Coaching and Communication Training for HPV Vaccination: A Cluster Randomized Trial.

BACKGROUND AND OBJECTIVES: US health departments routinely conduct in-person quality improvement (QI) coaching to strengthen primary care clinics' vaccine delivery systems, but this intervention achieves only small, inconsistent improvements in human papillomavirus (HPV) vaccination. Thus, we sought to evaluate the effectiveness of combining QI coaching with remote provider communication training to improve impact. METHODS: With health departments in 3 states, we conducted a pragmatic 4-arm cluster randomized clinical trial with 267 primary care clinics (76% pediatrics). Clinics received in-person QI coaching, remote provider communication training, both interventions combined, or control. Using data from states' immunization information systems, we assessed HPV vaccination among 176 189 patients, ages 11 to 17, who were unvaccinated at baseline. Our primary outcome was the proportion of those, ages 11 to 12, who had initiated HPV vaccination at 12-month follow-up. RESULTS: HPV vaccine initiation was 1.5% points higher in the QI coaching arm and 3.8% points higher in the combined intervention arm than in the control arm, among patients ages 11 to 12, at 12-month follow-up (both P < .001). Improvements persisted at 18-month follow-up. The combined intervention also achieved improvements for other age groups (ages 13-17) and vaccination outcomes (series completion). Remote communication training alone did not outperform the control on any outcome. CONCLUSIONS: Combining QI coaching with remote provider communication training yielded more consistent improvements in HPV vaccination uptake than QI coaching alone. Health departments and other organizations that seek to support HPV vaccine delivery may benefit from a higher intensity, multilevel intervention approach.

Applying the AFIX Quality Improvement Model to Increase Adult Immunization in Wisconsin.

OBJECTIVES: Assessment, Feedback, Incentives, and eXchange (AFIX) is a quality improvement model used to increase childhood and adolescent immunization rates in the United States. We evaluated implementation of a similar quality improvement model to boost adult immunization rates. METHODS: During November 2016 through May 2017, adult immunization outreach specialists conducted 124 in-person visits to clinics in Wisconsin that immunize adults, submit immunization information to the Wisconsin Immunization Registry (WIR), and agreed to participate in adult AFIX. Outreach specialists ran immunization assessment reports using the WIR and showed a paper copy of the report during the visit. Health care providers were encouraged to implement at least 1 of 18 strategies (eg, reminder-and-recall intervention, giving adult immunization resources to patients) to increase adult immunization rates. Outreach specialists conducted follow-up with health care providers at 3, 6, and 9-18 months after the initial visit to encourage strategy implementation. We compared AFIX sites with control clinics on practice type, geographic location, and clinic size. RESULTS: Clinics that participated in adult AFIX had a significantly larger increase in median adult immunization rates for completion of the human papillomavirus vaccine series at the 9- to 18-month follow-up than control clinics did (10.4% vs 7.7%; P = .02). The median immunization rate for 13-valent pneumococcal conjugate vaccine/23-valent pneumococcal polysaccharide vaccine completed in series was higher, but not significantly so, among adult AFIX clinics than among control clinics (12.6% vs 10.7%; P = .18). CONCLUSIONS: Adult AFIX resulted in increased awareness about adult immunization recommendations and may be a useful tool for increasing adult immunization rates.

Hepatitis A and Hepatitis B Vaccination Coverage Among Persons Who Inject Drugs and Have Evidence of Hepatitis C Infection.

OBJECTIVES: Despite recommendations for vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) for all adults at increased risk of infection, several US states have reported increases in HAV and HBV infections among persons who inject drugs. We investigated hepatitis A and hepatitis B vaccination coverage among a sample of persons who reported injecting drugs and had evidence of hepatitis C virus (HCV) infection. METHODS: We searched the Wisconsin Immunization Registry for the vaccination records of persons who underwent HCV testing at syringe services programs from January 1 through August 31, 2018, and were reported to the Wisconsin Division of Public Health as having positive HCV antibody test results and a history of injection drug use. We calculated the percentage of persons who were vaccinated according to national recommendations. RESULTS: Of 215 persons reported, 204 (94.9%) had a client record in the Wisconsin Immunization Registry. Of these 204 persons, 66 (32.4%) had received ≥1 dose of hepatitis A vaccine, 46 (22.5%) had received 2 doses of hepatitis A vaccine, and 115 (56.4%) had received 3 doses of hepatitis B vaccine. Hepatitis B vaccine coverage decreased with increasing age, from 88.0% (22 of 25) among adults aged 20-24 to 30.3% (10 of 33) among adults aged 35-39. CONCLUSIONS: These findings suggest that most persons who inject drugs in Wisconsin are susceptible to HAV infection and that most persons aged ≥35 who inject drugs are susceptible to HBV infection. In addition to routine vaccination of children, targeted hepatitis vaccination programs should focus on adults who inject drugs to help prevent future infections.

Meningococcal serogroup B outbreak response University of Wisconsin-Madison.

A meningococcal serogroup B (MenB) outbreak at a large public university prompted an emergency response to immunize undergraduates. OBJECTIVE: To report on a successful meningococcal serogroup B (MenB) vaccine clinic response at a large public university. METHODS: We assembled the team leaders to write this case report. RESULTS: Activation of the emergency plan and points of dispensing required cooperation of many units on campus under the leadership of university health officials with support from Centers for Disease Control and Prevention, state division of public health and the city-county health department. Significant efforts to provide consistent messages to students and parents regarding the outbreak and the availability of the MenB vaccines were made. Volunteers were recruited to staff the clinics alongside university healthcare providers. Over 22,000 doses of vaccine were administered. CONCLUSION: We report our experience and lessons learned which may be helpful to universities in preventing and responding to disease outbreaks.

Measuring maternal Tdap and influenza vaccination rates: Comparison of two population-based methods.

Pregnant women are routinely recommended to receive Tdap and influenza vaccines to prevent disease and complications among mothers and newborns. Monitoring population trends in maternal vaccination is important in order to evaluate the implementation of these recommendations and to identify pockets of need. We present two methods for measuring maternal vaccination among a state population and discuss the strengths and drawbacks of each method. First, we matched maternal information from records of Wisconsin births during 2013-2015 with maternal vaccination records in the Wisconsin Immunization Registry. Second, we used an all-payer health insurance claims database to identify Wisconsin women with deliveries during 2013-2015 and vaccinations received during pregnancy. Both methods produced similar trends and indicated a substantial increase in the percentage of women receiving Tdap during pregnancy, and lower vaccination rates among women who were Medicaid-insured. When available and timely, both methods are useful for monitoring maternal vaccination.

Pertussis and Influenza Vaccination Among Insured Pregnant Women ­ Wisconsin, 2013-2014.

On February 22, 2013, the Advisory Committee on Immunization Practices (ACIP) revised recommendations for vaccination of pregnant women to recommend tetanus-diphtheria-acellular pertussis vaccine (Tdap) during every pregnancy, optimally at 27-36 weeks of gestation, to prevent pertussis among their newborns. Since 2004, influenza vaccination has been recommended for pregnant women in any trimester to prevent influenza and associated complications for mother and newborn. To evaluate vaccination of pregnant women in Wisconsin after the 2013 Tdap recommendation, health insurance claims data for approximately 49% of Wisconsin births were analyzed. The percentage of women who received Tdap during pregnancy increased from 13.8% of women delivering during January 2013 (63.1% of whom received Tdap 2-13 weeks before delivery) to 51.0% of women delivering during March 2014 (90.9% of whom received Tdap 2-13 weeks before delivery). Among women delivering during November 2013-March 2014, 49.4% had received influenza vaccine during pregnancy. After the 2013 recommendation, Tdap vaccination among pregnant women increased but plateaued at rates similar to influenza vaccination rates. Prenatal care providers should implement, evaluate, and improve Tdap and influenza vaccination programs, and strongly recommend that pregnant patients receive these vaccines to prevent severe illness and complications among mothers and infants.

Completeness and accuracy of the wisconsin immunization registry: an evaluation coinciding with the beginning of meaningful use.

CONTEXT: Vaccination coverage rates can be improved through the application of complete and accurate immunization information systems (IISs). OBJECTIVE: Evaluate the completeness and accuracy of Wisconsin's IIS, the Wisconsin Immunization Registry (WIR). DESIGN: Cross-sectional evaluation, comparing vaccination medical records (MRs) from provider clinics with WIR records. PARTICIPANTS: Medical records of patients born during 2009 were randomly selected from 251 Wisconsin clinics associated with the Vaccines for Children Program. MAIN OUTCOME MEASURES: Completeness: percentage of patients with client records in the WIR, percentage of patients up-to-date (%UTD) with the 4:3:1:3:3:1:4 vaccination series, and percentage of patients' MR vaccinations matched by administration date (±10 days) and type to vaccinations documented in the WIR. Accuracy: percentages of matched vaccinations with the same administration date, same trade name (TN), and same lot number. RESULTS: Of the 1863 selected patient MRs, 98% (n = 1833) had WIR client records and 97% of their 30 899 vaccinations were documented in the WIR. The %UTD was 49.3% using the MR only, 76.5% using the WIR only, and 75.2% as estimated by the National Immunization Survey. Among matched vaccinations, 99% had the same administration date, 96% had the same TN, and 95% had the same lot number. Compared with patients from clinics that entered data into the WIR using data exchange from electronic health records, patients from clinics that entered data using the Web-based user interface were less likely to have client records in the WIR (odds ratio: 0.3; 95% confidence interval: 0.1-0.9) and less likely to have accurate TNs (odds ratio: 0.3; 95% confidence interval: 0.1-0.5). CONCLUSIONS: The WIR was complete and accurate among this sample of children born during 2009 and provided a vaccination coverage assessment similar to the National Immunization Survey. Our results provide support for the expectation that meaningful use and other initiatives that increase data exchange from electronic health records to IISs will improve IIS data quality.

The Wisconsin immunization registry experience: comparing real-time and batched file submissions from health care providers.

CONTEXT: The Wisconsin Immunization Registry is a confidential, web-based system used since 1999 as a centralized repository of immunization information for Wisconsin residents. OBJECTIVE: Provide evidence based on Registry experiences with electronic data exchange, comparing the benefits and drawbacks of using the Health Level 7 standard, including the option for real time data exchange vs the flat file method. DESIGN: For data regarding vaccinations received by children aged 4 months through 6 years with Wisconsin addresses that were submitted to the Registry during 2010 and 2011, data timeliness (days from vaccine administration to date information was received) and completeness (percentage of records received that include core data elements for electronic storage) were compared by file submission method. RESULTS: Data submitted using Health Level 7 were substantially more timely than data submitted using the flat file method. Additionally, data submitted using Health Level 7 were substantially more complete for each of the core elements compared to flat file submission. CONCLUSIONS: Health care organizations that submit electronic data to immunization information systems should be aware that the technical decision to use the Health Level 7 format, particularly if real-time data exchange is employed, can result in more timely and accurate data. This will assist clinicians in adhering to the Advisory Committee on Immunization Practices schedule and reducing over-immunization.

Estimating the effectiveness of tetanus-diphtheria-acellular pertussis vaccine (Tdap) for preventing pertussis: evidence of rapidly waning immunity and difference in effectiveness by Tdap brand.

BACKGROUND: We estimated the vaccine effectiveness (VE) of tetanus-diphtheria-acellular pertussis vaccine (Tdap) for preventing pertussis among adolescents during a statewide outbreak of pertussis in Wisconsin during 2012. METHODS: We used the population-based Wisconsin Immunization Registry (WIR) to construct a cohort of Wisconsin residents born during 1998-2000 and collect Tdap vaccination histories. Reports of laboratory-confirmed pertussis with onset during 2012 were matched to WIR clients. Incidence rate ratios (IRRs) of pertussis and Tdap VE estimates [(1 - IRR)*100%], by year of Tdap vaccine receipt and brand (Boostrix/Adacel), were estimated using Poisson regression. RESULTS: Tdap VE decreased with increasing time since receipt, with VEs of 75.3% (95% confidence interval [CI], 55.2%-86.5%) for receipt during 2012, 68.2% (95% CI, 60.9%-74.1%) for receipt during 2011, 34.5% (95% CI, 19.9%-46.4%) for receipt during 2010, and 11.9% (95% CI, -11.1% to 30.1%) for receipt during 2009/2008; point estimates were higher among Boostrix recipients than among Adacel recipients. Among Tdap recipients, increasing time since receipt was associated with increased risk, and receipt of Boostrix (vs Adacel) was associated with decreased risk of pertussis (adjusted IRR, 0.62 [95% CI, .52-.74]). CONCLUSIONS: Our results demonstrate waning immunity following vaccination with either Tdap brand. Boostrix was more effective than Adacel in preventing pertussis in our cohort, but these findings may not be generalizable to adolescent cohorts that received different diphtheria-tetanus-acellular pertussis vaccines (DTaP) during childhood and should be further examined in studies that include childhood DTaP history.

An immunization information system to meet evolving needs during the 2009-2010 Influenza A (H1N1) vaccination campaign.

In 2009, a monovalent H1N1 influenza (H1N1) vaccine was manufactured in response to the pandemic of 2009 influenza A (H1N1) virus infection that emerged earlier in the year. The overall allocation of the H1N1 vaccine to the states was the purview of the federal government; thereafter, the states were accountable for distributing and reporting the number of doses of H1N1 vaccine administered weekly. This report describes how the Wisconsin Immunization Registry (WIR) was updated and used during the H1N1 immunization campaign and its role in meeting the federal H1N1 immunization reporting requirements. Activities to enhance the registry's functionality included the creation of a rapid data entry screen for providers to facilitate the entry of data into the WIR, and enhancing the reporting capabilities of the WIR to generate H1N1-related reports at the local level. Results of these activities included an increase in the number of WIR users, higher reported numbers of seasonal influenza doses administered, and the establishment of data streams from new users. Data completeness, the ability to accurately forecast doses needed, and validating administered doses were challenges in the changing environment.

The use of an immunization information system to establish baseline childhood immunization rates and measure contract objectives.

Measuring progress toward national immunization objectives at the local level, although difficult, is becoming more feasible owing to statewide immunization information systems. This article describes how a state immunization program expanded the scope of immunization service contracts with local health departments (LHDs) to address the immunization rates among children living within their jurisdictions using the Wisconsin Immunization Registry (WIR) to measure achievement of population-based objectives. By contract year (CY) 2008, 99 percent of Wisconsin LHDs selected population-based contract objectives. In late 2008, the Wisconsin Immunization Program assessed all children at 24 months of age for completeness of the 4:3:1:3:3:1 (diphtheria, tetanus, pertussis/poliovirus/measles-containing vaccine/Haemophilus influenzae type b/hepatitis B/varicella) series by county for each of four CYs, using the WIR. From CY 2005 to CY 2008, LHDs in 61 (86%) of the 71 counties demonstrated increased series completeness rates for the series, and the overall statewide series completeness increased from 58 percent to 64 percent. However, the increases we observed cannot be attributed solely to LHDs' acceptance of population-based objectives because controlling for other factors known to influence immunization coverage levels was outside the scope of this case study. We found the WIR to be a powerful tool that can measure immunization coverage among local populations independent of the immunization provider, assess improvement toward contract objectives, and target resources toward pockets of need.

Surveillance for transmission and antibiotic adverse events among neonates and adults exposed to a healthcare worker with pertussis.

BACKGROUND: During a hospital obstetric rotation, a medical student demonstrated classic symptoms of pertussis. The diagnosis was confirmed by isolation of Bordetella pertussis. Because this exposure occurred in a high-risk hospital setting, control measures were undertaken to prevent transmission and illness. OBJECTIVES: To identify secondary cases of pertussis, to determine compliance with chemoprophylaxis recommendations, and to monitor for adverse events associated with chemoprophylaxis following a hospital exposure to pertussis. PATIENTS: More than 500 individuals were potentially exposed, including 168 neonates; antimicrobial chemoprophylaxis was administered to 281 individuals. Fifty-eight neonates and 194 adults began azithromycin chemoprophylaxis; 18 neonates and 2 adults began erythromycin chemoprophylaxis. METHODS: Active surveillance was instituted for (1) secondary cases of pertussis among healthcare coworkers, obstetric patients, their neonates, and labor companions and (2) antibiotic compliance and tolerance. RESULTS: No secondary cases of pertussis were confirmed by laboratory tests; however, 26 suspected cases and 5 clinically compatible cases were identified. Antibiotic courses were completed by 95% of the individuals who initiated therapy. Neonates taking azithromycin had statistically significantly less gastrointestinal distress compared with neonates taking erythromycin (12% vs 50%; P = .002); there were no cases of infantile hypertrophic pyloric stenosis. CONCLUSIONS: Although it was not possible to assess the effectiveness of the antibiotic regimens, the lack of laboratory-confirmed secondary cases suggests control measures were successful. Data from the 58 neonates who received azithromycin suggest it may be well tolerated in this age group.

Infant pertussis: who was the source?

BACKGROUND: In the United States in the 1990s, the incidence of reported pertussis in adults, adolescents and infants increased; infants younger than 1 year of age had the highest reported incidence. METHODS: In 4 states with Enhanced Pertussis Surveillance, we examined the epidemiology of reported pertussis cases to determine the source of pertussis among infants. A source was defined as a person with an acute cough illness who had contact with the case-infant 7-20 days before the infant's onset of cough. RESULTS: The average annual pertussis incidence per 100,000 infants younger than 1 year of age varied by state: 22.9 in Georgia; 42.1 in Illinois; 93.0 in Minnesota; and 35.8 in Massachusetts. Family members of 616 (80%) of 774 reported case-infants were interviewed; a source was identified for 264 (43%) of the 616 case-infants. Among the 264 case-infants, mothers were the source for 84 (32%) and another family member was the source for 113 (43%). Of the 219 source-persons with known age, 38 (17%) were age 0-4 years, 16 (7%) were age 5-9 years, 43 (20%) were age 10-19 years, 45 (21%) were age 20-29 years and 77 (35%) were age > or =30 years. CONCLUSIONS: The variation in reported pertussis incidence in the 4 states might have resulted from differences in awareness of pertussis among health care providers, diagnostic capacity and case classification. Among case-infants with an identifiable source, family members (at any age) were the main source of pertussis. Understanding the source of pertussis transmission to infants may provide new approaches to prevent pertussis in the most vulnerable infants.