Posted by: Sean Hubert, Project LOVE

Back-to-School….Back to the drawing board

In recent days I have seen some discussion on how to release the tension of back to school lines in public health clinics. Immunization coalitions create and execute plans for back to school outreach, but how effective are they? For some communities these outreach activities are very effective. But for some high VFC*-qualified communities, not as much.

Last year, Project LOVE partnered with several organizations to hold satellite clinics in areas where data has shown elevated school exclusion rates year after year. It also happened to coincide with high qualified free or reduced lunch programs which equate VFC-eligibility. It made sense to us to have these clinics in those identified areas for the family’s convenience and to hold them around and during exclusion day (for Ohio schools it’s two weeks after school starts). Information about these clinics were distributed to the parents through the school nurses on several occasions, including the letter stating your child will be excluded without the required immunizations. We were geared up and ready to take on the flow. But nothing happened. In all the clinics (8 areas in total) we had a handful of families show up.

Where did the rest go? You bet…our local health department. Apparently our families preferred to take the longer bus or car trip and spend the hours in wait rather than to go to the clinics set up in their neighborhoods. We know procrastination is habitual, but maybe so is going to the main health department. It doesn’t help that they are so darn friendly too (honestly!).
So the lesson learned was that we not hold convenient localized clinics but rather staff more personnel to help the main health department out. It’s not my first choice obviously, but it was our community’s choice. Throughout the summer using the media, we strongly encourage families to contact their medical provider early for an appointment, but with school starting next week (for us), that’s no longer an option. Most offices I have contacted are booked at least two weeks out.

I strongly support working closely with your school systems. They can help you identify many aspects as you plan back to school events such as school exclusion rates and assist you on getting the word out to the parents. If you are in a state where it is allowable to give immunizations at the school, holding clinics on site is a very effective option.

*VFC-Vaccine For Children federal program

Immunization Registries…More than just a database

IZTA is pleased to welcome a new guest blogger – Sean Hubert, the Director of Project L.O.V.E. – An immunization coalition serving Franklin County, Ohio. His first posting follows:

Project L.O.V.E. and its partners recently conducted a retrospective survey where we reviewed kindergarten immunization records in our public school system. We looked back to when these children were two to see how many were up-to-date on the recommended immunization schedule. The process was cumbersome and took many partner members and countless hours to complete the study. What we found was exactly what we expected; that our children were not well protected in our urban areas against vaccine preventable diseases. It was excellent we finally had data to back up what we have been saying for some time, but there had to be a better way of getting this data.

Of course there is and it’s by using immunization registries. Not only would it be a quick query search to pinpoint areas in need for additional immunization outreach, we could focus our partners in using their valuable time for actual outreach rather than research. Not to mention, the data that we would collect from the registry would be real-time compared to the 3 year old data we collected from the retrospective study.

So why didn’t we do that? Quite simply…our registry is filled with gaps since many immunization providers still aren’t using it. It really astonished me when first taking over Project L.O.V.E. that providers wouldn’t be using a free web-based system to track their immunizations. With so many perks for using the system such as free reminder/recall notices to patients, easy access in ordering and tracking vaccines as well as easily printable reports for daycare, school and camp forms, why wouldn’t they? Although we have made some stride in provider participation, it hasn’t been an easy sale. I hate to think that it will take legislation as some states have done to get all providers to use the system but it may be our only hope.

Registries make sense in so many ways and levels. Parents never need to worry again about a paper record that can be easily lost or destroyed. Providers could track their patients much better and make fewer calls to past providers as well as never worrying that they are over immunizing a child. And Public Health could structure their limited resources and funding to those families that really need the outreach as opposed to blanketed outreach. It just makes sense…but I’m preaching to the choir.

Maximizing Protection vs. Increasing Rates

It has been about four years now since I have told anyone that our Coalition works to 'increase immunization rates'. In my presentations, on our websites, in our marketing materials, in our meetings and campaigns we talk about maximizing immunization or disease protection not necessarily increasing rates. There are two very important reasons for this.

Reason One: Increasing immunization rates does not sound all that appealing or important to most people. If anything it sounds to people quite robotic and inhuman. For most people with the exception of some public health geeks (no offense here – I have the highest regard for public health geeks as I am one myself) raising immunization rates doesn’t mean anything. It is simply bean counting. In some ways it actually feeds peoples stereotypes that all we want to do is push more vaccines. ‘What do your immunization rates have to do with my life or my children?’ Now if you say you are going to help maximize immunization protection or improve protection from disease that sounds better. If we have learned anything from politics recently it is that words are important. The phrases you use to describe what you do say a lot about you. And it is proven that people react very differently to different words. In a focus group asking people about which was more positive my money would be on protection over rates any day.

The second reason and most importantly for me - as I am a public health/science geek myself - is that raising immunization rates is inaccurate. That is not my job. That is not what I do. Now immunization rates may increase as a result of what I do, but I am not focused on that. My job is to help protect people from disease. If there was no disease I could care less about immunization. So the focus of what we do should be on the diseases and using immunization as a tool that works to protect people from those diseases. Also, simply raising rates is an unrealistic goal.

Why? Because we could spend trillions of dollars and never have 100% of people vaccinated – it’s impossible and a waste of resources. Some people have contraindications, some people are not the right ages for certain vaccines, and some people are not at risk for specific diseases, and some people simply refuse to be vaccinated. Now given that set of cards we can target immunizations to help protect the most people from the most disease.

We are the experts when it comes to what disease are really effecting or would be affecting people’s lives if they didn’t get immunized. And most diseases (not tetanus) have a herd immunity threshold that allow us to protect a group of people even if not everyone in that group is vaccinated. So we are more maximizers and optimizers rather than blind vaccinators.

The moral of this blog is to stop using the words 'increasing immunization rates' and start using the terms maximizing/ optimizing/ improving/ broadening immunization or disease protection. In the end it sounds better and is far more representative of what we do.

What is Immunization Infrastructure and What Does It Have To Do With

When I tell people about my job and I let them know that my Coalition works on improving immunization infrastructure. Soon after I mention this word I see that people’s eyes kind of glaze over with a mixed sense of confusion and boredom. I find the word infrastructure is one that has this effect on people.

However, I still continue to use it because building immunization infrastructure is one of the most important things our Coalition does. But what does it mean?

It means creating a system or a structure so that vaccines can be administered correctly, timely, and optimally to the appropriate individuals in order to maximize protection from communicable diseases.

Infrastructure involves education, awareness, relationships, legislation, networks, tools, money, and reality. This all sounds very obscure. Let me give you an example.

Right now in the U.S. pertussis is a disease that is very common. It is common because the immunity from the DtaP that children receive starts to wane as they become teens and adults. So the disease has found a large reservoir of people who are not immune to pertussis. We know this is true. Pertussis is no fun to get as an adult but it can be deadly for a newborn.

Since 2004 in California we have had 13 newborns die because they contracted pertussis from an adult who was infected. How do we stop this? Simple – a safe and effective booster shot called Tdap given to teens and adults which will most likely reduce the amount of cases of pertussis in the general population reducing the amount of cases transmitted to newborns and basically saving babies' lives.

Unfortunately there does not exist an infrastructure to immunize teens or even adults. This immunization infrastructure has to be built. This means making providers and the public aware that they need to get a Tdap booster to fully protect them from pertussis which is quite common. And it means creating places where they can get these vaccines.

Working with providers, school clinics, pharmacies, teen clinics, and emergency rooms to make sure they can get the vaccine, store it safely, administer it properly, and get paid for administering it. This means helping establish relationships between providers, the general public, vaccine makers, and State and local health departments. Immunization Coalitions can help do all this.

And this is what creating immunization infrastructure is all about. Immunization Coalitions identify barriers or gaps in the infrastructure and work on ways to fill them. Single entities like hospitals, health departments, or school districts can not build infrastructure alone – they need organizations that stretch across all of these sectors bringing diverse partners together for the common cause of protecting people from disease.

What Motivates Vaccine Skeptics?

Over my five years as Director of the San Francisco Immunization Coalition I have met many people who were skeptical about immunization and vaccines. In general, I believe it is my job whether I am on the clock or not to give people the most factual, objective, up-to-date and science-based information about immunization to help keep them informed. I definitely think that vaccine skeptics take many forms and lumping them all together is not a useful way to understand them or inform them. Vaccine skeptics have different motivations and it is important to know who they are in order to talk them in the most honest and productive way. Here are a few but not all the types of people that are skeptical of vaccines (based on my own experience):

Emotional - Many people are not motivated entirely by rational thought but rather more motivated by emotion. Things like hope, fear, anger, trust, and joy motivate these types of people more than facts, statistics, or science. “Anti-vaccination” web sites usually do a good job at appealing to the emotions in order to get their point across. Understand for emotionally motivated people it is important to gain their trust in order to effectively get your point across. If they do not trust you on an emotional level they will not listen to what you say. And graphs of decreases in disease will not motivate them.

Political – when it comes to immunization, politics is a double-whammy. Why? Well because vaccines for the most part are made by large, corporate, pharmaceutical companies and advocated for and distributed in large part by the government. Unfortunately this plays strongly against the beliefs of two distinct groups of people with strong political motivations:

1. Libertarian/Anti-Government – whether you are aware or not there are many people in the U.S. that do no trust the government. Most libertarians dislike government more the further away it is. In other words they trust the Federal government the least and their local government the most, but they tend to believe limited or no government is the best. Sometimes it is hard to believe what motivates these people and other times it is not. But libertarians tend to look with skepticism on any program that is developed by the government and do not believe in collectivist arguments. The argument that one person should get immunized in order to protect others does not always play well with people that believe strongly in pure individualism.

2. Anti-Corporation/Anti-capitalist – you certainly have met someone who does not trust corporations or the private sector. In the Bay Area there are many people of this stripe. In general, pharmaceutical companies have become demonized and scapegoated for many of the health problems in the U.S. It is no wonder that people who believe that corporations are evil aren’t thrilled about putting something into their own or their children’s body made by a large, multinational corporation. However, most of these people, not all, will drive their children around in a car produced by a large multinational corporation in fact putting their trust in Volkswagen, Ford, Volvo, or Honda. Sometimes it is important to point out these distinctions in order to put beliefs more in context.

Conspiracy Theorist – the best way to understand conspiracy theorists is to read the definition of conspiracy theory. Examples: The government is knowingly poisoning our children. The United States is trying to sterilize African babies with the polio vaccine. The interesting thing about conspiracy theorists is that if they believe one conspiracy theory they tend to believe many conspiracy theories. Another interesting thing is that everyone and I mean everyone walking around today believes something that is absolutely false. The sensational and competitive nature of our media environment makes conspiracy theories a way to attract readers and viewers. And therefore they are prolific in our culture. A lot can be said of conspiracy theories but the most important is that almost all of them are not true. I always ask parents if they really want to base their children’s health on a conspiracy theory. Sometimes the truth isn't very interesting.

Fear of Needles – I do believe that there are large groups of people that have a deep-seated and profound fear of needles. Most vaccines are injected and I do believe this causes a lot of the fear of being immunized. It is certainly not pleasant to watch you child poked with several needles and therefore it is hard for some parents to be enthusiastic about immunization. Needles and injections are associated with drug addicts and aliens who come to colonize the Earth in those old movies. Most people do not associate needles with health. Therefore I wholeheartedly encourage the development of different ways to administer vaccines that are as effective.

How many people would be as opposed to immunization if they were administered through a bowl of ice cream?

When I think about all the reasons people could be fearful and skeptical of vaccination I am always amazed that almost 80% of children in the U.S. are properly immunized and that almost all countries capitalist (United States, Europe, Australia, Japan, etc.) or socialist (Venezuela, Cuba, etc.), democratic or autocratic have extensive immunization programs. And I always seem to reach the same conclusion based on this – immunizations must work.

National Infant Immunization Week (NIIW) and Immunization Registries

As I have stated before on this blog I believe that immunization coalitions have a strong role to play in promoting, raising funds for and helping to populate immunization registries. Precise tracking of immunizations is key to our ability to immunize young children on time in the future.

For these reasons our Coalition has decided to focus a lot of our energy for this year's NIIW activities on the immunization registry in San Francisco. We are sending a letter and an informational flyer to all immunization providers in San Francisco letting them know about the immunization registry, its benefits, and how they can join the growing list of providers using the registry to track immunizations. In addition, we are trying hard to recognize the providers in San Francisco that are currently using and actively entering and checking immunization records via the immunization registry.

How are we doing this? We have purchased travel mugs and printed our logo and appropriate immunization registry information on it (registry help desk phone #, registry website address). Inside each mug will be a $5 Starbucks card. On Monday of next week Coalition members will be going personally to each provider in San Francisco whose staff are utilizing the immunization registry and delivering our mug and gift card to the staff. This will remind them of the important role they are playing in helping improve the tracking and delivery of immunizations in the Bay area. We have found that keeping current registry users satisfied is as important as recruiting new ones. And NIIW is a good time to thank current users and reach out to new ones!

Immunization Coalitions, Vaccine Safety, and Immunization Registries

One thing I have tried to emphasize, as Director or the San Francisco Immunization Coalition is that Coalition’s can work on improving the safety of vaccines as much as we work on improving and increasing access to them. And continually improving the safety of vaccines will in itself increase people’s willingness to be immunized or have their children immunized.

While the U.S. vaccine supply is probably the safest, most technologically advanced and best monitored in the world, vaccines like everything else can always be made safer. One critical area where Coalition’s can have an impact on the safety of vaccines is the development of immunization registries.

By becoming engaged advocates for the advent of computerized immunization information systems or registries, immunization coalitions can help improve the safety as well as the efficacy of vaccines. Registries provide a more systematic and precise way to administer and monitor the vaccines given to patients. Our local registry comes with a software that advises the immunization provider of the vaccine recommendations, has popup alerts regarding past reactions to vaccines, and endows the immunization provider a tool to give the vaccines at the correct intervals – the intervals that were deemed as the most safe in research studies.

Registries allow for the quick and systematic retrieval of data including lot# in event of a vaccine recall. Registries allow for different providers to share and easily retrieve the immunization record of someone in their clinic/practice - which will reduce the over immunization or re-immunization that occurs when people lose their immunization record. This not only reduces the chances of adverse reaction it reduces wasted vaccine. Some registries automatically create VAERS reports, which facilitate and improve reporting of adverse reactions to vaccines. All these things improve the safety of vaccines. The complexity of the vaccination schedule combined with the mobility of today’s patient population make sophisticated immunization information systems essential to the safety of vaccines.

I even say in talks that people who are skeptical about vaccination should be advocating for registries if they are ingenuously worried about the safety of vaccines.

My next blog will talk about the different ways that Coalition’s can advocate for, support, provide input, and expertise for the development of immunization registries.

Not All Conferences Are Boring

Since I have been the Director of the San Francisco Immunization Coalition I have had the pleasure of attending the National Conference on Immunization Coalitions three times, 2003 in Scottsdale, Arizona, 2005 in Norfolk, Virginia and 2006 in Denver, Colorado. Of all the conferences I have been to throughout my career I felt the National Conference on Immunization Coalitions was the most dynamic and practical I had ever been to. The reason I believe these conferences were so positive for me is simply the type of people immunization coalitions attract.

In general, the participants at these Coalition Conferences - who came from all over the country and few from Canada - tend to be dynamic, personable, thoughtful, innovative, and generous of spirit. These are people who have a real desire to get out of the standard way public health bureaucracies operate and into the community. They are people who seemed like they wanted to find new ways of doing business all in an effort to better protect people from disease. These were my people. After the first conference I felt a real feeling that I was in the right career.

As a result of these positive experiences in the past with the National Conference on Immunization Coalitions I was very excited when I received a call from the National Conference Planning Committee asking if my Coalition would like to be the host for the 2008 National Conference on Immunization Coalitions. I was even more excited when my Advisory Board agreed that we would do it. So see you in San Francisco in 2008 coalition people!

Want Good Meeting Attendance – Feed People and Give Them Something to Do – Part 2

Another way to make sure that people continue to attend your meeting is giving them something tangible to do. Believe it or not when most people are asked to do something they feel a responsibility to do it. So it is important when someone volunteers an idea that the Chairperson at the Coalition meeting says, “That’s a great idea, can you make that happen? How will you make it happen and by when?” Most people come to Coalition meetings because they want to actively participate and get something done. And tangible projects and work will make people feel like the Coalition meeting is more than just a meeting.

After every meeting there should be action items that Committee members are responsible for. If there are no action items then you have a problem. In addition, it helps to space meetings out so that they are not too often or too few. Timing is everything. Our Coalition Committees meet approximately six times a year. Sometimes if there is an event or project it may be necessary to meet more often. But do not meet more often than necessary.

Sometimes attendance at meetings is arbitrary but in general there are some variables we can control that will positively effect whether or not somebody comes back to another Coalition meeting and most times these variables are very simple.

Want Good Meeting Attendance – Feed People and Give Them Something to Do – Part 1

The San Francisco Immunization Coalition has four working committees and an Advisory Board. Over my four year tenure at the Coalition each one of these committees has had growth and attrition in membership. Sometimes a committee will lose its chairperson or a few members that had a lot of energy. Some times attendance falls on a particular committee for no reason. In general, I do not worry too much if a meeting has low attendance as long as the committee is getting things done. But lets face it – a Coalition only functions as well as its members are willing and allowed to participate. We have learned there is one really effective and relatively cheap way to assure decent attendance at Coalition meetings – it is called food.

A couple of years ago our Marketing/Outreach Committee was sputtering. Attendance and energy were down. For a change of pace we decided to hold our meeting at the local Chevy’s Mexican restaurant. We scheduled the meeting at 3:00p.m. (which is dead time at Chevy’s) and told Coalition members that the Coalition would buy them an appetizer and a drink for attending. A magical thing happened – this committee has been producing amazing things ever since. This Committee meeting is now always held at Chevy’s. Of course we can’t attribute all the change in this committee to the change of meeting location but it does have a noticeable effect on the mood of the meeting. The good thing about Chevy’s is that they serve free chips and salsa, the bill for each meeting is rarely over $40 and for that we get a free meeting place, free chips and salsa, and a fun atmosphere to do the work of the Coalition. It also allows Coalition members to get out of their office buildings and gives them an incentive to come to our meeting. Ever since then the Coalition has been providing food at most Coalition meetings. Luckily, San Francisco has a wealth of relatively cheap and good restaurants. In general I try not to order the standard pizza or Chinese food and really try to do my research and introduce members to new cuisine that they may have never been aware existed. In general, this doesn’t cost the Coalition that much – maybe $2000 a year. But what it does is provide that extra incentive for members to come to a meeting and participate. You can even get local restaurants to donate the food. And in general healthier foods make people less sluggish and better ready to work in a meeting. A committee in a carbohydrate-induced coma is not the most productive committee. So consider feeding your Coalition members good food taking them on a local culinary tour of your town or city at every meeting. It works!

The Other Person’s Shoes

I am always saying in meetings and presentations that Coalitions exist to fill the gaps between the public and private sectors and between organizations. For some people this may sound very obscure or esoteric. Gaps between the public and private sector? Between organizations? What the heck does that mean?

Well in immunizations it means this. Vaccines are developed and manufactured by the private sector. They are regulated, recommended, promoted and to a large part distributed in the public sector. There are different organizations responsible for making the vaccines, administering them, making sure they are effective and safe, and making sure everyone is getting them. Unfortunately, these different organizations do not always talk to each other. They do not always have meetings together on a regular basis. They do not always understand the environment the other organization is in. There is information that each has that will benefit the others. That is where Coalitions come in.

One the main strengths of immunization coalitions are to have people from diverse backgrounds and diverse incentives sitting around the table talking to each other. In immunization we know that neither diseases nor patients stay in the confines of one organization. They move around and so therefore it requires a broader approach to solving problems.

At any given San Francisco Immunization Coalition Committee Meeting (we have four committees) you may have a public health nurse, a private pediatrician, a school health worker, a pharmaceutical representative, a community clinic manager, a health plan representative, a Coalition Director (me), a community college instructor, a government health official (State and/or local), and a regular community citizen all sharing information about immunization and finding new ways to prevent disease. This is not the only strength of Coalitions but it is a facet that should not be overlooked. Any economist (I am one myself) will tell you that a lack of information by members is the biggest impediment to building a perfect system/society. Getting diverse groups to share information is a powerful step in finding solutions to huge problems in immunization and in society. Successful Coalitions recognize this and act as a conduit for the flow of this information.