Strategic planning for the 2020-2021 flu season during the COVID-19 pandemic is critically important to ensure that states do not experience dual epidemics this year. In this November, 2020 webinar, NASHP, in partnership with AcademyHealth and Immunize Colorado, provided a national overview of flu prevention priorities from the Centers for Disease Control and Prevention (CDC), and a closer look at state strategies in Arizona and Illinois.
Despite the health benefits of immunizing pregnant women against influenza and pertussis (whooping cough) and protecting them and their infants from these life-threatening diseases, only half of pregnant women are vaccinated against both diseases and only one-third receive both the influenza and pertussis vaccines during pregnancy.
Three states are trying a number of innovative approaches to increase vaccination rates among pregnant women by providing incentives to health plans, increasing access to vaccinations through pharmacies, and using data to identify and target populations, regions, and providers with substandard influenza and Tdap (which protects against pertussis) vaccination rates.
Evidence shows pregnant women are at increased risk of developing complications from certain preventable diseases and can also risk passing those diseases on to their children. Following immunization, data shows that both mothers and infants are less likely to be hospitalized from complications. When a woman is vaccinated during pregnancy, she develops antibodies that are transmitted to her child before birth, which can then protect the infant during the first few months after birth. The US Centers for Disease Control and Prevention (CDC) recommends that women who are pregnant or planning to become pregnant get the flu vaccine and the Tdap vaccine during each pregnancy.
Low Immunization Rates Persist
Despite the CDC’s guidelines, many women do not receive the influenza and pertussis vaccines during pregnancy. According to the CDC’s recent report, Vital Signs: Burden and Prevention of Influenza and Pertussis Among Pregnant Women and Infants — United States, published in Morbidity and Mortality Weekly Report (MMWR), current rates of maternal immunization for influenza and Tdap are 53.7 percent and 54.9 percent, respectively. Only one-third of pregnant women received both the influenza and Tdap vaccines, and the rates are even lower for African-American pregnant women. The report noted that provider recommendations to patients can improve maternal immunization rates – when providers offered vaccinations or provided a referral to pregnant women, 65.7 and 70.5 percent received the flu and Tdap vaccine, respectively. Based on this data, the CDC recommends that providers begin discussing vaccinations with pregnant patients early and continue the conversation during each visit.
Overall, women enrolled in public insurance programs were less likely to be vaccinated during pregnancy than women with private insurance, due in part to access barriers. State Medicaid agencies, which cover 43 percent of all births across the United States and up to 60 percent of births in some states, can use innovative approaches to identify pregnant women in need of vaccinations, gather data to identify strategies and targeted approaches, and encourage providers to increase vaccination rates to improve health and save on costs.
The 2019 MMWR data are especially notable in light of the Healthy People 2020 goal to increase the number of pregnant women vaccinated against influenza to 80 percent. While most states remain far from that goal, California, Colorado, and Wisconsin are working to improve maternal vaccination rates for both their Medicaid populations and privately insured women.
California’s Medi-Cal Strategies
In California, pregnant women covered by Medi-Cal, the state’s Medicaid plan, see providers who are less likely to stock or recommend the Tdap vaccine. Women on Medi-Cal receive prenatal Tdap immunizations at much lower rates than privately insured women, and infants born to mothers with Medi-Cal coverage are twice as likely to contract pertussis compared to privately insured infants. California is using a number of strategies to improve maternal immunization rates for women on Medi-Cal, including setting expectations for contracted health plans, monitoring and providing incentives, and addressing barriers at the clinician and patient level:
- Medi-Cal managed care contracts require health plans to ensure the timely provision of all Advisory Committee on Immunization Practices (ACIP)-recommended immunizations for members, and report data to the California Immunization Registry (CAIR). Medi-Cal managed care contracts also require that contracted health plans monitor their primary care provider sites for the provision of preventive services, including all ACIP-recommended immunizations for adults and children.
- California’s 2019-2020 budget includes funding for incentive payments in the managed care delivery system for timely prenatal care as well as for prenatal providers who administer the Tdap vaccine to pregnant members. Some of California’s Medi-Cal managed care health plans are also trying to lower the financial barriers to providing vaccines by allowing providers to directly bill the health plan outside of capitation rates, providing free Tdap starter doses to clinics, and encouraging group purchasing of vaccines.
- Medi-Cal encourages its health plans to follow up on potential quality of care issues when cases of pertussis in infants born to unvaccinated mothers are identified through public health department notification.
- California pharmacists are authorized to provide immunizations without a physician’s order. Most major chain pharmacies in California offer Tdap immunizations as part of their vaccine portfolio. All routinely recommended adult vaccines are covered by Medicaid without prior authorization (in both fee-for-service and managed care plans) when given in a provider’s office or in a pharmacy. Recent state regulations require pharmacists to notify providers of immunizations administered and to enter all doses into the California Immunization Registry, making it possible for providers to know whether vaccine referrals to pharmacies are successful.
Colorado and Wisconsin’s Use of Data
One of the challenges to improving maternal immunization rates is obtaining and monitoring data, especially as many states do not require providers to report immunizations to their Immunization Information Systems (IIS). Quality data, though, is needed by states working to tailor their strategies for improving immunization uptake to the areas of highest need and to monitor trends. Specifically, the Centers for Medicare & Medicaid Services identifies data linking of Medicaid eligibity and claims data with vital statistics data as a critical mechanism for surveillance, programmatic monitoring, and evaluation of maternal immunization.
- Colorado is using data matching to determine the rates of maternal immunization in each county. Colorado has successfully matched 96 percent of patient medical record numbers with Colorado Immunization Information System (CIIS) records. The CIIS data matching has allowed the state to map immunization rates by provider and region and identify gaps in maternal immunization uptake. Colorado is now using this data to determine the areas of highest need in the state to inform and guide outreach programs. Currently, Colorado is also piloting text and email reminders to encourage patients to get vaccinated.
- Wisconsin is also using data matching to obtain baseline immunization rates. Wisconsin matched 96 percent of women who gave birth in 2018, as recorded by the Vital Records Office, with data from the Wisconsin Immunization Registry. Like Colorado, Wisconsin used this data to create data maps to identify influenza and Tdap vaccination levels in each region of the state. Wisconsin was also able to track vaccination rates by age, race, type of insurance, and quality of prenatal care. Next steps for the state include monitoring these trends, identifying areas of highest need, and using the data to improve maternal immunization rates.
In addition to partnering with state public health departments and their immunization programs, state Medicaid agencies can partner with providers to ensure vaccines are stocked and to promote vaccine recommendations for pregnant women so they become routine. For example, the American College of Obstetricians and Gynecologists has released a number of resources designed to support health care providers in increasing maternal vaccination rates, including the Maternal Immunization Tool Kit, strategies for immunization implementation, and a guide to starting an office-based immunization program. The American Academy of Pediatrics also offers recommendations on cost-saving measures for the purchase and administration of immunizations. Finally, the CDC has compiled a toolkit for prenatal care providers that includes resources for provider and patient vaccination education.
In addition to these resources, other states can learn from the work California, Colorado, and Wisconsin have done to identify gaps and improve vaccination rates among pregnant women covered by state Medicaid programs.
The National Academy for State Health Policy (NASHP) would like to thank Abby Klemp at the Wisconsin Department of Health Services, Sarah Royce at the California Department of Public Health, and Karen Mark at the California Department of Health Care Services for their time and insight. NASHP would also like to thank the US Centers for Disease Control and Prevention for their assistance with this blog and for funding this project.
States are using creative and collaborative methods to increase flu immunization rates after 185 children died from influenza during the 2017-2018 season — the highest toll reported since the 2009 flu pandemic. The health and economic toll of last season’s flu outbreak in children nationwide included more than 48,000 hospitalizations and 6.5 million medical visits.
Increasing flu vaccination rates, especially early in the season, can help reduce flu-related illness and complications, yet nearly 80 percent of children who died from the flu last season had not received the flu vaccine. Compared to this time last year, estimated flu vaccination rates for children are up, but a recent poll found that one-third of parents said their child was unlikely to receive the flu vaccination this year.
Hawaii has been fighting the flu and improving childhood vaccinations in innovative ways for nearly a decade, relying on close collaboration between state education and health agencies to operate “pop-up,” school-based vaccination clinics to protect children’s health.
Removing barriers to vaccine access can help increase vaccination rates. Medicaid covers the flu vaccine for all enrolled children, as recommended by the Advisory Committee on Immunization Practices, which removes a financial barrier. However, removing non-financial barriers to accessing the flu vaccine – such as inconvenience – can also help increase vaccination rates. The Community Preventive Services Task Force recommends providing vaccinations in schools and childcare settings to address this barrier.
Despite having very few school-located health clinics, Hawaii operates a yearly “pop-up” influenza program called Stop Flu at School. The program provides free flu vaccinations to all elementary and middle-school children in participating schools and is the result of a partnership between its state departments of health and education and the private health insurance association. The voluntary program improves accessibility to the vaccination by providing it during the school day. The Stop Flu at School program is made possible by a blend of private insurer in-kind and monetary donations, state support, and several federal funding sources. Federal support comes from funds for pandemic flu preparedness, the Vaccines for Children program (VFC), which provides immunizations at no charge to physicians’ offices and public health clinics that are registered as VFC providers, and the Section 317 Immunization Program immunization program funds. The state health department serves as the VFC provider for the pop-up clinics which allows VFC eligible children to receive influenza vaccine through the Stop Flu at School program. Insurance status is tracked for program participants and documented on consent forms. Insurance status is used as a proxy for VFC program eligibility.
An evaluation of the program from 2007 to 2011 found that close to 50 percent of the target age group received the flu vaccine as a result of the program, and nearly one-third of students vaccinated were covered by Medicaid. Data that tracked influenza-like illness in Hawaii suggests there was less flu activity during the program’s first years (2007-2010), compared to previous years. State health officials also credit their experience operating the Stop Flu at School program with enabling them to effectively conduct emergency mass vaccinations during the H1N1 pandemic, which occurred in 2009.
Mobile or pop-up school-based vaccination clinics provide an effective vehicle to increase access to vaccinations and protect the health of children, and have the potential to reduce overall disease burden and costs.
As Hawaii demonstrates, these clinics require leadership and collaboration between state agencies and the private sector. Alabama provides another example of state leadership in this area – the governor recently issued a resolution urging all schools to participate in school-based immunization programs.
In addition to leadership and cross-agency partnerships, implementing mobile vaccination clinics also requires planning and resources. State officials will find videos, checklists, and other resources in this Mobile Immunizations Toolkit developed by Spokane Regional Health District, which shows how Spokane County in Washington State worked with health departments, schools, and health care providers to create school- and community-based mobile immunization clinics.