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AIM Adolescent Resource Guide
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Overview of activity

The Indiana State Department of Health Immunization Program implemented a requirement for VFC providers to stock MenB vaccine and planned to require or recommend the vaccine for incoming students in grade 12.

Ages targeted

Adolescents aged 16 to 18 years

Background/impetus for the activity

In June 2015, the ACIP revised its recommendation for MenB vaccine, expanding from the existing recommendation for routine use in certain medically at-risk populations and outbreaks, to also include a “permissive” or Category B recommendation for individuals aged 16 to 23 years, with a preference for vaccination at 16 to 18 years of age.

Description of activity

As with any change in vaccine recommendations, the Indiana Immunization Program responded to the MenB permissive recommendation by reviewing information about the vaccine and disease incidence in the state, the language of the ACIP recommendation, the state administrative code relevant to vaccines, and VFC program policies. Based on the VFC provider agreement, which states that providers must offer all ACIP recommended vaccines and makes no distinction between Category A versus Category B recommendations, the program’s interpretation was that VFC providers must stock MenB vaccine. In addition, the program wanted to minimize missed opportunities and felt that the ACIP language regarding “individual clinical decision” signified that a provider should administer the vaccine if they determine that a patient needs or wants the vaccine. The program also checked with the Indiana Department of Insurance and its Medicaid program to ensure that the MenB vaccine and an administration fee would be covered by insurance. Taking all of this information into account, the Immunization Program communicated to its VFC providers that they must stock the MenB vaccine and discuss MenB with all patients aged 16 to 18 years. The program communicated multiple times with providers about the new requirement and asked them to comply within 60 days.

The Immunization Program requires providers to stock at least one box of 10 doses, unless they can show proof that they would not see at least five patients aged 16 to 18 years in a 2-year span. A few providers with eligible patient populations that did not stock MenB vaccine were suspended from the VFC program. Due to the cost of MenB vaccine, the program asks providers to stock only one of the two brands. However, the program does require LHDs or other providers with documented patients to carry both products. For example, providers who are attempting to do catch up college students (up to aged 19 years) in their county.

With respect to school requirements, the program has a committee that discusses changes to school requirements. The committee was aware that the MenB vaccine was in the pipeline, and the program started informing schools that MenB vaccine could be required for school entry at some point in the near future. When the ACIP issued a permissive recommendation, the committee first decided to not include MenB as a school requirement. However, the committee then reviewed the relevant state administrative code, which is broadly written to say that all school-aged children shall be protected against “meningitis,” which would include MenB disease.

The Immunization Program does not need legislative approval to update the list of vaccines required for school entry but must give 2 years’ notice of new requirements. The program is required to release the 2-year schedule every November, showing new requirements as recommended for the upcoming year, and as required for the following year. For example, MenB vaccine for incoming seniors is recommended for the 2017-2018 school year and required in the proposed 2018-2019 schedule (see image above). This requirement complements the existing grade 12 requirement for a second dose of MCV4 vaccine and a new requirement for Hepatitis A (HepA) vaccine in grades 6 and 12. The congruence of dose spacing between the HepA, HPV, and MenB vaccines enhances the program’s efforts to spur vaccine series completion among adolescents.

The program received significant provider pushback on the MenB school requirement. Providers felt the state was overriding “individual clinical decision” and going over and above the ACIP/CDC recommendation. The state chapter of the AAP also did not support the requirement. After substantial discussion, both parties agreed the program will change the 2018-2019 requirement to a recommendation with documentation of parent refusal after consulting with a physician.

Role of immunization program and other agencies/groups involved

The Immunization Program determines and implements changes to its VFC provider policies so they are consistent with new ACIP recommendations, and develops new school requirements in conjunction with its school requirements advisory committee. The committee usually meets in July to discuss current recommendations and then solicits comments. Participants on this committee include the Indiana Immunization Coalition, the Indiana Department of Education, the Indiana School Nurses Association, and one or two provider representatives (typically a LHD and a private provider). Based on the program’s discussions with the state chapter of the AAP on the MenB vaccine school requirement, a member of the AAP state chapter will now also now sit on this committee.

Dissemination

The program communicated information about the MenB VFC policy and related educational materials to providers via the program’s monthly newsletter, email blasts, and mailed letters. School requirements are sent to each school corporation operating in the state via the superintendent and school nurse. School requirements are also sent to health care professionals through the Indiana Professional Licensing Agency.

Intersection with other program activities

The MenB VFC policy change occurred during influenza season, during which the program has frequent interactions with providers. The program used these opportunities to discuss the MenB vaccine, such as clearing up confusion between the MCV4 and MenB vaccines. The program also uses influenza vaccine orders as a compliance tool. The program has put a hold on providers’ influenza vaccine orders to ensure compliance with IIS reporting, dose-level accountability, and stocking of VFC vaccines, including MenB vaccine.

The Immunization Program added information on MenB vaccine into its vaccine training workshop (“Immunizations from A to Z”), which providers are encouraged to complete at least once every 2 years.

The Indiana system IIS, known as CHIRP (Children and Hoosier Immunization Registry Program), was updated for MenB ordering and forecasting. However, MenB vaccine is not yet included in the program’s centralized reminder recalls. The program is making changes to the IIS to accept parent refusal information via HL7 messaging, instead of via manual entry, in case the MenB school requirement is revised per the agreement with the state chapter of the AAP. 

Funding

Program activities related to the VFC policy change and school requirements for MenB vaccine are funded through its CDC cooperative agreement.

Staffing

Program activities related to the VFC policy change and school requirements for MenB vaccine involve the Program Manager, VFC coordinator, and IIS staff. In addition, the chief nurse consultant acts as the program’s liaison with school nurses.

Implementation status

The VFC policy for MenB vaccine is in place. MenB is not a required vaccine for school, but it is still on the school vaccine chart as recommended.

Successes

  • The VFC policy for MenB vaccine is in place. MenB is not a required vaccine for school, but it is still on the school vaccine chart as recommended.
  • Using influenza vaccine orders as a compliance tool has been successful because providers are highly motivated to have influenza vaccine in stock. (Influenza vaccine orders have been held for 43 providers) —
  • Discussions with the state chapter of the AAP regarding their concerns with the MenB vaccine school requirement led to a unique compromise solution and strengthened this partnership going forward.

Challenges

  • In its initial communications with providers about the requirement to stock MenB vaccine, the program did not take into account that some providers do not see patients aged 16 to 18 years. After pushback from these providers, the program adjusted the requirement to exclude providers who could provide evidence that they did not see the relevant patient population.
  • The program experienced barriers in trying to communicate the updated VFC policy for MenB vaccine to its providers. For example, the program used its VFC listserv to email providers, but found that these emails often were not read, and that some email addresses were invalid or were for generic practice email accounts that were not regularly monitored. In addition, a practice’s VFC contact was often not the person making vaccine stocking decisions, so the information did not always reach the most appropriate person. The program determined that letters sent by postal mail, targeted to the medical director, were the most effective way to communicate this VFC policy change.
  • From the Immunization Program’s perspective, federal guidance did not address whether Category B recommendations should be treated any differently under the VFC program. The program proceeded with its policy based on its interpretation of the VFC provider agreement. The program had put considerable effort into ensuring provider compliance with stocking all VFC vaccines (eg, rotavirus and HPV vaccines), and thought that having a different policy for MenB vaccine would be unfair and inconsistent.
  • Many providers were confused about the difference between the MenB and MCV4 vaccines, which the program addressed via educational materials and discussions with providers.
  • Many VFC providers called to express their disagreement with the requirement to stock a vaccine that had received a Category B recommendation from the ACIP. The program was able to resolve most of these calls by sharing data on MenB disease in the state (eg, most of the recent meningitis cases in the state were caused by MenB) and reminding providers that the recommendation states the vaccine should be offered if the patient wants it after discussing it with the provider.
  • The program’s requirement to stock a box of 10 doses was challenging at first because the first few shipments of one of the available brands had a very short shelf life. To minimize vaccine wastage, the program worked with providers to move vaccine among neighboring providers, if necessary.
  • Medicaid initially declined some claims for MCV4 and MenB vaccines given in the same visit. The two vaccines have the same billing code. The program worked with Medicaid to create an identifier for providers to use in these situations, so that Medicaid could tell that it was two different vaccines given in the same visit, not the same vaccine being billed twice.

Other lessons learned/Advice to other programs

  • Programs should review data on the types of meningitis disease circulating in their state. The Indiana Immunization Program was unaware that MenB was circulating in the state before looking at the data, but nearly 80% of the 15 meningitis cases seen in Indiana in 2014-2015 were caused by MenB. If a state finds that MenB is circulating in the state, these data can help support MenB vaccine policies
  • Based on the program’s experience establishing a MenB vaccine school requirement, the state chapter of the AAP will now be represented on the program’s school requirements committee to ensure that its perspective is taken into account, and that it can keep its membership informed.
  • Programs should ensure that existing partners are sufficiently informed and involved with changes to program policies and requirements, especially in unique situations (eg, Category B vaccine recommendation).
  • The program’s goal is to maintain an effective delivery system for viable vaccines to the eligible population. In doing so, it must balance broad provider participation against issues of provider compliance. Indiana is willing to lose some providers who are unwilling to comply in order to have an immunization system of greater integrity. To ensure that provider dropout does not contribute to decreased access to immunization providers, the program monitors access and potential pockets of need via program data (eg, from IIS) and communication with LHDs, which are on the frontlines.

For more information

Contact David McCormick, Program Manager, in the Indiana State Department of Health Immunization Program at (317) 233-1325 or dmccormick@isdh.in.gov.

Indiana Resources: Men B Provider and School Req

Item Name Posted By Date Posted
Indiana Immunization Coalition MenB campaign Link Administration 11/6/2018
IN VFC MenB reminder March-final.pdf PDF (170.94 KB) Administration 8/2/2018
IN VFC MenB Notice.pdf PDF (125.34 KB) Administration 8/2/2018
IN Men B final reminder-DM edits.pdf PDF (216.61 KB) Administration 8/2/2018
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