Calling the Shots Immunization Finance Policies and Practices (2000) / Chapter Skim
Currently Skimming:
Building, Monitoring, and Sustaining Immunization Capacity
Building, Monitoring, and Sustaining Immunization Capacity
Pages 103-141
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From page 103... ...
To this end, the governmental public health system encompasses three key functions: assurance, assessment, and policy development. As discussed in Chapter 1, the framework for the present study represents these functions somewhat differently, identifying six specific roles of the national immunization system (see Figure 1-6~: · vaccine purchase, · service delivery, · infectious disease prevention and control, · surveillance of vaccine coverage and safety, 103
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From page 104... ...
Although we focus principally on the public infrastructure for immunization services at the federal and state levels, we recognize that these efforts interact with local health agencies, private health care providers, and private insurers in a complex manner. Most important, the presence or absence of private health care services, including insurance coverage and standard benefits that provide immunization services for children, adolescents, and adults at reasonable cost, influences the infrastructure burden that is located within the public health sector.
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From page 105... ...
These sentinels are essential to the prevention of disease outbreaks and transmission because they reveal longterm trends and provide early warnings of new patterns of disease reports. The persistent presence of infectious disease in reservoirs scattered around the world requires constant vigilance within each U.S.
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From page 106... ...
. Disease prevention and control, on the other hand, is an intrinsic role of public health agencies, which look beyond individual health to address the risk to whole populations.
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From page 107... ...
These laboratories support surveillance activities, conduct outbreak inquiries, and monitor for new or emerging infectious diseases. Public
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From page 108... ...
Efforts to collect infectious disease data require stability, consistency, and federal and state collaboration to enhance the monitoring of longterm trends and the analysis of datafrom different regions of the country. SURVEILLANCE OF VACCINE COVERAGE AND SAFETY For the first half of the 20th century, the prevention and control of vaccine-preventable disease were the frontier of the public health infrastructure.
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From page 109... ...
The changing demographics of society, the mixing of young children in day care settings, new patterns of health care delivery, high rates of uninsured children, and the shrinking size and morale of health departments all fostered circumstances in which disease transmission occurred within major metropolitan areas even though disease reports were low, and state health officials believed statewide immunization coverage was at acceptable levels (see Chapter 2~. The measles epidemic demonstrated that new approaches were necessary to protect vulnerable populations from disease approaches that depended more heavily on surveying the populations at greatest risk to determine their immunization coverage levels and to identify points of vulnerability that might emerge from a variety of causes, including shifts in population trends, disruptions in health care services, and new behaviors among providers or clients.
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From page 110... ...
In contrast, the CASA and managed care assessments estimate coverage levels for particular entities responsible for the children's care (health care providers in the former case and managed care plans in the latter)
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From page 111... ...
National Immunization Survey. The NIS is a national telephone survey of households and providers that is used to estimate vaccination coverage levels for children aged 19 to 35 months (information provided by CDC)
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From page 112... ...
CDC provides guidelines for conducting these surveys, which involve collecting coverage data from school health records in 35 randomly selected schools for a sample of children. These studies are the least expensive and easiest to perform of the assessments reviewed here, but their data lag the period of performance by 3 to 4 years; thus, for example, they offer little help in monitoring the effects of recent immunization efforts (Orenstein et al., 1999~.2 Coverage levels reported in the NIS are often higher than those in retrospective school entry surveys.
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From page 113... ...
However, significant barriers challenge such efforts to track vulnerable groups: · Surveys of baseline coverage for Medicaid populations, including the coverage rates for families served by managed care organizations, are not consistently available, nor can results be compared across survey designs. · The difficulty of gaining routine access to households of very poor families, due in part to the high rates of mobility among such families, poses significant methodological barriers to data collection efforts.
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From page 114... ...
A few organizations (such as the Employee Benefits Research Institute and the Health Research and Educational Trust, formerly sponsored by KPMG Peat Marwick) study coverage patterns for private industry to determine whether coverage levels vary by type of plan, but these studies cannot demonstrate where certain groups or regions might be vulnerable to reduced immunization protection or disease outbreaks.
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From page 115... ...
within a range of 2-19 percent. Some HMOs excuse low performance with claims that plan participants receive immunization services outside the network of HMO providers, in settings such as county health departments or community clinics, and data on this utilization may not be reported back routinely to the plans or recorded in patients' medical records (Schauffler et al., 1999~.
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From page 116... ...
launched the All Kids Count national childhood immunization registry initiative in response to both the measles outbreak of the late 1980s and the low immunization rates of preschool children in the United States (Watson et al., 1997~. These computerized information systems were designed to perform three functions: (1)
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From page 117... ...
. To address the lack of consistency among different registry systems, the All Kids Count initiative developed a 20-item list of ideal components for registries (RWIF, 1996~.7 The CDC National Immunization Program (NIP)
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From page 118... ...
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From page 119... ...
The costs and benefits of immunization registries for adult populations (particularly those over age 65) are similarly uncertain.
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From page 120... ...
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From page 122... ...
The shift in service delivery for low-income children from a small cadre of public health providers and community-based clinics to a larger and more diverse network of health plans and private providers has increased coverage rates, but has also created more complexity in assuring service delivery and monitoring immunization coverage. The transition in service settings has also complicated the information management and administration of populationwide services within public health agencies.
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From page 123... ...
A consistent, national standard for measuring coverage levels among diverse populations and multiple health care settings does not currently exist. The result is uncertainty in comparing rates across private and public health care plans or geographic areas.
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From page 124... ...
The experience with measles outbreaks in 1989-1991 and more recent disease reports suggest that during periods of complacency, low levels of immunization coverage among vulnerable groups may remain undetected and unaddressed, and can erupt into infectious disease outbreaks (NVAC, 19911. Monitoring Vaccine Safety As a biological product, vaccines may cause unintended side effects, some of which can be serious.
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From page 125... ...
vaccine and the onset of autism illustrate the range of issues and responses that arise in vaccine safety discussions. In fuly 1999, the Advisory Committee on Immunization Practices (ACIP)
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From page 126... ...
There are two federal programs related to vaccine safety: the Vaccine Adverse Events Reporting System (VAERS) and the National Vaccine Injury Compensation Program (VICP)
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From page 127... ...
Court of Federal Claims administer a collaborative process for determining qualification for compensation. VICP covers adverse events caused by the following vaccines: diphtheria, pertussis, tetanus (DTP, DTaP, DT, TT, or TD)
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From page 128... ...
Vaccine safety concerns can be expected to acquire greaser importance as the incidence of infectious disease diminishes and more vaccines are approved for general use. Data monitoring and reliable reporting systems need to be in place so that public health agencies can respond appropriately to concerns and uncertainties of the public and health providers about the need for vaccines during times when disease outbreaks are not apparent.
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From page 129... ...
. On the basis of this evidence, TFCPS strongly recommended reducing out-of-pocket costs as an effective strategy to improve vaccination coverage (Briss et al., 2000~.
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From page 130... ...
Many local and state health agencies have sought to improve immunization rates by enhancing access to vaccines in health care settings, whether by extending hours or adding staff; introducing express services; or adding immunization services to hospitals, pharmacies, and nursing homes. These strategies are designed to reduce the distance from the setting to the at-risk population, increase the hours during which vaccination services are offered, deliver vaccinations in clinical settings in which they were previously not provided, or reduce administrative barriers to obtaining vaccination services within clinics (e.g., by developing a drop-in clinic or an "express lane" vaccination service)
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From page 131... ...
New vaccines may be introduced in nontraditional settings (such as school clinics, workplace sites, and pharmacies) in which strategic oversight is required to monitor coverage levels and address safety concerns, including the potential for adverse events.
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From page 132... ...
The TFCPS report recommends that home visits be used to improve vaccination coverage among socioeconomically disadvantaged populations. Home visit interventions, however, when applied only to improve vaccination coverage, are highly resource-intensive relative to other available options for improving coverage since they require specialized staff training and must address concerns for staff safety.
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From page 133... ...
These findings caused many researchers and health professionals to rethink traditional strategies for improving vaccination coverage levels and to focus on addressing missed opportunities in health care and other public service settings (Santoli et al., 1998~. Researchers recommended several new strategies aimed at encouraging providers to vaccinate both children and adults.
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From page 134... ...
. The TFCPS task force strongly recommends the use of reminderrecall interventions to improve vaccination coverage for all age groups.
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From page 135... ...
. TFCPS concluded that there is insufficient evidence to assess the effectiveness of standing orders in improving vaccination coverage in children (Briss et al., 2000~.
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From page 136... ...
Three such strategies have been formulated: · Increasing community demand for vaccinations through various educational and reminder interventions · Establishing requirements or incentives for immunization · Enhancing awareness of immunization status through devices such as client-held medical records Increasing Community Demand for Vaccinations. Three specific strategies are commonly used to increase community demand: client reminderrecall systems, comprehensive interventions that include education, and communitywide or clinic-based education-only interventions.
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From page 137... ...
The interventions may incorporate a variety of associated strategies to improve vaccination, including client and/or provider reminders, provider education, expanded hours or access in clinical settings, lowering of out-of-pocket costs, client-held vaccination records, and WIC interventions. Having reviewed the relevant research, TFCPS strongly recommends the use of comprehensive interventions that include education for children and adults in communitywide and clinic-based settings in a range of contexts (Briss et al., 2000~.
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From page 138... ...
Many state and local health departments and providers have encouraged use of client-held medical records to improve coverage rates by increasing clients' knowledge about vaccinations and/or reducing missed opportunities in health care settings. Based on the small number of studies of this strategy, limitations in study designs, and variations in the interventions and research findings, TFCPS concluded that insufficient evidence exists to assess the effectiveness of client-held medical records in improving vaccination coverage (Briss et al., 2000~.
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From page 139... ...
There is also a need for extensive and ongoing collaboration among local public health agencies, private health plans, and public and private health care providers to monitor and improve coverage levels. Finding 4-12.
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From page 140... ...
The immunization infrastructure within each state needs to have the capacity to perform a set of critical surveillance, disease control, safety oversight, and immunization improvement strategies to sustain current coverage rates. Reductions in this capacity will contribute to a weakening of vaccination levels and possible disease outbreaks.
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From page 141... ...
12. The TFCPS report includes only three strategies (increasing community demand for vaccination, enhancing access to vaccination services, and implementing provider-based interventions)
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