡ Rate is based on adults 50 years of age and older who have two documented doses of Shingrix® vaccine in their NDIIS record.¥ Rate is based on adults 65 years of age and older who have one documented dose of PCV13 vaccine administered after age 65 in their NDIIS record.€ Rate is based on adults 65 years of age and older who have one documented dose of PPSV23 vaccine administered after age 65 in their NDIIS record.
10
11
12
1/9/2019
5
County % decreaseRichland 59.5%Ransom 54.7%Barnes 42.8%Cass 40.0%Lamoure 35.1%Billings 33.3%Stutsman 25.7%Eddy 24.4%Emmons 18.0%Traill 15.9%Cavalier 15.3%Wells 13.7%Hettinger 13.2%
Decrease in infant immunization coverage rates from
week 1 to week 18 of 2020
County % decrease 1 dose Tdap
Stutsman 13.9%Barnes 11.3%Richland 11.2%Cass 10.9%Steele 10.3%Sargent 5.6%Lamoure 1.8%Griggs 1.7%Kidder 1.6%Foster 0.7%Ransom 0.6%Traill 0.4%
County % decrease 1 dose MCV4
Stutsman 13.0%Richland 11.7%Barnes 11.5%Cass 11.5%Steele 10.3%Sargent 6.6%Lamoure 1.8%Griggs 1.8%Logan 1.4%Foster 0.7%Ransom 0.6%Bottineau 0.4%Traill 0.4%
County % decrease HPV up-to-date
Cass 15.2%Stutsman 14.4%Barnes 9.1%Richland 6.9%Steele 3.7%Ransom 2.8%Griggs 2.7%Sargent 2.0%
Decrease in adolescent immunization coverage rates from week 1 to week 18 of 2020
PROVIDER VACCINATION PRACTICESAbbi Berg, MPH 15
13
14
15
1/9/2019
6
16
Due May 6th
189 respondents, not just VFC enrolled 3 hospitals
9 FQHCs
8 IHS/Tribal
1 Mass Vaccinator
14 Other (correctional, university health, long term care)
13 Pharmacy
79 Private providers
47 Local public health
15 Rural health centers
STATE OF VACCINATION SURVEY
0
20
40
60
80
100
120
140
160
180
Yes No
Currently Vaccinating Based on Facility Type
Hospital FQHCs IHS/Tribal Mass Vaccinator Other
17
18
No (22) 7 Local public health offices 2 Urban, 5 rural
8 Pharmacies
1 Private provider
3 IHS/Tribal
3 Other (university health, long term care, corrections)
CURRENTLY VACCINATING?
16
17
18
1/9/2019
7
REASONS FOR NOT VACCINATING
• Staff pulled for COVID-19 response.• Offices are closed to the public.• Pharmacies doing curbside service
so vaccination isn’t possible.• Concerns over exposing staff and
other patients/ customers.
19
20
Yes (154) 3 Hospitals
9 Federally Qualified Health Centers (FQHCs)
6 Tribal
1 Mass vaccinator
11 Other
5 Pharmacies
77 Private Providers
40 LPHUs
15 Rural Health Centers (RHCs)
CURRENTLY VACCINATING?
21
Options selected frequently were: Screening patients for symptoms
Staggering appointments
Rooming patients immediately
Cohorting ill patients to separate sections, floors, wings or buildings to reserve clinic space for well patients
Utilizing drive-thru COVID testing sites to allow for vaccination in clinics
Working with LPHUs to partner for vaccinations
WAYS TO ENSURE HEALTH OF PATIENTS
19
20
21
1/9/2019
8
22
Other: Requiring mask wearing 100% of the time by staff and patients.
Separating pediatric and adult vaccination days
Patients call in from parking lot and are called back when their exam room is ready. Roomed immediately upon entry.
Well child exams and vaccination in the morning, sick visits in afternoon.
Clinics closing early for deep cleaning.
Only allowing one parent for minors, everyone else must come alone.
WAYS TO ENSURE HEALTH OF PATIENTS
23
Registration, consent and screening done over the phone prior to appointments Call upon arrival and prepare vaccinations prior to them
entering the office Alternative vaccination opportunities such as using time
when students are scheduled to return their school equipment Use separate doors for well patients Discontinuation of walk-in vaccinations, by appointment
only
WAYS TO ENSURE HEALTH OF PATIENTS
24
Nurses doing home visits for vaccination while wearing PPE Only allowing one family/client in the facility at a time Space appointments to allow for cleaning in between Curbside vaccination
WAYS TO ENSURE HEALTH OF PATIENTS
22
23
24
1/9/2019
9
25
Almost all providers are vaccinating all age-appropriate groups at their facilities.
Two private providers were only vaccinating 0 – 24 months old.
One health system is only vaccinating children under 6 years of age.
One district LPHU is only vaccinating 0 – 24 months.
AGES VACCINATING
28 26
17
41 2
66
28
17
0
10
20
30
40
50
60
70
1-Aug 1-Sep 1-Oct 1-Nov 1-Dec 1-Jan NA, Normalvaccination
levels
NA, Don'tsee this ageof patient
Unsure
Kindergarten Catch-Up Vaccination Dates
26
32 33
11
5 4 2
60
25
17
0
10
20
30
40
50
60
70
1-Aug 1-Sep 1-Oct 1-Nov 1-Dec 1-Jan NA, Normalvaccination
levels
NA, Don't seethis age of
patient
Unsure
7th Grade Catch-Up Vaccination Dates
25
26
27
1/9/2019
10
Yes (104) No (8) 7 IHS/Tribal
1 RHC
Not applicable (77) This is based on facility type: pharmacy, LPHU, hospital etc.
CURRENTLY OFFERING WELL CHILD VISITS
29
Office closed
Clients don’t want to come in
Rural areas will require more planning because they usually use school vaccination clinics to catch children up
Lack of school clinics
Prioritizing facilities/appointments for ill children
Telehealth appointments
Staff responding to COVID-19 cases and investigations
Staff shortages/furloughs
Clinic is housed within a closed building
Staff do not feel comfortable
Lack of PPE
BARRIERS TO VACCINATION
30
Overwhelming majority said that parents are willing to vaccinate but don’t want to bring children into facility
Many also reported mixed feelings such as some parents delaying while others prioritizing vaccinations to keep their children safe.
Parents of infants more willing to vaccinate and hold off on bringing in older children.
Some LPHUs are seeing more children as parents feel more comfortable at their offices, instead of large health systems or pediatrician’s office.
PARENTAL ATTITUDES TOWARDS VACCINATION
28
29
30
1/9/2019
11
31
North Dakotans are at risk for vaccine preventable diseases if not caught up on missed immunizations. Health care providers and local public health units can
implement safe ways to immunize. Back-to-school immunization requirements cannot be
relaxed due to the risk of outbreaks in schools.
CONCLUSIONS
32
Use NDIIS reminder/recall functionality to bring patients back in for missed immunizations.
Conduct mass, drive-thru back-to-school immunization clinics. Use NDIIS reminder/recall to notify patients of events.
Vaccinate at every opportunity, even sick visits.
Work collaboratively in your communities to ensure access to immunizations.
Communicate the importance of immunizations to parents/patients.
Promote the VFC Program, as many North Dakotans have experienced unemployment.
RECOMMENDATIONS
2020 – 2021 INFLUENZA VACCINE PREBOOK
33
31
32
33
1/9/2019
12
Yes (65) No (87) Unknown (37) Influenza vaccine is going
to be increasingly important this season.
INCREASE FLU PREBOOK?
35
Expect SARS-CoV-2 to still circulate in Fall Increasing flu vaccination coverage will decrease stress on
healthcare Decrease doctor visits and hospitalizations
Decrease individuals seeking diagnostics
Focus on adults at higher risk from COVID-19 staff and residents of LTCF
adults with underlying illnesses and African-Americans
adults who are part of critical infrastructure.
Vaccinating children prevents flu in adults.
INCREASING INFLUENZA VACCINATION THIS FALL
36
Plan for how to increase influenza vaccination rates this fall. Prebook additional doses of influenza vaccine. How will you replace workplace vaccination, if employees
are working from home? How will you ensure influenza vaccination while social
distancing? Drive-thru clinics
Staggering of patients
INCREASING INFLUENZA VACCINATION THIS FALL
34
35
36
1/9/2019
13
37
COVID-19 UPDATE
38
Symptom-based strategy: At least 10 days have passed since symptoms first appeared,
AND
At least 3 days (72 hours) have passed since recovery, defined as: Resolution of fever, without the use of fever-reducing medications, AND
Progressive improvement or resolution of respiratory symptoms (e.g., cough, shortness of breath)
CHANGE IN REMOVAL FROM ISOLATION
39
Test-based Strategy: Resolution of fever without the use of fever-reducing medications,
AND
Improvement in respiratory symptoms (e.g., cough, shortness of breath), AND
Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive upper respiratory specimens collected at least 24 hours apart (total of two negative specimens).
CHANGE IN REMOVAL FROM ISOLATION
37
38
39
1/9/2019
14
40
For patients with laboratory-confirmed COVID-19 who have not had any symptoms, health care providers might use either: Time-based Strategy: At least 10 days have passed since the date of their
first positive COVID-19 diagnostic test, assuming they have not subsequently developed symptoms since their positive test. Because of the absence of symptoms, it is not possible to gauge where these individuals are in the course of their illness.
Test-based Strategy: Because of the absence of symptoms, it is not possible to gauge where these individuals are in the course of their illness. Follow the Test-based Strategy above with the modification that initiation of testing can begin immediately.
CHANGE IN REMOVAL FROM ISOLATION
41
The NDDoH continues to recommend that clinicians use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Health care providers should not turn patients away for COVID-19 testing who have upper or lower respiratory illness. COVID-19 testing is critical in order to identify cases and prevent further spread through case investigation and contact tracing. Health care providers are asked to have a high suspicion for COVID-19 and test accordingly.
COVID-19 TESTING GUIDANCE
42
Clinicians should consider testing any patient with one (1)of the following signs/symptoms with new or worsening onset: cough
shortness of breath
difficulty breathing
OR
COVID-19 TESTING GUIDANCE
40
41
42
1/9/2019
15
43
Two (2) of the following signs/symptoms with new or worsening onset: fever (measured or subjective)
runny nose
sore throat
chills
myalgia
fatigue
headache
loss of taste and/or smell
COVID-19 TESTING GUIDANCE
44
May 4: NYC Health Department disseminated HAN regarding 15 children with multisystem inflammatory syndrome hospitalized between April 17 and May 1 •May 6: NYS Department of Health disseminated HAN
regarding 64 children (including NYC) since May 5th •More than 150 suspected cases of MIS in children have
been reported to NYS to date •Unverified reports from Atlanta, Boston, Minnesota, and
New Jersey
MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN REPORTED IN THE UNITED STATES
Per CDC: 05/11/2020
45
Prominent Features Persistent fever
Inflammation Increased lab values: neutrophilia, elevated C-reactive protein, lymphopenia, etc
Evidence of single or multi-organ dysfunction Shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder
Some had features consistent with Kawasaki disease
About two-third had PCR negative, but vast majority were serology positive
Mostly teenagers
MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN ASSOCIATED WITH SARS-COV-2
Per CDC: 05/11/2020
43
44
45
1/9/2019
16
46
Case definition Health advisory Reporting to NDDoH
MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN ASSOCIATED WITH SARS-COV-2
NORTH DAKOTA IMMUNIZATION PROGRAMNorth Dakota Immunization Program Staff
Molly Howell, MPH Program Manager
Phone: 701.328.4556Email: mahowell@nd.gov
Mary Woinarowicz, MANDIIS Manager
Phone: 701.328.2404Email: mary.woinarowicz@nd.gov
Abbi Berg, MPHVFC/Quality Improvement Manager
Phone: 701.328.3324Email: alberg@nd.gov
Rachael Goebel, MPHNDIIS Coordinator
Phone: 701.214.7322Email: rgoebel@nd.gov
Miranda BaumgartnerVFC/QI Coordinator (West)
Phone: 701.328.2035Email: mlbaumgartner@nd.gov
Jennifer GalbraithImmunization Surveillance Coordinator
Phone: 701.328.2335Email: jgalbraith@nd.gov
Sherrie MeixnerVFC/QI Coordinator (East)
Phone: 701.541.7226Email: smeixner@nd.gov
Carmen Cardenas, MPHNDIIS Data Quality Coordinator
Phone: 701.328.4169Email: ccardenas@nd.gov
VacantCDC Public Health Advisor
Phone: Email:
QUESTIONS?48
46
47
48