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ARKANSAS DEPARTMENT OF HEALTH

The Ups and Downs of Immunization

J. Gary Wheeler, MD

October 6, 2015

Conflict of interest

• Multiple individual stocks of pharmaceutical companies that produce vaccines

• All managed by financial advisor

• Less than 1% of portfolio

Objectives

• Current state of immunization in Arkansas (pertussis, HPV)

• History of immunization/allopathic medicine

• Messaging to promote immunization in 2015

Estimated Vaccination Coverage Among

Children Aged 19-35 Months, and AR

rank, NIS 2014

4 DTap

3 Polio

FS HIB

3 Hep B

2 Hep A

7 vaccine series

US 84 93 92 82 92 91 83 58 72

AR 2013 74 89 88 70 87 87 70 36 57

AR 2014 80 92 89 78 91 91 79 43 66

AR rank 43 34 42 43 35 30 45 47 44

Estimated Vaccination Coverage With Selected

Vaccines Among Adolescents Aged 13-17

Years, NIS, 2014

State-level Cumulative Influenza

Vaccination Coverage Estimates for

the 2012-13

States Coverage Ranking, Arkansas is number (23)

Barriers to Immunization Success

• Implementation and interoperability of new EHRs and the IIS

• Lack of vaccination reporting by providers

• Quality of immunization information reported

• Inconsistent application of ACIP recommendations

• Increasing cost of vaccine –poor reimbursement

Barriers to Immunization Success

• Increasing costs to administer –poor reimbursement

• Fragmented funding systems

• Access (vaccine, location, and appointment availability)

• Exemptions

• Family Educational Rights and Privacy Act (FERPA)

ARKANSAS DEPARTMENT OF HEALTH 9

One Doctor’s Story

• I was just informed by my office lady that I will have to purchase a $3000 emulation software to sync the vaccine data bank with my computer system . If that is a mandatory thing to do shots, then I will send all my kids to the HD for vaccines and stop the VFC program at my office . The system is failing the public miserably. We are getting reimbursed less, I had to by a new refrigerator for all the vaccines for VFC this year. In order to do vaccines, I had to hire a new nurse. Otherwise my office could not function and I could not be an opportunity to vaccinate.

– Perry Wilbur, MD Mountain Home

Reimbursement for

Immunizations

• Vaccine Administration:

– Arkansas Medicaid pays providers $9.56 per shot

(Arkansas Medicaid regional cap is $19.54)

– Private insurance companies have various

reimbursement rate for providers

• Vaccine:

– VFC: No charge to providers; no reimbursement

– Non-VFC: flexible pricing; reimbursement is often

average wholesale pricing

2014 Childhood Vaccine Financing Map and NIS 19-35 month Rank

Rhode Island 1

http://aattp.org/wp-content/uploads/2014/06/288464d1310524424-some-doctors-saying-vaccinate-your-child-go-elsewhere-treatment-n-whooping-cough-tubes-300x225.jpg

Recent US Outbreaks

• California, 2010: 9143 cases including 10 infant deaths

• Michigan, 2009-10: 902 and 1564 cases, respectively

• Ohio, 2010: 964 cases in just two counties, and this outbreak continued

Washington 2012

• During January 1–June

16, 2012, a total of 2,520

pertussis cases were

reported in Washington, of

which 2,069 were

confirmed (83.4%

laboratory-confirmed and

16.6% epidemiologically

linked) and 451 were

probable

MMWR July 20, 2012 / 61(28);517-522

Washington 2012

• DTaP coverage among children aged 19–35 mths 81.9% for ≥4 doses in 2010

• 43.1% of patients aged 11–12 years and 77.2% of patients aged 13–19 years

• Exemption rate was 4.5% in 2011-12

Outbreak in Arkansas 2012

• Increased reports of pertussis

• Most occurred in children in 4th and 5th grade

• 29 students and 19 other community confirmed cases of pertussis Many more probable/suspect cases were involved

• Combination of immunization, school exclusion, contact treatment utilized\

• High costs to families, schools and health dept.

Vaccine quality?

• Some of the resurgence of pertussis is likely related to differences between DTwP vs DTaP.

• Estimates of only 3-4 years protection from DTaP

• Some long term booster effect if primary vaccine was DTwP

• Quadrivalent first licensed in 3/2007 for girls 11-12 yo for cancer prevention

• In 2008, the target audience was expanded to include American Indian/Alaska Native, Korean American and Vietnamese American audiences based on their increased risk for cervical cancer

• 2009 a bivalent HPV vaccine was approved by the FDA and the quadrivalent vaccine was approved for “permissive” use in males

• Digital media campaign in 2010

• 2013 recommendations for males

• Updated professional campaign 2014

HPV Vaccine

• 100% of sexually active men and women acquire genital HPV at some point in their lives.

– An estimated 79 million females aged 14–59 years are

infected with HPV infection. 14 million new infections/year in

the US

• HPV infection is most common in people in their teens and early 20s

• Most people will never know that they have been infected

Prevalence of HPV in the U.S. Epidemiology

Cancer and HPV

Adolescents 13-17 Years, National

Immunization Survey-Teen, 2006-2012

• Australia (80% of school-aged girls vaccinated) High-grade cervical lesions have declined in women less than 18 years of age

• For 15-24 year old females, the proportion of genital warts cases declined by 85%

• Genital warts have declined by 71% among males of the same age, indicating herd immunity

• United States (33% of teens fully vaccinated) 56% decline in HPV 6/11/16/18 in girls age 14-19

• Substantial decrease in genital warts among female military under age 26 between 2007 to 2010

Is the Vaccine working?

History of medicine in America

A clue?

Comparison of Annual and Current Reported Morbidity, Vaccine-Preventable Diseases and Vaccine Adverse Events, United States

Disease 20th Century Annual Morbidity* 2000** %change

Diphtheria 175,885 4 -99.99

Measles 503,282 81 -99.98

Mumps 152,209 323 -99.79

Pertussis 147,271 6,755 -95.41

Polio (wild) 16,316 0 -100

Rubella 47,745 152 -99.68

Cong. Rubella Syndrome 823 7 -99.15

Tetanus 1,314 26 -98.02

Invasive Hib Disease 20,000 167 -99.16

Total 1,064,845 7,515 -99.29

Vaccine Adverse Events 0 5,296 +++

* Maximum cases reported in pre-vaccine era and year

+ Estimated because no national reporting existed in the prevaccine era

** Provisional

Vaccination Coverage Among Children in Kindergarten — United States, 2013–14 School Year. MMWR October 17, 2014 / 63(41);913-920

Arkansas Exemptions

Exemption laws

• Medical exemptions in all states

– Adverse reactions

• Religious and philosophical exemptions vary from state to state

• Prior law in Arkansas: religious

• Current law Act 999 (2003): philosophical or religious

– “path of least resistance”

All you need in this life is ignorance and confidence, and then success is sure

How Mark Twain might help us

• Allopathic medicine and its competitors

• Well described in Twain’s literature of the 20th century

• Allopathic tools – Leaches

– Emetics

– Cathartics

– Alcohol

– Narcotics

K. Patrick Ober, MD Mark Twain and Medicine

The _____pathic schools

• Fill in

– Osteo- (first school in Kirksville in 1875)

– Homeo-

– Hydro-

– Electro, magneto-

– And the faith healers and the bedresters

Hydrotherapy

• “I began to take the baths and found them most enjoyable: so enjoyable that if I hadn’t had a disease I would have borrowed one, just to have a pretext for going on.”

– Mark Twain, “Aix-les-Bains”

prevention

• “We had a good doctor, one of them old fashioned industrious kind that don’t go fooling around waiting for a sickness to show up and call game and start fair, but gets in ahead and bleeds you at one end and blisters you at the other, and gives you a dipperful of castor oil and another one of hot salt water with mustard in it, and so gets all you machinery agoing at once , and then sets down with nothin on his mind and plans out the way to handle the case.”

– Mark Twain “Tom Sawyer’s Conspiracy”

mercury

• “I don’t like medicines—and moreover I have but a pale and feeble confidence in them. There’s an old Denver pox-patient here who is loaded to the eyes with mercury, and is a poisoned hulk. As between mercury and pox, which would you prefer?”

• Mark Twain, letter 1899

Alternative therapies

• Populist and feminist flavor

• Treatment did not require prescription

• Cheaper

• Sense of control

• Close contact of an allopathic failure

• Focus on health

• Fashionable

• Rebellion against the hurried and hectic lifestyles of America

• Absence of credentialing

• Need hope

messaging

- - - … - - -

• Provider: Meghan is due for some shots today: Tdap and the meningococcal vaccine. There is also the HPV vaccine…

• Parent: Why does she need an HPV vaccine? She’s only 11!

• Provider: We want to make sure she gets the shots before she becomes sexually active.

• Parent: Well I can assure you Meghan is not like other girls- she’s a long way off from that!

• Provider: We can certainly wait if that would make you feel more comfortable.

Sound familiar?

• Studies consistently show that a strong recommendation from you is the single best predictor of vaccination

• In focus groups and surveys with moms, having a doctor recommend or not recommend the vaccine was an important factor in parents’ decision to vaccinate their child with the HPV vaccine

• Not receiving a recommendation for HPV vaccine was listed a barrier by mothers

• Unpublished CDC data, 2013

What’s in a recommendation?

• The “HPV vaccine is cancer prevention” message resonates strongly with parents In focus groups and online panels, mothers wanted more information on the types of HPV cancers

• In focus groups mothers stated they were influenced to vaccinate their child because HPV vaccine prevents cancer, they had a family history of cervical cancers, and/or because they had a personal experience with cervical cancer

• Message: HPV vaccine is very important because it prevents cancer. I want your child to be protected from cancer. That’s why I’m recommending that your daughter/son receive the first dose of the HPV vaccine series today.

Cancer message

• Study examined the frequency of vaginal HPV and the association with non-coital sexual behavior in longitudinally followed cohort of adolescent women without prior vaginal intercourse

• HPV was detected in 46% of women prior to first vaginal sex

• 70% of these women reported non-coital behaviors that may in part explain genital transmission

• Shew, J J Infect Dis. 2012

HPV in virgins

poster/flyer

• I gave HPV vaccine to my boys and girls

• It doesn’t matter how your child behaves, if the person she ultimately has a physical relationship is infected

• If your son doesn’t think he needs the vaccine, tell him the Mike Douglas story

Wednesday, October 07, 2015

Other important messages

• Yale Law School: CCP Risk Perception Studies Report No. 17. Jan 27,2014

– 1. vaccine risks are neither a matter of concern for the vast

majority of the public nor an issue of contention among

recognizable subgroups;

– 2. ad hoc forms of risk communication that assert there is

mounting resistance to childhood immunizations

themselves pose a risk …… and diminish motivation to

cooperate with universal vaccination programs.

Exemptions in Arkansas

Think he’s protected?

He’s not vaccinated

It’s your choice. Get the facts.

Mom focus groups

Communicating effectively about vaccines ASTHO 2010

Key messages

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