Building a Better Tomorrow (Rah, Rah, Vaccines!) Christoph Diasio MD FAAP Sandhills Pediatrics Southern Pines NC.

Building a Better Building a Better TomorrowTomorrow

(Rah, Rah, Vaccines!)(Rah, Rah, Vaccines!)

Christoph Diasio MD FAAPChristoph Diasio MD FAAPSandhills PediatricsSandhills PediatricsSouthern Pines NCSouthern Pines NC

DisclosuresDisclosures

I do not intend to discuss any I do not intend to discuss any unapproved uses of vaccines.unapproved uses of vaccines.

I do not have any financial interests I do not have any financial interests in vaccine companies.in vaccine companies.

The value of vaccinesThe value of vaccines

One of the greatest achievements of One of the greatest achievements of human beings in our time on Earthhuman beings in our time on Earth

Responsible for a greater reduction of Responsible for a greater reduction of suffering than anything except modern suffering than anything except modern sanitationsanitation

We have the best thing imaginable, an We have the best thing imaginable, an almost magic shield against horrors, and almost magic shield against horrors, and some parents don’t want it because of some parents don’t want it because of what they read on the INTERNET ??what they read on the INTERNET ??

Why do I care?Why do I care?

To be the parent/physician/nurse to a To be the parent/physician/nurse to a child is think about the potential of child is think about the potential of that lifethat life

I watched children die and suffer I watched children die and suffer horribly from vaccine preventable horribly from vaccine preventable diseases and we have the tools to diseases and we have the tools to prevent thisprevent this

JulieJulie

Otherwise healthy 2 yo girl from Otherwise healthy 2 yo girl from MississippiMississippi

Seen by PCP, dx pneumonia, Seen by PCP, dx pneumonia, appropriate abx appropriate abx worse, admitted c worse, admitted c approp. inpatient abx. approp. inpatient abx. worse, worse, flown to us at LeBonheur Children’s flown to us at LeBonheur Children’s (Memphis)(Memphis)

6 chest tubes, oscillator vent.6 chest tubes, oscillator vent.

JulieJulie

Original blood culture- Strep Original blood culture- Strep pneumoniae (sensitive to EVERY abx pneumoniae (sensitive to EVERY abx tested)tested)

From Mississippi, so they had not From Mississippi, so they had not started PCV7 yet.started PCV7 yet.

Likely a preventable illnessLikely a preventable illness Survived! A HUGE save!Survived! A HUGE save!

Seriously, you want to believe Seriously, you want to believe Jenny McCarthy?Jenny McCarthy?

How do I argue with a media personality?How do I argue with a media personality? Lots of ways to approach the anti-vax/vax Lots of ways to approach the anti-vax/vax

hesitant. Start by asking why?hesitant. Start by asking why? The most effective technique is to explain The most effective technique is to explain

to them that “my children and every child to them that “my children and every child of the staff in this clinic is UTD on the of the staff in this clinic is UTD on the _standard_ schedule”_standard_ schedule”

Dr BobDr Bob

The Starbucks theory of VaccinologyThe Starbucks theory of Vaccinology If it is different for my unique child, it If it is different for my unique child, it

must be better! (does the half-caf., twist must be better! (does the half-caf., twist of lemon, frappucino _really_ taste that of lemon, frappucino _really_ taste that much better?)much better?)

Modern vaccine schedule is NOT an Modern vaccine schedule is NOT an accident- the conclusion of literally 100’s accident- the conclusion of literally 100’s of person-years of research and evidenceof person-years of research and evidence

Dr Bob- It’s just his opinionDr Bob- It’s just his opinion

History contextHistory context

Smallpox was an unbelievable Smallpox was an unbelievable scourge of humanityscourge of humanity

So awful that people would So awful that people would voluntarily infect themselves voluntarily infect themselves (variolation) with smallpox hoping for (variolation) with smallpox hoping for a milder casea milder case

Cowpox/Edward Jenner- major Cowpox/Edward Jenner- major success but rapid pushback against success but rapid pushback against compulsory vaccinationcompulsory vaccination

PolioPolio

Killed and crippled 1000’s of children in Killed and crippled 1000’s of children in America aloneAmerica alone

Cutter lab incident- in rush to distribute Cutter lab incident- in rush to distribute vaccine post the initial Salk trial, vaccine post the initial Salk trial, manufacturing error led to infected children manufacturing error led to infected children from the vaccinefrom the vaccine

Modern genesis of anti-vax themes in AmericaModern genesis of anti-vax themes in America Govt is hiding infoGovt is hiding info Conspiracy btw docs/pharma/gov’tConspiracy btw docs/pharma/gov’t

Disparate timing of flu vaccine Disparate timing of flu vaccine delivery VFC vs privatedelivery VFC vs private

Section on Practice mgt of AAP listservSection on Practice mgt of AAP listserv #1 topic is flu vaccine- delays in delivery, #1 topic is flu vaccine- delays in delivery,

cost, wastage etccost, wastage etc Last season multiple complaints on listserv Last season multiple complaints on listserv

about delays in VFC vaxabout delays in VFC vax webbased convenience sample survey donewebbased convenience sample survey done

Significant variation btw delivery of 1Significant variation btw delivery of 1stst shipment shipment private vs VFC vaccine BY STATEprivate vs VFC vaccine BY STATE

Presented poster at National Immunization Conf. Presented poster at National Immunization Conf. in DC in DC

Disparate Timing In the Delivery of Influenza Vaccine In Pediatric Offices Disparate Timing In the Delivery of Influenza Vaccine In Pediatric Offices Tuesday, March 29, 2011Tuesday, March 29, 2011

Elizabeth Elizabeth SobczykSobczyk, MSW, MPH, MSW, MPH , Manager, Immunization Initiatives, American , Manager, Immunization Initiatives, American Academy of Pediatrics Academy of Pediatrics

Christoph Diasio, MD, FAAP , Pediatrician, Sandhills Pediatrics, Inc Christoph Diasio, MD, FAAP , Pediatrician, Sandhills Pediatrics, Inc Background:Background:  Children who receive Vaccines for Children (VFC) influenza   Children who receive Vaccines for Children (VFC) influenza

vaccine are less likely to be immunized than their privately insured counterparts. vaccine are less likely to be immunized than their privately insured counterparts. There is also evidence that administering vaccine in September and October There is also evidence that administering vaccine in September and October saves $6-9 million annually. Due to additional distribution steps, VFC vaccine saves $6-9 million annually. Due to additional distribution steps, VFC vaccine may be shipped later than privately purchased vaccine. Delays in VFC vaccine may be shipped later than privately purchased vaccine. Delays in VFC vaccine delivery create a disparity of care and place an extra burden on pediatric delivery create a disparity of care and place an extra burden on pediatric practices.practices.

Objectives:Objectives:  To assess the difference in the timing of VFC and privately   To assess the difference in the timing of VFC and privately purchased influenza vaccine delivery to private pediatric offices.purchased influenza vaccine delivery to private pediatric offices.

Methods:Methods:  In November 2010, a geographically diverse convenience sample of   In November 2010, a geographically diverse convenience sample of approximately 800 pediatricians was asked to complete a web-based survey.  approximately 800 pediatricians was asked to complete a web-based survey.  Physicians were ask to provide the exact date of delivery for their first shipment Physicians were ask to provide the exact date of delivery for their first shipment of VFC and privately purchased influenza vaccine.of VFC and privately purchased influenza vaccine.

Results:Results:  Fifty-seven pediatricians in 24 states completed the survey. The   Fifty-seven pediatricians in 24 states completed the survey. The difference between mean first delivery date of VFC and private multidose vaccine difference between mean first delivery date of VFC and private multidose vaccine is 4 weeks; between VFC and private preservative free vials is 4.5 weeks; is 4 weeks; between VFC and private preservative free vials is 4.5 weeks; between VFC and private FluMist is 6 weeks. Although many states only had 1 between VFC and private FluMist is 6 weeks. Although many states only had 1 respondent, several state-level observations were made. Five states (IL, PA, NY, respondent, several state-level observations were made. Five states (IL, PA, NY, NJ, and MD) received VFC influenza vaccine 6-12 weeks later than privately NJ, and MD) received VFC influenza vaccine 6-12 weeks later than privately purchased vaccine.  Three states (TN, NC and WA) did not report similar relative purchased vaccine.  Three states (TN, NC and WA) did not report similar relative delays. North Carolina received VFC vaccine as early as privately purchased delays. North Carolina received VFC vaccine as early as privately purchased vaccine but in small shipments.vaccine but in small shipments.

Conclusions:Conclusions:  In this limited sample, the delivery of VFC vaccine lagged behind   In this limited sample, the delivery of VFC vaccine lagged behind that of privately purchased vaccines, yet state-level variability exists. This that of privately purchased vaccines, yet state-level variability exists. This variability appears to be, in part, due to state-level ordering and distribution variability appears to be, in part, due to state-level ordering and distribution practices, creating disparity in care. States who distribute vaccine efficiently practices, creating disparity in care. States who distribute vaccine efficiently should share best practices with other VFC grantees. should share best practices with other VFC grantees.

Flu vax deliveryFlu vax delivery

Some states 9 weeks disparity!Some states 9 weeks disparity! (In NC ours arrived before private vax!)(In NC ours arrived before private vax!) Conclusion was state-level ordering Conclusion was state-level ordering

practices are responsiblepractices are responsible Federal system- CDC grants vax to Federal system- CDC grants vax to

states who determine who gets what states who determine who gets what whenwhen

Effective state govt is good!Effective state govt is good!

Flu disease can be badFlu disease can be bad

6 yo presented to ER- looked slightly 6 yo presented to ER- looked slightly dry, ER doc calls for admission dry, ER doc calls for admission

On arrival to floor, arrestsOn arrival to floor, arrests Code unsuccessfulCode unsuccessful

How do we get to scale for flu How do we get to scale for flu vax?vax?

Huge challenge! Vaccinate almost Huge challenge! Vaccinate almost entire patient population, but have entire patient population, but have private and VFC stock, and you won’t private and VFC stock, and you won’t know when you will get what!know when you will get what!

Ideas we triedIdeas we tried

Saturday flu only clinicSaturday flu only clinic Tent in parking lot- exam rooms with a Tent in parking lot- exam rooms with a

nurse per roomnurse per room Night clinicsNight clinics Express lane clinicsExpress lane clinics

1 nurse who only gives flu vax all day long1 nurse who only gives flu vax all day long Add-on flu vax formAdd-on flu vax form

FLU (SHOT) VACCINE PATIENT Today’s date:_________ Sandhills Pediatrics, Inc

Main ofc: 195 W Illinois Ave; Southern Pines, NC 28387; 910-692-2444 7 Lakes ofc: 1035 Seven Lakes Drive; Suite A; West End NC 28387; 910-673-1600 NAME ________________________________ DOB _______________________ Address:______________________________________phone____________________ Change of Insurance? YES NO Insurance Type _________________________ 90657 Bought State Flu 6-35months LOT#__________________________ 90658 Bought State Flu 3+ years 90471 Administration of first vaccine, no doc counseling 90465 First Vaccine Admin; Risk/Benefit counseled by provider __________ (provider initials) ICD-9 V04.81 for all above Vaccine screening questions: Yes No ___ ___ sick today ___ ___ allergy to food, meds, vaccines ___ ___ cancer, leukemia, AIDS, immune deficiency ___ ___ seizure or brain problem ___ ___ prolonged steroids, radiation therapy ___ ___ pregnancy or possible pregnant in next 1 month ___ ___ vaccination in last 4 weeks ___ ___ blood or IVIG in last 12 months I have received and had an opportunity to read the vaccine information sheets my child will have today. Ha recibido y he tenido la opportunidad de leer informacion sobre las vacunas antes de recibirlas mi hijo/hija. Signed _________________________________ Nurse signature __________________________ 0.25 mL given 0.5 mL given ____ SRS Flu given in:R Delt L Delt RAT LAT ____ NCIR

Online schedulingOnline scheduling

We gave over 8000 doses of flu We gave over 8000 doses of flu vaccine last year- if even a fraction vaccine last year- if even a fraction of those appts are made via internet, of those appts are made via internet, decreases call volumedecreases call volume

Measure what you do, and Measure what you do, and improve!improve!

Can’t manage what you can’t measure!Can’t manage what you can’t measure! P-lanP-lan D-oD-o S-tudyS-tudy A-ctA-ct Continuous Quality improvementContinuous Quality improvement

What works well in your clinic? What are What works well in your clinic? What are the barriers? Experiment and innovate!the barriers? Experiment and innovate!

StorageStorage

Vaccines are worth a lot of money!Vaccines are worth a lot of money! Need a temp. monitor/alarm system that measures Need a temp. monitor/alarm system that measures

liquid/glass bead temp in fridge (less swing than air liquid/glass bead temp in fridge (less swing than air temp c opening door)temp c opening door)

Consider a “purpose built vaccine fridge/freezer” non-Consider a “purpose built vaccine fridge/freezer” non-household fridgehousehold fridge

- you get what you pay for!- you get what you pay for!Need insurance to replace loss in case of fire, fridge Need insurance to replace loss in case of fire, fridge

death, fridge freezes vax, or HUMAN ERROR (door left death, fridge freezes vax, or HUMAN ERROR (door left open)open)-ask insurance co rep. “what could happen to make -ask insurance co rep. “what could happen to make your company not pay my claim” and file that email your company not pay my claim” and file that email away somewhere safe….away somewhere safe….

-may need a fridge maintenance contract!-may need a fridge maintenance contract!

A real A real vaccine vaccine fridgefridge

Varicella is NOT benign!Varicella is NOT benign!

Many parents (and some docs) think Many parents (and some docs) think of varicella as a “benign rite of of varicella as a “benign rite of childhood”childhood”

Pre-vaccine, 4 million cases with 100 Pre-vaccine, 4 million cases with 100 deaths/yrdeaths/yr

Superinfection with bacteria can be Superinfection with bacteria can be deadlydeadly

M-R-S-A widely prevalent now!M-R-S-A widely prevalent now!

Superinfected VaricellaSuperinfected Varicella

VPDs are horribleVPDs are horrible

Keep fighting the good fightKeep fighting the good fight Vaccination is the best way to Vaccination is the best way to

protect tomorrowprotect tomorrow

Keep building a better tomorrow!Keep building a better tomorrow!