Anticipating Successful Vaccine Adoption…

Advocacy Programmes to SupportAdvocacy Programmes to Support the Willingness to Vaccinate

John D. Grabenstein, RPh, PhDMerck Vaccines & Infectious Diseases

West Point Pennsylvania USAWest Point, Pennsylvania, USA

8 July 2008Fondation Mérieux

Veyrier-Du-Lac, Les Pensières

Advocacy Programmes to Support Willingness to Vaccinate

Even vaccines based on sound scientific id ill f lfill h i i l ifevidence will not fulfill their potential, if not

transformed into vaccination.

Vaccinations require professionals willing to vaccinate their patients. p

Advocacy programmes prepare and support a cadre of professionals willing to vaccinate.

Ad l t t dAdvocacy programmes accelerate rate and magnitude of vaccination delivery.

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Components Of Advocacy Programmes To Enhance Vaccination By Health-Care Providers

• Educate• Educate To increase awareness of disease burden To provide technical info, thus confidence To provide technical info, thus confidence

• Share “Best Practices" To simplify offering and delivering

vaccination To ease the task of staying up-to-date To ease the task of staying up to date

• Foster the “Standard of Care"

• Adopt “Quality Indicators"

Web-Based & Selected Other Education Resources US Centers for Disease Control & Prevention www cdc gov/vaccines/ed US Centers for Disease Control & Prevention, www.cdc.gov/vaccines/ed

Immunization: You Call the Shots Epidemiology & Prevention of Vaccine-Preventable Diseases Various other topics via webcast podcast etc Various other topics via webcast, podcast, etc. Immunization Practice Toolkit, www2.cdc.gov/nip/isd/immtoolkit/default.htm Storage and Handling Toolkit, www2a.cdc.gov/nip/isd/shtoolkit/splash.html

"Shots 2008" for personal digital assistants Imm ni ationEd org "Shots 2008" for personal digital assistants, www.ImmunizationEd.org US Department of Defense, Military Vaccine Agency, Immunization

University, www.vaccines.mil/ImzUP j t I i R di (PIR) Project Immunize Readiness (PIR), https://www.projectimmunereadiness.amedd.army.mil/ or www.vhcpir.org

www.usamma.army.mil/vaccines/ccm/cold_chain_management.cfm . World Health Organization IVB Document Centre World Health Organization, IVB Document Centre,

www.who.int/vaccines-documents/DoxGen/H3DoxList.htm Teaching Immunization Delivery & Evaluation (TIDE), www.musc.edu/tide Teaching Immunization for Medical Education (TIME),

www.aptrweb.org/education/TIME/time.html Merck Vaccine Network--Africa (MVN-A), www.merck.com/mvna,

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Kenya, Mali, Uganda and Zambia

DoD’s Immunization University

What is Immunization University? A collection of training programs and resources to enhance the skills of professionals and paraprofessionals “Imz U” offers training through distanceparaprofessionals. Imz U offers training through distance learning and on-site classes. www.vaccines.mil/ImzU

Training ResourcesTraining Resources• Project Immune Readiness (50 hours)• Immunization-Allergy Technician Course• Immunization ToolkitImmunization Toolkit• Immunization Tracking Systems• et cetera

Cli i Q lit I t P (CQIP)Clinic Quality Improvement Program (CQIP)“Six-Sided” Training & Competency Files Policies & Procedures (prototype SOPs)Communication Tools Clinical Guidelines for Managing Adverse Events

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Don’t reinvent the wheel, learn from those around you…

Awareness of Disease Burden

• Influenza – vaccine first licensed ~ 1945Worldwide annual toll – <1 B cases, 300,000—500,000 deathsLocal --

• Measles – vaccine first licensed ~ 1963W ld id 242 000 d th i 2006Worldwide – 242,000 deaths in 2006Local --

• Hepatitis B vaccine first licensed ~ 1981• Hepatitis B – vaccine first licensed ~ 1981Worldwide – 350 MM chronic carriersLocal --

• Pneumococcal disease – vaccine first licensed ~ 1947 • Haemophilus influenzae b – vaccine first licensed ~ 1985p• Rotavirus – vaccine licensed ~ 1998, 2005• Human Papillomavirus – vaccine first licensed 2006

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Human Papillomavirus vaccine first licensed 2006

Source: WHO

Vaccination Choices: Provider as Advocate

Opinion of: Immunization Op o o u at oPatient Provider Influenza Pneumococcalyes yes 87% 84%yes yes 87% 84%no yes 70% 63%yes no 8% 7%yes no 8% 7%no no 7% 5%

Source: CDC. Adult immunization: Knowledge, attitudes, and practices--DeKalb and Fulton Counties, Georgia, 1988. MMWR 1988;37:657-61. www.cdc.gov/mmwr/preview/mmwrhtml/00021583.htmg p

Provider Recommendation Can Overcome Negative Attitudes Among Patients

Vaccination Rates Among High-Risk Patients With Negative Attitudes

100

%)

No MD Recommendation

MD Recommendation

60

80

Rat

e (%

40

cina

tion

0

20Vacc

Source: Nichol KL MacDonald R Hauge M Factors associated with influenza and pneumococcal

0Influenza PPV

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Source: Nichol KL, MacDonald R, Hauge M. Factors associated with influenza and pneumococcal vaccination behavior among high-risk adults. J Gen Intern Med 1996;11:673-7.

Share Best PracticesTo simplify offering and delivering vaccination• www.immunize.org• www cdc gov/vaccineswww.cdc.gov/vaccines• www.immunise.health.gov.au • www.who.int/topics/immnization • www.ecdc.europa.eu/health_topics/VI/VI.html

To ease the task of staying up-to-dateTo ease the task of staying up to date• Immunization Action Coalition, www.immunize.org/subscribe• National Network for Immunization Information,

www immunizationinfo orgwww.immunizationinfo.org• CDC's ImmuEd listserv, listserv@cdc.gov, “Subscribe ImmuEd

<firstname lastname>" https //ser ice go deli er com/ser ice/m lti s bscribe html?codehttps://service.govdelivery.com/service/multi_subscribe.html?code=USCDC&origin=

• FDA’s Center for Biologics Evaluation & Research, fd / b / bi f / li t ht

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www.fda.gov/cber/pubinfo/elists.htm

Strategies for Increasing Adult Vaccination Rates

•Standing Orders•Computerized Record Reminder•Chart Reminder•Performance Feedback •Home Visits•Mailed/Telephoned Reminders p•Expanding Access in Clinical Settings

“drop in” or “express lane”•Patient Education•Personal Health Records

Source: www.cdc.gov/vaccines/recs/rate-strategies/adultstrat.htm

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Foster the “Standard of Care"

Source: www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Adopt Quality Indicators

Quality-improvement (QI) programs to enhance clinic operations and vaccination rates.

•DoD Clinic Quality-Improvement Program (CQIP), www vaccines mil/CQIPwww.vaccines.mil/CQIP

•CDC Comprehensive Clinic Assessment Software pApplication (CoCASA), www.cdc.gov/vaccines/programs/cocasaCDC A t F db k I ti X h•CDC Assessment, Feedback, Incentives, eXchange (AFIX) program, www.cdc.gov/vaccines/programs/afix

•National Quality Forum: www.qualityforum.org

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DoD Clinic Quality-Improvement Program i il/CQIPwww.vaccines.mil/CQIP

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Immunization StandardsTypical Format1. Immunization availability2. Information and education before immunization3. Vaccine storage and handling4. Indications and contraindications to immunization5. Immunization record keeping5 u at o eco d eep g6. Training7. Adverse events after immunization

C di N ti l Ad i C itt I i ti C di id li f hildh dCanadian National Advisory Committee on Immunization. Canadian guidelines for childhood immunization practices. Can Comm Dis Rep 1997;23(ACS-6):1-12. www.phac-aspc.gc.ca/publicat/ccdr-rmtc/97vol23/23sup/acs6.html

Gershon AA, et al. Quality standards for immunization. Clin Infect Dis 1997;25:782-6. www.journals.uchicago.edu/IDSA/guide/OC31_782.pdfj g g _ p

National Vaccine Advisory Committee. Adult immunization programs in nontraditional settings: Quality standards and guidance for program evaluation. MMWR 2000;49(RR-1):1-13.

ftp.cdc.gov/pub/Publications/mmwr/rr/rr4901.pdf Poland GA, et al, National Vaccine Advisory Committee. Standards for adult immunization practices.

Am J Prev Med 2003;25:144-50Am J Prev Med 2003;25:144-50. American Academy of Pediatrics. Standards for child and adolescent immunization practices.

Pediatrics 2003;112:958-963.American Pharmaceutical Association. Guidelines for pharmacy-based immunization delivery.

www.aphanet.org/pharmcare/immguide.html 1997 Aug

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g g gUS Department of Defense. Immunizations and Chemoprophylaxis. 29 Sep 2006,

www.apd.army.mil/pdffiles/r40_562.pdf

Sources of Advocacy

• National or jurisdictional authoritiesACIP, NACI, ATAGI, STIKO, FACI, Oberster Sanitätsrat, MOHs,

SAGE othersSAGE, others • Professional societies Professional membership associations p

• Coalitions and nongovernmental organizations Immunization Action Coalition, www.immunize.org R i l ( d lt/ di t i ) i i ti liti Regional (adult/pediatric) immunization coalitions Cervical cancer task forces (prophylaxis, early detection)

• Patient, public groups p g p National Meningitis Assn: www.nmaus.org, www.musa.org Influenza: www.FamiliesFightingFlu.org Voices for Vaccines: www voicesforvaccines org Voices for Vaccines: www.voicesforvaccines.org

• Employers Corporations Military units (www.vaccines.mil)

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www.vaccines.mil

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Drivers (if Present) or Barriers (if Absent) Leading Professionals to Support Vaccination Policies

• Preparedness of practice site (eg, office, clinic, institution) T i i f t ff ( f i l & f i l) Training of staff (professional & paraprofessional)

» Ongoing access to educational resources I f t t ( d t ld h i ) Infrastructure (eg, records, computers, cold chain) Assessment, feedback on implementation of policies P t h d t ti k i f t Posters, handouts, stickers, screening forms to standardize messages and simplify processes Systems to convey reminder and recall messages Systems to convey reminder and recall messages

• Routine screening processes and "standing orders"• Information exchange of vaccination status (eg electronic• Information exchange of vaccination status (eg, electronic

registries)• Financial circumstances

Adopt Standing Orders

Source: Immunization Action Coalition www immunize org/catg d/p3075 pdf

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Source: Immunization Action Coalition, www.immunize.org/catg.d/p3075.pdf See also: www.immunize.org/standingorders/

Observed vs. Expected Effects

25Hypothetical example

20C

15Casesper10 000

1010,000

5

0Unvaccinated Vaccinated

23

Unvaccinated Vaccinated

Factors that Affect Decisions on Accepting Vaccination

Perceived susceptibility to the diseasep yPerceived seriousness of the diseaseP i d b i ( id ff t )Perceived barriers (side effects, access)Perceived vaccine benefitsSocial influence of a respected person

Sources:• Carter WB et al Health Serv Res 1986;20:897 932• Carter WB, et al. Health Serv Res 1986;20:897-932.• Janz NK, Becker MH. Health Educ Quarterly 1984;11(Spr):1-47. • Peterson C, Stunkard AJ. Soc Sci Med 1989;28:819-28.• Montano DE. Med Care 1986;24:438-53.;• Rosenstock IM, et al. Public Health Rep 1959;74:98-103.

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Components Of Advocacy Programmes To Enhance Vaccination By Health-Care Providers

• Educate• Educate To increase awareness of disease burden To provide technical info, thus confidence To provide technical info, thus confidence

• Share “Best Practices" To simplify offering and delivering

vaccination To ease the task of staying up-to-date To ease the task of staying up to date

• Foster the “Standard of Care"

• Adopt “Quality Indicators"