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AIM Adolescent Resource Guide
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Overview of activity

The North Dakota Department of Health (NDDoH) Immunization Program implemented a centralized, statewide recall of adolescents age 12 to 17 years using data from their immunization registry in an effort to increase immunization rates.

Ages targeted

Adolescents age 12 to 17 years 

Background/impetus for the activity

In 2012, the NDDoH Immunization Program received a PPHF funding award specific to adolescent recall. The Program applied for the funding to address low adolescent immunization rates, as well as low utilization by immunization providers of the state registry’s reminder/recall functionality. Coverage rates for adolescents age 11 to 18 years, according to data from the North Dakota Immunization Information System (NDIIS), were: 58% for at least one dose of Td/Tdap vaccine; 56% for at least one dose of MCV4; and 12% for three doses of HPV vaccine. Healthy People 2020 goals are 80% for Tdap and MCV4 and 60% for HPV series completion. 

Description of activity

In April 2013, the Immunization Program initiated a centralized, statewide recall effort of adolescents 12 to 17 years. The Immunization Program utilized information from the NDIIS to recall adolescents age 12 to 15 years who were at least 30 days overdue for their first dose of Tdap, first dose of MCV4, second or third dose of HPV, or first or second dose of varicella vaccines. A parallel recall was conducted for adolescents age 16 to 17 years who were at least 30 days overdue for their first dose of Tdap, second dose of MCV4, second or third dose of HPV, or second dose of varicella vaccines. 

Recall was initially conducted by telephone, using an automated dialing system, and regular mail, using postcards. Every adolescent eligible for recall received both a call and a postcard. Both methods used a general notice informing the parents/guardians that their adolescent was due or past due for immunizations, and advised them to contact a health care provider or local public health unit. To conduct the recall, NDIIS staff utilized existing reminder/recall
functionality in the NDIIS to identify adolescents who were at least 30 days past due for the vaccines of interest and then exported their contact information to a spreadsheet. Address information was checked against the US Postal Service National Change of Address (NCOA) dataset, while telephone data were submitted to Thomson Reuters for updating. Updates to contact information identified through this process were entered into NDIIS.  

The Immunization Program has made several improvements to the adolescent recall process over time, and now mails letters instead of postcards and has discontinued telephone recall.

Role of Immunization Program and other agencies/groups involved

The Immunization Program planned and implemented this activity. The ND Immunization Advisory Committee provided input into the design and wording of postcards and letters, and the decision on which vaccines should be included in the recall. When the recall effort included telephone calls, the Program sent telephone data to a third-party autodialer service. Mailed notices were, and continue to be, sent out through the state’s Central Duplicating Services.


Dissemination

Beginning with the initial recall effort, the Immunization Program has informed health care
providers prior to recall notices being distributed via its VFC provider listserv, so that they
can prepare for parent calls and have an adequate vaccine supply on hand. The Program
informs providers which vaccines are included in the recall and encourages them to use the
forecasting tool in the NDIIS to determine which vaccines are needed by individual patients.
The Program now also issues a public news release about upcoming recalls. 

Intersection with other program activities

Over time the Immunization Program has added recall efforts targeted to infants, kindergarten-aged children, seventh graders, and adolescents who have not initiated the HPV vaccine series. The Program is also piloting adult recall in three counties (for pneumococcal and zoster vaccines).

Funding

The recall effort was initially funded by a 3-year PPHF cooperative agreement, and now relies on PPHF funding in the general immunization cooperative agreement. 

Staffing

For the ongoing recall effort, NDIIS staff run each recall report, send the spreadsheet to Central Duplicating Services to process for distribution, and enter into the NDIIS the address changes identified from the NCOA dataset. Program staff also handle parent telephone calls and provider questions related to the recall effort. 

Implementation status

The adolescent recall effort began in April 2012, with the first recall notices distributed in April 2013. The recall effort is ongoing and typically is conducted quarterly.

Successes

  • During the initial PPHF grant period, approximately 424,000 individual recalls were conducted.
  •  Statewide immunization recall has been an effective method of increasing adolescent vaccination rates. During the initial grant period, significant increases in immunization rates were seen in the NDIIS:

Adolescents age 13 to 15 years: from 72% to 78% for at least one Td/Tdap dose; 68% to 77% for at least one MCV dose; for HPV series completion, 23% to 36% in females and 4% to 27% in males; and 54% to 76% for at least two varicella doses.

Adolescents age 16 to 18 years: from 69% to 76% for at least one Td/Tdap dose; 60% to 75% for at least one MCV dose; for HPV series completion, 31% to 43% in females and 4% to 27% in males; and 39% to 66% for at least two varicella doses. 

  • Data quality in the NDIIS has improved due to address submission to the USPS NCOA, with more than 13,000 addresses updated in the NDIIS. In addition, more than 9,500 adolescents in the NDIIS were marked as “moved” or “gone elsewhere” (MOGE). Less than 0.5% of postcards or letters mailed were returned to the NDDoH as undeliverable; children with undeliverable recall notices are marked as lost-to-follow-up in the NDIIS.  
  •  The Immunization Program conducted a provider satisfaction survey regarding the recall effort, and the feedback from providers was mostly positive. Providers indicated that they like recall being conducted centrally, and that the recall effort has helped spread out demand for adolescent immunization beyond the summer months. Providers also expressed interest in recall for other populations, which the Immunization Program has since implemented. 


Challenges

  • The initial recall effort used postcards with a broadly worded recall notice; Program staff and providers fielded numerous calls from parents wondering which vaccines their adolescent needed. As a result, the Program switched to using letters to allow for dissemination of additional information because letters can specify adolescents’ names and which vaccines are due. Postage costs are higher for letters than postcards, but the burden on staff for fielding calls has been greatly reduced.
  • Providers do not always utilize the forecasting functionality in the NDIIS, and there have been some issues with providers telling parents that their adolescent is up-to-date, leading parents to call the Program wondering why they received a recall notice. The issue has most often occurred with the second doses of MCV4 and varicella vaccine. To address the issue, the Program continues its provider education efforts around current ACIP recommendations and NDIIS functionality.
  • The Immunization Program has inadvertently recalled deceased children. Though deceased individuals are removed from the NDIIS based on vital records data, sometimes records have slipped through the cracks based on the timing of adding records to NDIIS.  An ongoing process was created to ensure this situation does not occur. An ongoing challenge is that the Program is not notified of out-of-state deaths.
  • The Program realized that because local Air Force bases do not enter vaccine doses into the NDIIS, there is no historical data for those adolescents and therefore recall may not be accurate. For this reason, individuals with Air Force base addresses are excluded from recall efforts.. 

Other lessons learned/Advice to other programs

  • After a few quarters of the recall effort, the State Attorney General’s Office advised the NDDoH that automated phone calls could not be used to contact parents for immunizations per the state’s “Do Not Call” Law. The autodialer portion of the recall effort was therefore discontinued. Before launching a similar effort, Immunization Programs should check whether the recall could violate any state laws.
  • Some parents are uncomfortable with receiving recall notices by telephone and wondered how the NDDoH accessed their phone number. Programs should take this into consideration when deciding on which contact methods to use. 
  • The Immunization Program, together with the ND Immunization Advisory Committee, decided not to include the first dose of HPV vaccine in the recall. Coverage rates were so low that most adolescents would have been included in the recall (increasing the cost), and the Program wanted to avoid potential pushback from parents that could negatively impact their seeking other recommended vaccines. The Program now conducts a separate recall effort specific to initiating the HPV vaccine series.
  • For parents/guardians who do not want to receive recall notices, the Immunization Program created an opt-out form on its website, which provides a simple way for parents/ guardians to permanently opt-out of the recall if they so choose.
  • Recall efforts that include 18-year-olds should be sent to the adolescent directly, not the parent, as they are considered an adult.
  • It is important to notify providers prior to distributing recall notices, so they can prepare for an increase in phone calls from parents with questions and appointment requests, and have an adequate supply of vaccine.
  • Using a tool, such as USPS NCOA, to identify address changes prior to distributing recall notices helps to minimize undeliverable mail and associated costs.

For more information

Contact Program Manager Molly Howell, North Dakota Immunization Program Immunization, at (701) 328-4556 or mahowell@nd.gov.

North Dakota Resources: Quarterly Recall

Item Name Posted By Date Posted
Program Practice Interviews Link Administration 1/31/2019
North Dakota Immunization Recall Website Link  more ] Administration 1/31/2019
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