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ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
The Ups and Downs of Immunization
J. Gary Wheeler, MD
October 6, 2015
ARKANSAS DEPARTMENT OF HEALTH
Conflict of interest
• Multiple individual stocks of pharmaceutical companies that produce vaccines
• All managed by financial advisor
• Less than 1% of portfolio
ARKANSAS DEPARTMENT OF HEALTH
Objectives
• Current state of immunization in Arkansas (pertussis, HPV)
• History of immunization/allopathic medicine
• Messaging to promote immunization in 2015
ARKANSAS DEPARTMENT OF HEALTH
Estimated Vaccination Coverage Among
Children Aged 19-35 Months, and AR
rank, NIS 2014
4 DTap
3 Polio
1 MMR
FS HIB
3 Hep B
1 Var
4 PCV
2 Hep A
7 vaccine series
US 84 93 92 82 92 91 83 58 72
AR 2013 74 89 88 70 87 87 70 36 57
AR 2014 80 92 89 78 91 91 79 43 66
AR rank 43 34 42 43 35 30 45 47 44
ARKANSAS DEPARTMENT OF HEALTH
Estimated Vaccination Coverage With Selected
Vaccines Among Adolescents Aged 13-17
Years, NIS, 2014
ARKANSAS DEPARTMENT OF HEALTH
State-level Cumulative Influenza
Vaccination Coverage Estimates for
the 2012-13
States Coverage Ranking, Arkansas is number (23)
ARKANSAS DEPARTMENT OF HEALTH
Barriers to Immunization Success
• Implementation and interoperability of new EHRs and the IIS
• Lack of vaccination reporting by providers
• Quality of immunization information reported
• Inconsistent application of ACIP recommendations
• Increasing cost of vaccine –poor reimbursement
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ARKANSAS DEPARTMENT OF HEALTH
Barriers to Immunization Success
• Increasing costs to administer –poor reimbursement
• Fragmented funding systems
• Access (vaccine, location, and appointment availability)
• Exemptions
• Family Educational Rights and Privacy Act (FERPA)
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ARKANSAS DEPARTMENT OF HEALTH
One Doctor’s Story
• I was just informed by my office lady that I will have to purchase a $3000 emulation software to sync the vaccine data bank with my computer system . If that is a mandatory thing to do shots, then I will send all my kids to the HD for vaccines and stop the VFC program at my office . The system is failing the public miserably. We are getting reimbursed less, I had to by a new refrigerator for all the vaccines for VFC this year. In order to do vaccines, I had to hire a new nurse. Otherwise my office could not function and I could not be an opportunity to vaccinate.
– Perry Wilbur, MD Mountain Home
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ARKANSAS DEPARTMENT OF HEALTH
Reimbursement for
Immunizations
• Vaccine Administration:
– Arkansas Medicaid pays providers $9.56 per shot
(Arkansas Medicaid regional cap is $19.54)
– Private insurance companies have various
reimbursement rate for providers
• Vaccine:
– VFC: No charge to providers; no reimbursement
– Non-VFC: flexible pricing; reimbursement is often
average wholesale pricing
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ARKANSAS DEPARTMENT OF HEALTH
2014 Childhood Vaccine Financing Map and NIS 19-35 month Rank
Rhode Island 1
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ARKANSAS DEPARTMENT OF HEALTH
http://aattp.org/wp-content/uploads/2014/06/288464d1310524424-some-doctors-saying-vaccinate-your-child-go-elsewhere-treatment-n-whooping-cough-tubes-300x225.jpg
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ARKANSAS DEPARTMENT OF HEALTH
Recent US Outbreaks
• California, 2010: 9143 cases including 10 infant deaths
• Michigan, 2009-10: 902 and 1564 cases, respectively
• Ohio, 2010: 964 cases in just two counties, and this outbreak continued
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ARKANSAS DEPARTMENT OF HEALTH
Washington 2012
• During January 1–June
16, 2012, a total of 2,520
pertussis cases were
reported in Washington, of
which 2,069 were
confirmed (83.4%
laboratory-confirmed and
16.6% epidemiologically
linked) and 451 were
probable
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MMWR July 20, 2012 / 61(28);517-522
ARKANSAS DEPARTMENT OF HEALTH
Washington 2012
• DTaP coverage among children aged 19–35 mths 81.9% for ≥4 doses in 2010
• 43.1% of patients aged 11–12 years and 77.2% of patients aged 13–19 years
• Exemption rate was 4.5% in 2011-12
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ARKANSAS DEPARTMENT OF HEALTH
Outbreak in Arkansas 2012
• Increased reports of pertussis
• Most occurred in children in 4th and 5th grade
• 29 students and 19 other community confirmed cases of pertussis Many more probable/suspect cases were involved
• Combination of immunization, school exclusion, contact treatment utilized\
• High costs to families, schools and health dept.
•
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ARKANSAS DEPARTMENT OF HEALTH
Vaccine quality?
• Some of the resurgence of pertussis is likely related to differences between DTwP vs DTaP.
• Estimates of only 3-4 years protection from DTaP
• Some long term booster effect if primary vaccine was DTwP
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ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
• Quadrivalent first licensed in 3/2007 for girls 11-12 yo for cancer prevention
• In 2008, the target audience was expanded to include American Indian/Alaska Native, Korean American and Vietnamese American audiences based on their increased risk for cervical cancer
• 2009 a bivalent HPV vaccine was approved by the FDA and the quadrivalent vaccine was approved for “permissive” use in males
• Digital media campaign in 2010
• 2013 recommendations for males
• Updated professional campaign 2014
HPV Vaccine
ARKANSAS DEPARTMENT OF HEALTH
• 100% of sexually active men and women acquire genital HPV at some point in their lives.
– An estimated 79 million females aged 14–59 years are
infected with HPV infection. 14 million new infections/year in
the US
• HPV infection is most common in people in their teens and early 20s
• Most people will never know that they have been infected
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Prevalence of HPV in the U.S. Epidemiology
ARKANSAS DEPARTMENT OF HEALTH
Cancer and HPV
ARKANSAS DEPARTMENT OF HEALTH
Adolescents 13-17 Years, National
Immunization Survey-Teen, 2006-2012
ARKANSAS DEPARTMENT OF HEALTH
• Australia (80% of school-aged girls vaccinated) High-grade cervical lesions have declined in women less than 18 years of age
• For 15-24 year old females, the proportion of genital warts cases declined by 85%
• Genital warts have declined by 71% among males of the same age, indicating herd immunity
• United States (33% of teens fully vaccinated) 56% decline in HPV 6/11/16/18 in girls age 14-19
• Substantial decrease in genital warts among female military under age 26 between 2007 to 2010
Is the Vaccine working?
ARKANSAS DEPARTMENT OF HEALTH
History of medicine in America
A clue?
ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
Comparison of Annual and Current Reported Morbidity, Vaccine-Preventable Diseases and Vaccine Adverse Events, United States
Disease 20th Century Annual Morbidity* 2000** %change
Diphtheria 175,885 4 -99.99
Measles 503,282 81 -99.98
Mumps 152,209 323 -99.79
Pertussis 147,271 6,755 -95.41
Polio (wild) 16,316 0 -100
Rubella 47,745 152 -99.68
Cong. Rubella Syndrome 823 7 -99.15
Tetanus 1,314 26 -98.02
Invasive Hib Disease 20,000 167 -99.16
Total 1,064,845 7,515 -99.29
Vaccine Adverse Events 0 5,296 +++
* Maximum cases reported in pre-vaccine era and year
+ Estimated because no national reporting existed in the prevaccine era
** Provisional
ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
Vaccination Coverage Among Children in Kindergarten — United States, 2013–14 School Year. MMWR October 17, 2014 / 63(41);913-920
ARKANSAS DEPARTMENT OF HEALTH
Arkansas Exemptions
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ARKANSAS DEPARTMENT OF HEALTH
Exemption laws
• Medical exemptions in all states
– Adverse reactions
• Religious and philosophical exemptions vary from state to state
• Prior law in Arkansas: religious
• Current law Act 999 (2003): philosophical or religious
– “path of least resistance”
ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
All you need in this life is ignorance and confidence, and then success is sure
ARKANSAS DEPARTMENT OF HEALTH
How Mark Twain might help us
• Allopathic medicine and its competitors
• Well described in Twain’s literature of the 20th century
• Allopathic tools – Leaches
– Emetics
– Cathartics
– Alcohol
– Narcotics
K. Patrick Ober, MD Mark Twain and Medicine
ARKANSAS DEPARTMENT OF HEALTH
The _____pathic schools
• Fill in
– Osteo- (first school in Kirksville in 1875)
– Homeo-
– Hydro-
– Electro, magneto-
– And the faith healers and the bedresters
ARKANSAS DEPARTMENT OF HEALTH
Hydrotherapy
• “I began to take the baths and found them most enjoyable: so enjoyable that if I hadn’t had a disease I would have borrowed one, just to have a pretext for going on.”
– Mark Twain, “Aix-les-Bains”
ARKANSAS DEPARTMENT OF HEALTH
prevention
• “We had a good doctor, one of them old fashioned industrious kind that don’t go fooling around waiting for a sickness to show up and call game and start fair, but gets in ahead and bleeds you at one end and blisters you at the other, and gives you a dipperful of castor oil and another one of hot salt water with mustard in it, and so gets all you machinery agoing at once , and then sets down with nothin on his mind and plans out the way to handle the case.”
– Mark Twain “Tom Sawyer’s Conspiracy”
ARKANSAS DEPARTMENT OF HEALTH
mercury
• “I don’t like medicines—and moreover I have but a pale and feeble confidence in them. There’s an old Denver pox-patient here who is loaded to the eyes with mercury, and is a poisoned hulk. As between mercury and pox, which would you prefer?”
• Mark Twain, letter 1899
ARKANSAS DEPARTMENT OF HEALTH
Alternative therapies
• Populist and feminist flavor
• Treatment did not require prescription
• Cheaper
• Sense of control
• Close contact of an allopathic failure
• Focus on health
• Fashionable
• Rebellion against the hurried and hectic lifestyles of America
• Absence of credentialing
• Need hope
ARKANSAS DEPARTMENT OF HEALTH
messaging
- - - … - - -
ARKANSAS DEPARTMENT OF HEALTH
• Provider: Meghan is due for some shots today: Tdap and the meningococcal vaccine. There is also the HPV vaccine…
• Parent: Why does she need an HPV vaccine? She’s only 11!
• Provider: We want to make sure she gets the shots before she becomes sexually active.
• Parent: Well I can assure you Meghan is not like other girls- she’s a long way off from that!
• Provider: We can certainly wait if that would make you feel more comfortable.
Sound familiar?
ARKANSAS DEPARTMENT OF HEALTH
• Studies consistently show that a strong recommendation from you is the single best predictor of vaccination
• In focus groups and surveys with moms, having a doctor recommend or not recommend the vaccine was an important factor in parents’ decision to vaccinate their child with the HPV vaccine
• Not receiving a recommendation for HPV vaccine was listed a barrier by mothers
• Unpublished CDC data, 2013
What’s in a recommendation?
ARKANSAS DEPARTMENT OF HEALTH
• The “HPV vaccine is cancer prevention” message resonates strongly with parents In focus groups and online panels, mothers wanted more information on the types of HPV cancers
• In focus groups mothers stated they were influenced to vaccinate their child because HPV vaccine prevents cancer, they had a family history of cervical cancers, and/or because they had a personal experience with cervical cancer
• Message: HPV vaccine is very important because it prevents cancer. I want your child to be protected from cancer. That’s why I’m recommending that your daughter/son receive the first dose of the HPV vaccine series today.
Cancer message
ARKANSAS DEPARTMENT OF HEALTH
ARKANSAS DEPARTMENT OF HEALTH
• Study examined the frequency of vaginal HPV and the association with non-coital sexual behavior in longitudinally followed cohort of adolescent women without prior vaginal intercourse
• HPV was detected in 46% of women prior to first vaginal sex
• 70% of these women reported non-coital behaviors that may in part explain genital transmission
• Shew, J J Infect Dis. 2012
HPV in virgins
ARKANSAS DEPARTMENT OF HEALTH
poster/flyer
ARKANSAS DEPARTMENT OF HEALTH
• I gave HPV vaccine to my boys and girls
• It doesn’t matter how your child behaves, if the person she ultimately has a physical relationship is infected
• If your son doesn’t think he needs the vaccine, tell him the Mike Douglas story
Wednesday, October 07, 2015
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Other important messages
ARKANSAS DEPARTMENT OF HEALTH
• Yale Law School: CCP Risk Perception Studies Report No. 17. Jan 27,2014
•
– 1. vaccine risks are neither a matter of concern for the vast
majority of the public nor an issue of contention among
recognizable subgroups;
– 2. ad hoc forms of risk communication that assert there is
mounting resistance to childhood immunizations
themselves pose a risk …… and diminish motivation to
cooperate with universal vaccination programs.
Exemptions in Arkansas
ARKANSAS DEPARTMENT OF HEALTH
Think he’s protected?
He’s not vaccinated
It’s your choice. Get the facts.
ARKANSAS DEPARTMENT OF HEALTH
Mom focus groups
Communicating effectively about vaccines ASTHO 2010
ARKANSAS DEPARTMENT OF HEALTH
Key messages