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AIM Adolescent Resource Guide
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Overview of activity

The North Dakota Department of Health Immunization Program Manager listens to ACIP meetings via the CDC webcast link (www.cdc.gov/vaccines/acip/meetings/webcastinstructions.html) to quickly disseminate to providers information related to new or revised immunization recommendations and begin planning programmatic adjustments.

Ages targeted

All adolescents

Background/impetus for the activity

When the ACIP makes a new or revised vaccine recommendation, Immunization Programs must disseminate this information to their providers and make decisions about the adjustments needed in program processes (eg, IIS forecasting) and educational materials. North Dakota Immunization Program’s approach is described using two recently revised ACIP adolescent vaccine recommendations as examples:
—
- In June 2015, 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” recommendation for individuals aged 16 to 23 years of age, with a preference for vaccination at 16 to 18 years.

—- In October 2016, the ACIP lowered the recommended number of HPV vaccine doses from
3 to 2 doses for adolescents who initiate the vaccination series by aged 14 years.

Description of activity

When a new or revised vaccine recommendation is scheduled for discussion at an ACIP meeting (held three times per year), the Program Manager listens to the relevant portions of the live meeting webcast. After the meeting, the Program Manager writes a brief summary of the recommendation and related ACIP discussion. This summary is shared with program staff and is sent to the program’s public and private VFC providers.

The Immunization Program staff internally discusses what needs to be done in response to the recommendation, including revising or developing educational resources and making changes to the North Dakota Immunization Information System (NDIIS). The program also solicits feedback from the state Immunization Advisory Committee (NDIAC), especially from provider members regarding how they expect to implement the recommendation and any potential issues they foresee.

Changes to NDIIS may be needed to reflect new or updated ACIP recommendations such as revisions to the vaccine ordering system, forecasting algorithm, reminder/recall protocol, and algorithm for generating coverage rate reports. Changes to the forecasting algorithm take the longest to implement, as they are done by an outside vendor that supports IIS forecasting in several states. The program pays the vendor a flat annual maintenance fee for their services, so ACIP recommendation changes do not affect cost to the program for forecaster revisions.

Some of the decisions and issues specific to the new MenB permissive recommendation addressed by the Immunization Program include:
—- The Immunization Program recommends to its providers that they keep some MenB vaccine in stock, even if they do not plan to routinely recommend the vaccine, in case of patient/parent request.


—- The program sought feedback from the NDIAC on how to address MenB vaccine
forecasting in the NDIIS, given that it is a permissive recommendation and NDIIS cannot forecast a permissive recommendation differently than a routine recommendation. The options were to forecast MenB vaccine either for all adolescents aged 16 to 23 years or only for those adolescents who received a first dose (ie, forecasting subsequent doses). The NDIAC decided to have NDIIS forecast the vaccine for all adolescents, in part to prompt providers to discuss the availability of the vaccine with patients and parents.

—- The NDIIS forecaster had to take into account that the two available MenB vaccine products were not interchangeable and initially had different schedules. NDIIS forecasts the next dose as the same brand as the first dose received; if the other brand is used for the next dose, then the forecaster will show that additional dose(s) of that brand are needed.

—- The program decided not to include MenB vaccine in its quarterly reminder/recall of adolescents aged 12 to 17 years, because nearly every adolescent aged 16 to 17 would be included. This would be costly, and because the vaccine is not routinely recommended for all adolescents, it could also be confusing to parents. 

Some of the decisions and issues specific to the revised HPV recommendation addressed
by the Immunization Program include:

—- The Immunization Program decided to exclude HPV from its quarterly adolescent
reminder/recall efforts until the forecaster is ready, because the program does not want to recall adolescents for a third dose who are no longer recommended to receive one.
—
- The program will change how it calculates and reports HPV coverage rates, which affects the coverage rate reports that it posts on its website as well as those that are generated for quarterly provider site rate report cards and AFIX visits.

Role of Immunization Program and other agencies/groups involved

The Immunization Program is responsible for implementing new or revised ACIP recommendations in the state and disseminating relevant information to public and private immunization providers. The North Dakota state chapters of the American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP) are not as active as in other states, so the Immunization Program is the main resource for providers (other than for those in large health systems).

Dissemination

The Immunization Program uses its VFC provider listserv to communicate guidance on new and revised ACIP recommendations to its providers. Other dissemination tools include monthly “Lunch and Learn” webinars, a quarterly newsletter, and biennial immunization conferences. Non-VFC providers are more difficult to reach, but they also may attend the lunchtime programs and the state immunization conference. The program also reaches out to various associations (eg, Pharmacy Association, Long Term Care Association, NDAAP) to provide education at their conferences. The Immunization Program also notifies North Dakota Medicaid of changes/additions to ACIP recommendations to ensure rapid coverage on the Medicaid formulary.

Intersection with other program activities

New or revised ACIP recommendations must be integrated into all of the program’s activities relevant to the recommendation, including parent and provider education efforts, NDIIS, and VFC policy and procedures.

Funding

This activity is funded as part of the Immunization Program’s CDC cooperative agreement.

Staffing

All staff are involved in implementing new or revised ACIP recommendations as part of their normal duties. The Immunization Program Manager listens to and summarizes relevant ACIP meetings. All staff members are trained to address questions and answers/ calls to the program’s toll-free number, and an increased amount of staff time is devoted to answering the increased volume in calls following a recommendation change. NDIIS staff test the vendor’s forecaster changes before putting it into production.

Implementation status

This activity occurs as needed, ie, whenever ACIP updates vaccine recommendations.

Successes

—- Listening to the ACIP discussion related to new or revised recommendations can provide a deeper understanding of the issues and rationale, which is helpful for addressing provider questions.
—
- The program has a very small staff; training all staff to answer provider questions helps improve their own understanding of the recommendation and distributes the workload of responding to provider calls.
—
- The NDIIS uses CDC’s Clinical Decision Support for Immunization (https://www.cdc.gov/vaccines/programs/iis/cdsi.html), which has reduced the amount of staff time to provide cases for the immunization forecaster to the vendor. Additionally, all Immunization Program staff test forecaster changes in the NDIIS test environment, which ensures issues are identified prior to production.

Challenges

- Permissive recommendations, such as for MenB vaccine, generate a high volume of provider calls with questions and requests for guidance, which require extra communication and call response by the program. To help providers make their own decisions, the program explains the rationale for the recommendation being permissive rather than routine.

- Permissive recommendations can lead to differential implementation across providers. For example, the largest health system in North Dakota has its own immunization advisory committee, which decided to routinely recommend MenB vaccine for all of its patients aged 16 to 23 years. Interpretation of MenB vaccine coverage data will need to take into account these differences.

—- Addressing recommendations for vaccines with more than one brand that are not
interchangeable is more challenging, such as for MenB vaccine. IIS forecasting must
take into account that a person who receives two different brands will require additional doses. Also, providers do not want to stock multiple brands in their offices. In addition, availability was an issue for one of the MenB vaccine brands after its FDA approval and ACIP recommendation.

—- Providers do not usually like to implement ACIP recommendations until they are published in Morbidity and Mortality Weekly Report (MMWR), but the CDC encouraged immediate implementation of the 2-dose HPV recommendation. This led to a lot of questions and confusion among providers.
—
- When changes to IIS forecasting algorithms are complicated, such as for the 2-dose HPV vaccine recommendation, it can take several months for the vendor to complete the revisions. Providers generally follow the NDIIS forecaster, so although the recommendations changed for HPV vaccine, since the forecaster wasn’t updated immediately, providers continued to administer three doses. The program develops guidance materials for providers in the interim, such as an HPV vaccine algorithm flowchart that it posted on its website.

Other lessons learned/Advice to other programs

- Participating in meetings at which new and revised recommendations are discussed
(eg, ACIP meetings and AIM calls that occur after ACIP meetings) helps programs to stay informed. Providers should not hear about ACIP updates before the Immunization Program. Also, it can take up to 90 days for ACIP meeting minutes to be published online, so listening to the webcasts is the fastest way to get the information.—

- It is helpful to review ACIP meeting agendas beforehand to identify the specific items of interest. The meetings last two days and it is not usually feasible to listen to the entirety.

- IIS staff should be included in conversations about upcoming or recent ACIP recommendation changes so that the IIS can be updated in as timely a manner as possible.

For more information

For more information:
Contact Molly Howell, Immunization Program Manager in the North Dakota Department of Health Immunization Program at (701)c 328-4556 or mahowell@nd.gov

North Dakota Resources: Men B & School Req

Item Name Posted By Date Posted
NDDoH Vaccine Management Policy (pg.14 Men B) Link Administration 11/7/2018
North Dakota Lunch and Learns Link Administration 11/7/2018
North Dakota Immunization Coverage Rates Link Administration 11/7/2018
North Dakota HPV algorithm flowchart Link Administration 11/14/2018
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