Childhood Immunization How Far We’ve Come And How Far We Have to Go

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Childhood Immunization How Far Weve Come And How Far We Have to Go. Alan R. Hinman, MD, MPH Indiana Immunization Conference October 16-17, 2007. Outline of presentation. Current status of childhood immunization in the US How immunizations are financed in the US Inequities in financing - PowerPoint PPT Presentation

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  • Childhood ImmunizationHow Far Weve ComeAnd How Far We Have to Go Alan R. Hinman, MD, MPHIndiana Immunization ConferenceOctober 16-17, 2007

  • Outline of presentationCurrent status of childhood immunization in the USHow immunizations are financed in the USInequities in financingCausesPossible solutionsFurther issues with adult immunization

  • Diphtheria 175,885 0 100Measles 503,282 66 >99Mumps 152,209 314 >99Pertussis 147,271 25,616 83Polio (paralytic) 16,316 1** 100Rubella 47,745 11 >99 CRS 823 1 >99 Tetanus 1,314 27 98Hib/unk (
  • U.S. Haemophilus influenzae Type b Cases - 1985-2001**2001 data provisional

  • Impact of PCV7 Vaccine on Racial Disparities in Invasive Strep pneumoniae InfectionFlannery et al. JAMA 2004; 291: 2197 - 2203

  • Herd Effect in Adults 65+ YearsPCV7 types v. 16 types only in PPV ABCs 1998/99 average vs. 2003*PPV= 23 valent pneumococcal polysaccharide vaccine

  • Varicella-related Hospitalization Rates*, 1994-20020.002.004.006.008.0010.0012.0014.00199419951996199719981999200020012002YearRate (per 100,000 population)
  • Hepatitis A Incidence by County, 1987-97 and 2005 Rate per 100,0000-45-910-1920+1987-1997 2005

  • Incidence of hepatitis A per 100,000 population, by vaccination recommendation status, 1966-2006*Vaccination recommended in high-risk groupsVaccination recommended in high-risk areasSource: NNDSS * 2006 data provisional

  • Number of Vaccines in the Routine Childhood and Adolescent Immunization Schedule198519952006MeaslesRubellaMumpsDiphtheriaTetanusPertussisPolioHib (infant) HepBVaricellaPneumococcal diseaseInfluenzaMeningococcal diseaseHepARotavirusHPVMeaslesRubellaMumpsDiphtheriaTetanusPertussisPolioHib (infant) HepBVaricellaMeaslesRubellaMumpsDiphtheriaTetanusPertussisPolio

    71016

  • Increasing Vaccine-Specific Coverage Rates Among Preschool-Aged Children DTP(3+) is not a Healthy People 2010 objective. DTP(4) is used to assess Healthy People 2010 objectives.Note: Children in the USIS and NHIS were 24-35 months of age. Children in the NIS were 19-35 months of age.Source: USIS (1967-1985), NHIS (1991-1993) CDC, NCHS, and NIS (1994-December 2003), CDC, NIP and NCHS; No data from 1986-1990 due to cancellation of USIS because of budget reductions.DTP(3+)MMR(1+)Hib (3+)2010 TargetHep B (3+)Polio (3+)Varicella (1+)PCV 7 (3+)2005

  • Vaccination coverage among children 19-35 months of age, 2006VaccineUSA INDTP/DTaP 4+85.2%84.5%Polio3+92.9%92.4%MMR1+92.4%89.5%Hib3+93.4%90.7%Hep B3+93.4%92.1%Varicella1+89.3%88.0%PCV3+87.0%87.3%

  • Vaccination coverage among children 19-35 months of age, 2006Series USAIN 4+ DTP/3+ Po/1+ MCV 83.2%82.6%4/3/1/3+ Hib 82.3%80.8%4/3/1/3/3+ Hep B 80.6%79.5%4/3/1/3/3/1+ Varicella 77.0%75.9%

  • Estimated Vaccination Coverage Among Children Enrolled in Kindergarten - United States, 2006-2007 School Year>3 Polio96.3%>4 DTP96.0%>1 MMR95.6%>3 Hep B96.8%>1 Var 96.5% or history of varicella disease

    CDC, MMWR 2007; 56:819-821

  • Eliminating Racial Disparity in Immunization Coverage 4:3:1:3:3:1 Estimated Vaccination Coverage by Race/Ethnicity, 19-35 Month Old Children, USNational Immunization Survey, MMWR Sept 14, 2006

    Chart1

    66.261.766

    73.968.471.3

    77.270.975.9

    7676.375.6

    non-Hispanic White

    non-Hispanic Black

    Hispanic

    Year

    Percentage

    Sheet1

    Year2002200320042005

    non-Hispanic White66.273.977.276

    non-Hispanic Black61.768.470.976.3

    Hispanic6671.375.975.6

  • Immunization Coverage Rates of 19-35 month old Children in the United States, 2006CDC. MMWR 2007;56:881-885

  • Estimated vaccination coverage among adolescents 13-17, US 2006MMR 2+ 86.9%Hep B 3+81.3%Varicella*89.6%Td/Tdap**60.1%MCV11.7%

    *Vaccine or disease**Since age 10 years

  • Types of costs in immunizationVaccine purchaseVaccine administrationNon-vaccine costs

  • Federal Contract Prices for Vaccines Recommended Universally for Children and Adolescents 1985, 1995, 2006Federal contract price shown for 1985 and 1995 are averages that account for price changes within that year. $45$155$1182

  • Sources of financing childhood immunizationsGovernmentFederalState/localInsurancePrivatePublicOut-of-pocket

  • 317 Immunization Program317 grants support:

    Purchase of vaccine for free administration at local health departmentsImmunization deliverySurveillanceCommunicationEducation

  • Percent Increase of the Cost of Full Series vs. Percent Increase of Section 317 Appropriation2005 estimate includes one dose of MCV4 and one dose of Tdap in adolescents.

  • Childhood Vaccine Doses Distributed by Funding SourceCalendar Year 2005Source: Vaccine manufacturers Biologics Surveillance Data 2005 Note: Does not include influenza vaccine

  • How Public Health Reaches Children through VFCVFC program has 45,000 provider sites75% of sites are private providers25% are public sector sites

    Collectively, VFC providers vaccinate 90% of childrenVFC vaccine for VFC-eligible childrenPrivate purchase vaccine for other children

    Improving VFC providers practices improves vaccinations for almost all children

  • Contrasts Between317 and VFC Funding Sources* Underinsured only at Federally Qualified Health Centers and Rural Health Clinics

    Attributes317VFCSourceDiscretionary annual appropriationMandatoryEligibilityNot restrictedMedicaid-enrolled; Uninsured; Native American, Alaska Native; Underinsured*StabilitySignificant fluctuations possibleStable funding stream

  • VFC and Section 317 Vaccine Funding to Immunization Programs

    Chart3

    1490000001990

    1503000001991

    1831000001992

    2151000001993

    2225000001994

    157400000213945000

    144200000254873000

    158700000337885000

    143100000458645000

    139629000427268000

    180027000509017000

    201122000801925000

    223233000919634000

    221873000887856000

    2099980001058919000

    2348970001207206000

    2333230001714466000

    2324560001899377000

    Section 317

    VFC

  • Two-Tiered State Vaccination Policies at Local Health DepartmentsTraditionally, health department clinics vaccinated any child brought for vaccinationUnderinsured children ineligible for VFC vaccine except at FQHCs and RHCs (~3,000 clinics)VFC designated FQHCs and RHCs as safety-net providers for underinsured childrenState and 317 funding used for underinsuredDue to inadequate state/317 funding, many states cannot purchase vaccine for underinsured childrenResult is a two-tiered policyGovernment purchased vaccine not available to underinsured at health department clinicsAccess to new vaccines for some based on insuranceEthical tension for public health officials and providers

  • Two-Tiered States: 2005Invasive pneumococcal disease13 states did not purchase PCV7 vaccine for underinsured children in health department clinicsInvasive meningococcal disease31 states did not purchase MCV4 vaccine for underinsured children in health department clinicsThese states do not have a public health department safety net to vaccinate children against these diseases

  • Grantees Provision of Vaccines to Underinsured Children, 2006 (N=49)Source: Grace Lee et al; Harvard University

    Q1

    4900

    4900

    4621

    21271

    4450

    4270

    34150

    Yes

    No/Not yet

    Missing

    % supplying to VFC-eligible

    Q3

    39100

    32170

    37111

    14341

    16330

    30190

    22270

    Yes

    No/Not yet

    Missing

    % supplying to underinsured

    Time to imple

    11123

    143410

    10314

    10100

    10000

    20000

    Universal

    Universal select

    VFC enhanced

    VFC enhanced select

    VFC only

    Number of states

    Mening prior

    20

    2

    3

    1

    4

    1

    4

    Number of states

    meningprior2

    119

    02

    21

    01

    22

    01

    40

    VFC only

    VFC + non-VFC

    mening prior3

    20

    2

    3

    1

    4

    1

    4

    vaccine choice

    25

    9

    12

    q4

    0.1428571429

    0.4761904762

    0

    0.0476190476

    0.3333333333

    0

    0

    q5

    2126

    2334

    2123

    138

    2913

    2020

    1814

    Yes

    No

    % states 2-tiered private

    q6

    245

    740

    143

    219

    1526

    238

    527

    Yes

    No

    % states 2-tiered public

    Sheet1

    Not implementedImplemented

    VFC financingSupplyVFCSupply

    YesNo/Not yetMissingtotalYesNoMissingYesNoMissingYesNoYesNo

    VZV490049339236

    Prevnar49004913302419

    Pediarix46214911011635238

    MMRV212714991443204712316

    Menactra4450493022211725348

    Tdap42704942115111261918

    HepA34150498521122823525

    YesNo/Not yetMissingtotal

    VZV3910049

    Prevnar3217049

    Pediarix3711149

    MMRV1434149

    Menactra1633049

    Tdap3019049

    HepA2227049

    UniversalUniversal selectVFC enhancedVFC enhanced selectVFC only

    Q4Yes% change policy0-2 months111238*only 44 states answered

    VZV30.14285714293-4 months14341022

    Prevnar100.47619047625-6 months103149

    Pediarix007-8 months101002

    MMRV10.04761904769-12 months100