>>> GOOD MORNING, I'D LIKE TO
CALL INTO SESSION THE SECOND DAY
OF OUR FEBRUARY 2013 ADVISORY
COMMITTEE ON IMMUNIZATION
PRACTICES MEETING AND TO START
OUT TODAY GOING TO ASK DR.
WHARTON TO TAKE THE PODIUM FOR
AN ANNOUNCEMENT.
>> THANK YOU, DR. TEMTE.
I AM DELIGHTED TO BE HERE THIS
MORNING TO SHARE WITH YOU SOME
INFORMATION.
THE DISTINGUISHED SERVICE MEDAL
IS THE HIGHEST PUBLIC HEALTH
SERVICE COMMISSION AWARD.
THIS AWARD IS GIVEN TO
COMMISSIONED OFFICERS FOR
OUTSTANDING CONTRIBUTIONS TO THE
MISSION OF THE PUBLIC HEALTH
SERVICE.
SUCH ACHIEVEMENTS MAY RANGE FROM
THE MANAGEMENT OF A MAJOR HEALTH
PROGRAM TO AN INITIATIVE
RESULTING IN THE MAJOR IMPACT ON
THE HEALTH OF A NATION.
IT CAN ALSO BE CONFERRED FOR
ONETIME HEROIC ACT RESULTING IN
GREAT SAVINGS TO LIFE, HEALTH,
OR PROPERTY.
THIS MORNING I HAVE THE
PRIVILEGE TO PRESENT A
DISTINGUISHED SERVICE MEDAL TO A
U.S. PUBLIC HEALTH SERVICE
COMMISSIONED OFFICER WHO HAS
RECENTLY RETIRED.
I'M GOING TO READ YOU A SEGMENT
FROM THIS AWARD NOMINATION.
THE U.S. IMMUNIZATION PROGRAM IS
ONE OF THE TOP PUBLIC HEALTH
SUCCESSES.
THOUSANDS OF DEATHS A YEAR ARE
PREVENTED IN CHILDREN AND ADULTS
GIVEN TO VACCINES GIVEN
THROUGHOUT THE LIFESPAN.
CDC'S ADVISORY COMMITTEE HAVE
SET STANDARD OF CARE FOR THE
PUBLIC HEALTH SERVICE OF THE
NATION FOR ITS IMMUNIZATION
RECOMMENDATION AND CONTROL OF
VACCINE PREVENTABLE DISEASES.
THESE RECOMMENDATIONS ARE
COMPLEX AND CAN CHANGE RAPIDLY
FOR MANY REASONS INCLUDING
EPIDEMICS, OUTBREAKS, OTHER
PUBLIC HEALTH EMERGENCIES,
VACCINE SHORTAGES, NEW PRODUCT
LICENSURE, EDUCATING CLINICIANS
AND THE PUBLIC PRACTITIONERS ON
THE CONSTANTLY EVOLVING
RECOMMENDATIONS HAS BEEN A
CRITICAL COMPONENT OF THE
ENORMOUS SUCCESS OF THE U.S.
IMMUNIZATION PROGRAM.
SINCE 1995 THIS OFFICER ALMOST
SINGLE-HANDEDLY RAISED THE
STANDARDS AND APPROACH FOR
VACCINE EDUCATION TO NEW HEIGHTS
AS THE LEADER OF THE CDC'S
IMMUNIZATION EDUCATION TEAM.
THIS OFFICER LED A POLICY
DEVELOPMENT FOR SEVERAL VACCINES
AND MADE MAJOR CONTRIBUTIONS TO
OTHERS.
ADDITIONALLY THIS OFFICER WAS A
NATIONAL LEADER IN EDUCATING
PROVIDERS AND PUBLIC HEALTH
PRACTITIONERS ON CURRENT
VACCINATION POLICY AND VACCINE
SAFETY.
BECAUSE OF THIS OFFICER'S
PERSISTENT, INNOVATIVE AND
INVALUABLE EFFORTS THE OFFICER
BECAME THE PUBLIC FACE OF CDC'S
IMMUNIZATION PROGRAM.
THIS OFFICER IS RECENTLY RETIRED
CAPTAIN BILL ATKINSON AND I HOPE
HE CAN COME FORWARD.
I SEE YOU DRESSED UP FOR THE
OCCASION.
>> I DIDN'T KNOW.
THANK YOU.
I'D HAVE WORN MY GOOD SHOES IF
I'D KNOWN THIS WAS GOING TO
HAPPEN.
>> THANK YOU, MELINDA, AND DR.
ATKINSON.
WE'RE GOING TO MOVE ON TO THE
UNFINISHED BUSINESS SECTION AND
WE'RE JUST LOOKING AT THE
PROPOSED PROPOSED TABLE AND
FOOTNOTES FOR THE INCLUSION AND
UPDATED HIB STATEMENT AND HIB
RESOLUTION.
SO, DR. SANTELLI?
>> GOOD MORNING.
BASED ON THE DISCUSSION
YESTERDAY AND A DOCUMENT THAT WE
SENT OUT, OKAY -- THIS ISN'T
DOING ANYTHING.
NO.
OH, HERE IT IS.
OKAY.
WE'LL TELL YOU WHAT WE DID WHILE
THE SCREEN'S COMING UP.
SO BASED ON THE DISCUSSION WE --
OH, YAY!
WE MADE SOME CHANGES TO THE
OPTION ONE THAT'S SHOWN SCREEN
YESTERDAY ON PAPER.
WE GOT COMMENTS FROM A NUMBER
INDIVIDUAL ACIP MEMBERS.
AND ABOUT HALF WHO WE HEARD FROM
ACTUALLY THOUGHT IT WAS FINE AS
IT WAS.
THERE WAS ANOTHER HALF WHO FELT
THERE WERE TOO MANY LINES IN IT,
TOO MUCH INFORMATION AND THAT IT
MIGHT BE CONFUSING AND
RECOMMENDED THE REMOVALRT IN RE.
WE ALSO, BASED ON THAT AND
WANTING TO REVISE IN THE SPIRIT
OF THAT, HAVE PROPOSED ANOTHER
OPTION FOR YOU TO LOOK AT.
WHICH IS OPTION TWO.
WE'LL GIVE YOU A MINUTE TO LOOK
AT THAT.
AND NOW TURNING IT OVER TO YOU
ALL FOR DISCUSSION AND COMMENT.
>> AND JUST -- I THINK SINCE
THIS IS A VOC RESOLUTION AND THE
LANGUAGE IS BINDING, WE PROBABLY
ARE GOING TO NEED TO VOTE ON
THIS AS WELL, SO JUST SO WE'RE
AWARE OF THAT.
DR. DUCHIN?
>> THANK YOU, I THINK OPTION TWO
IS OUTSTANDING.
EXCELLENT.
EXCELLENT COMPROMISING AND GOOD
DRAFT LANGUAGE.
>> I'M SEEING A LOT OF NODS OF
AFFIRMATION HERE.
IS THERE A MOTION?
DR. REUBEN?
>> I MAKE A MOTION TO ACCEPT
OPTION NUMBER TWO FOOTNOTE FOR
THE RESOLUTION AND THE HIB
STATEMENT WHICH I GUESS WOULD
HAVE THE SAME VERBIAGE.
>> OKAY.
IS THERE A SECOND?
AND I BELIEVE DR. BENNETT WOULD
LIKE TO SEE OPTION ONE ONE MORE
TIME.
SO, THE MOTION -- FURTHER
DISCUSSION?
THE MOTION IS TO ACCEPT OPTION
TWO IF DR. SANTELLI CAN PUT THAT
BACK ON UP.
AND SHALL WE START WITH DR.
CAMPOS-OUTCALT AND GO CLOCKWISE?
>> YES.
>> YES.
>> YES.
>> YES.
>> HARRIMAN, YES.
>> HARRISON, YES.
>> DUCHIN, YES.
>> VASQUEZ, YES.
>> ROSENBAUM, YES.
>> SAYRE, YES.
>> RUBIN, YES.
>> TEMTE, YES.
>> YES.
>> AND I BELIEVE THAT CONCLUDES.
WE HAVE UNANIMOUS -- COMMENT?
>> I HAVE A QUESTION ABOUT THE
TEXT OF THE WHOLE REPORT AND
THAT WILL ALSO INDICATE THAT IT
DOES ALSO -- [ INAUDIBLE ] AND I
JUST THE VACCINE COULD BE USED
BY OTHER PRACTITIONERS IF THEY
CHOSE TO DO SO.
I JUST WANT THAT UNDERSTANDING.
I DON'T KNOW HOW MUCH VERBIAGE
THEY'LL BE IN THE ACTUAL TEXT.
>> ARE YOU TALKING ABOUT THE
RECOMMENDATION OR THE VOC
RESOLUTION?
>> OH, NEVER MIND.
I AM TALKING ABOUT THE
RECOMMENDATION.
>> OKAY.
I BELIEVE THIS CONCLUDES THE --
OH.
>> YEAH.
I WAS JUST GOING TO SAY THE
RECOMMENDATION, IS LISTED AS A
VACCINE THAT COULD BE USED FOR
HIB VACCINATIONS.
>> FURTHER DISCUSSION?
THEN I AM HAPPY TO SAY THAT WE
CONCLUDE THE UNFINISHED BUSINESS
PORTION AND HAVE THE PLEASURE OF
INVITING DR. ADA HINSHAW FROM
THE SERVICES UNIVERSITY OF
HEALTH SCIENCES IN BETHESDA UP
TO THE PODIUM.
DR. HINSHAW IS THE CHAIR OF THE
COMMITTEE ON THE ASSESSMENT OF
HEALTH OUTCOMES RELATED TO
RECOMMENDED CHILDHOOD
IMMUNIZATION SCHEDULE AND A
MEMBER OF THE TEAM THAT AUTHORED
THE IOM REPORT ON THE SAFETY OF
THE CHILDHOOD VACCINE.
DR. HINSHAW?
THANK YOU FOR BEING ABLE TO
PRESENT HERE.
>> THANK YOU.
IT IS A PLEASURE TO BE HERE THIS
MORNING AND TO BE ABLE TO TALK
WITH THIS AUDIENCE PARTICULARLY
WITH THE ACIP GROUP ABOUT THE
REPORT THAT HAS JUST COME OUT ON
THE CHILDHOOD IMMUNIZATION
SCHEDULE AND SAFETY.
I MUST SAY TO YOU THAT THIS WAS
A SHIFT IN THINKING, AND I THINK
IT MAY BE A SHIFT IN THINKING
FOR MANY IN OUR CULTURE WHO ARE
LOOKING AT IMNIZATIMUNIZATION A
VACCINE MANY THAT TESTIFIED AT
THE PUBLIC MEETING AND SEVERAL
MEMBERS EARLY AT THE FIRST
MEETING WE HAD TO KEEP REMINDING
EACH OTHER, WE ARE TALKING ABOUT
THE IMMUNIZATION SCHEDULE, NOT
INDIVIDUAL VACCINES, NOT ADVERSE
EVENTS IN RELATIONSHIP TO
INDIVIDUAL VACCINES, BUT THE
CONTEXT OF THE ENTIRETY OF THE
SCHEDULE.
THAT CLEARLY IS QUITE A REPORT
TO BE ASKED TO PROVIDE FOR YOU
AND WE HAVE MADE THE FIRST STEPS
TOWARD THAT.
BUT THERE IS MUCH THAT NEEDS TO
BE DONE IN THIS AND I THINK
PROBABLY IT'S GOING TO BE A
CULTURAL SHIFT FOR A LOT OF
PEOPLE.
SO, THIS IS NOT UNUSUAL IN THAT
SENSE.
THIS STUDY ACTUALLY CAME OUT OF
THE RECOMMENDATION FROM THE
SAFETY WORKING GROUP AND THIS
WAS BACK IN 2009, IN WHICH THEY
TALKED ABOUT LOOKING AT RESEARCH
METHODOLOGY SPECIFICALLY.
STUDY DESIGNS AND THE ETHICAL
CONDUCT, THE ETHICAL CONDUCT OF
THE RESEARCH UNDER THOSE
DESIGNS, AND THE FEASIBILITY OF
THOSE.
AND THEY WERE PARTICULARLY
INTERESTED IN LOOKING AT AND
EXAMINING OUTCOMES IN
RELATIONSHIP TO A SCHEDULE KIND
OF ISSUE, WHICH IS UNVACCINATED,
VACCINATED DELAYED, AND
VACCINATED CHILDREN.
SO, VERY INTERESTING THAT THIS
HAS BEEN THOUGHT ABOUT FOR SOME
TIME AND WE ARE NOW BEGINNING TO
TAKE UP THAT PARTICULAR AGENDA.
THE STATEMENT OF THE TASK CAME
DIRECTLY FROM THE NVAC WORKING
GROUP.
YOU WILL SEE CLEARLY WE WERE
LOOKING AT SCIENTIFIC FINDINGS
AND STAKEHOLDER CONCERNS AS THEY
WERE RELATED TO SAFETY OF THE
RECOMMENDED CHILDHOOD
IMMUNIZATION SCHEDULE.
AND I ALWAYS DO PUT EMPHASIS ON
THAT BECAUSE OF THIS CULTURAL
SHIFT THAT WE'RE ALL MAKING WHEN
WE LOOK IN THIS DIRECTION.
NOT SUCH A SHIFT FOR THOSE IN
THIS PARTICULAR GROUP, BUT IT IS
FOR MANY PEOPLE IN THE VACCINE
COMMUNITY.
OBVIOUSLY FROM THE NVAC APPROACH
WE WERE PARTICULARLY ASKED TO
LOOK AT DIFFERENT KIND OF
METHODOLOGIES AND STUDY DESIGNS,
PROS AND CONS, WHAT WOULD INFORM
QUESTIONS ABOUT THE SCHEDULE
WHICH ARE MANY.
THERE COULD BE HUNDREDS OF
QUESTIONS THAT ARE ASKED ABOUT
THE CHILDHOOD IMMUNIZATION
SCHEDULE, AND THE ISSUES IN
TERMS OF SAFETY AND OUTCOME.
SO, TO TAKE A LOOK AT THOSE, AND
PARTICULARLY LOOK AT THE ETHICAL
FEASIBILITY OF THESE DIFFERENT
DESIGNS.
AND YOU HAVE A COPY, I BELIEVE,
OF THE CHILDHOOD IMMUNIZATION
SCHEDULE AND SAFETY BRIEF THAT
WE HAD SENT TO YOU, SO YOU
SHOULD HAVE THAT IN YOUR PACKETS
AND HAVE -- I SAW IT OUT ON THE
TABLE, AND SO YOU HAVE AN
ABILITY TO LOOK AT THAT.
THE REPORT HAS BEEN RELEASED, SO
I CAN TALK ABOUT DIFFERENT
ASPECTS OF IT TO SAY THE LEAST.
THE COMMITTEE MEMBERS WERE
CAREFULLY CHOSEN FOR PARTICULAR
AREAS OF BACKGROUND THAT WERE IN
THE STATEMENT OF THE TASK AS
ALWAYS, BUT IN THIS CASE
RESEARCH METHODS, PEOPLE WHO
KNEW ABOUT OUTCOMES AND PEOPLE
WHO ARE VERY MUCH CONCERNED
ABOUT STAKEHOLDER CONCERNS.
AS A METHODOLOGY IT'S STEVE
FUCHA AND DAMAGE HEDN HEDGET, A
PAJ ROHANI FROM MICHIGAN.
THOSE ARE THREE VERY BIG
METHODOLOGISTS WITH US.
AND OTHERS HAD BACKGROUND SUCH
AS PAUL BYRD AND AL GREENBERG,
SO WE HAD A NUMBER OF PEOPLE
LOOKING SPECIFICALLY AT THE
METHODOLOGIES AND STUDY DESIGN.
THE STAKEHOLDERS INVOLVED WERE
FROM THE PARENTS' VIEWPOINT NAT
LEYLAND AND FROM THE PUBLIC
HEALTH OFFICIALS' VIEWPOINT, DR.
ARGON, SO WE HAD A NUMBER OF
PEOPLE.
THE ETHICAL CONCERNS WERE
COVERED BY A NUMBER OF THE MDs
AND HEALTH PROFESSIONALS ON THE
PANEL, BUT ALSO COVERED
SPECIFICALLY BY TWO ETHICIST
LAINIE ROSS AND ALTA CHARO.
THAT GIVES YOU THE BACKGROUND
FOR WHERE WE STARTED AT THESE
PARTICULAR ISSUES THAT HAD BEEN
PUT IN FRONT OF US.
THE COMMITTEE PROCESS WAS AS
USUAL WITH THE IOM.
INFORMATION GATHERED FROM THE
PUBLIC AND THAT WAS DONE THROUGH
THREE DIFFERENT INFORMATION
GATHERING MEETINGS.
WE ALSO THEN DID EXTENSIVE
REVIEWS OF THE LITERATURE ON
SCIENTIFIC FINDINGS OF SEVERAL
KINDS, SAFETY, STAKEHOLDER
CONCERNS, AND OBVIOUSLY HEALTH
OUTCOMES.
SO, THOSE ARE ALL IN THE REPORT,
CHAPTERS FOUR AND FIVE.
AND YOU CAN TAKE A LOOK AT THOSE
FINDINGS IN CASE YOU GO THROUGH
THE REPORT ITSELF.
WE DID ALSO COMMISSION AN
INDEPENDENT PAPER WHICH HELPED
US TO LOOK SPECIFICALLY AT THE
DIFFERENT POSSIBLE
METHODOLOGIES.
THIS WAS DONE BY MARTIN CURLDORF
WHO IS FROM HARVARD AND IS A
METH
METH
METHODOLOGIST.
AND IT'S IN YOUR FOLDER SO YOU
CAN LOOK AT THAT.
WE HAD MANY E-MAIL MESSAGES THAT
WERE SENT TO US READ THAT
REPORT.
WE DID PUT IT ON THE WEB, SO ALL
OF THIS WAS AVAILABLE FOR THE
PUBLIC TO RESPOND TO AND TO GIVE
US INPUT ON WHICH REALLY DID
HELP IN THAT SENSE.
NOW, MULTIPLE IDENTIFIED
STAKEHOLDERS AS YOU CAN IMAGINE.
BUT THE THREE THAT WE LOOKED AT
THE CLOSEST WERE THE PUBLIC,
PUBLIC HEALTH OFFICIALS, AND
HEALTH CARE PROVIDERS.
SO, THAT'S THE LITERATURE THAT
WE PRIMARILY WENT THROUGH
BECAUSE WE WANTED TO BE SURE
THAT WE HAD COVERED THOSE VERY
MAJOR PRIMARY STAKEHOLDERS IN
OUR REVIEW.
THE STAKEHOLDER CONCERNS WERE
SEVERAL.
IE, ENDORSING THE NEED FOR
RESEARCH TO UNDERSTAND THE
PUBLIC'S KNOWLEDGE, BELIEFS AND
CONCERNS ABOUT THE CHILDHOOD
IMMUNIZATION SCHEDULE, NOT
INDIVIDUAL VACCINES, BUT THE
FULL SCHEDULE OR THE EARLY
SCHEDULE.
WE ACTUALLY ONLY LOOKED AT THE
CONCERNS WITHIN THE FIRST 0-6
YEARS.
THE REST OF THE SCHEDULE IS VERY
IMPORTANT AND NEEDS TO BE LOOKED
AT AND DOCUMENTED MUCH MORE
CLOSELY IN THAT SENSE.
WHAT WENT THROUGH ALL OF THE
MATERIAL THAT WE AMASSED, AND
THERE WERE A NUMBER OF
SCIENTIFIC ARTICLES, ET CETERA,
THAT WE HAD GONE THROUGH, WAS A
MAJOR PROBLEM FOR THE
STAKEHOLDER WAS THEY THOUGHT TOO
MANY VACCINES WERE GIVEN TOO
FAST, PARTICULARLY IN THE FIRST
2 YEARS, THAT WAS ONE ISSUE.
AND THE OTHER BIG ISSUE WAS
COMMUNICATION.
THE OTHER BIG ISSUE PARTICULARLY
COMMUNICATION THREADED THROUGH
ALL OF THE LITERATURE THAT WE
READ AND THAT THREADED THROUGH
THE KIND OF PUBLIC TESTIMONY
THAT WE RECEIVED.
A CONCERN WAS WHO DO THEY TRUST,
WHO DO THEY GO TO FOR
INFORMATION, HOW CAN THEY TRUST
THAT INFORMATION.
THAT WAS A BIG ISSUE AS WELL.
AND INTERESTINGLY ENOUGH WHEN WE
THOUGHT ABOUT IT AND LOOKED AT
KINDS OF COMMUNICATION STUDIES,
MARKETING STUDIES THAT MIGHT BE
DONE, WE THOUGHT IN TERMS OF
WHAT DOES THE LITERATURE TELL US
ABOUT WHO THEY TRUST THE MOST AT
THIS POINT IN TIME.
FIRST THE HEALTH CARE PROVIDER.
IF THEY'RE GOING TO DO A
VACCINATION OR NOT DO A
VACCINATION THAT'S USUALLY WHO
THEY GO TO.
AND THE SECOND ONE WAS A
SURPRISE TO US, I DON'T KNOW WHY
GIVEN CURRENT MEDIA KIND OF
STANDARDS, THE SECOND WAS THE
CELEBRITY.
GARY FREID'S WORK, UNIVERSITY OF
MICHIGAN, SHOWED US THAT
LITERALLY 17% OF THE PARENTS
LISTENED TO CELEBRITIES.
SO, WHAT CAN WE DO ABOUT THAT AS
WE THINK ABOUT POSSIBLE
INTERVENTION OR POSSIBLE
APPROACH?
IOM DOESN'T GET INTO THAT PART
AS YOU WELL KNOW.
BUT IT'S INTERESTING TO THINK
ABOUT 17% WHO IS A FAIRLY HIGH
NUMBER WHO LITERALLY GO TO
CELEBRITIES AND HOW MIGHT WE USE
THAT.
THAT'S THE PROFESSIONAL PART
WE'RE TALKING ABOUT, OKAY?
SO, WE MADE A MAJOR
RECOMMENDATION OFF THE
STAKEHOLDERS' CONCERN AND THAT
WAS ESSENTIALLY THAT NVPO
SYSTEMATICALLY SELECT AND ASSESS
EVIDENCE REGARDING PUBLIC
CONFIDENCE AND CONCERNS ABOUT
THE ENTIRE CHILDHOOD
IMMUNIZATION SCHEDULE, AND
PARTICULARLY WITH A GOAL FOR THE
THEME THAT THREADED ALL THE WAY
THROUGH, AND THAT WAS TO IMPROVE
COMMUNICATION BETWEEN THOSE WHO
ARE GENERATING INFORMATION ABOUT
VACCINES AND THEIR SAFETY AND
THE SCHEDULE, THE FULL SCHEDULE
AS WE PUT THOSE VACCINES ALL
TOGETHER AND THEIR SAFETY, AND
IN BETWEEN HOW WE HELP HEALTH
PROFESSIONALS WORK WITH AND HAVE
MATERIALS TO WORK WITH AND
COMMUNICATE WITH THE PUBLIC OR
THE PARENT IN THAT SENSE.
WE THEN MOVED ON TO THE
SCIENTIFIC EVIDENCE THAT WOULD
HELP US TO UNDERSTAND SAFETY OF
THE CHILDHOOD IMMUNIZATION
SCHEDULE.
WE LOOKED AT SEVERAL ASPECTS OF
WHAT WE DEFINED AS BEING
ELEMENTS OF THE SCHEDULE, BUT WE
WILL SAY TO YOU CLEARLY, THESE
ARE NOT WELL DEFINED IN THE
LITERATURE.
SO, WE CAME UP WITH A NUMBER OF
VACCINATIONS WITHIN A CERTAIN
TIME, NUMBER OF DAYS IN WHICH
VACCINATIONS ARE DELAYED, SPACES
BETWEEN VACCINATIONS, AGES AT
VACCINATION, AS THEY'RE SPACED
ACROSS SEVERAL VAX NATICCINATIO
SOME OF THOSE THINGS WERE LOOKED
THROUGH THE LITERATURE.
AND THEN WE LOOKED AT HEALTH
OUTCOMES AND HEALTH OUTCOMES IN
RELATIONSHIP TO SCHEDULE ARE NOT
WELL DEFINED, SO THAT, AGAIN, IS
SOMETHING WE REALLY NEED TO
CONSIDER IS HOW WE MAKE A MORE
CONCRETE DEFINITION ACROSS THE
AGENCIES SO THAT OUR RESEARCHERS
CAN REALLY HAVE COMPARABLE DATA
AND COMPARABLE STUDY IN THAT
SENSE.
THE TYPES OF HEALTH OUTCOMES
THAT WE LOOKED AT ARE THOSE THAT
ARE IN THE LITERATURE,
EVERYTHING FROM ALLERGIES,
ASTHMA, AUTISM, AUTOIMMUNE
DISEASE, ET CETERA.
ARE THOSE THE BEST HEALTH
OUTCOMES?
ARE THERE OTHERS?
THAT'S, AGAIN, THE PROFESSIONAL
IN ME ASKING THOSE QUESTIONS.
BUT CLEARLY OUR NEXT
RECOMMENDATION IN CHAPTER FIVE
WAS TO DO THE MORE DEFINITIVE
LOOKING AT THIS SCHEDULE BY OUR
EXPERTS AND TO FIND THE ELEMENTS
THAT WE NEED TO BE STUDYING.
WHAT ARE THE IMPORTANT ELEMENTS
OF THE SCHEDULE THAT MIGHT OR
COULD OR DO MAKE A DIFFERENCE IN
SAFETY?
SECONDLY, WHAT ARE THE HEALTH
OUTCOMES TO LOOK AT THAT WILL
HELP US TO KNOW ABOUT SAFETY AND
ADVERSE EVENTS IN RELATIONSHIP
TO THE SCHEDULE.
AND THEN THIRDLY, SOMETHING THAT
OUR STAKEHOLDERS RAISED OVER AND
OVER IS THAT THERE ARE CERTAIN
SUBPOPULATIONS THAT OBVIOUSLY
ARE OF MUCH CONCERN, PEOPLE WHO
HAVE DIABETES IN THEIR HISTORY,
PEOPLE WHO HAVE ALLERGIES AND
ASTHMA IN THEIR FAMILY HISTORY,
ET CETERA.
ARE THOSE POPULATIONS MORE AT
RISK OR NOT AND HOW DO WE BEGIN
TO TAKE A LOOK AT THAT, OKAY?
THAT THEN LED US TO THE ISSUE OF
FUTURE STUDY.
OKAY?
AND AS YOU CAN SEE HERE, WE WERE
VERY CONCERNED THAT THERE ARE
MANY, MANY STUDIES TO BE DONE
AROUND THE CHILDHOOD
IMMUNIZATION SCHEDULE, SO IF WE
WANTED TO TALK ABOUT RESEARCH
METHODOLOGIES AND STUDY DESIGN,
WHERE DOES IT START.
WE STARTED WITH THOSE THAT CAME
FROM THE NVAC RECOMMENDATION
VERY EARLY AND BEGAN TO LOOK AT
UNVACCINATED VERSUS VACCINATED
VERSUS ALTERNATIVE SCHEDULES
VERSUS DELAYED VACCINES VERSUS
NO VACCINES, ET CETERA.
THAT WAS THE AREA THAT WE CHOSE
PARTICULARLY.
BUT WE ALSO SAID THAT IT'S VERY
IMPORTANT WE LISTEN AND THINK
ABOUT STAKEHOLDERS' CONCERNS
THAT WE PRIORITIZE THOSE BECAUSE
WE ARE REALLY STARTING AND THERE
IS SO MUCH RESEARCH TO BE DONE
IN THIS AREA, HOW DO WE
PRIORITIZE WHERE TO START.
AND IT SEEMED TO US THE PLACES
TO START WERE, ONE, THE
STAKEHOLDER CONCERNS, THAT WAS
CENTRAL, AND THEN BE ABLE TO
LINK THOSE TO THE PRIORITY
RESEARCH AREAS TO EITHER
BIOLOGICAL POSSIBILITY OR
EPIDEMIOLOGICAL EVIDENCE.
AND MANY OF THE STUDIES AND THE
DESIGNS THAT WE HAVE TALKED
ABOUT IN OUR REPORT ARE ONES
THAT WOULD HELP US TO UNDERSTAND
OR PROVIDE US WITH
EPIDEMIOLOGICAL EVIDENCE.
SO, THAT LED US TO THE
RECOMMENDATION IN CHAPTER SIX,
THE FIRST ONE, WHICH REALLY
LOOKS AT THE SAFETY OF THE
SCHEDULE AND ITS PROCESS IN
SETTING PRIORITIES FOR RESEARCH
AND WE PROVIDED THE CRITERIA
AROUND THREE MAJOR ISSUES THAT
OUGHT TO GO INTO THIS PRIORITY.
STAKEHOLDER CONCERNS, BIOLOGICAL
POSSIBILITIES, AND
EPIDEMIOLOGICAL EVIDENCE.
NOW, IN LOOKING AT THAT, THERE
ARE MANY EXISTING SYSTEMS THAT
DETECT ADVERSE EVENTS AND THEY
GIVE US BEAUTIFUL DATABASES,
LARGE DATABASES, THAT WE CAN
THEN USE FOR SECONDARY ANALYSIS
AND THAT REALLY IS A KIND OF
DESIGN THAT THE COMMITTEE FELT
WAS THE MOST POSSIBLE AT THIS
POINT IN TIME.
AS WE LOOKED AT ALL THE
SCIENTIFIC EVIDENCE, LOOKING AT
THE ELEMENTS AS WE DEFINED THEM
IN THE SCHEDULE AND THE OUTCOMES
AS WE DEFINED THEM IN TERMS OF
THOSE THAT ARE CURRENTLY IN THE
LITERATURE.
WE DID N NOT FIND ANY STUDIES TT
SUGGEST THAT THE SCHEDULE IS
UNSAFE.
BUT WE ADMIT UP FRONT AND
SEVERAL TIMES THROUGH THE REPORT
THAT THE AMOUNT OF RESEARCH IN
THESE AREAS IS LIMITED, AND SO
THIS IS WHY WE THEN MOVE TO
LOOKING AT KINDS OF STUDIES AND
WHAT WAS MOST FEASIBLE.
WE CLEARLY BELIEVED THAT THE
SECONDARY ANALYSIS OR THE
OBSERVATIONAL STUDIES THAT CAN
BE DONE THROUGH SECONDARY
ANALYSIS WERE THE MOST VALUABLE
FOR US AT THIS POINT IN TIME AS
WE LOOKED TO SEE IF THERE --
WHERE THE ISSUES ARE.
NOW, I WAS IMPRESSED WITH THIS
WORK AND YOU PROVIDED TESTIMONY
FOR US, UNIVERSITY OF COLORADO,
HE IS LOOKING AT DAYS OF DELAY
IN VACCINATIONS BEING GIVEN IN
RELATIONSHIP TO HEALTH CARE
UTILIZATION.
THIS IS ONE KIND OF QUESTION YOU
CAN ASK ABOUT THE SCHEDULE.
AND IN ASKING THAT QUESTION, HE
CLEARLY PROVIDES DATA THAT SHOWS
THAT THE MORE DELAY, THE MORE --
THE HIGHER THE RATE OF
HOSPITALIZATION TO THOSE
CHILDREN.
NOW, THESE ARE THE KINDS OF
ISSUES THAT WE REALLY WANT,
AGAIN, TO BE ABLE TO LOOK AT.
IS THAT DATA CONSISTENT IN OTHER
STUDIES?
THAT'S WHAT WE HAVE TO ASK, SO
THERE'S MUCH TO BE DONE HERE IN
THAT PARTICULAR SENSE, OKAY?
WE ALSO TOOK A VERY FIRM STAND
ON THE FACT THAT ANY STUDY THAT
PLACES CHILDREN IN A STUDY GROUP
THAT DOES NOT RECEIVE VACCINES
ACCORDING TO THE EXISTING
GUIDANCE WOULD BE EXPOSING THOSE
CHILDREN TO GREATER RISK FOR
CONTACTING VACCINE-RELATED
DISEASES.
NOW, I'M CLEARLY READING THIS TO
YOU RIGHT OFF THE SLIDE BECAUSE
IT'S A VERY IMPORTANT POINT.
AND IN OUR MIND AND IN THE MIND
OF THE INDIVIDUAL COMMITTEE, IT
IS UNETHICAL.
SO, THE SECOND RECOMMENDATION IN
CHAPTER SIX CLEARLY DEALS WITH
REFRAINING FROM INITIATING
RANDOMIZED CONTROL TRIALS OF
THIS SCHEDULE THAT COMPARES
SAFETY OUTCOMES IN SOLELY
VACCINATED CHILDREN WITH
UNVACCINATED CHILDREN OR THOSE
VACCINATED BY AN ALTERNATIVE
SCHEDULE.
AND THE REASON WE DID THIS WAS
BECAUSE BOTH THE UNETHICAL
PIECE -- AND THAT IS THE MOST
CRITICAL ISSUE.
BUT ALSO IF YOU THINK ABOUT WHAT
IT WOULD TAKE IN TERMS OF THE
NUMBER OF CHILDREN, THE NUMBER
OF PARENTS, KEEPING THOSE
CHILDREN AND PARENTS IN THE
STUDY FOR YEARS ON END, BECAUSE
WE'RE TALKING ABOUT THIS
SCHEDULE, AGAIN, AND ACROSS A
NUMBER OF YEARS AS CHILDREN ARE,
IN FACT, VACCINATED.
SO, DOING THAT KIND OF RESEARCH
STUDY WOULD BE VERY, VERY
EXPENSIVE.
IF, IN FACT, WE FIND THROUGH
SECONDARY ANALYSIS AND
OBSERVATIONAL STUDIES THAT THERE
IS SOMEjJz THAT THAT
OUGHT TO BE DONE, THEN ONE
RECONSIDERS THAT RECOMMENDATION.
SO, WE WERE REALLY QUITE CLEAR
ABOUT IT BECAUSE OF THE ETHICAL
ISSUE INVOLVED, PARTICULARLY
WITH VACCINATED AND
UNVACCINATED.
ONE COULD THINK ABOUT IT WITH
SOMETHING LIKE STAKEHOLDERS
RAISE THE ISSUE OF IF WE COULD
DO AN ALTERNATE SCHEDULE BY
WHICH STAYING WITHIN THE
GUIDELINES OF ACIP THAT THE
CHILD COULD BE VACCINATED FOR
CERTAIN ISSUES EARLY IN A RANGE
THAT'S GIVEN FOR VACCINATION
PROCESS AND SOME LATER, WHAT
CONCERNED THEM IS THE FIVE
INJECTIONS ALL IN ONE VISIT, ET
CETERA.
NOW, WITH COMBINED VACCINES
WE'RE GETTING TO SOME OF THAT
ISSUE SO WE MAY BRIE HANDLING
THAT IN A DIFFERENT WAY BUT
THAT'S WHERE THE ISSUE CAME FROM
IS THERE A TRIAL THAT CAN BE
DONE IN THAT AREA.
BUT THE PROBLEM IS IT'S A VERY
EXPENSIVE TRIAL.
YOU'LL HAVE TO KEEP PEOPLE IN IT
FOR YEARS ON END.
AND IT WILL, IN FACT, YOU GET
THAT MUCH DIFFERENCE IN HEALTH
OUTCOMES UNTIL WE'VE WELL
DEFINED THOSE OUTCOMES FOR A
PERIOD OF TIME, OKAY?
SO, AT THIS POINT THE
RECOMMENDATION IS NO RANDOMIZED
CLINICAL TRIALS.
WE THEN DID GO AHEAD TO LOOK AT
SECONDARY ANALYSES AND I TALKED
ABOUT THAT SOME.
WE WERE VERY IMPRESSED WITH THE
VSD.
YOU KNOW THAT A LOT BETTER THAN
I DO.
I'M NOT GOING TO PREACH TO THE
CHOIR HERE ON THAT PARTICULAR
SYSTEM, BUT THERE WAS CONCERN
ABOUT WHERE WE COULD HUGE
DATABASES.
I THINK IT'S 100,000 POPULATION
A YEAR ARE COMING IN A YEAR ON
THAT DATABASE, NOW UP TO
SOMEWHERE AROUND 9.5 MILLION.
THAT'S A LOT OF PEOPLE YOU CAN
MATCH, CONTROL FOR VARIABLES,
REALLY ASK PARTICULAR QUESTIONS.
THERE IS WORK FOCUSING ON AND
USING THE VSD SYSTEM.
THERE'S OTHER SYSTEMS COMING
ONLINE, THE PRISM SYSTEM FROM
THE FDA AND ONE MIGHT THINK
ABOUT HOW ONE COULD SUPERIMPOSE
STUDIES AROUND THE IMMUNIZATION
SCHEDULE AROUND THE NATIONAL
CHILDREN'S STUDY, BECAUSE THAT
STUDY IS UNDER WAY.
IT WILL INVOLVE HISTORIES OF
IMMUNIZATIONS, ET CETERA, IS
THERE A WAY TO USE THAT STUDY TO
BE ABLE TO DO THIS, SO THE GROUP
ALSO TALKED ABOUT SOME OF THOSE
POSSIBILITIES IN THAT SENSE AND
MADE A FINAL RECOMMENDATION.
AND THAT IS THAT THE HEALTH AND
HUMAN SERVICE DEPARTMENT AND ITS
PARTNERS PARTICULARLY LOOK AT
HOW WE SUPPORT THE VSD, TO STUDY
THE SAFETY OF THE RECOMMENDED
IMMUNIZATION SCHEDULE THAT
SEEMED AT THIS POINT TO BE THE
BEST POSSIBLE DATABASE TO USE
FOR SECONDARY ANALYSIS AND HOW
COULD THAT DATABASE BE
STRENGTHENED.
IN OTHER WORDS, IT'S ALL PRIVATE
MANAGED CARE ORGANIZATIONS RIGHT
NOW, HOW DO WE GET PUBLIC HEALTH
CARE ORGANIZATIONS INTO THAT
SYSTEM.
DOES IT HAVE ALL THE FAMILY
MEDICAL HISTORY THAT WE NEED.
THAT'S ANOTHER ISSUE FOR LOOKING
AT THAT DATABASE.
SO, WE CLEARLY RECOMMENDED THAT
THERE BE SUPPORT FOR THAT KIND
OF ENHANCEMENT AND STRENGTHENING
OF THAT DATABASE.
READY TO TAKE QUESTIONS, OKAY?
THANK YOU.
>> THANK YOU VERY MUCH FOR A
WONDERFUL PRESENTATION.
JUST FOR THE MEMBERS, WE DO HAVE
A BRIEF REPORT WITHIN THE
HAND-OUTS, AND I GUIDE YOU TO
THAT.
ALSO THE ENTIRE REPORT I THINK
IS VERY WORTHWHILE FOR US TO BE
FAMILIAR WITH, BUT LET'S OPEN IT
UP FOR ANY COMMENTS OR
QUESTIONS.
MS. ROSENBAUM?
>> THANK YOU VERY MUCH, THAT WAS
TERRIFIC.
MY QUESTION FOR YOU ACTUALLY
GOES TO THE LAST RECOMMENDATION.
AND SPECIFICALLY I'M WONDERING
WHAT YOU -- WHAT LIMITS -- I
THOUGHT THIS FOR A LONG TIME,
THAT THE REPORTING PLAN FOR THE
LIMITED, AND I'M WONDERING IF
YOU COULD ELABORATE ON WHETHER
OTHER PLANS JUST HAVE NOT BEEN
INCLUDED OR WERE UNWILLING TO
PARTICIPATE.
I DON'T -- I DON'T KNOW MUCH
ABOUT HOW THE BELLWETHER PLANS
WERE CHOSEN, BUT IT STRUCK ME
THAT THEY ARE VERY NONDIVERSE.
>> YES.
>> AND VERY LOW PARTICIPANTS IN
PUBLIC INSURANCE PROGRAMS.
SO, I WONDER WHAT YOUR FINDINGS
ON THAT SCORE WERE.
>> THAT WAS ONE OF OUR CONCERNS,
IS WITH ONLY PRIVATE MANAGED
CARE ORGANIZATIONS IN THAT PLAN
WITH CDC THAT WE DID NOT HAVE
SOME OF THE LOW-INCOME PUBLIC
POPULATION.
WE ALSO DO NOT HAVE SOME OF THE
STATES REPRESENTED.
GEORGIA IS THERE, SO YOU HAVE TO
SAY WITH TONGUE IN CHEEK WHERE
ARE WE NOT REPRESENTED AROUND
THE COUNTRY IN TERMS OF
POPULATION IN THAT SENSE.
SO, OUR CONCERN WAS THAT THOSE
AREAS BE STRENGTHENED AND
ENHANCED.
THE PEOPLE WHO KNEW THAT
DATABASE, AND I MUST ADMIT TO
YOU, IT'S NOT MY FORTE, OKAY,
BUT THE PEOPLE THAT KNEW THAT
DATABASE WERE VERY CONCERNED IF
WE WANT TO LINK IT TO SUCCESSFUL
POPULATIONS WHICH IS A MAJOR
ISSUE FOR THE STAKEHOLDERS, THEN
HOW WE DEFINE THOSE POPULATIONS
AND LOOK AT IT IN THAT SECONDARY
ANALYSIS AND THAT WILL MEAN WE
NEED TO HAVE FAMILY MEDICAL
HISTORY TO DO THAT.
SO, THAT'S THE LINKAGE WE'RE
MAKING ON SOME OF THOSE KIND OF
PIECES, OKAY?
OTHERWISE I WOULD REFER YOU TO
THE PEOPLE THAT REALLY KNOW THAT
DATABASE WELL, THANK YOU.
>> DR. DESTAFANO?
>> I GUESS I CAN COMMENT
VSD IS IN OUR OFFICE.
THE COMPOSITION OF THE CURRENT
PLANS THAT ARE IN THE VSD IS
GUIDED PRIMARILY BY THE DATA
REQUIREMENTS THAT WE SET FOR IT.
THE -- FIRST OF ALL, WE NEED
PLANS THAT HAVE GOOD LINKABLE
DATABASES AND IN PARTICULAR
SOLID VACCINE REGISTRIES WITH
DETAILED VACCINATION INFORMATION
AS WELL AS, YOU KNOW, THEM BEING
ABLE TO LINK THOSE WITH ALL
LEVELS OF CARE FROM PATIENT FROM
EMERGENCY ROOM TO
HOSPITALIZATION.
WE'VE LOOKED TO TRY TO EXPAND
THE VSD SEVERAL TIMES OVER THE
YEARS, AND HAVE TRIED PILOT
EFFORTS WITH LARGE HEALTH
INSURANCE PLANS, BUT
BASICALLY -- I THINK WE'VE
SCOURED THE COUNTRY, AND THESE
ARE PRETTY MUCH THE PLANS THAT
HAVE THE SORTS OF DATA THAT WE
ARE LOOKING FOR.
I THINK WE NEED TO CERTAINLY
PERHAPS START LOOKING AT THE
POSSIBILITY OF INCLUDING OTHER
PLANS WITH MORE REPRESENTATION
OF LOWER INCOME OR, YOU KNOW,
PUBLIC HEALTH PLANS AND SUCH.
BUT REALLY IT'S BEEN AN ISSUE OF
DATA QUALITY.
AND THE FDA PRISM SYSTEM IS IN
MANY SENSES, WHICH IT IS PART
OF, TRYING TO USE THE LARGER
HEALTH PLANS, GOING FOR, IF YOU
WILL, QUANTITY OVER QUALITY.
AND, YOU KNOW, THOSE PLANS HAVE
SOMEWHAT LIMITED INFORMATION AND
THAT'S DETAIL OF IMMUNIZATIONS
AND MORE DIFFICULTY IN GETTING
MORE DETAILED INFORMATION IF IT
IS NEEDED FROM A MEDICAL RECORD.
>> I'M WONDERING, TOO, WHETHER
THE FRIENDS FOR HEALTH
INFORMATION TECHNOLOGY MIGHT NOT
OFFER ANOTHER RUN AT THIS AS THE
CARE SETTINGS THEMSELVES COME
ONLINE MORE, WHETHER IT'S WORTH
GOING TO THE LARGE -- I MEAN,
BECAUSE NOW 75% OF ALL MEDICAID
BENEFICIARIES ARE IN A MANAGED
CARE PLAN, AND THE NUMBER OF
CHILDREN IN THESE PLANS IS
PROBABLY CLOSER TO, YOU KNOW,
85%, 90% OF ALL CHILDREN.
AND SO GIVEN THE FACT THAT
MEDICAID IS NOW INSURING ABOUT
ONE OUT OF EVERY THREE CHILDREN
IN THE UNITED STATES, IT'S SUCH
A HUGE NUMBER, WHETHER IT MIGHT
NOT BE WORTH GOING BACK TO SOME
OF THE REALLY BIG PLANS, SOME OF
THE OTHERS, TO SEE WHETHER WITH
SOME TECHNOLOGY UPGRADES THEY
MIGHT BE ABLE TO COME ONLINE.
>> THAT'S A GOOD POINT.
CERTAINLY WE REALIZE WITH, YOU
KNOW, THE INCREASING OF
UTILIZATION OF HEALTH CARE
MEDICAL RECORDS THAT, YOU KNOW,
THE VSD AND SUCH SYSTEMS WILL
CONTINUE TO EVOLVE.
I THINK WE'LL TAKE THAT
RECOMMENDATION TO HEART.
THANK YOU.
>> DR. JENKINS?
>> GIVEN THE CHALLENGES OF SOME
OF THE STAKEHOLDERS IN TERMS OF
DISSEMINATION OF THE SUMMARY OF
THE REPORT, TRANSLATING IT INTO
SOME MESSAGE THAT WOULD BE
ACCEPTABLE TO THE PUBLIC, HAVE
YOU TALKED ABOUT IN TERMS OF NOW
THAT YOU HAVE THE REPORT HOW TO
GET IT OUT?
I THINK THERE'S ALWAYS A CONCERN
WITH, YOU KNOW, ANY OF THESE
REPORTS THAT, YOU KNOW, YES, YOU
HAVE REALLY GREAT FINDINGS
AND -- BUT HOW DO YOU GET IT OUT
TO THE PUBLIC?
>> EXACTLY.
AND THIS IS ALWAYS THE CONCERN.
WE HAVE DONE TESTIMONIES IN
CONGRESS.
WE'VE DONE TESTIMONIES WITH THE
PRESS.
WE'VE TRIED TO GET THE PRESS
INVOLVED IN TALKING ABOUT THE
REPORT, AND THEY'VE HAD THE
BRIEF, THE SAME ONE THAT YOU
HAVE IN FRONT OF YOU.
AND, OF COURSE, WE'RE TALKING TO
GROUPS LIKE YOURS WHO ARE
PROFESSIONAL GROUPS AND IN
TERMS -- AND POLICY GROUPS WHICH
ARE VERY IMPORTANT IN TERMS OF
THESE RECOMMENDATIONS THAT HAVE
BEEN MADE.
HOW MUCH FURTHER WE CAN GO, THE
INSTITUTE OF MEDICINE ONLY
PUSHES SO FAR.
IT'S PRIMARILY A POLICY
ORGANIZATION, NOT A DISTRIBUTION
ORGANIZATION.
BUT WORKING WITH GROUPS LIKE
YOURS, LET'S PUT OUR HEADS
TOGETHER.
>> DR. HINSHAW, TO KIND OF
FOLLOW-UP, I'M CURIOUS ABOUT
WHAT THE PUBLIC RESPONSE TO DATE
HAS BEEN AFTER THE RELEASE IF
THERE HAS BEEN MUCH.
>> LET ME ASK SUSANNE LANDY TO
SPEAK TO THAT, SHE'S A MAJOR
STAFFER FOR THE COMMITTEE.
I'D LIKE YOU ALL TO MEET HER,
FROM THE INSTITUTE OF MEDICINE,
AND SHE HANDLES MUCH OF THE
PUBLIC MESSAGES COMIMING IN.
>> HI, THIS IS SUSANNE SPEAKING.
AFTER THE REPORT'S RELEASED, WE
HAD SOME WONDERFUL PRESS
COVERAGE IN SOME MAJOR NEWS
NETWORKS, ALL VERY POSITIVE.
WE HAVEN'T RECEIVED MANY MORE
PUBLIC COMMENTS AFTER THE REPORT
WAS RELEASED, BUT WHEN WE DID
POST THE COMMISSION PAPER
EARLIER ON IN THE STUDY PROCESS,
WE RECEI900 COMMENTS
FROM THE PUBLIC, SO THERE IS
CERTAINLY A LOT OF INTEREST AND
A LOT OF CONCERN FROM PEOPLE WHO
REPORT AS CONCERNED PARENTS.
AND YOU CAN READ MORE ABOUT THE
SUMMARY OF THEIR CONCERNS IN THE
REPORT IN CHAPTER FOUR WHERE WE
DISCUSS A LITTLE BIT MORE ABOUT
THE COMMENTS WE RECEIVED.
>> AND AS A FOLLOW-UP, IS THERE
GOING TO BE ANY EFFORT FROM IOM
TO REVIEW, COLLATE, AND
DISSEMINATE THE PUBLIC COMMENTS
GOING BACK ON IN?
JUST I THINK THAT'S SUCH A GOOD
BELLWETHER FOR US TO SEE WHAT
THE RESPONSE IS.
>> SO, THE PUBLIC COMMENTS ARE
ACTUALLY ALL LISTED IN OUR
PUBLIC ACCESS FILE, WHICH CAN BE
REQUESTED, AND SO YOU ARE
WELCOME TO REVIEW THEM.
WE DID SUMMARIZE THEM IN THE
REPORT.
I'M NOT SURE IF THERE'S GOING TO
BE ANY ADDITIONAL EFFORT ON
COLLATING THOSE COMMENTS, BUT
IT'S CERTAINLY SOMETHING THAT WE
CAN LOOK IN TO AND TAKE INTO
ACCOUNT.
>> THANK YOU.
MISS STINCHFIELD?
>> ON THE 900 PUBLIC COMMENTS
BEFORE YOU LEAVE THE
CAN YOU CHARACTERIZE THEMES ON
THOSE COMMENTS?
WERE THEY SUPPORTIVE?
WERE THEY DISBELIEVING OF THE
REPORT?
WERE THERE ANY THINGS THAT THEY
WERE COMMENTS ON MORE THAN
OTHERS?
>> SURE.
SO, LIKE, DR. HINSHAW SAID IN
HER PRESENTATION, ONE OF THE
OVERWHELMING KERN CONCERN OF WAS
THE IMMUNE SYSTEM OVERLOAD, THE
CONCEPT OF TOO MANY VACCINES AT
ONCE COULD HAVE A DETRIMENTAL
EFFECT TO THE CHILDHOOD IMMUNE
SYSTEM, AND THAT'S SOMETHING WE
HEARD IN THE COMMENTS AND IN OUR
PUBLIC TESTIMONY.
AGAIN, THE CONCEPT OF
POPULATIONS THAT MIGHT BE
SUSCEPTIBLE TO ADVERSE EFFECTS
OF VACCINES IS SOMETHING WE
HEARD.
AND SINCE THE REPORT HAS COME
OUT, MOST OF THE COMMENTS -- WE
HAVEN'T RECEIVED MANY COMMENTS
LIKE THAT.
IT'S BEEN PRETTY QUIET ON THAT
FRONT.
>> DR. SUN?
>> GOOD MORNING.
THANK YOU.
DR. HINSHAW, I HAVE A QUESTION,
ON THE RECOMMENDATION 62, WHICH
IS THE HHS SHOULD REFRAIN FROM
INITIATED RANDOMIZING TRIALS
CHILDHOOD IMMUNIZATION SCHEDULE
THAT COMPARES SAFETY OUTCOMES
BUT ALSO ALL THOSE VACCINATED BY
USE OF AN ALTERNATE SCHEDULE,
AND THE REASON I ASK IS I WAS
WONDERING WHY DID THE COMMITTEE
THINK THAT THE LATTER PHRASE WAS
NECESSARY?
AND THE REASON I ASK IS BECAUSE
WHEN WE THE FDA LABELS WITH
VACCINE SCHEDULES ARE USUALLY
DONE WITH -- AS SCHEDULED IN THE
TRIALS.
AND SO ANY REDUCTION IN THOSE
SCHEDULES MAY -- WILL HAVE TO
RELY ON CONTROL -- ADEQUATE AND
WELL-CONTROLLED STUDY.
AND SO THE INABILITY TO DO THAT
WOULD, FOR EXAMPLE, PREVENT ANY
CONSIDERATIONS OR REDUCTION IN
SCHEDULE, THAT MAY BE JUST AS
SAFE AND EFFECTIVE.
THAT IS THE CONCERN I'M ASKING
ABOUT.
>> THE COMMITTEE FELT STRONGLY
ABOUT THAT AT THIS POINT IN TIME
BECAUSE THE LIMITED RESEARCH
THAT IS THERE IN TERMS OF
SUGGESTING THEIR TK STAKEHOLDER
CONCERNS ABOUT THE SCHEDULE THAT
COULD BE LOOKED AT OVER SO MANY
YEARS WITH SO MANY SUBJECTS.
AND QUITE FRANKLY, VERY
EXPENSIVE STUDIES THAT WOULD
NOT -- WOULD NOT COME TO
FRUITION FOR SOME PERIOD OF
TIME.
BUT THE MAJOR ISSUE IS HERE AT
THE BOTTOM ON THIS SLIDE, AND
THAT IS THE ISSUE AROUND THE
UNETHICAL NATURE.
SO, YOU CAN THINK ABOUT RCTs
THAT MIGHT VARY THE SCHEDULE IN
SOME WAYS, AS YOU'RE TALKING
ABOUT.
IF WE HAVE SOME EPIDEMIOLOGICAL
RECOMMENDATIONS FROM THE LARGE
DATA SETS THAT RECOMMENDS OR
SUGGESTS THAT THAT IS A
PLAUSIBLE ISSUE, THEN THAT IS
SOMETHING THAT COULD LEAD TO
SUCH A STUDY.
BUT ANYTHING WHICH IN OUR
ESTIMATION WOULD, IN FACT, DENY
A CHILD CERTAIN VACCINATIONS
THAT WE KNOW ARE VALUABLE AND
PREVENT CERTAIN DISEASES WOULD
BE UNETHICAL.
I'M SURE THAT'S NOT AN UNUSUAL
RESPONSE FOR YOU TO HEAR.
SO, WE'RE NOT SAYING DON'T EVER
DO THEM, WE'RE SAYING REFRAIN
FROM THEM RIGHT NOW BECAUSE WE
THINK WE NEED THE
EPIDEMIOLOGICAL AND THE
BIOLOGICAL PLAUSIBILITY DATA
BEHIND IT, THEN, TO SAY WHERE TO
TARGET SUCH STUDIES IF THEY ARE
APPROPRIATE.
BUT IN OUR ESTIMATION, THEY
WOULD NEVER BE APPROPRIATE IF
YOU ARE DENYING A CHILD A
CERTAIN TYPE OF VACCINE THAT WE
KNOW MAKES A DIFFERENCE ON
VACCINE PREVENTIBLE DISEASES.
I DON'T KNOW WHAT ELSE TO SAY TO
YOU THAN THAT.
>> DR. PICKERING?
>> YEAH.
I HAVE A SUGGESTION FOR SUSANNE
AND A QUESTION FOR DR. HINSHAW.
SUSANNE, WE HAVE AT ACIP 31
LIAISON ORGANIZATIONS AND WOULD
BE HAPPY TO WORK WITH YOU TO GET
THIS REALLY NICE REPORT OUT TO
THEM IN A MANNER THAT'S
UNDERSTANDABLE THATAT THEN COUL
BE FURTHER COMMUNICATED TO
MEMBERSHIP, SO IF YOU ARE
INTERESTED, WE CAN WORK WITH YOU
ON DOING THAT.
>> THAT WOULD BE GREAT.
THANK YOU VERY MUCH.
>> THANK YOU.
THAT'S A GREAT SUGGESTION.
>> AND I'VE GOT A TWO-PART
QUESTION FOR YOU IS ONE THAT WE
DEAL WITH ON THIS COMMITTEE IS
HOW DID YOU DEFINE AND CHOOSE
YOUR STAKEHOLDER REPRESENTATIVES
FOR THE COMMITTEE.
>> FOR THE COMMITTEE?
>> YEAH, FOR THE COMMITTEE.
BECAUSE YOU STATED THERE WAS ONE
OR TWO STAKEHOLDERS ON.
>> YES.
>> AND HOW DID YOU SELECT THOSE
INDIVIDUALS?
AND THEN SECONDLY IS, WHAT ARE
THE MOST CONTIENTIOUS ISSUE OR
ISSUES THAT YOUR COMMITTEE
DEALT?
>> THANK YOU.
FIRST OF ALL, HOW DID WE SELECT
THE STAKEHOLDERS, WE WERE
LOOKING PARTICULARLY FOR THOSE
THAT DEALT WITH PUBLIC HEALTH
OFFICIALS LIKE DR. ARGON, FOR
INDIVIDUALS THAT DEAL WITH LARGE
POPULATIONS WHO ALSO HAVE THE
KNOWLEDGE AND FEEL RESPONSIBLE
FOR VACCINATION SCHEDULES FOR AN
ENTIRE POPULATION LIKE THAT.
WE WERE REALLY CONCERNED ABOUT
THE COMMUNITY IMMUNITY ISSUE AND
WANTED THAT INDIVIDUAL AT THE
TABLE BECAUSE OF THAT KIND OF
BACKGROUND.
ALL OF THE MEMBERS HAD AN
UNDERSTANDING OF COMMUNITY
IMMUNITY BUT HE IS REALLY ONE
THAT IS RESPONSIBLE FOR THAT AND
WATCHES THAT CLOSELY, AND SO WE
CHOSE DR. ARGON BECAUSE OF
RECOMMENDATIONS THAT CAME IN TO
US.
AND ALSO CHOSE PEOPLE WHO WERE
CAREFULLY NOT HEAVILY INTO
VACCINE WORK AND VACCINE STUDIES
BUT HAVE GOOD KNOWLEDGE OF
VACCINE WORK IN THAT SENSE
BECAUSE THERE WAS A REAL ATTEMPT
TO KEEP BIASES FROM MOVING FROM
ONE COMMITTEE TO UNDERSTAND.
YOU UNDERSTAND IOM HAS DONE 60
STUDIES IN THE AREA OF VACCINES
AND SO THEY'RE VERY CAREFUL NOT
TO CROSS THESE INDIVIDUALS ANY
MORE THAN IS APPROPRIATE.
NOW, THE PARENTS WHO CAME, THIS
IS SOMEONE THAT WAS RECOMMENDED
TO US, AGAIN, WE HAD A SERIES OF
RECOMMENDATIONS FOR THAT
STAKEHOLDER.
AND SHE CAME RECOMMENDED HIGHLY
TO US BECAUSE SHE HAS A REAL
SENSE -- SHE HAS A CHILD WHO IS
SHE THINKS HAS A VACCINE RELATED
A ADVERSE EVENT, AND SHE'S
LOOKED INTO IT CAREFULLY AND
THOUGHT ABOUT IT CAREFULLY AND
WAS WILLING TO GIVE A LOT OF
THOUGHT WITH US ABOUT IT AND
THAT WAS VERY IMPORTANT THAT SHE
WOULD HAVE THAT KIND OF
STRAIGHT-ON ATTITUDE ABOUT IT.
YEAH.
NOW, SECOND PART OF YOUR
QUESTION, I'M SORRY?
THE MOST DIFFICULT ONES?
PROBABLY THE MOST DIFFICULT ONES
WERE TRYING TO SORT OUT THOSE
CRITERIA FOR SUGGESTING
PRIORITIES FOR RESEARCH IN THIS
AREA.
BECAUSE IT'S VERY DIFFICULT TO
KNOW CAN WE GET TO BIOLOGICAL
PLAUSIBILITY AND CAN WE GET TO
EPIDEMIOLOGICAL DATA, AND WE
CAN.
SO, WE CLEARLY TRIED TO LOOK AT
CRITER
CRITERIA, BUILDING OFF THE
STAKEHOLDERS' CONCERNS BECAUSE
THAT'S WHERE WE STARTED,
STAKEHOLDER CONCERNS,
PARTICULARLY PARENTS, AND WHAT
OTHER CRITERIA COULD WE PUT
TOGETHER TO SAY THESE ARE THE
STUDIES THAT NEED TO COME FIRST
AND SECOND, OKAY?
WE DON'T REALLY HAVE THAT KIND
OF DATA BUT WE WERE CONCERNED
ABOUT PROVIDING THAT CRITERIA IN
THAT SENSE.
OKAY?
>> DR. HARRISON?
>> YEAH.
I'M CURIOUS AS TO WHERE THIS IS
GOING.
SO, A LOT OF THE OUTCOMES THAT
YOU'VE MENTIONED HAVE ALREADY
BEEN LOOKED AT PRETTY
EXTENSIVELY.
THE SAFETY OF INDIVIDUAL
VACCINES HAS BEEN LOOKED AT
FAIRLY EXTENSIVELY.
SO, IN THE ABSENCE OF SCIENTIFIC
EVIDENCE, WHY ARE WE EVEN
TALKING ABOUT ALTERING THE
SCHEDULE?
IT'S BASED ON THE BEST
SCIENTIFIC EVIDENCE.
I'M A LITTLE UNCOMFORTABLE IN
THE WAY THIS SORT OF SEEMS TO BE
DRIFTING.
>> WELL, WE'RE NOT TALKING ABOUT
ALTERNATIVE SCHEDULES IN THAT
SENSE.
WE'VE TALKED ABOUT IF PEOPLE
WANT TO STUDY THAT, THERE ARE
WAYS TO STUDY THAT.
AND THERE ARE WAYS TO DO THAT
WITHOUT ENDANGERING CHILDREN OR
THEIR PARENTS IN TERMS OF THE
STAKEHOLDER CONCERNS.
BUT THE ISSUE IS IN ALL THE DATA
THAT WE LOOKED AT, THERE WAS NO
DATA THAT SUGGESTED THAT THE
CURRENT CHILDHOOD IMMUNIZATION
SCHEDULE IS UNSAFE.
THE ISSUE IS HOW MUCH HAVE WE
STUDIED SCHEDULES.
AND ARE THERE OTHER QUESTIONS
THAT PEOPLE THINK WE OUGHT TO
ASK, BUT IF WE ARE GOING TO ASK
THOSE, THEN ASK THEM ONLY BASED
THOSE THREE CRITERIA THAT WE
LAID OUT, THE STAKEHOLDER
CONCERNS, BUT THEN LINKED WITH
EPIDEMIOLOGICAL DATA OR
BIOLOGICAL PLAUSIBILITY.
I DON'T KNOW WHETHER I ANSWERED
THAT OR NOT, BUT THAT'S --
>> RIGHT.
AND I FULLY UNDERSTAND THE
STAKEHOLDER CONCERNS, BUT
SOMETIMES THE RESPONSE TO
CONCERNS IS THIS IS THE EVIDENCE
AND THIS IS WHAT WE FEEL, YOU
KNOW, IS A REASONABLE APPROACH,
YOU KNOW, A REASONABLE
VACCINATION SCHEDULE.
>> UH-HUH.
AND, IN FACT, THAT'S WHAT CAME
OUT AT THIS POINT WITH THIS SET
OF DATA CAME OUT FROM OUR REPORT
THAT WE DID NOT FIND ANY
SCIENTIFIC EVIDENCE THAT THE
SCHEDULE IS NOT SAFE.
AND WE REPEATED THAT OVER AND
OVER AGAIN IN PRESS CONFERENCES
AND CONGRESSIONAL TESTIMONIES.
AND IT'S A VERY IMPORTANT PIECE.
ON THE OTHER HAND, WHY DID NVAC
ASK US TO EVEN LOOK AT THIS.
WHY ARE THEY TRYING TO THINK
ABOUT OTHER METHODOLOGIES?
I'M ASSUMING THAT'S BECAUSE THEY
THINK THERE ARE OTHER QUESTIONS
TO BE ASKED, BUT THEY MAY NOT
BE -- THEY MAY BE SAFETY
QUESTIONS IN A DIFFERENT WAY,
LIKE, JASON GLANCE'S WORK, OKAY?
IF YOU LOOK AT DELAYED
VACCINATIONS AND YOU CAN LOOK AT
THAT IN THAT DATABASE, THE VSD,
AND YOU LOOK AT HEALTH CARE
UTILIZATION ISSUES, HE CLEARLY
FOUND A RELATIONSHIP THERE THAT
ONE WOULD NOT WANT, CHILDREN
WITH MORE DELAYED VACCINATIONS
HAVE HIGHER RATES OF
HOSPITALIZATION.
OKAY?
SO, THERE ARE SOME THINGS TO
LOOK AT THAT PEOPLE ARE
BEGINNING TO ASK ABOUT THESE --
ABOUT THE WHOLE SCHEDULE OR
PARTS OF THE -- COMPONENTS OF
THE SCHEDULE IN THAT SENSE.
>> DR. GORMAN?
>> THIS IS A FOLLOW-UP ON DR.
SUN'S QUESTION.
ACCORDING TO EXISTING GUIDANCE,
WAS THAT WORD CHOSEN CAREFULLY
SO IT WAS NOT ACCORDING TO
PRESENT LABELING?
THE ACIP THE GROUP THAT YOU SIT
ISSUES OF YOU OFTEN MAKES
GUIDANCES THAT ARE NOT IN
CONCORDANCE WITH THE
RECOMMENDATIONS, AND HOW TO
ADMINISTER THE DIMINISHED SUPPLY
OF VACCINES?
WAS GUIDANCE CHOSEN SPECIFICALLY
AND WHICH GROUPS DO YOU THINK
OFFER GUIDANCE THAT IS
AUTHORITATI
AUTHORITATIVE?
>> THOSE ARE WHY WE WERE TRYING
TO COME UP WITH RESEARCH
METHODOLOGIES, STUDY DESIGNS BY
WHICH YOU COULD ASK THOSE
QUESTIONS, AND THEY'RE EMPIRICAL
QUESTIONS.
YOU COULD LOOK AT YOUR DATA SETS
AND THEN GAIN SOME SENSE OF WHAT
TO DO ABOUT THAT.
WE DIDN'T SPECIFICALLY TALK
ABOUT SOME OF THOSE SITUATIONS,
OKAY?
>> DR. HARRIMAN?
>> JUST A QUICK QUESTION.
YOU MENTIONED THE WORK FROM
COLORADO THAT INDICATED THAT
CHILDREN WHO WERE DELAYED IN
THEIR VACCINATIONS HAD INCREASED
RATES OF HOSPITALIZATION.
WAS THAT ANY HOSPITALIZATION OR
HOSPITALIZATION SPECIFIC TO A
VACCINE PREVENTIBLE DISEASE?
>> ANY HOSPITALIZATION.
>> OKAY.
>> HE LITERALLY LOOKED AT HEALTH
CARE UTILIZATION STATISTICS.
NOW, WHAT'S THE EVIDENCE THAT
THOSE TWO ARE LINKED?
CLEARLY IN THE STATISTICS THEY
ARE.
BUT THAT TAKES MORE STUDIES TO
SEE IF THAT'S REPLICATED AS YOU
AND I BOTH KNOW, AND IT TAKES
UNDERSTANDING WHY WOULD THAT
HAPPEN.
THE DATA ALSO SHOWS THAT PEOPLE
WHO HAVE DELAYED VACCINES HAVE
FEWER OUTPATIENT VISITS.
WELL, THAT MAKES SENSE BECAUSE
THEY DIDN'T GO FOR THEIR
VACCINATIONS ALL THE TIME, OKAY?
THEY MAY HAVE CLUMPED THEM OR
THEY MAY HAVE SKIPPED SOME.
BUT, YOU KNOW, THE ISSUE AROUND
AN INCREASED RATE OF
HOSPITALIZATION OR HOSPITAL
ADMISSIONS, WHY?
I MEAN, IT RAISES AS MANY
QUESTIONS AS IT ANSWERS.
>> ONE COULD COME UP WITH SOME
HYPOTHESIS FOR THAT.
THANK YOU.
>> WE SHOULD BE ABLE TO TAKE A
CLOSER LOOK AT IT.
>> DR. DESTEFANO?
>> JASON GLANCE'S WORK IS DONE
AS THE VSD AND THIS PAPER WAS
PRIMARILY GETTING AT THE ISSUE
OF DIFFERENCES IN HEALTH CARE
UTILIZATION BETWEEN PARENTS WHO
CHOSE DIFFERENT VACCINATION
SCHEDULES OR DELAYED VACCINATION
FOR THEIR CHILDREN.
AND I THINK ONE OF THE MAIN
THRUSTS OF IT WAS TO HIGHLIGHT
THE DIFFICULTIES IN TERMS OF
STUDY AND ISSUES OF HEALTH
OUTCOMES JUST BECAUSE IN GENERAL
THE HEALTH CARE UTILIZATION
PATTERNS OF THESE TYPES OF CARE
RAISES ALL SORTS OF
COMPARABILITY AND CONFOUNDING
ISSUES.
ALSO WANT TO ADD I THINK JASON
HAS ALSO DONE SOME ANALYSES THAT
HAVE BEEN PUBLISHED THAT LOOK AT
PERTUSSIS AND SHOW THAT CHILDREN
WHO DELAYED PERTUSSIS
VACCINATION HAVE INCREASED RISK
OF PERTUSSIS DISEASE.
>> THANK YOU.
VERY HELPFUL.
>> AND SO IT'S GOOD TO SEE SOME
OBVIOUS THINGS OUT THERE.
OTHER COMMENTS, QUESTIONS?
OKAY.
WELL, I'D LIKE, AGAIN, TO THANK
DR. HINSHAW FOR A WONDERFUL
PRESENTATION.
>> SURELY.
>> AND YOUR WILLINGNESS TO COME
TALK TO US TODAY.
>> THANK YOU VERY MUCH.
>> AND IF I CAN ASK DR.
COYNE-BEASLEY TO COME UP AND
INTRODUCE THE SESSION ON ADULT
IMMUNIZATION.
>> GOOD MORNING.
IT GIVES ME GREAT PLEASURE TO
INTRODUCE THE ADULT IMMUNIZATION
WORKGROUP SESSION THIS MORNING.
DR. CAROLYN BRIDGES THE CDC LEAD
WILL ACTUALLY HELP PROVIDE A
SUMMARY OF THE PRESENTATIONS AT
THE CONCLUSION.
I'D LIKE TO FIRST ACKNOWLEDGE
ALL THE MANY INDIVIDUALS WHO
ACTUALLY WORKED TIRELESSLY ON
THIS WORKGROUP, OUR OTHER ACIP
MEMBERS INCLUDE KATHLEEN
HARRIMAN AND JOHN TEMTE AND I'D
LIKE TO EXPRESS MY GRATITUDE FOR
THE CONSULTANTS AND LIAISONS AS
WELL AS THE VETERANS DAY MEMBERS
WHO ACTUALLY COLLECTIVELY
DEVOTED THEIR WISDOM AND THEIR
INSIGHT TO THE SYNTHESIS OF WHAT
CAN BE A VERY DIFFICULT ADULT
IMMUNIZATION SCHEDULE.
YOU CAN ACTUALLY FIND THAT
SCHEDULE NOW PUBLISHED IN THE
FEBRUARY MMWR SURVEILLANCE
SUMMARIES.
WE HAVE MANY PEOPLE WHO WILL BE
SHARING THEIR KNOWLEDGE AND
RESEARCH WITH US TODAY.
OUR FIRST PRESENTATION WILL BE
FROM DR. WALTER WILLIAMS A
MEMBER OF OUR CDC WORKGROUP WHO
WILL TALK TO US ABOUT ADOLESCENT
IMMUNIZATION COVERAGE AND
PROVIDE AN UPDATE FOR US.
NEXT WE'LL HAVE DR. LAURIE
HURLEY FROM UNIVERSITY OF
COLORADO WHO WILL PRESENT TO US
A 2012 SUMMARY OF GENERAL
INTERNAL MEDICINE AND FAMILY
PRACTITIONERS AND PHYSICIANS ON
ADULT IMMUNIZATIONS.
OUR LAST PRESENTATION WILL
ACTUALLY BE FROM DR. CHRIS
SHEEDY WHO WILL PRESENT THE
RESULTS FROM A 2012 SURVEY ON
CONSUMERS, AGAIN, ON ADULT
IMMUNIZATIONS AND FINALLY WE'LL
CONCLUDE WITH A SUMMARY BY DR.
CAROLYN BRIDGES.
I'D LIKE TO NOW CALL TO THE
PODIUM DR. WALTER WILLIAMS AND
THANK YOU FOR YOUR ATTENTION.
>> GOOD MORNING.
>> TO ASSESS VACCINATION
COVERAGE LEVELS AMONG ADULTS AGE
19 AND OLDER CDC ANALYZED DATA
FROM THE 2011 NATIONAL HEALTH
INTERVIEW SURVEY FOR
PNEUMOCOCCAL VACCINES, HEPATITIS
A, HEPATITIS B, HPV AND --
HAVING SOME TECHNICAL
DIFFICULTIES HERE.
OKAY, THANK YOU.
I WILL DESCRIBE THE DATA SOURCE
USED FOR THIS REPORT TO
HIGHLIGHT COVERAGE HIGHLIGHTS
AND GIVE SPECIFIC ADULT
VACCINATION COVERAGE ESTIMATES
FOR EACH OF THE VACCINES BY
SELECTED CHARACTERISTICS AND
PROVIDE A FEW CONCLUSIONS.
THE DATA SOURCE IS THE NATIONAL
HEALTH INTERVIEW SURVEY.
IT IS AN ANNUAL IN-HOUSE SURVEY
OF THE UNITED STATES
NONINSTITUTIONALIZED CIVILIAN
POPULATION.
RESPONDENTS ARE POLLED IN THEIR
HOUSEHOLDS.
THERE'S A PARTICULAR -- EXCUSE
ME.
RECEIPT OF RECOMMENDED
VACCINATIONS FOR ADULTS OR ONE
RANDOMLY SELECTED ADULT FOR EACH
FAMILY IN THE HOUSEHOLD, THE
PRESENCE OF HIGH-RISK CONDITIONS
ARE BASED ON ACIP
RECOMMENDATIONS AND WERE POLLED
USING QUESTIONS IN THE 2011
NHIS.
HIGH-RISK STATUS FOR HEPATITIS A
AND B WAS NOT COLLECTED IN 2011
IN H.I.S., INFORMATION ON
HIGH-RISK STATUS, AGAIN, WAS
BASED ON QUESTIONS BASED ON
RECOMMENDATIONS FROM THE ACIP.
VACCINATION QUESTIONS WERE ASKED
OF A SINGLE ADULT SELECTED IN
EACH FAMILY IN THE HOUSEHOLD.
THE FINAL SAMPLE ADULT COMPONENT
RESPONSE RATE FOR THE 2011 NHIS
WAS 66.3%.
A FEW HIGHLIGHTS.
COMPARED WITH THE 2010 NHIS
THERE WERE MODEST INCREASES ONLY
FOR AT LEAST ONE DOSE OF HPV
VACCINE, 8.8 PERCENTAGE POINT
INCREASE TO 29.5% IN WOMEN, 19
TO 26 YEARS.
THAT VACCINATION AMONG PERSONS
19 TO 64 YEARS A 4.3 PERCENTAGE
POINT INCREASE TO 12.5%.
COVERAGE FOR OVERALL FOR TETANUN
THERE WERE LIMITED INCREASES FOR
PNEUMOCOCCAL
OLDER, HEPATITIS B
VAC NATIONS FOR TO 49
AND HEPATITIS A VACCINATIONS AND
PNEUMOCOCCAL VACCINATIONS 19 TO
RECEIPT OF ONE DOSE FOR ME
TO 26 YEARS AND HERPES ROSTER
FOR ADULTS 65 AND OLDER.
LOOKING AT PNEUMOCOCCAL VAX
NANGESS, THERE ARE TWO 23 VALENT
POLYSACCHARIDE AND 13 VALENT N
VACCINES.
AND LOOKING AT HIGH-RISK
CONDITIONS VACCINATION OVERALLS
WITH 20.1%, 1.6 PERCENTAGE POINT
INCREASE COMPARED TO 2010.
WHITE NONHISPANICS HAD HIGHER
VACCINATION COVERAGE LEVELS THAN
HISPANICS AND NONHISPANICS.
FOR PERSONS 65 YEARS AND OLDER
OVERALL COVERAGE WAS 62.3%, A
2.6 PERCENTAGE POINT INCREASE
COMPARED TO 2010.
WHITE NONHISPANICS HAD HIGHER
COVERAGE RATES THAN NONHISPANIC
BLACKS, HISPANICS AND
NONHISPANIC ASIANS.
TURNING TO TETANUS VACCINATIONS
FOR THE PAST TEN YEARS, OVERALL
FOR PERSONS 19 TO 49 YEARS,
COVERAGE WAS 64.5%.
THERE WERE NO CHANGES COMPARED
WITH 2010.
WHITE NONHISPANICS HAD HIGHER
COVERAGE THAN BLACK
NONHISPANICS, HISPANICS AND
NONHISPANIC ASIANS.
LOOKING AT TETANUS VACCINATIONS
COVERAGE OVERALL WAS 63.9%,
AGAIN, NO CHANGE FROM 2010.
AND, AGAIN, WHITES HAD HIGHER
COVERAGE THAN BLACK HISPANICS
AND NONHISPANIC ASIANS.
FOR TETANUS VACCINATIONS FOR THE
PAST TEN YEARS FOR PERSONS 65
AND OLDER COVERAGE OVERALL WAS
54.4%, AGAIN, NO DIFFERENCE FROM
2010.
WHITE, AGAIN -- WHITES, AGAIN,
HAD COVERAGE HIGHER THAN
NONHISPANIC BLACKS,AND ASIANS.
TDAP VACCINATION COVERAGE IS
SHOWN ON THIS GRAPHIC FOR THE
PAST SIX YEARS.
OVERALL COVERAGE REMAINED LOW AT
12.5% DESPITE A 4.3 PERCENTAGE
POINT INCREASE.
THERE WERE INCREASES IN
UPS WITH THE OVERAGE FOR ALL
EXCEPTION OF NONHISPANIC ASIANS.
THE HIGHEST INCREASE OCCURRED
AMONG PERSONS WHO REPORTED A
RACE OTHER THAN ASIAN, BLACK,
WHITE, OR NONHISPANIC
ETHNICITIES.
THERE WAS ALSO A LARGE INCREASE,
10.9 PERCENTAGE POINTS, AMONG
PERSONS LIVING IN A HOUSEHOLD
WITH AN INFANT AGE LESS ONE
YEAR.
THIS IS OF PROGRAMMATIC
IMPORTANCE SINCE PROTECTION OF
TDAP OF PERSONS WHO HAVE CONTACT
WITH INFANTS OF LESS THAN ONE
YEAR PROVIDES PROTECTION AGAINST
RISK FOR TRANSMISSION AGAINST
UNPROTECTED INFANTS.
THE TDAP ESTIMATES HAVE HIGH
POTENTIAL FOR BIAS.
THERE WERE MANY PERSONS EXCLUDED
AMONG THE 25,000 AND MORE OF
RESPONDENTS, ABOUT 32% WERE
HOSE WITHOUT A YES-OR-NO
RESPONSE FOR TETANUS VACCINATION
TEN YEARS, THOSE
WITHOUT A RESPONSE TO TETANUS
VACCINATION IN 2005 THROUGH
2011, THOSE WHO REPORTED TETANUS
VACCINATIONS BUT WERE NOT TOLD
WHAT TYPE OR DID NOT KNOW THE
VACCINE TYPE.
SO, WE CONDUCTED A SENSITIVITY
ANALYSIS TO SEE THE IMPACT OF
THESE EXCLUSIONS ON POTENTIAL
FOR BIAS.
DEPENDENT ON THE ACTUAL
PROPORTION OF PE
RECEIVED TDAP VACCINATCOVERAGE
FROM 8% TO A HIGH AS HIGH AS --
I'M SORRY, 36.4%.
LOOKING AT TDAP VACCINATION, THE
PROPORTION OF TDAP OF ALL
TETANUS VACCINATIONS RECEIVED
AMONG ADULTS OVERALL, 19 TO 64
YEARS, 55.9% WERE NOT TOLD BY
THEIR PHYSICIAN OR PROVIDER WHAT
TYPE OF VACCINATION THEY
RECEIVED.
8.9% COULD NOT RECALL.
AMONG THE REMAINING 35%, 61.1%
RECEIVED TDAP.
AMONG HEALTH CARE WORKER
RESPONDENTS, 38.8% WERE NOT TOLD
BY THEIR PROVIDER WHAT TYPE
TETANUS VACCINATION THEY
RECEIVED, 5.4% COULD NOT RECALL
TETANUS VACCINATION AMONG HEALTH
CARE PERSONNEL WAS
LOOKING AT TETANUS VACCINATION
AMONG HEALTH CARE PERSONNEL
COMPARED TO NONHEALTH CARE
PERSONNEL, THE PROPORTION AMONG
HEALTH CARE PERSONNEL WAS HIGHER
STATISTICALLY.
LOOKING AT HEPATITIS A
VACCINATIONS, HEPATITIS A WAS
HIGHER FOR PERSONS WHO HAD
TRAVELED OUTSIDE THE UNITED
STATES TO COUNTRIES WITH HIGH
PREVALENCE OF HEPATITIS A
COMPARED TO THOSE WHO HAD NOT
TRAVELED TO A COUNTRY OF HIGH --
AND COVERAGE WAS 21.1% IN THAT
GROUP AN INCREASE3.5
PERCENTAGE POINTS OVER 2005.
2010, I'M SORRY.
HEPATITIS A VACCINATION AT LEAST
TWO DOSES AMONG PERSONS 19 TO 49
YEARS OVERALL WAS 12.5%, AN
INCREASE OF 1.8 PERCENTAGE
POINTS FROM 2010.
THERE WAS A 1.9 PERCENTAGE POINT
INCREASE AMONG NONHISPANIC
WHITES.
THE GROUP WITH THE HIGHEST
COVERAGE WAS AMONG ASIANS,
NONHISPANICS AT 19.1%.
THE HIGHEST, I'M SORRY, WAS
AMONG PERSONS WHO REPORTED A
RACE OTHER THAN ASIAN, BLACK, OR
WHITE AND NONHISPANIC ETHNICITY
WITH NONHISPANIC ASIANS HAVING
THE SECOND HIGHEST COVERAGE.
FOR HEPATITIS B VACCINATIONS,
PERSONS 19 TO 49 YEARS COVERAGE
WAS 35.9%, A 2.1 PERCENTAGE
POINT INCREASE COMPARED TO 2010.
WHITE NONHISPANICS HAD HIGHER
HEPATITIS B COVERAGE THAN BLACKS
AND HISPANICS DESPITE A 3.6
PERCENTAGE POINT INCREASE AMONG
HISPANICS.
PERSONS WITH DIABETES, 19 TO 59
YEARS AS WELL AS 60 YEARS AND
OVER, THERE WERE NO CHANGES
COMPARED TO 2010 COVERAGE
ESTIMATES.
LOOKING AT ZOSTER FOR PERSONS 60
YEARS AND HOLDER, COVERAGE WAS
15.8%.
NO CHANGE COMPARED TO 2010.
BLACKS, NONHISPANICS AND
HISPANICS HAD INCREASES OVER 3%
BUT STILL HAD LOWER COVERAGE
COMPARED TO WHITES NONHISPANICS.
LOOKING AT HUMAN PAPILLOMA
COVERAGE AMONG FEMALES AGE 19 TO
26 YEARS OVERALL COVERAGE WAS
29.5% AND 8.8 PERCENTAGE POINT
INCREASE COMPARED TO 2010.
THE HIGHEST INCREASE ACTUALLY
OCCURRED AMONG WOMEN 19 TO 21
YEARS OVERALL, A 14.9 PERCENTAGE
POINT INCREASE TO 43.1
PERCENTAGE POINTS.
THIS FINDING MIGHT REFLECT
RECEIPT OF VACCINE DURING
ELIGIBILITY FOR THE VACCINE FOR
CHILDREN PROGRAM, THAT IS, AGE
18 AND UNDER AND 19 AND OLDER
WHEN THE SURVEY WAS ACTUALLY --
WHEN THESE RESPONDENTS WERE
ACTUALLY INTERVIEWED.
HUMAN PAPILLOMA VIRUS
VACCINATION AMONG MALES 19 TO 26
YEARS OVERALL WAS 2.1%
REFLECTING A 1.5 PERCENTAGE
POINT INCREASE COMPARED TO 2010.
AS WE KNOW, IN OCTOBER 2011,
THERE WERE RECOMMENDATIONS FOR
VACCINATING MALES AGAINST HUMAN
PAPILLOMA VIRUS INFECTIONS UP
THROUGH AGE 21 YEARS WITH
VACCINATION PERMISSIVE FOR MALE
ADULTS 22 TO 26 YEARS.
THESE COVERAGE ESTIMATES DO NOT
REFLECT THAT RECOMMENDATION.
LOOKING AT HEALTH CARE
PERSONNEL, TETANUS VACCINATION
INCLUDING PERTUSSIS VACCINES FOR
THE PAST FIVE, SIX YEARS,
OVERALL HEALTH CARE PERSONNEL
VACCINATION LEVELS WERE 26.8%, A
6.5 PERCENTAGE POINT INCREASE
COMPARED TO 2010.
WHITE NONHISPANICS HAD HIGHER
VACCINATION COVERAGE LEVELS THAN
BLACK NONHISPANIC.
THERE WAS AN INCREASE AMONG
HISPANICS OF 16.3 PERCENTAGE
POINTS TO 31.1% AND THIS
COVERAGE ESTIMATE WAS SIMILAR TO
THAT AMONG WHITES.
LOOKING AT HEPATITIS B
VACCINATION FOR HEALTH CARE
PERSONNEL 19 AND OLDER, OVERALL
THE COVERAGE WAS 63.8%.
THERE WAS NO DIFFERENCE BETWEEN
2010 AND 2011.
WHITE NONHISPANIC HEALTH CARE
PERSONNEL HAD HIGHER COVERAGE
THAN BLACK NONHISPANICS,
HISPANIC AS WELL AS ASIAN --
SORRY, NONHISPANIC ASIANS HAD
HIGHER COVERAGE COMPARED TO
WHITES WHERE WHITES HAD HIGHER
COVERAGE COMPARED TO NONHISPANIC
BLACKS AND HISPANICS.
THGE REPORTS HAVE FIVE
LIMITATI
FIRST, THE NHIS EXCLUDES PERSONS
IN THE MILITARY AND THOSE
RESIDING IN INSTITUTIONS WHICH
CAN RESULT IN UNDERESTIMATION OR
OVERESTIMATION OF COVERAGE
ESTIMATES.
THE RESPONSE RATE WAS 63.3% AND
A LOW RESPONSE RATE CANESULT
IN SAMPLING BIAS IF THE
NONRESPONSE IS UNEQUAL AMONG
PARTICIPANTS REGARDING
VACCINATIONS.
SELF-REPORTED VACCINATION IS
SUBJECT TO RECALL BIAS.
WE DO KNOW, HOWEVER, THAT REPORT
OF -- SELF-REPORT OF
PNEUMOCOCCAL VACCINATION HAS
BEEN FOUND TO BE SENSITIVE AND
SPECIFIC.
THE TDAPIMATES ARE SUBJECT
TO BIAS DUE TO THEANY
EXCLUSIONS TO THAT DESCRIBED IN
A PREVIOUS SLIDE AND ALSOAGE OFN
FORINES REPORTED AS EVER
RECEIVED, THAT WOULD INCLUDE TH.
IT'S UNCLEAR IF VACCINATIONS
OCCURRED AS AN ADULT OR PART OF
A CHILD OR ADOLESCENT PROGRAM.
OVERALL, WE CONCLUDE THAT
COVERAGE REMAINS LOW FOR THE
THREE VACCINES THAT ARE INCLUDED
IN HEALTHY PEOPLE 2020, THAT IS
THE PNEUMOCOCCAL VACCINE AND
ZOSTER VACCINE AND HEPATITIS B
VACCINE.
THERE WERE SOME INCREASES IN
2010.
BUT LIMITED INCREASES IN OTHER
VACCINES.
AND RACIAL AND ETHNIC
DISPARITIES REMAIN.
OBVIOUSLY MUCH NEEDS TO BE DONE
AND WE'LL HEAR A BIT MORE IN THE
UPCOMING PRESENTATIONS ABOUT
SOME OF THE THINGS THAT ARE
GOING ON IN THAT REGARD.
I'D LIKE TO ACKNOWLEDGE MY
COLLABORATORS ON THIS REPORT.
AND THANK YOU.
>> THANK YOU VERY MUCH.
I THINK WE'RE GOING TO HOLD
COMMENT UNTIL THE NEXT
PRESENTATION AND THE SUMMARY BY
DR. BRIDGES JUST BECAUSE THEY'RE
ALL VERY SIMILAR CONTENT.
IF WE CAN HAVE DR. HURLEY COME
UP TO THE MICROPHONE.
>> THANK YOU.
I REALLY APPRECIATE THIS
OPPORTUNITY TO PRESENT OUR DATA,
AND I BELIEVE OUR DATA PROVIDES
SOME INSIGHT INTO THE LOW
COVERAGE THAT DR. WILLIAMS IS
REPORTING.
SO, OUR STUDY OBJECTIVES WERE TO
ASSESS IN A NATIONALLYREPRESENT
MEDICINE PHYSICIANS AND ISTS, C
REGARDING ASSESSING PATIENT NEED
FOR AND STOCKING RECOMMENDED
ADULT VACCINES, BARRIERS
STOCKING AND ADMINISTERING ADULT
VACCINES, CHARACTERISTICS OF
PHYSICIANS WHO PERCEER
FINANCIALBARRIERS TO DELIVERING
VACCINES TO ADU PRACTICES, ES,
REGARDING VACCINATION OUTSIDE OF
THE MEDICAL HOME, AND LASTLY,
ATTITUDES REGARDING THE ACIP
ADULT IMMUNIZATION SCHEDULE.
SOME OF YOU MIGHT BE INTERESTED
SENTINEL PHYSICIAN TO
PERFORM RAPID TURNAROUND SURVEYS
TO GAIN INFORMATION TO INFORM
POLICIES.
SENTINEL PHYSICIANS ARE
RANDOM SAMPLES OF
THE AMERICAN COLLEGE OF
PHYSICIANS AND THE AMERICAN
ACADEMY OF FAMILY PHYSICIANS.
SAMPLING ISSEN TO T
NETWORKS ARE OVERALL
ACIP AND AAFD MEMBERSHIP.
A PREVIOUS DEMONSTRATED WE
WERE ABLE TOEVE COMPARABLE
RESULTS TO THE MORE COMMON
USED METHOD OF RANDOMLY SAMPLING
RESPECT TO PHYSICIAN A MASTER
DEMOGRAPH
CHARACTERISTIC, AND RESPONSES
REGARDING ATTITUDES RELATED TO
VACCINE ISSUES.
WE DEVELOPED QUESTIONS JOINTLY
WITH THE CDC AND MODIFIED THE
QUESTIONS BASED ON INPUT FROM
ADVISORY COMMITTEES REPRESENTING
BOTH SPECIALTIES IN SIX STATES.
WE PRETESTED AND PILOTED THESE
QUESTIONS AMONG PRIMARY CARE
PHYSICIANS NATIONALLY AND THEN
ADMINISTERED THE SURVEY BY
INTERNET AND MAIL FROM MARCH
THROUGH JUNE OF LAST YEAR USING
METHODS KNOWN TO PRODUCE HIGH
RESPONSE RATES.
IN GENERAL, FAMILY MEDICINE AND
GENERAL INTERNAL MEDICINE
RESULTS WERE SIMILAR AND
THEREFORE ARE PRESENTED TOGETHER
FOR EASE OF PRESENTATION AND I
WILL BE HIGHLIGHTING ANY
SIGNIFICANT DIFFERENCES.
WE ALSO CONDUCTED BIVAIRIANT AND
MULTIPLE VARIABLE ANALYSES
LOOKING AT THE PRIMARY OUTCOME
OF PERCEPTION OF FINANCIAL
BURDEN OF DELIVERING VACCINES TO
ADULTS.
WE ACHIEVED AN OVERALL RESPONSE
RATE OF 71%.
79% FOR GENERAL INTERNISTS AND
62% FOR FAMILY MEDICINE
PHYSICIANS.
RESPONDENTS WERE SIMILAR TO
NONRESPONDENTS WITH RESPECT TO
DEMOGRAPHICS AND PRACTICE
CHARACTERISTICS.
MOVING ON TO OUR FIRST OBJECTIVE
OF DESCRIBING CURRENT PRACTICES
REGARDING ASSESSING NEED FOR AND
STOCKING RECOMMENDED ADULT
VACCINES.
IN TERMS OF WHEN IMMUNIZATION
STATUS IS BEING ASSESSED, ALMOST
ALL PHYSICIANS REPORTED THAT
THEY ASSESS IMMUNIZATION STATUS
AT AN ANNUAL AND AT AN INITIAL
VISIT BUT ONLY 30% REPORTED THAT
THEY DO SO AT EVERY VISIT.
THIS SLIDE IS SOMEWHAT BUSY, BUT
DESCRIBES WHAT PHYSICIANS -- HOW
PHYSICIANS REPORTED ASSESSING
IMMUNIZATION STATUS.
ALMOST ALL PHYSICIANS REPORTED
THAT THEY CHECK THEIR OWN
MEDICAL RECORD AND ASK THE
PATIENT VERBALLY.
THREE-QUARTERS REPORT THAT THEY
REVIEW OUTSIDE MEDICAL RECORDS,
61% HAVE THE STAFF MEMBER ASK
THE PATIENT VERBALLY.
ABOUT HALF ASK QUESTIONS ON A
QUESTIONNAIRE REGARDING
IMMUNIZATION STATUS, 30% HAVE A
STAFF REVIEW OUTSIDE MEDICAL
RECORDS, AND ONLY 20% REPORTED
CHECKING A STATE OR REGIONAL
IMMUNIZATION INFORMATION SYSTEM
TO DETERMINE IMMUNIZATION STATUS
OF NOTE, 92% OF PHYSICIANS
REPORTED THREE OR MORE WAYS TO
ASSESS IMMUNIZATION STATUS, ONLY
2% RELIED EXCLUSIVELY ON
PATIENT-SUPPLIED INFORMATION.
I WANT TO MAKE A SPECIAL NOTE
THAT FAMILY MEDICINE PHYSICIANS
REPORTED THEY WERE MORE LIKELY
TO USE AN IMMUNIZATION
INFORMATION SYSTEM TO DETERMINE
IMMUNIZATION STATUS.
THE NEXT SERIES OF SLIDES
DOCUMENT WHAT PHYSICIANS
REPORTED IN TERMS OF ASSESSING
NEED FOR AND STOCKING THE
VARIOUS ROUTINELY RECOMMENDED
BARS INDICATE ASSESSING
NEED FOR VACCINE, SOLID BARS
INDICATE STOCKING VACCINE,
GENERAL INTERNAL MEDICINE IS
REPRESENTED IN GREEN, FAMILY
MEDICINE IS REPRESENTED IN
ORANGE.
AS YOU CAN SEE ON THIS SLIDE,
MOST PHYSICIANS REPORT -- ALMOST
ALL PHYSICIANS REPORTED
ASSESSING NEED FOR AND STOCKING
SEASONAL INFLUENZA AND
PNEUMOCOCCAL VACCINES.
SIMILARLY, ALMOST ALL PHYSICIANS
REPORTED ASSESSING NEED FOR AND
STOCKING CD AND TDAP VACCINES.
WHILE MOST PHYSICIANS ARE
ASSESSING NEED FOR OR REPORTED
ASSESSING NEED FOR HERPES SOFTER
VACCINE
ZOSTER VACCINES, ONLY HALF
REPORTED STOCKING IT.
FEWER PHYSICIANS REPORTED NEED
FOR STOCKING HEPATITIS VACCINES,
FAMILY MEDICINE PHYSICIANS WERE
MORE LIKELY TO ASSESS NEED FOR
AND STOCK HEPATITIS B VACCINE
AND FAMILY PHYSICIANS WERE MORE
LIKELY TO ASSESS NEED FOR
HEPATITIS A VACCINES AND THESE
WERE STATISTICALLY SIGNIFICANT
DIFFERENCES BETWEEN THE
SPECIALTIES.
ABOUT HALF OF GENERAL INTERNISTS
REPORTED ASSESSING NEED FOR AND
STOCKING HPV VACCINE, THIS
COMPARES TO ABOUT THREE-QUARTERS
OF FAMILY MEDICINE PHYSICIANS
REPORTING ASSESSING NEED FOR AND
STOCKING HPV VACCINE AND THIS
ALSO WAS A STATISTICALLY -- ARE
THESE ARE STATISTICALLY
SIGNIFICANT DIFFERENCES.
ON THIS SLIDE WE GROUPED WHAT WE
CONSIDER TO BE CATCH-UP VACCINES
OR VACCINES THAT INDIVIDUALS
SHOULD HAVE RECEIVED IN
CHILDHOOD.
AND FOR ALL THREE OF THESE
VACCINES, FAMILY MEDICINE
PHYSICIANS WERE MORE LIKELY TO
ASSESS NEED FOR AND STOCK THESE
VACCINES.
31% OF FAMILY MEDICINE AND 20%
OF GENERAL INTERNAL MEDICINE
REPORTED STOCKING ALL ROUTINELY
RECOMMENDED VACCINES.
TO O
OBJECTIVE LOOKING AT BARRIERS TO
STOCKING AND ADMINISTERING ADULT
VACCINES.
THE TOP FIVE REPORTED BARRIERS
WERE ALL FINANCIAL, WITH 44% TO
60% OF PHYSICIANS REPORTING
THESE BARRIERS TO BE MAJOR OR
MODERATE BARRIERS.
THESE BARRIERS INCLUDED LACK OF
ADEQUATE REIMBURSEMENT FOR
PATIENTS NOT SE, DIFFICULTY A
INSURANCE COVERAGE FOR VACCINES,
LACK OF ADEQUATE REIMBU VACCINE
LASTLY, THE UPFRONT COST OF
BUYING VACCINES.
MOVING ON TO OUR MULTIVARIABLE
ANALYSIS.
BECAUSE ABOUT HALF OF THE
PHYSICIANS WERE REPORTING
SIGNIFICANT -- OR BELIEVING THAT
THERE WERE SIGNIFICANT FINANCIAL
BARRIERS TO ADMINISTERING ADULT
VACCINES AND HALF WEREN'T, WE
WERE INTERESTED IN CHARACTERI
CHARACTERIZING THOSE PHYSICIANS
THAT PERCEIVED GREATER FINANCIAL
BARRIERS TO DELIVERING VACCINES.
THIS SLIDE IS A SUMMARY SLIDE OF
OUR MULTIVARIABLE ANALYSIS.
WHAT WE FOUND WAS THAT THE
SOUTHERN REGION WORKING IN
PRIVATE PRACTICE IN SMALLER
PRACTICES AND WORKING IN
PRACTICES THAT SERVED A GREATER
PROPORTION OF PATIENTS WITH
MEDICARE PART "D"S A S AS IN D
PERCEIVED A HIGHER FINANCIAL
BURDEN TO DELIVERING ADULT
VACCINES, GENDER, AGE, PRACTICE
LOCATION, PROPORTION OF PATIENTS
WITH MEDICARE PART "B" OR
MEDICAID WERE NOT ASSOCIATED
WITH RECEIVING A GREATER
FINANCIAL BURDEN TO DELIVERING
VACCINES.
MOVING ON TO OUR NEXT OBJECTIVE,
LOOKING AT THE RELATIONSHIP WITH
OUTSIDE VACCINATORS OR
VACCINATORS OUTSIDE THE MEDICAL
HOME.
WE ASKED PHYSICIANS WHERE THEY
MOST COMMONLY REFER A PATIENT
FOR A VACCINE IF THEY DON'T
STOCK IT OR CAN'T DELIVER IT FOR
ANOTHER REASON.
AND THE MOST COMMON PLACE TO
REFER TO WAS A PHARMACY OR
RETAIL STORE WITH 25% OF
PHYSICIANS REPORTING THEY OFTEN
OR ALWAYS DO THIS AND 36% SAYING
THEY SOMETIMES DO THIS.
THE SECOND MOST COMMON PLACE TO
REFER WAS TO A PUBLIC HEALTH
DEPARTMENT WITH 21% OF
PHYSICIANS SAYING THEY OFTEN OR
ALWAYS REFER THERE AND 40%
SAYING THEY SOMETIMES REFER
THERE.
WE ALSO ASKED WHY DO YOU REFER
TO AN OUTSIDE VACCINATOR.
AND THE MOST COMMON REPORTED
REASON WAS THAT A PATIENT'S
INSURANCE DOES NOT COVER THE
VACCINE, WITH 18% SAYING THEY
OFTEN OR ALWAYS DO THIS AND 43%
SAYING THEY SOMETIMES REFER FOR
THIS REASON.
AND THE SECOND MOST COMMON
REASON TO REFER WAS THAT
PATIENTS' INSURANCE COVERS THE
VACCINE BUT THE PROVIDER
PERCEIVES THAT THE REIMBURSEMENT
IS INADEQUATE, AND 11% SAID THAT
THEY OFTEN OR ALWAYS REFER FOR
THIS REASON AND 29% REPORTED
THAT THEY SOMETIMES REFER FOR
THIS REASON.
WHILE PHYSICIANS WERE OPEN TO
MULTIPLE METHODS OF RECEIVING
INFORMATION FROM OTHER
VACCINATORS, THE MOST PREFERRED
METHOD WAS FOR THE INFORMATION
TO BE SENT TO THE PROVIDER BY
THE VACCINATOR WITH
PHYSICIANS THIS.
3 LOOK UP THE
INFORMATION IN A STATE OR
REGIONAL IIS,18% PREFERRED
TO HAVE THE INFORMATION RELAYED
DOCTOR'S VISIT.
OF NOTE 44% OF FAMILY MEDICINE
COMPARED TO 25% OFIMs
PREFERRED TO USE THE IIS.
ON THIS SLIDE, WE HAVE THE
PROPORTION OF PHYSICIANS WHO
REPORTED RECEIVING INFORMATION
REGARDING VACCINES ADMINISTERED
OUTSIDE OF THE MEDICAL HOME BY
OTHER VACCINATORS LESS THAN 50%
OF THE TIME.
SO, HERE HIGHER PERCENTAGES
INDICATE POOR COMMUNICATION.
I WANT TO HIGHLIGHT THE PHARMACY
AND RETAIL STORE AND PUBLIC
HEALTH DEPARTMENT BECAUSE I'VE
ALREADY TOLD YOU THAT THESE ARE
THE TWO MOST COMMON PLACES TO
REFER SOMEONE FOR VACCINE.
59% OF PHYSICIANS SAID THAT THEY
HEAR BACK FROM A PHARMACY OR
RETAIL STORE LESS THAN 50% OF
THE TIME, AND 83% OF PHYSICIANS
SAID THAT THEY HEAR BACK FROM A
PUBLIC HEALTH DEPARTMENT LESS
THAN 50% OF THE TIME.
ALTHOUGH AS YOU CAN SEE ON THE
REMAINDER OF THE SLIDE,
COMMUNICATION WAS NOT
NECESSARILY BETTER FROM THE
OTHER LOCATION. NEXT SERIES OF
HAVE ATTITUDES REGARDING THE
ROLE OF DIFFERENT ADULT VACCINE
PROVIDERS.
THIS FIRST SLIDE REPRESENTS THE
PRIMARY CARE PHYSICIAN
THE RESPONSES ARE IN TWO SHADES
OF ORANGE AND THE
RESPONSES ARE IN TWO
GREEN.
AS YOU CAN SEE ON THIS SLIDE,
THAT IT WAS ULTIMATELY THEIR SD
VACCINES, AND THIS WAS EVEN IF
THE VACCINES WERE RECEIVED
OUTSIDE OF THE MEDICAL HOME. AL
NOTED, 47% STRONGLY AGREED THAT
PATIENTS PREFER TO
VACCINES AT THE OFFICE RATHER
THAN A PHARMACY OR RETAIL STORE.
CIANSAGREED, STRONGLY, THAT VA
OVIDERS, AND
LASTLY, ABOUT 50% AGREED,
STRONGLY, THAT IT IS NOT THEIR
RESPONSIBILITY TO STOCK CATCH-UP
VACCINES.
THERE WAS A STATISTICAL
DIFFERENCE HERE BETWEEN FAMILY
MEDICINE AND GENERAL INTERNAL
MEDICINE WI INTERNAL
MEDICINE BEING MORE LIKELY TO
RESPONSIBILITY TO STOCK CATCH-UP
VACCINES.
THIS SLIDE REPRESENTS ATTITUDES
REGARDING THE SUBSPECIALIST
ROLE, AND AS YOU SEE, MOST
PHYSICIANS AGREED THAT IT WAS
PROBLEM MAT YOU CAN WHEN
SUBSPECIALIST PROVIDE VACCINES
BECAUSE OF LACK OF DOCUMENTATION
OF RECEIPT OF VACCINE.
29% AGREED AND 4% STRONGLY THAT
MANY PATIENTS RECEIVE VACCINES
IN THIS SETTING, SO NOT TOO MANY
AGREED.
AND LASTLY, SLIDE
REPRESENTS ATTITUDES REGARDING
THE PHARMACIST ROLE.
MOST PHYSICIANS AGREED, 21%
STRONGLY, THAT IT IS HELPFUL TO
HAVE PHARMACISTS SHARE THE ROLE
OF VACCINATING ADULTS.
27% AGREED.
7% STRONGLY THAT PHARMACISTS DO
NOT HAVE ADEQUATE TRAINING
ADMINISTER VACCINES.
THERE WAS ALSO A SPECIALTY
DIFFERENCE HERE WITH FAMILY
MEDICINE BEING MORE LIKELY TO
AGREE THAT PHARMACISTS DO NOT
HAVE ADEQUATE TRAINING TO
DELIVER VACCINES.
AND ONL 7% OF
PHYSICIANS AGREED, 3% STRONGLY,
THAT PHARMACISTS ARE NOT ABLE TO
DELIVER VACCINES IN THEIR AREA.
SO, OUR LAST OBJECTIVE,
ATTITUDES REGARDING THE ACIP
SCHEDULE.
SO, ON THIS SLIDE IF PHYSICIANS
AGREED WITH THE COMMENTS, THEY
WERE BASICALLY EXPRESSING
POSITIVE SENTIMEN TOWARDS THE
SCHEDULE.
AND ON HERE, JUST TO ORIENT YOU,
THE AGREE RESPONSES ARE IN TWO
SHADES OF ORANGE.
THE DISAGREE RESPONSES IN GREEN,
AND THEN NOT FAMILIAR WITH THIS
IS IN PURPL
AND AS YOU CAN SEE, ALMOST ALL
PHYSICIANS AGREED, STRONGLY,
THAT THEY WERE COMFORTABLE USING
THIS SCHEDULE TO DETERMINE WHAT
VACCINE AND ADULT PATIENT MIGHT
NEED.
ALSO MOST PHYSICIANS AGREED, 42%
STRONGLY, THAT THE SCHEDULE IS
EASILY ACCESSIBLE WHEN NEEDED.
MOST AGREED, 28% STRONGLY, THAT
THE SCHEDU PROVIDES CLEAR
GUIDELINES ON CATCH-UP
VACCINATIONS.
THE MAJORITY AGREED, 26% STRONG
PROVIDES CLEAR GUIDANCE ON WHAT
TO DO WHEN IMMUNIZATION STATUS
IS UNKNOWN.
AND LASTLY, MOST 19%
STRONGLY, THAT THE FOOTNOTE
SECTION OF THE SCHEDULE IS CLEAR
AND CONCI
ON THIS SLIDE, PHYSICIANS WERE
EXPRESSING NEGATIVE SENTIMENTS
TOWARDS THE SCHEDULE IF THEY
AGREED WITH THE COMMENTS.
25% OF PHYSICIANS AGREED AND
ONLY 4% STRONGLY THAT THE
AGE-BASED INDICATIONS FOR
IMMUNIZATIONS ARE DIFFICULT TO
FOLLOW.
29% AGREED AND ONLY 3% STRONGLY
THAT THE MEDICAL CONDITION-BASED
INDICATIONS ARE DIFFICULT TO
FOLLOW.
AND LASTLY, ONLY 12% AGREED, 3%
STRONGLY, THAT THEY DO NOT USE
THE SCHEDULE TO GUIDE THEIR
VACCINE RECOMMENDATIONS.
THERE ARE SEVERAL LIMITATIONS TO
OUR STUDY.
RESPONDENTS MAY HAVE DIFFERED
SLIGHTLY FROM NONRESPONDENTS.
SENTINEL PHYSICIANS MAY
DIFFERENT FROM PHYSICIANS
OVERALL.
AND LASTLY, THESE SURVEY RESULTS
REPRESENT REPORTED PRACTICE BUT
ACTUAL PRACTICE WAS NOT
OBSERVED.
SO, IN SUMMARY, PHYSICIANS ARE
NOT ASSESSING AND/OR STOCKING
SEVERAL RECOMMENDED ADULT
VACCINES.
A MINORITY OF PHYSICIANS
PARTICULARLY GENERAL INTERNAL
MEDICINE PHYSICIANS, ARE USING
IMMUNIZATION INFORMATION SYSTEMS
TO TRACK VACCINES FOR ADULT
PATIENTS.
THE TOP REPORTED BARRIERS TO
DELIVERING ADULT VACCINES WERE
FINANCIAL
AND PHYSICIANS FROM THE SOUTH IN
PRIVATE PRACTICE, IN SMALLER
PRACTICES, WITH HIGHER
PROPORTIONS OF PATIENTS WITH
MEDICARE PART "D" PERC
HIGHER FINANCIAL BURDEN TO
DELIVERING VACCINES.
PHYSICIANS ARE REFERRING TO
PATIENTS TO OTHER VACCINATORS,
BUT THERE'S NO SYSTEMATIC
APPROACH, AND COMMUNICATION
REGARDING VACCINATIONS IS
PERCEIVED AS POOR.
PRIMARY CARE PHYSICIANS
PERCEIVED THEMSELVES AS HAVING A
CENTRAL ROLE IN ENSURING
PATIENTS RECEIVE VACCINES.
AND LASTLY, ATTITUDES REGARDING
THE ADULT IMMUNIZATION SCHEDULE
WERE GENERALLY FAVORABLE, BUT
SOME PHYSICIANS FIND ASPECTS OF
THE SCHEDULE UNCLEAR OR ARE
UNFAMILIAR WITH IT.
I'D LIKE TO THANK ALL MY
COLLABORATORS.
AND I GUESS WE'LL WAIT FOR
QUESTIONS UNTIL AFTER THE
SESSION.
>> THANK YOU VERY MUCH.
IF WE COULD HAVE DR. SHEEDY COME
ON UP.
>> GOOD MORNING, EVERYBODY.
THANKS.
IT'S MY PLEASURE TO BE HERE TO
PROVIDE THE CONSUMER
PERSPECTIVE.
I HOPE YOU FIND IT INTERESTING
PARTICULARLY JUXTAPOSED AGAINST
SOME OF THE FINDINGS THAT LAURA
JUST PRESENTED TO US.
I'LL BEGIN THIS MORNING BY
SHARING A FEW HIGHLIGHTS FROM A
RECENT SURVEY OF U.S. ADULTS ON
THIS TOPIC.
WE'LL DISCUSS A NEW
COMMUNICATION PROGRAM WE'RE
KICKING OFF AT CDC TO HELP
PROMOTE ADULT IMNIZATIONS AND
I'LL SHARE ACTIVITIES AND REMIND
FOLKS OF RESOURCES THAT ARE
ALREADY AVAILABLE.
SO, LET ME START BY SHARING SOME
RESULTS FROM A RECENT SURVEY OF
U.S. ADULTS REGARDING THEIR
ADULT IMMUNIZATION KNOWLEDGE,
ATTITUDES, AND SELF-REPORTED
BEHAVIORS.
THE SURVEYS HAVE BEEN A HELPFUL
MECHANISM FOR US TO GET CONSUMER
PERSPECTIVE ON CHILDHOOD AND
INFLUENZA IMMUNIZATION ISSUES
OVER THE YEARS.
BEFORE 2011, THE SURVEYS WERE AN
ANNUAL SERIES OF
SELF-ADMINISTERED MAIL SURVEYS
ASSEMBLED FROM APPROXIMATELILY
200,000 U.S. HOUSEHOLDS.
BEGINNING IN 2011 THEY STARTED
NEW SURVEYS, BASED ON 50,000
U.S. HOUSEHOLDS AND OFFERING
INTERNET ACCESS, COMPUTERS,
COMPUTERS AND TECHNICAL
ASSISTANCE TO PANELISTS TO AVOID
BIAS.
THE DATA I'LL BE SHARING COME
FROM THE FALL SURVEY WHICH WAS
ADMINISTERED THIS PAST SEPTEMBER
AND OCTOBER.
THIS WAS A RECONTEXTED SURVEY
SENT TO A RANDOM SAMPLE OVER
6,000 HOUSEHOLDS THAT HAD
RETURNED THE LARGER CONSUMER
STYLE SURVEY CONDUCTED EARLIER
IN 2012.
THE RESPONSE RATE WAS ABOUT 80%
AND THE DATA ARE WEIGHTED
ACCORDING TO THE 2009 CURRENT
POPULATION SURVEY OF THE U.S.
CENSUS BY GENDER, AGE, RACE,
ETHNICITY, HOUSEHOLD INCOME AND
HOUSEHOLD SIZE.
THIS SLIDE SHOWS A SUMMARY OF
THE DEMOGRAPHICS OF THE
APPROXIMATELY 3,500
PARTICIPANTS.
NOW I'LL TURN TO RESULTS
BEGINNING WITHED
VACCINE BEHAVIORS.
IN ADDITION TO IMMUNIZATION
QUESTIONS RESPONDENTS WERE ASKED
HOW MANY TIMES THEY VISITED A
PRIMARY CARE DOC OR A SPECIALIST
IN THE PAST 12 MONTHS.
74%, ALMOST THREE-QUARTERS OF
ADULTS, REPORTED SEEING A
PRIMARY CARE DOCTOR AT LEAST
ONCE IN THE LAST 12 MONTHS.
MANY REPORTED SEEING A PRIMARY
CARE DOC MULTIPLE TIMES.
38% REPORTED SEEING A SPECIALIST
IN THE PAST 12 MONTHS.
RESPONDENTS WERE ASKED ARE ANY
OF THE FOLLOWING VACCINES
RECOMMENDED FOR YOU AS AN ADULT.
NOW, OBVIOUSLY IT'S CHALLENGING
TO KNOW HOW MANY OF THE YES AND
NO RESPONSES ARE CORRECT
REGARDING HEPATITIS A, A, AND
PNEUMOCOCCAL VACCINES BUT THE
REASON I WANTED TO SHARE THIS
SLIDE IS BECAUSE OF THE HIGH
PERCENT OF RESPONDENTS WHO
REPORTED THEY DON'T KNOW IF THE
VACCINES ARE RECOMMENDED FOR
THEM.
THIS IS NOT NECESSARILY
SURPRISING GIVEN THE COMPLEXITY
OF OUR ADULT IMMUNIZATION
RECOMMENDATION AS WELL AS THE
LIMITED ATTENTION THOSE
RECOMMENDATIONS HAVE RECEIVED IN
U.S. PUBLIC DISCOURSE, SAY, IN
COMPARISON TO INFANT
IMMUNIZATIONS OR INFLUENZA.
NEXT RESPONDENTS WERE ASKED HAVE
YOU RECEIVED THE FOLLOWING
VACCINE AS AN ADULT.
CLEARLY NHIS IS OUR SOURCE FOR
OFFICIAL COVERAGE ESTIMATES.
THIS IS SIMPLY THE RESPOND
DENTS' PERCEPTIONS AND
RECOLLECTIONRECEIVED THE VACCIN.
YOU CAN SEE THAT WITH THE
EXCEPTION OF FLU, FEW ADULTS
BELIEVE THEY HAVE RECEIVED ADULT
VACCINES INCLUDING OTHER ADULTS,
AND MANY DO NOT KNOW IF THEY'VE
RECEIVED THEM.
THIS INABILITY FOR ADULTS TO
RECALL WHETHER THEY HAVE
RECEIVED VACCINE UNDERSCORES THE
POTENTIALLY IMPORTANT ROLE THAT
IN HELPING THE PUBLIC KEEP TRACK
OF THE VACCINES THEY'VE
RECEIVED.
WE ALSO ASKED PARTICIPANTS IN
THE PAST YEAR HAS THE FOLLOWING
VACCINE BEEN RECOMMENDED FOR YOU
BY A MEDICAL PROFESSIONAL.
YOU CAN SEE THAT, AGAIN, WITH
THE EXCEPTION OF FLU VACCINES,
FEW ADULTS BELIEVE THAT A
MEDICAL PROFESSIONAL RECOMMENDED
VACCINES TO THEM IN THE PAST
YEAR.
IF THEIR PERCEPTIONS ARE
CORRECT, WE'RE MISSING
OPPORTUNITIES TO DISCUSS
VACCINES WITH ADULTS AND IF THE
PERCEPTIONS AREN'T CORRECT, AND
MENDING
VACCINES MORE FREQUENTLY, THEY
MAY NOT BE DOING SO IN A
MEMORABLE OR MEANINGFUL WAY FROM
THE PATIENT'S PERSPECTIVE.
NEXT I'D LIKE TO SHARE A FEW
FINDINGS RELATED TO RESPONDENTS'
ATTITUDES TOWARD ADULT
IMMUNIZATIONS.
FIRST WE ASKED HOW IMPORTANT DO
YOU THINK VACCINES ARE WHEN IT
COMES TO PROTECTING YOUR HEALTH.
THE VAST MAJORITY OF
RESPONDENTS, ABOUT 82%, SAID
THEY THINK VACCINES ARE
IMPORTANT OR VERY IMPORTANT FOR
PROTECTING THEIR HEALTH.
NEXT WE ASKED HOW IMPORTANT DO
YOU THINK VACCINES ARE WHEN IT
COMES TO PROTECTING YOUR FAMILY
AND LOVED ONES' HEALTH.
73% SAID IMPORTANT OR VERY
IMPORTANT.
WHEN ASKED HOW IMPORTANT DO YOU
THINK VACCINES ARE WHEN IT COMES
TO PROTECTING YOUR COMMUNITIES'
HEALTH, AGAIN, A MAJORITY, 68%,
SAID IMPORTANT OR VERY
IMPORTANT.
OUT OF OUR TEN ATTITUDAL
VARIABLES ASSESSING ADULTS'
ATTITUDES TOWARD VACCINES IN
GENERAL ALL SHOW THE SAME
ENCOURAGING PATTERNS OF
DIRECTIONALITY.
AN IMPORTANT IMPLICATION OF THIS
IS THAT PROVIDERS ENGAGING IN
ADULT IMMUNIZATION CONVERSATIONS
WITH THEIR PATIENTS WILL BE
DOING SO WITH A POPULATION THAT
IS GENERALLY SUPPORTIVE OF THE
VALUE OF VACCINES.FINALLY WE AS
WHICH OF THE FOLLOWING ARE
IMPORTANT TO YOU WHEN YOU'RE
VACCINES YOU SHOULD GET.ICH
THERE'S NOTHING TERRIBLY
SURPRISING HERE.
A PROVIDER RECOMMENDATION WAS
THE MOST FREQUENTLY SELECTED
FACTOR IN INFLUENCING
VACCINATION DECISIONS.
AND LIKE FINDINGS FROM RESEARCH
WE'VE DONE RELATED TO CHILDHOOD,
ADOLESCENT AND FLU VACCINES, A
LONG TRACK RECORD OF SAFETY IS
ALALSO AN IMPORTANT COMPONENT O
THE ADULT VACCINATION DECISIONS,
SO WE NEED TO MAKE SURE THAT
ADULTS AND THEIR PROVIDERS HAVE
CLEAR, CREDIBLE, AND TIMELY
INFORMATION ON VACCINE SAFETY.
COST AND CONVENIENCE ARE
IMPORTANT COMPONENTS AS WELL.
REMINDING US THAT IT WILL TAKE
MORE THAN COMMUNICATION AND
AWARENESS RAISING TO INCREASE
ADULT VACCINATION COVERAGE.
SO, IN SUM, MOST RESPONDENTS
AGREE THAT VACCINES ARE
IMPORTANT FOR PROTECTING HEALTH
AND PREVENTING SPREAD OF
DISEASE.
A HEALTH CARE PROVIDER
RECOMMENDATION IS THE NUMBER ONE
REPORTED FACTOR IN INFLUENCING
VACCINATION DECISIONS AND ADULTS
ARE SEEING THEIR DOCS.
THREE-FOURTHS OF ADULTS REPORTED
HAVING VISITED A PRIMARY CARE
DOC AT LEAST ONCE IN THE PAST
YEAR.
HOWEVER, ADULTS PERCEIVE
RECEIVING FEW RECOMMENDATIONS
FOR ADULT VACCINES FROM HEALTH
CARE PROFESSIONALS AND AWARENESS
OF RECOMMENDED VACCINES OTHER
THAN INFLUENZA APPEARS TO BE
QUITE LOW.
THE NEXT I'D LIKE TO TALK ABOUT
A NEW COMMUNICATION EDUCATION
EFFORT THAT WE'RE WORKING ON
HERE AT CDC
AND I WANT TO BEGIN WITH THIS
SLIDE TO EMPHASIZE WHAT WE'RE
DOING ON THE COMMUNICATION FRONL
APPROACH TO INCREASING ADULT
IMMUNIZATION.
WE CAN'T EXPECT COMMUNICATION TO
ADDRESS BARRIERS THAT ONLY
POLICY AND SYSTEM CHANGE CAN
OVERCOME AND I THINK LAURA'S
PRESENTATION HIGHLIGHTED MANY OF
THOSE.
RY CRITICAL PIECES
THAT THE NATIONAL ADULT IMMU
IMMUNIZATION PARTNERS ARE
WORKING ON.
WE CAN INCREASE DEMAND THROUGH
PROVIDER AND CONSUMER BEHAVIOR
CHAFFORTS.
HERE ARE SOME OF THE HEALTH
COMMUNICATION STRATEGIES WE CAN
USE TO AFFECT BEHAVIOR CHANGE
AMONG ADULTS AND HEALTH CARE
PROFESSIONALS TO
COMMUNITY DEMAND FOR
IMMUNIZATION RANGING FROM
INCREASING CONSUMER AWARENESS TO
THE DEVELOPMENT AND
DISSEMINATION OF PROVIDER
EDUCATION RESOURCES.
OUR NEW ADULT IMMUNIZATION
PROGRAM IS AIMED AT RAISING
AWARENESS AND PROMOTING TIMELY
IMMUNIZATION ACCORDING TO THE
RECOMMENDED SCHEDULE BY
TARGETING BOTH ADULTS AND HEALTH
CARE PROFESSIONALS.
AS THE FIRST -- AS THE FIRST
SUCH PROGRAM AT CDC INITIAL
FUNDING FOR TWO YEARS WE HOPE TO
LAY A STRONG FOUNDATION FOR A
BRANDED GENERAL CAMPAIGN THAT
CAN INFORM AND SUPPORT THE WORK
OF THE NATIONAL ADULT
IMMUNIZATION SUMMIT AND OTHER
PARTNERS AND, OF COURSE, WE
INTEND TO CONTINUE TO BUILD ON
THAT FOUNDATION LONG TERM AS
WE'VE DONE WITH OUR INFLUENZA
AND INFANT IMMUNIZATION
COMMUNICATION EFFORTS WITH
WHATEVER RESOURCES WE DO HAVE
AVAILABLE.
AGAIN, OUR GOAL IS TO DEVELOP A
BRAND THAT CAN BE ADAPTED FOR
ALL ADULT AUDIENCES AND TO
DEVELOP CLEAR SCIENCE-BASED AND
ACTIONABLE MESSAGES TO INCREASE
AWARENESS OF AND INTEREST IN
ADULT VACCINES GENERALLY.
AND IN ADDITION WHILE WE WANT TO
REACH ALL ADULTS GIVEN THE LOW
RATES OF AWARENESS AND LOW
COVERAGE RATES, WE ALSO KNOW
THAT THE MOST SUCCESSFUL
COMMUNICATION IS TAILORED TO
SPECIFIC AUDIENCE SEGMENTS.
ONE OF OUR CHALLENGES IS THERE
ARE MANY DISTINCT GROUPS WITHIN
THE U.S. ADULT POPULATION WHO
REQUIRE SUCH TARGETED
COMMUNICATION.
OVER TIME WE'D LIKE TO HAVE
RESOURCES TAILORED FOR ALL OR
MOST OF THEM, BUT GIVEN
CONSIDERATIONS SUCH AS IN
STAFFING AS WELL AS CONSIDERING
WHAT GAPS ARE ALREADY BEING
FILLED BY PARTNERS, WE DECIDED
TO START WITH GROUPS WHO WERE AT
HIGH RISK FOR COMPLICATIONS OF
VACCINE PREVENTABLE DISEASES AND
ALSO LIKELY TO MORE REGULARLY
SEE HEALTH CARE PROFESSIONALS.
THIS INCLUDES ADULTS AGE 40 AND
OVER WITH CHRONIC HEALTH
CONDITIONS, SPECIFICALLY HEART
DISEASE, COPD AND ASTHMA AND
ADULTS AGE 60 AND OVER.
IN ADDITION WE'LL CONTINUE OUR
ONGOING ACTIVITIES TO REACH
PREGNANT WOMEN INCLUDING THROUGH
EXISTING PARTNERSHIPS WITH ACOG
AND OTHERS.
WE KNOW HEALTH CARE
PROFESSIONALS PLAY THE CRITICAL
ROLE IN ADULT VACCINATION AND
OUR FOCUS WILL BE ON THOSE
RESPONSIBLE FOR ADMINISTERING
VACCINES INCLUDING PRIMARY CARE
PHYSICIANS, P.A.s AND NURSES,
ADULTS WITH CHRONIC DISEASES ARE
OFTEN UNDER THE CARE OF
SPECIALISTS AS WELL WHO HELP
MANAGE THEIR CONDITION AND THEY
MAY SEE THEM MORE REGULARLY THAN
THEIR PRIMARY CARE DOC OR NOT.
WHILE SPECIALISTS MAY NOT HAVE
THE CAPACITY TO PROVIDE VACCINES
IN THEIR OFFICES, THEY CAN PLAY
A SIGNIFICANT ROLE BY EDUCATING
PATIENTS ABOUT THE NEED FOR
VACCINES AND REFERRING THEM TO
APPROPRIATE HEALTH CARE
PROFESSIONALS.
WE'LL WORK WITH ASSOCIATIONS OF
SPECIAL IT IS, CARDIOLOGISTS AND
ENDOCRINOLOGISTS AND OTHERS TO
ENCOURAGE MEMBERS TO RECOMMEND
VACCINES TO PATIENTS AND
VACCINATE THEM OR REFER THEM.
NOT ALL MEDICAL PRACTICES
ADMINISTER ALL VACCINES,
PHARMACISTS CAN PLAY A CRITICAL
ROLE IN ENSURING THAT ADULTS GET
IMMUNI
IMMUNIZED.
20% OF ALL ADULTS VISIT A
PHARMACIST AT LEAST ONCE A YEAR
AND, OF COURSE, THE NUMBER MAY
BE HIGHER WITH PEOPLE WITH
CHRONIC HEALTH CONDITIONS.
RETAIL AND LARGE PHARMACIES HAVE
THE CAPACITY AND INTEREST IN
PROMOTING ADULT IMMUNIZATION SO
WE LOOK FORWARD TO EXPANDING THE
WORK WE'VE DONE WITH RETAIL
PHARMACY CAMPAIGNS ON FLU
VACCINATIONS TO INCLUDE OTHER
ADULT IMMUNIZATIONS.
A FEW WORDS ABOUT OUR GENERAL
APPROACH.
OUR PROGRAM WILL BE DESIGNED
FOLLOWING SOCIAL MARKETING AND
COMMUNICATION PRINCIPLES AND
WILL BE HEAVILY INFORMED WITH
RESEARCH WITH TARGET AUDIENCES.
PRINT, RADIO AND DIGITAL MEDIA
PRODUCTS WILL BE TESTED WITH
TARGET AUDIENCES PRIOR TO
DISTRIBUTION THROUGH SOME
LIMITED PAID AND UNPAID OR
EARNED PLACEMENT.
WE'LL STRIVE TO MAKE OUR
COMMUNICATION MESSAGES,
MATERIALS, AND PRODUCTS
CULTURALLY AND LINGUISTICALLY
APPROPRIATE KEEPING IN MIND THAT
PERSISTENT DISPARITIES THAT
EXIST WRITTEN IN PLAINGE
AND DELIVERED THROUGH TRUSTED
SOURCES AND EFFECTIVE CHANNELS
FOR EACH AUDIENCE AND CDC WILL
WORK CLOSELY WITH THE NATIONAL
ADULT IMMUNIZATION SUMMIT AND
OTHER PARTNERS INCLUDING
NATIONAL RELEVANT MEDICAL
ASSOCIATIONS AND CONSUMER
GROUPS.
AS A FIRST STEP, WE CONDUCTED A
LITERATURE REVIEW.
KEY GAPS IN THE RESEARCH RELATED
TO ADULT IMMUNIZATION
COMMUNICATION INCLUDED WHAT DO
ADULTS KNOW AND THINK ABOUT THE
ADULT IMMUNIZATION SCHEDULE,
WHAT TYPE OF MESSAGES AND
CREATIVE APPROACHES MOTIVATED
ADULTS TO GET VACCINATED, WHAT
ADULTS WANT TO KNOW ABOUT
IMMUNIZATION AND HOW THEY PREFER
TO RECEIVE IT AND WHAT WE CAN DO
TO SUPPORT HEALTH CARE
PROFESSIONALS AND MAKING
VACCINATION A ROUTINE PART OF
PREVENTIVE CARE AND
COMMUNICATING A STRONG
RECOMMENDATION FOR VACCINATION.
TO BEGIN TO ADDRESS THESE GAPS,
WE'LL BE CONDUCTING FOCUS
INFORMATIVE RESEARCH WITH BOTH
ADULTS AND HEALTH CARE
PROFESSIONALS.
RESEARCH WITH ADULT AUDIENCES
WILL BE DONE WITH A NUMBER OF
FOCUS GROUPS ACROSS THE COUNTRY.
THEY WILL BE SEGMENTED WITH
CHRONIC CONDITIONS INCLUDING
ADULTS WITH AND WITHOUT THE
CONDITIONS, AGE AND RACE
ETHNICITY.
THROUGH THE KNOW CUSS GROUPS WE
HOPE TO BETTER UNDERSTAND NOT
JUST WHAT ADULTS KNOW AND FEEL
ABOUT ADULT VACCINATIONS BUT
ALSO HOW WE CAN EFFECTIVELY
EDUCATE AND MOTIVATE THEM TO GET
VACCINATED.
RESEARCH WILL BE DONE THROUGH
IN-DEPTH INTERVIEWS AND WE HOPE
TO BETTER UNDERSTAND THE
ADDITIONAL BARRIERS HEALTH CARE
PROFESSIONALS FACE IN ASSESSING
ADULT VACCINATION STATUS,
RECOMMENDING VACCINES AND
ADMINISTERING THEM.
WE ALSO HOPE TO IDENTIFY WAYS TO
SUPPORT THEM SO THEY CAN
EFFECTIVELY EDUCATE PATIENTS AND
MAKE STRONG RECOMMENDATIONS FOR
VACCINATIONS.
OUR NEXT STEPS ARE REALLY TOO
NUMEROUS TO LIST ON ONE SLIDE,
BUT HERE ARE A FEW, INCLUDING
SHARING AVAILABLE RESEARCH
FINDINGS AT THE ADULT
IMMUNIZATION SUMMIT MEETING IN
MAY.
I WON'T GO INTO THE DETAILS OF
THIS SLIDE, BUT I DID WANT TO
HIGHLIGHT A FEW OF OUR RECENT
EFFORTS AND SUCCESSES RELATED TO
GETTING SOME ATTENTION TO THE
RELEASE OF THE 2013 ADULT
IMMUNIZATION SCHEDULE AND THE
2011 ADULT IMMUNIZATION COVERAGE
ESTIMATE, THESE INCLUDEDHING A
WEBSITE AND HOLDING A PRESS
CONFERENCE WHICH GOT MORE
NATIONAL AND MEDIA ATTENTION
THAN I EXPECTED IT TO GET AND
WAS HAPPILY SURPRISED BY THAT.
AND CONDUCTING A RADIO MEDIA
TOUR WITH APPROXIMATELY 40 RADIO
STATIONS ACROSS THE COUNTRY AND
A SPECIAL THANKS TO THE
PARTICIPANTS IN THAT ACTIVITY.
FINALLY I WANT TO JUST REMIND
EVERYONE THAT WE DO CURRENTLY
HAVE SOME HELPFUL RESOURCES
AVAILABLE.
INCLUDING THE ONLINE ADULT
VACCINATION QUIZ AND MANY OTHER
PRODUCTS.
AND THANK YOU TO THE PEOPLE
LISTED ON THIS SLIDE WHO
CONTRIBUTED TO THIS
PRESENTATION.
>> THANK YOU VERY MUCH.
AND, DR. BRIDGES?
>> THANKS VERY MUCH TO OUR
SPEAKERS.
I APPRECIATE THEM PUTTING
TOGETHER THE DATA FOR OUR
SESSION.
I JUST WANTED TO ADD SOME
SUMMARY THOUGHTS AND
INFORMATION.
SO, WHILE COVERAGE AMONG ADULTS
CONTINUES TO LAG, THERE WERE
SOME HOPEFUL SIGNS IN THE SURVEY
INFORMATION THAT I HOPE YOU SAW.
NUMBER ONE, PROVIDERS DO SEE
IMMUNIZATIONS AS BEING IMPORTANT
AND A BIG PART OF THEIR WORK.
AND MOST ADULT PATIENTS ARE
WILLING TO ACCEPT VACCINATIONS
PARTICULARLY WHEN RECOMMENDED BY
THEIR PROVIDERS.
BUT CLEARLY THERE ARE SOME
IMPORTANT AREAS THAT NEED
IMPROVEMENT.
FIRST, INCREASING AWARENESS AND
USE OF IMMUNIZATION INFORMATION
SYSTEMS BY ADULT VACCINE
PROVIDERS TO HELP IMPROVE
DOCUMENTATION AND COMMUNICATION
AMONG THE MANY DIFFERENT TYPES
OF PROVIDERS THAT VACCINATE
ADULTS AND CARE FOR ADULTS.
ALSO WE NEED TO IDENTIFY WAYS TO
EITHER REDUCE BARRIERS FOR
COVERAGE AND PAYMENT OR IDENTIFY
WAYS TO HELP PROVIDERS
UNDERSTAND WAYS TO REDUCE THOSE
BARRIERS.
WE NEED INCREASING AWARENESS
ABOUT VACCINES AMONG THE PUBLIC
FOR ADULTS, AND INCREASING ADULT
PATIENT VACCINE NEEDS ASSESSMENT
IS PART OF ROUTINE CARE BY
PROVIDERS.
PEOPLE HAVE TALKED ABOUT THE
IMPORTANCE, AGAIN, OF THE
PROVIDER RECOMMENDATION.
I JUST WANTED TO POINT TO SOME
DATA, AGAIN, THAT HIGHLIGHTS THE
TOP GRAPH SHOWS INFORMATION FROM
THE CDC INTERNET PANEL SURVEY.
WE FOUND THIS RESULT VERY
CONSISTENTLY.
AMONG PREGNANT WOMEN WHOSE
PROVIDERS BOTH RECOMMENDED AND
OFFERED INFLUENZA VACCINATION,
COVERAGE WAS 75%.
AMONG THOSE WHO RECEIVED A
RECOMMENDATION FROM THEIR
PROVIDER BUT THE VACCINE WAS NOT
OFFERED AT THE VISIT, THAT WAS
37.5%, SO HALF.
IF THERE WAS NO RECOMMENDATION
BY THE PROVIDER OF COVERAGE WAS
10%, SO THE PROVIDER
RECOMMENDATION IS KEY.
NOT ONLY FOR PROVIDERS WHO ARE
PHYSICIANS, BUT OTHER STUDIES
FROM THE PHARMACIST COMMUNITY,
SHOWS THE RECOMMENDATION CAN BE
VERY HELPFUL.
THE LOWER SLIDE FROM THE
DIABETES CHALLENGE.
THIS IS A STUDY IN WHICH
PATIENTS WERE DIABETES WERE
ENROLLED TO RECEIVE ADDITIONAL
COUNSELING FROM THEIR
PHARMACIST.
THEY USUALLY HAD TWO OR MORE
VISITS AND COMPARED TO YEAR ONE
TO YEAR TWO, INFLUENZA
VACCINATION INCREASED FROM 32%
AMONG THE PATIENTS WITH DIABETES
TO 65% IN YEAR TWO.
AND CERTAINLY THERE WAS A
SIGNIFICANT OUTPERFORMANCE OF
THE COVERAGE FROM OTHER LOCAL
PLANS USING THIS MEASURE.
THERE ARE OTHER EXAMPLES THAT I
WANTED TO HIGHLIGHT THESE TWO.
DID, ONE OF THE EFFORTS THAT
WE'VE UNDERTAKEN IS THE NATIONAL
ADULT IMMUNIZATION SUMMIT.OF YOH
RTED IN UENZA VACCINE
IT'S NOW 13th
AND ADULT SUMMIT LAST YEAR.
FOR THE COMI MAY 3,
TWOTHE NATIONAL ADULT AND INFLA
SUMMIT.
WE'LL CONTIN EMPHASIS
ON INFLUENZA
BUT ALSO ABOUT HA MEETING
WILL BE DEVOTED TOLTIMMUNIZATIO
OVER 300 DIFFERENT ORGANIZATIONS
REPRESENTED.
AND THE GOAL IS TO INCREASEOVER.
THERE ARE FIVE WORKING GROUPS AS
PART OF THE ADULT SUMMIT, FOUR
OF WHICH ALIGNED WITH THE HHS
INTERAGENCY TASK FORCE ON ADULT
IMMUNIZATIONS A
EXCHANGE OF
THOSE GROUPS.
ONE OF THE ACTION THE
ADU WAS
TAKE WAS TO E ADULT IMMUNIZATI
ON THE SUMMIT
HAD BEEN WORKING ON A NEW
OUTLINE TO UPDATE WHAT SHOULD GO
INTO THE STANDAE UPDATE WAS NEE
OF TYPE OF PROVIDERS INVOLVED
WAS NOT NECESSARILY A
SIGNIFICANT PART OF THE PRIOR
TOENCOURAGE MORECATION AND DOC
ADULT, VACCINATION AMONG THERIO
O SUMMIT TO NVAC AND
WE HOPE TO SEE A DRAFT OF THAT
REPORT OVER THE NEXT SEVERAL
MONTHS.
SO, THE OVERARCHING MESSAGE OF
THE ADULT STANDARD IS ALL ADULT
PROVIDERS HAVE A ROLE IN
ACCESSING VACCINATION STATUS OF
THEIR RECOMMENDED VACCINES AN
VACCINATIN DIDOCKES REFERRING T
VACCINE PROVIDERS AND THEN
VACCINE WAS RECEIVED.
I'LL STOP THERE AND WE CAN TAKE
QUESTIONS FROM ALL THE DIFFERENT
SPEAKERS.
THANK YOU.
>> SO, LET'S HAVE THE SPEAKERS
COME UP TO THE MICROPHONE, AND
THANK YOU VERY MUCH FOR A SERIES
OF WONDERFUL PRESENTATIONS HERE.
QUESTIONS, DISCUSSION?
DR. KEITEL?
>> YES.
I'D LIKE TO THANK ALL OF THE
SPEAKERS FOR THEIR INFORMATIVE,
DISAPPOINTING AND PROVOCATIVE
RESULTS THAT THEY DESCRIBED.
I JUST HAVE TWO SMALL QUESTIONS.
THE FIRST IS FOR DR. SHEEDY AS
RELATES TO THE NUMBER OF ADULTS
THATSHEEDY,
ABOUT THE NUMBER OF ADULTS THAT
SEEK CARE, DO YOU HAVE MORE
INFORMATION YARD TO HOW MANY OF
THOSE VISITS ARE FOR A CUTE
CARE?
I KNOW IT'S A MISSED OPPORTUNITY
AS OPPOSED TO A ROUTINE, ROUTINE
VISIT FOR THEM?
>> I DON'T THINK THAT WE DO.
NOT SEEING KATE, WHO IS MORE
FAMILY.
NO, WE DON'T.
>> AND THE SECOND IS FOR DR.
WILLIAMS.
I UNDERSTAND THERE HAS BEEN SOME
INVESTIGATION OF THE ACCURACY OF
RECALL FOR I AM NATION FOR
PNEUMOCOCCAL, HOW ACCURATE IS A
RECALL FOR ADULTS, IN MY
EXPERIENCE IT'S ON SHAKY GROUND.
>> THERE'S A STUDY THAT JIM
SINGLETON IS WORKING ON IN OUR
GROUP THAT COULD PROVIDE A BIT
MORE INFORMATION ABOUT VACCINES
OTHER THAN INFLUENZA AND
PNEUMOCOCCAL, I'M NOT AWARE OF
THE RESULTS OF THE STUDY.
>> THANK YOU, VERY MUCH, IT WAS
INCREDIBLY USEFUL.
I HAVE SA SERIES OF QUESTIONS, I
WILL PUT THEM OUT THERE AND
PEOPLE CAN ANSWER AS
APPROPRIATE.
THE FIRST IS DO WE HAVE ANY IDEA
FROM HE
STUDIES, WHAT THE AVERAGE COST
IS TO A PHYSICIAN TO HAVE STOCK,
ENOUGH PHARMACEUTICAL PRODUCT TO
BE ABLE TO MANAGE THE CURRENT
PRACTICE.
IN OTHER WORDS, ARE YOU LAYING
OUT $100,000 A YEAR, $75,000 A
YEAR.
DO WE KNOW THAT?
THAT IS NUMBER ONE.
AND NUMBER TWO, IS IT WORTH
THINKING ABOUT A SURVEY, A NEW
SURVEY GETTING PHYSICIANS TO
RESPOND TO A QUESTION ABOUT
WHETHER THE -- THEY UNDERSTAND
THE NEW ACA PROVISION AND
WHETHER IT WOULD CHANGE ANY OF
THE DECISIONS ABOUT WHETHER TO
STOCK AND SHEVLE, GIVEN THE FACT
THAT THERE'S A COVERAGE WITH
FIRST DOLLAR PAYMENT.
AND NUMBER THREE, HAVE YOU
ANY -- HAVE ANY OF YOU THOUGHT
ABOUT GOING INTO THE FIELD TO
SURVEY PARTICULARLY PRACTICES
PRIMARY CARE PRACTICES AND
MEDICALLY UNDER SERVED
COMMUNITIES.
I'M CONCERNED APPROXIMATE OFFICE
SPACE PRACTICES AND WOULD LIKE
TO KNOW WHAT THE ISSUES ARE FOR
MEDICALLY UNDER SERVED COMMUNITY
PRACTICES BECAUSE ACTUALLY, I
WAS QUITE INTEREST ED SOME OF
YOUR DATA SHOW, NOT AS BIG
DISPARITY AS I MAY HAVE THOUGHT
FOR AFRICAN AMERICAN AND LATINO
PATIENTS.
I THINK THE HEALTH CARE
PROVIDERS ARE IMPORTANT THERE.
AND FINALLY WHETHER YOU HAVE ANY
SPECIFIC SURVEY INFORMATION
ABOUT HOW HEALTH INFORMATION
TECHNOLOGY IS CHANGING THE WAY
PHYSICIANS THINK ABOUT THEIR
PRACTICE.
>> I'M GOING TRY AND TACKLE AS
MANY OF THOSE AS I CAN.
ONE OF THE QUESTIONS WAS ABOUT
STOCKING VACCINES AND THE COST.
I SEE SHE WANTS.
--
NO.
OKAY.
MICRO PHONE.
I WAS JUST GETTING A CUE TO MAKE
A COMMENT.
I'M SORRY.
I DON'T HAVE INFORMATION ON
THAT.
AND WE CAN TAKE A LOOK AND SEE
WHAT DATA IS THERE.
I THINK TOM McGUIRE MAY HAVE
ONE, IT'S WORTH KNOWING.
>> THE OTHER QUESTION IS DOING A
SURVEY.
DOING A SURVEY ABOUT PHYSICIANS
UNDERSTANDING OF THE PROVISIONS
OF THE AFFORDABLE KAY ACT, IT'S
A GREAT IDEA AND WE HAVE OTHER
OPPORTUNITIES IN THE FUTURE TO
DO SURVEYS OF PRIMARY CARE
PHYSICIANS AND THIS IS A TOPIC
ALSO THAT HAS COME UP IN
DISCUSSIONS WITH THE SUMMET
ABOUT HOW TO EDUCATE PROVIDERS
ABOUT ONE OF THE BARRIERS WITH
ONE PROVISION OF THE AFFORDABLE
CARE ACT MIGHT BE THE KENNER
ABOUT THE IN-NETWORK PROVIDERS.
AND AGAIN, WITH ADULTS SEEING SO
MANY DIFFERENT PROVIDERS AND NOT
NECESSARILY GOING BACK TO THE
PRIMARY CARE PROVIDER AND
PRIMARY CARE PROVIDERS NOT
STOCKING ALL VACCINES WHEN THEY
TRY TO GET IT FROM THE
PHARMACISTS IT CAN BE A
DIFFICULTY FINANCIALLY, MORE
OUT-OF-POCKET COSTS.
AND WE HAVE HEARD THAT
REPEATEDLY.
AND A QUESTION ABOUT GOING AND
LOOKING AT UNDER SERVED AREAS,
AS PART OF THE ADULT INTERAGENCY
WORKING GROUP, HERSA IS AN
ACTIVE PARTICIPANT ANDER THEY
ARE, WOULDING AT WAYS TO DO THAT
AND WE HAVE AMY GROOM HERE FROM
INDIAN HEALTH SERVICE AND THE
SUCCESS THEY HAVE HAD USING
STANDING ORDERS AND TRACKING
ADULT I AM NATIONS IS A TESTMENT
TO WHAT CAN BE DONE WITH
RESOURCES AND EFFORT AND
CHAMPIONS THAT REALLY WORK ON
ADULT ISSUES.
AND THEN YOUR FINAL QUESTIONS
WAS ABOUT ELECTRONIC HEALTH
RECORDS AND THE MEANINGFUL USE
ISSUES AND HOW IT IMPACTS ADULT
I AM NATIONS, AND AS PART OF THE
ADUED
SUMMET.
WE ARE TRYING TO MAKE SURE WE
HAVE VACCINES AS A PART OF THAT
SYSTEM.
I'M REA SURED THAT WE ARE, BUT
IT'S SOMETHING THAT WE WILL
CONTINUE TO WORK WITH THEM ON
>> OKAY, DR. SAWYER.
>> I HAVE TWO QUESTIONS, BOTH
RELATE TO I AM NATION SERVICE
SYST
-- RELATE TO IMMUNIZATION
SERVICE.
WHAT INFORMATION DO WE HAVE
ABOUT THE ADULT DATA, SOME STATE
SYSTEMS HAVE ONLY STARTED.
SOME PERHAPS DO NOT HAVE ADULT.
AND OF THOSE STATES THAT HAVE
DATA RECORDS, WHAT ARE THE
STATISTICS ABOUT THE
COMPLETENESS OF THAT
INFORMATION.
FOR THE SUR RAY, ARE YOU ABLE TO
STRATIFY BY STATE COMPARED TO
THE PERCENT OF THE ADULT
POPULATION IN THE REGISTERTIES.
AND FURTHER STRATIFIED WITH
INTERFACES BETWEEN THE HEALTH
RECORD AND THE IIS?
>> REGARDING IISSs, 49 OF 50
STATES HAVE THEM AND AS OF
INFORMATION FROM A COUPLE OF
YEARS AGO, 82% HAVE THE ABILITY
TO ENTER INFORMATION OF PEOPLE
OF ALL AGES.
SO INCLUDING ADULTS.
I'M NOT SURE HOW MUCH OF THAT
INFORMATION IS ACTUALLY ENTERED
AS A RESULT OF A ADULT VAC
NATION OR -- VACCINATION OR
CHILDHOOD VACCINATION.
I DON'T KNOW HOW MUCH
INFORMATION IS AVAILABLE FOR US
TO USE, TO STRATIFY OUR RESULTS
BY THE CAPABILITIES OF EACH
STATE.
IIS, BUT I THINK IT'S A GREAT
QUESTION AND WE WILL LOOK INTO
IT AND I -- SHANNON?
>> YEAH, I THINK WE ARE UP TO 47
TATES THAT HAVE THE ABILITY TO
ACCEPT ADULT VACCINATION
INFORMATION INTO THE IIS, I
DON'T KNOW THE PROPORTION, THEY
ARE OPT VERSUS OPT OUT, THAT IS
REQUIRING SOME SORT OF CONSENT
TO ADD THEIR INFORMATION THAT
CAN CERTAINLY BE A POTENTIAL
BARRIER, YOU SAW THE PROPORTION
OF INTERNISTS THAT ARE FAMILIAR
WITH IT, IT'S LOW ON.
SO WE HAVE ROOM FOR IMPROVEMENT
THERE.
ONE OF THE THINGS THAT WILL HELP
WITH INPUTTING DATA IN THE
REGISTRY IS THAT THERE ARE A
NUMBER OF STATES THAT REQUIRE
THAT PHARMACISTS WHO VACCINATE
ENTER DATA INTO REGISTRY.
THAT IS HELPING IN A NUMBER OF
TATES WHERE THE PHARMACISTS ARE
REQUIRED TO DO THAT.
AND AMY, DID YOU HAVE OTHER
COMMENTS ABOUT THE REGISTRY FROM
YOUR PERSPECTIVE?
>> THANKS I THINK IN THE INDIAN
HEALTH SERVICE WE HAVE BEEN
DOING CHANGES WITH A NUMBER OF
REGISTRIES.
OUR CHALLENGE AND THAT THEY ARE
NOT ABLE TO ACCEPT THE VOLUME OF
DATA.
WE ARE TRYING TO GET THAT TAKEN
CARE OF AND WORK OUT THE
TECHNICAL ISSUES ON THE STATE
SIDE.
THERE'S THE ISSUE OF OPT IN
VERSUS OPT OUT, THAT IS A
CHALLENGE.
IT DIFFERS FROM CHILDREN TO
ADULT.
SO FOR THE PROVIDER THAT WANTS
TO SEND THE DATA, MAKES IT
DIFFICULT FOR THEM TO
EFFECTIVELY INTERFACE WITH THE
REGISTRY.
>> IF I IS CAN MAKE A QUICK
COMMENT.
I HAVE A FAIRLY MATURE STATE
BASED REGISTRY THAT IS
INTEGRATED WITH MY EHR WHICH I
USE ON NEARLY DAILY BASIS AND
FOR ALL MY ADULT PATIENTS I
ROUTINELY REVIEW THAT COMPONENT
BECAUSE I CAN GET TO THAT
EASILY.
I'M UP TO 85% SATURATION OF ALL
MY ADULTS GIVING ALL THE
APPROPRIATE VACCINES BECAUSE
IT'S EASY TO DO.
WE HAVE A NUMBER OF PEOPLE LINED
UP SO, I'M KEEPING TRACK OF WHO
IS RAISING HANDS AND WE WILL TRY
TO GET TO EVERYONE.
>> GREG POLAND AMERICAN COLLEGE
OF PHYSICIANS.
A QUESTION, A COMMENT AND A
PLEA.
FIRST THE QUESTION, WALT FOR
YOU, AN INFORMATIONAL ONE.
ON YOUR SLIDES WITH IT WILL SAY
TE
TETANUS VACCINATION, AND YOU
HAVE DATA 2010/2011.
DOES THAT MEAN IT'S BACK TEN
YEARS AND THE DELTA PFS BETWEEN
2010 AND 2011?
>>.
>> EACH ESTIMATE WAS BASED ON
DATA FOR THE PAST TEN YEARS.
SO 2010, IT WAS TEN YEARS
LEADING UP TO 2010 INCLUDING
THAT YEAR.
THE SAME FOR 2011, WE COMPARED
THE POINT ESTIMATES FOR THE
TWO -- THANK YOU, I JUST NEEDED
THAT CLARIFICATION.
COMMENT.
IS -- TO CONGRATULATE CDC FOR
TAKING A NEW WAY FORWARD.
I'M DELIGHTED TO HEAR THAT A
COMMUNICATION SPECIALIST HAS
BEEN INCLUDED IN THIS.
SO, I THINK THAT IS REALLY
EXCELLENT, BECAUSE ONE OF THE
THINGS THOO THE DATA POINTS OUT,
I THINK IS THAT WE SHOULD
IMMEDIATELY STOP DOING WHAT WE
HAVE BEEN DOING.
OTHERWISE, OTHERWISE, KEN AND I
WERE JUST TALKING, IT'S ROUGHLY
20 TO 80 YEARS BEFORE WE REACH
THE 2020 GOAL FOR ADULTS.
AND THAT LEADS TO KIND OF A
PLEA.
THAT IS, IF WHAT WE HAD HEARD
THIS MORNING WAS AND LET'S TAKE
OUT INFLUENZA, THAT 10,000 TO
15,000 CHILDREN WERE DIED AND UP
TO MAYBE 60% THAT WE WERE
WOEFULLY SHORT OF OUR PUBLIC
HEALTH GOALS.
I THINK WE WOULD BE TALKING
ABOUT FUNDAMENTAL TRUCK WHICH
YOU AREAL CHANGES.
AND I THINK, IT'S SOMETHING THAT
I HOPE THIS COMMITTEE AND OTHERS
WILL INCREASINGLY FOCUS ON
BECAUSE LIKE IT OR NOT, THE
DEMOGRAPHICS ARE GOING TO FORCE
US TO DO SO.
THIS SHOULD BE ON OUR AGENDA
EVERY MEETING.
THERE SHOULD BE 20 OR 30 FTEs AT
CDC DEVOTED TO THIS.
MEDICAL EDUCATION FOR INTERNISTS
IS WOEFULLY INADEQUATE ON THIS.
THE MEDICAL IS SUB SPECIALTITIES
ARE INADEQUATELY INVOLVED AND OF
COURSE, THERE'S PAYER ISSUES.
MAYBE WE NEED TO BE STARTING TO
TALK ABOUT NOT JUST A CDC, A VFA
GIVEN THE DATA THAT WAS POINTED
OUT.
I DID WANT TO POINT OUT TWO
THINGS IN REGARD TO AMERICAN
COLLEGE OF PHYSICIANS.
ALMOST 3 YEARS AGO, THE AMERICAN
COLLEGE OF PHYSICIANS AND ITS
COUNCIL OF MEDICAL SUB
SPECIALTIES ENDORSED A CLINICAL
PRACTICE STANDARD THAT CALLS FOR
ALL PHYSICIANS CARING FOR ADULT
PATIENTS TO INQUIRE ABOUT I AM
NATI
-- ABOUT IMMUNIZATION
STANDARDS.
AND FOR THOSE WHO HAVE ACT HE
SES TO THE INFORMATION.
THEY HAVE AN ADVISER APP, IT'S
FREE AND EASY TO USE.
I USED IT ALL THE TIME IN MY
CLINICAL PRACTICE.
I CANNOT REMEMBER ALL THE FO
FOOTNOTES AND IT'S VERY
ACCESSIBILITY AND USER FRIENDLY.
>> I THINK YOU WOULD BE PLEASED
WITH THE MULTI-DISCIPLINE TEAM
THAT WE HAVE WORKING ON THIS.
WE HAVE GROUPS THAT BRING A
TREMENDOUS AMOUNT TO THE TABLE.
THERE'S GREAT POWER IN NUMBERS.
TO BE ABLE TO DO THIS AT THIS
TIME WAS A WONDERFUL, YOU KNOW,
MECHANISM OR COLLABORATIVE IN
PLACE.
>> STILL, BRAVO TO CDC FOR DOING
THAT.
>> MANY OF US HAVE BEEN WATCHING
ADULT IMMUNIZATION FOR MANY,
MANY YEARS, THIS PRESENTATION
WAS SORT OF THE SAME TAKE HOME
MESSAGE.
IT WAS NOT ONLY DISAPPOINTING
BUT IT WAS REALLY, REALLY
DEPRESSING.
I THINK, I THINK WHEN I AGREE
WITH GREG THAT WHEN YOU REFLECT
ON ADULT IMMUNIZATION VERSUS
CHILDHOOD, THEY ARE WORDS APART.
THERE'S THREE CRITICAL AREAS
THAT WE COULD SHORE UP AND THAT
WOULD STRENGTHEN OUR ADULT
PROGRAM.
THE FIRST IS MEASUREMENT.
I CAN'T BELIEVE THAT WE STILL
DON'T MEASURE REAL DATA A
FORADULT IMMUNIZATION, WE
MEASURE SELF-REPORT THAT IS
INACCURATE AND THE
RECOMMENDATION HAS BEEN MADE FOR
YEAR THAT THERE'S VALIDATION OF
THE NIS, THE OLD SAYING, WHAT
GETS MEASURED GETS DONE.
I THINK THAT APPLIES TO ADULT
IMMUNIZATION, THE NEXT TWO AREAS
THAT NEED TO BE STREN THETH GTH
THE -- UNTIL WE REALLY ADDRESS
THE SYSTEM ISES THAT EXIST, WE
ARE NOT GOING TO MAKE ANY REAL
INROADS AND THE SYSTEMS INCLUDE
THINGS LIKE THE INFORMATION
SYSTEM, BUT THEY INCLUDE THINGS
LIKE WHAT IS GOING ON IN THE
PRACTICES AND I JUST WANTED TO
ASK IF ANYONE AT THE CDC IS
WORKING WITH THE PATIENT CENTER
MEDICAL HOME AS AN APPROACH TO
INCREASING ADULT IMMUNIZA TMPTI
THAT IS A SYSTEM THAT IS
OCCURRING RIGHT NOW, IT'S GOING
TO HAVE HUGE IMPLICATIONS AND IT
ACTUALLY MEANS THERE ARE GOING
TO BE PEOPLE IN THE OFFICES WHO
ARE RESPONSIBLE FOR THINGS LIKE
ADULT IMMUNIZATION, SO WE SHOULD
BE IN THE FOREFRONT OF WORKING
WITH THOSE PEOPLE TO MAKE SURE
IT HAPPENS.
AND THE OTHER AREA IS FINANCE.
AS WAS MENTIONED VACCINE IANS
FOR ED
-- VACCINES HAVE BEEN TALKED
ABOUT FOR TEN OR 15 YEARS AND
NOTHING HAS HAPPENED, INSTEAD,
WE HAVE A COMPLEX MEDICARE
SYSTEM THAT DOES NOT ASSURE
COVERAGE FOR VACCINATION.
WE CANNOT KEEP HITTING OUR HEAD
AGAINST THE WALL UNTIL WE
ADDRESS THE TWO ISSUES.
>> IN TERMS OF THE PATIENT
CENTER MEDICAL HOME, THAT IS
SOMETHING THAT YOU KNOW IS DONE
AS YOU SAY IN PRACTICES AND YOU
KNOW, PART OF OUR IDEA BEHIND
HAVING THE ADULT IMMUNIZATION
SUMMET IS THAT WE WORK CLOSELY
WITH THE PROFESSIONAL MEDICAL
ORGANIZATIONS WHO ARE WORKING
WITH THEIR MEMBERSHIP ON PATIENT
CENTER MEDICAL HOME, I DON'T
KNOW IF ANYONE WANTS TO TALK
ABOUT SOME OF THE THINGS THAT
ACP HAS BEEN DOING TO TRY TO
EDUCATE THE MEMBERSHIP, BUT ONE
TO HIGHLIGHT I THINK IS, ONE OF
THE MODULES THAT THEY HAVE AND
OTHERS MAY HAVE AS WELL FOR THE
MAINTENANCE, AND TRAINING
OPPORTUNITIES TO TRY TO HELP
PROVIDERS TO HELP GAIN FEEDBACK.
SANDY OR GREG, YOU WANT TO PAUK
ABOUT THAT?
>>?
>> I HAVE A COUPLE OF THINGS.
FIRST I WANTED TO BEGIN WITH A
PUBLIC THANK YOU TO CAROLYN AND
WAULTER FOR ALL YOU DID IN
COORDINATING THE EFFORT TO MAKE
SURE NOBODY JUMPED THE GUN.
AND SENDING DRAFTS BACK AND
FORTH TO MAKE SURE THAT WHEN IT
WAS RELEASED THERE WAS A SPLASH.
IT WAS SO HELPFUL TO HAVE THE
NEW SCHEDULE AVAILABLE AT THE
SAME TIME WALTER PUT FORWARD THE
REPORT CARD, THE THINGS THAT
WERE AND WERE NOT SUCCESSFUL, IT
SHOWS WHAT WE NEED TO DO AND I
THINK ADDED TO THE MEDIA
ACCEPTANCE OF THIS.
GREG HAD MENTIONED THAT
IMMUNIZATION APP.
AND AS OF MONDAY, WE GOT THE
WORD THAT APPLE ACCEPTED ALL OF
THE UPDATES.
SO IF YOU HAVE THE OLD ONE, THE
PSA VIDEO IS AVAILABLE FOR
RELEASE, IF YOU ARE INTERESTED
IN GETTING THAT.
THAT THAT WAS A THING I PUT
TOGETHER LAST TIME.
WE HAVE THAT, THAT YOU CAN SEND
OUT OR TO GET THE WORD OUT ABOUT
THE APP, LET JEAN KNOW AND WE
CAN FORWARD THE LINK TO ANYONE
WHO IS INTERESTED.
OUR ACP STAFF WOULD BE HAPPY TO
DO THAT.
BUT WE ARE REAL EXCITED ABOUT
NEW ACP INITIATIVES OVER THE
NEXT YEAR TO TRY TO LINK THE
CERTIFICATATION REQUIREMENTS.
THANK YOU FOR ALL THAT THE CDC
IS DOING AND THE HELPING THE
AMERICAN COLLEGE OF PHYSICIANS,
WHICH IS PART OF THE FEDERATION
OF MEDICINE.
AND NOW AS AN AMA REP, I'M PROUD
TO TALK ABOUT OUR FEDERATION OF
MEDICINE.
>> THANK YOU.
THIS IS A QUESTION FOR DR.
HURLEY, I APPRECIATE YOUR TALK
VERY MUCH.
IF YOU HAVE A PROVIDER AND YOU
HAVE TO REFER A PATIENT
SOMEPLACE, IN SOME NEIGHBORHOODS
THE PHARMACY IS A GOOD PLACE TO
REFER.
ARE YOU SHOWING PLACES WHERE
PHYSICIANS FEEL THEY DO NOT HAVE
PLACES TO REFER THE PATIENTS TO.
ONE OF THE THINGS THAT
FACILITIES GO AWAY FROM IS
PROVIDING DIRECT PATIENT CARE.
IS THERE A HOLE THERE?
SAYING I DO NOT GIVE THAT
VACCINE, AND I DON'T KNOW THAT I
CAN SEND THIS PERSON TO A PLACE
IN THE COMMUNITY?
>> OUR DATA WOULD NOT ADDRESS
THAT QUESTION.
BUT IT'S A GOOD QUESTION.
I MEAN, I WORK IN A CLINIC WHERE
I HAVE A PUBLIC HEALTH
DEPARTMENT AROUND THE CORNER
FROM WHERE I WORK, I CAN REFER
PATIENTS THERE.
ACROSS THE STATE OF COLORADO,
THERE'S NOT NECESSARILY A HEALTH
DEPARTMENT READILY AVAILABLE TO
REFER TO. THINK IN THAT PARTICU,
IN SMALLER COMMUNITIES THE
BIGGER CHANGE TENDS TO BE
INVOLVED.
IN CITIES AND LARGE AREAS, BUT
IN A SMALLER COMMUNITY WITH THE
LOCAL PHARMACY, THEY DECIDE,
NORKS IT'S NOT SOMETHING THAT I
WANT TO DO.
I THINK IT'S A QUESTION.
>> OKAY.
>> CAN I JUST ADD TO THAT, D
DOCTOR QUICKLY, AT THE SAME TIME
THEY WERE RELEASED THE FOLKS AT
HARVARD WHO RAN THE HEALTH MAP
SIGHT OPENED UP THE ADULT
VACCINE FINDER SITE.
I GUESS I WOULD ENCOURAGE STATE
AND LOCAL HEALTH DEPARTMENTS TO
REACH OUT TO THEIR VACCINES AND
THEIR INFORMATION TO HELP PEOPLE
FIND VACCINES.
IT'S ONE POTENTIAL RESOURCE, BUT
IT DOES NOT ANSWER THE QUESTIONS
FOR RURAL COMMUNITIES.
>> THANK YOU.
GREAT PRESENTATION.
THEY RAISED A WHOLE LOT OF
QUESTIONS.
I WILL ASK A QUICK ONE AND BE
MINDFUL OF THE TIME.
I FIND IN THE IMMUNIZATION
PRACTICE, SOMETIMES THE QUALITY
OF PRACTICE CORRELATES WITH THE
SIZE OF THE GROUP.
SOME OF THE LARGER
MULTI-SPECIALTY -- MULTI-CLINIC
SITES HAVE BETTER SYSTEMS IN
PLACE TO ASSESS AND ASSURE
COVERAGE.
YOU FOUND THAT SMALLER PRACTICES
CORRELATED WITH SOME OF THE LESS
DESIRABLE OUTCOMES.
MY QUESTION IS ACROSS THE U.S.,
WHAT PROPORTION OF ADULTS GET
CARE FROM THE SMALLER PRACTICES.
HOWEVER YOU WANT TO DEE FINE.
THAT LESS THAN FIVE PROVIDERS.
WE NEED TO FIGURE THIS OUT TO
FOCUS THE APPROPRIATE REMEDIES.
DEPENDING ON WHAT TAPE OF
PRACTICE YOU HAVE, DIFFERENT
SOLUTIONS WILL BE NEEDED.
>> I HAVE LOOKED FOR THAT
RESOURCE, JUST SORT OF DEE
SCRIPTIVE DATA, WHO IS SEEN BY
SMALLER, LARNLER, PRIMARY CARE
PHYSICIANS.
IT WOULD ADD TO A MANU SCRIPT.
I HAVE NOT SEEN.
THAT BUT IF THERE'S SOMEBODY IN
THE ROOM WHO HAS A RESOURCE.
OH, THERE YOU GO.
BUT YOU ARE INSURANCE, RIGHT?
GO AHEAD.
>> DOCTOR, DO YOU HAVE AN ANSWER
FOR THAT?
>> I DON'T, I HAVE ANOTHER
COMMENT.
SORRY.
WE WILL TAKE A COUPLE MORE, I
HAVE PEOPLE IN THE QUEUE AND I
AM MINDFUL OF THE TIME AS WELL.
DR. JENKINS.
>> I THANK YOU AND IT WAS
SOBERING.
AND DR. WILLIAMS, I WANTED TO
ASK YOU, IT WAS HELPFUL TO LOOK
AT THE RACIAL AND ETHNIC
DIFFERERENCES, THEY ARE VERY
DIFFERENT FOR CERTAIN VACCINES
WHICH IS INTERESTING.
BUT I WAS NOT SURE WHETHER IT
WAS -- YOU ARE AVAILABLE TO LOOK
AT THE IMPACT OF INSURANCE
VERSUS NOT BEING INSURED OR
HAVING A PRIMARY CARE PERSON OR,
IS -- ARE YOU ABLE TO GET THAT
LEVEL OF DATA FROM THE SURVEY
AND HAVE YOU ALREADY DONE IT?
>> YES, THE NATIONAL HEADLIGHT
INTERVIEW SURVEY DOES HAVE AREAS
RELATED TO PHYSICIANS, VISITS,
OF VISITS DURING THE PREVIOUS
YEAR.
WHETHER OR NOT THE RESPONDENT
HAS INSURANCE.
WE DID NOT DO DETAILED ANALYSIS
FOR THIS REPORT, JUST TO KEEP IT
SIMPLE AND MAKE IT A REPORT
CARD.
WE DO ROUTINELY DO THOSE
ANALYSIS.
WHEN WE LOOK AT WHETHER OR NOT A
RESPONDENT HAS A MEDICAL HOME,
HAS INSURANCE, NOT INSURANCE,
CONSISTENTLY THE VACCINES ARE
HIGHER AMONG THOSE THOO HAVE A
MEDICAL HOME AND INSURANCE.
>> THAT IS CONSISTENT WITH THE
INFORMATION THAT WE HAVE
KENNERING THE AFFORDABLE CARE
ACT.
>> HAVE YOU ALREADY?
OKAY.
SO, DR. SHAFTNER.
>> THANKS, JOHN, NATIONAL
FOUNDATION FOR INFECTIOUS
DISEASES.
I HAVE A QUESTION FOR DR.
HURLEY, ONE OF HER RESULTS HAD
ME SCRATCHING MY HEAD.
IF I UNDERSTAND CORRECTLY, I
THINK THE SURVEY IS VERY WELL
DONE IT INDICATED THAT 78% OF
RESPONDING PHYSICIANS AGREED
THAT THE ADULT I ADULT
IMMUNIZATION SCHEDULE, THAT THEY
WERE COMFORTABLE WITH IT.
MY SURVEY, WHEN I GIVE
CONTINUING EDUCATION PROGRAMS TO
PHYSICIANS, PHYSICIANS WHO ARE
INTERESTED ENOUGH TO COME TO
CONTINUING EDUCATION PROGRAMS, I
ALWAYS BEGIN BY ASKING FOR A
SHOW OF HANDS OF INDIVIDUALS IN
THE AUDIENCE WHO ARE FAMILIAR
WITH THE SCHEDULE AND MY RESULTS
ARE EXACTLY THE REVERSE OF
YOURS.
IN FACT, THE PROPORTION OF
PHYSICIANS IN THE AUDIENCES THAT
I ADDRESSED THAT ARE FAMILIAR
WITH THE ADULT IMMUNIZATION
SCHEDULE IS LESS THAN 10%.
I KNOW MINE IS ANECDOTAL.
COULD YOU COMMENT?
>> I DON'T KNOW THAT I'M GOING
TO COMPLETELY RECONCILE THAT.
I THINK THERE'S AN ELEMENT OF
SOCIAL BIAS.
THESE PHYSICIANS KNEW THEY WERE
BEING SURVEYED VACCINES.
THEY MAY HAVE BEEN MORE
KNOWLEDGEABLE ABOUT THE
SCHEDULE.
WHILE IT'S NOT COMFORTING TO
KNOW THAT, I THINK THAT MIGHT BE
THE EXPLANATION.
I TOO SHOW I DO RESIDENT
EDUCATION AT MY INSTITUTION ON
VACCINES.
I SHOW THE IMMUNIZATION
SCHEDULE, IT'S MORE LIKE THE
PERCENTAGES THAT I SHOWED IN THE
SLIDE.
I AGREE THAT THERE'S VARIABLITY
NATIONAL.
>> THANK YOU.
>> IT'S MY INTENTION TO BRING US
BACK HERE AT 10:45 REGARDLESS OF
THE BREAK.
I KNOW THAT WE HAVE MORE DOCTORS
THAT INDICATE THAT THEY HAVE
QUESTIONS, AND I AM WILLING TO
KEEP THINGS GOING, WE HAVE A
MARATHON SESSION ON INLUENZA
THAT WILL BE 2-1/2 HOURS.
IF YOU HAVE BRIEF QUESTIONS, I
THINK WE CAN DO THAT.
>> JUST A QUICK COMMENT.
ONE INCENTIVE, I HATE TO BRING
IT UP BUT MONEY TALKS.
ONE INCENTIVE FOR PROVIDERS THAT
DO NOT HAVE VACCINES STOCKED IN
THE OFFICE WOULD BE FOR SOME
TYPE OF FINANCIAL INCENTIVE FOR
THEM TO REFER TO AGENCY OR A
PLACE THAT THE VACCINES COULD BE
GIVEN.
>> DOCTOR, JUST TO BUILD ON THE
COMMENT.
I HAVE A FEELING THAT THERE'S A
LOT VARIATION IN PHYSICIAN
ACQUISITION STORAGE.
HOW THEY MANAGE THE VACCINES AND
I THINK THEY COULD EDUCATE
PHYSICIANS ON HOW TO DEAL WITH
IT MORE EFFECTIVELY AND THAT
WOULD ADDRESS THE COST.
>> FINAL COMMENT.
REGARD REGARD THE IMMUNIZATION
PROGRAM, A BARRIER TO LOCAL
HEALTH DEPARTMENTS FILLING THE
GAP IS THAT WE ARE NOT
CONSIDERED IN NETWORK PROVIDERS.
WE ARE WORKING WITH BILLABLES
PROJECT TO IMPROVE OUR ABILITY
TO BILL PRIVATE INSURANCE, UNTIL
WE CAN ADDRESS THE ISSUE OF
HEALTH DEPARTMENTS BEING IN
NETWORK PROVIDERS TO GIVE THE
IMMUNIZATIONS, WE CANNOT FILL IN
THE GAPS FOR THE PATIENTS AND WE
STAND READY AND WILLING TO DO
SO, BUT WE NEED HELP.
>> AND THE ETA COVERAGE IS NOT
GOING TO HELP YOU GUYS IF YOU
ARE NOT IN NETWORK.
>> WELL, I THINK THANK FOR A
FUTFUL DISCUSSION HERE, THIS WAS
WONDERFUL.
>> WHY DON'T WE GET STARTED.
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