So what went wrong?

If Texas was doing so well less than 10 years ago, why does the state currently rank so low? No one reason seems to explain the fall.

According to Candie Phipps, director of advocacy and health policy at the Texas Pediatric Society, the size of Texas and the dynamics of its population are major obstacles to proper immunization. “Texas is so big, and by having such a young population, we have more people to immunize and that tends to bring down our rates quite a bit,” Phipps says. 

Every day 11,000 babies are born in the U.S, and about 1,000 of these are born in Texas. Furthermore, the vaccination schedule for children under 6 years of age is complicated. Children in this age group require between 18 and 22 shots. Attempting to administer all of these shots and maintain an accurate, updated record on each vaccination is an enormous task.

Another reason for Texas’ poor performance could be the lack of a proactive approach in stressing to the public the importance of vaccinating children. “Texas spent no money last year on a public education campaign for immunizations,” Phipps says. “When people don’t understand the importance of immunizations, they tend to forget about them.” She says getting health care and immunization information to individuals along the border has proved especially problematic.

Jane Rider, M.D., a San Angelo pediatrician and the legislative chair of TPS, also points out a deficiency in public immunization education. “In the last four to six years, there has not been an emphasis on immunization in the state,” she says. “Adequate resources have not been directed toward immunizations.”

Insufficient health care coverage could be another factor. Some might be aware of the importance of vaccinations, but may not have the means to obtain them.

While recently reported vaccine shortages don’t affect the published CDC rankings, they could add another dimension to the problem in the near future. Shortages in measles-mumps-rubella, diphtheria-tetanus-pertussis and tetanus-diphtheria vaccines as well as others have the potential to diminish further the state’s immunization coverage.

Who’s got it right?

In the 2000 National Immunization Survey, North Carolina had the highest immunization level ranking: 87.6 percent of its children ages 19 to 35 months were completely immunized. The secret to North Carolina’s success is a combination of strategies used to promote vaccinations across the state, according to Laura Leonard, spokeswoman for the immunization branch of the North Carolina Department of Health and Human Services.

Along with 14 other states, North Carolina takes advantage of a system called universal vaccine purchasing, (UVP), where the state purchases vaccines in bulk, then distributes them to health care providers. “All children in North Carolina are eligible to receive free [required] vaccines,” Leonard says.

North Carolina also employs an immunization registry, a confidential, computerized information system used to collect vaccination data about all children within a specific geographic area. If all parties participate fully and the vaccine registry is complete, it can be an excellent tool in the stewardship of public health. It can be used to help keep kids up to date on their shots and to prevent unnecessary doses administered by multiple providers. Most importantly, a well-maintained registry can help state and local health officials target under-immunized pockets of the population.

“Because we don’t have infinite resources in this state, we need to direct them where the problems really are and not be spending a lot of money where the problems really aren’t,” Rider says. “I think everybody benefits from having the data and being able to design a program that really targets the areas where the problems are.”

In North Carolina, 100 public health departments report their immunization data to one statewide registry. These smaller health departments are active in doing their parts to promote high immunization levels by tracking and conducting follow-ups to keep children on schedule with their shots.

Finally, North Carolina seems to have a general awareness of the lingering threat of disease. “The majority of the parents realize the importance of vaccines, both for their children and for the general public,” Leonard says.

Texas health care officials acknowledge that the low immunization rates in pre-schoolers is a problem, and they are working aggressively to fix it. TAFP, along with TPS, TMA and the Texas Academy of Internal Medicine, has produced a set of recommendations to address this problem with the goal of improving the health and safety of Texas children.

Keeping Track

The first recommended solution is to improve the state’s existing immunization registry, ImmTrac. In 1994, TDH and Electronic Data Systems, a private information technology provider, worked together to develop ImmTrac. The registry contains millions of records for more than 4.5 million children under 18 years of age.

The theory of maintaining an immunization registry is fairly simple. Following the birth of a child, the parent can register the child in ImmTrac by checking a box on the child’s birth certificate, indicating consent to participate in the program. The parent is asked to sign an ImmTrac release form at each of the child’s vaccination appointments. The party administering vaccines then reports its vaccination records to ImmTrac, where the statewide data are compiled.

But the reality is that the Texas immunization registry is not getting the job done. “Currently we’re not able to maximize the full benefits of a statewide registry because we don’t have a complete history on a lot of the children who are in ImmTrac,” Linville says. “ImmTrac’s potential is yet to be seen.”

ImmTrac currently functions as an opt-in registry, which means that parental consent is required before a child’s information can be included and updated in the registry. Furthermore, neither physicians nor health plans are obligated to report immunizations to the registry. All this adds up to a rather incomplete record.

“Oh, it’s a disaster,” says Phipps. “Ninety-nine percent of the children sign up for [the registry initially], but the physicians and health care plans don’t participate in it because it is such a burden to constantly check whether or not [the patients] want to remain within ImmTrac.

“The paperwork burden on physicians is just through the roof,” Phipps adds, pointing out a major factor in physician non-participation. “Our main request is to make [ImmTrac] an opt-out registry where you just assume the children are in it.”

Many agree that the paperwork deters providers from contributing information to the registry. Jane Rider, M.D., who has participated in ImmTrac for five years also admits that it is “a bit of a hassle,” and says that the extra work adds about three or four minutes to the vaccination process. When administering 20 vaccines a day, those extra minutes add up quickly.  Decreasing the time needed to report to the registry could increase overall participation in ImmTrac. 

Frequently issues surrounding parental consent hamper the updating of vaccination records in the registry. Physicians and health providers often are unable to give complete immunization information because of confusion over how consent is tracked or whether it has even been given. An opt-out registry could alleviate much of this confusion by automatically placing the child in the registry unless the parent specifically requests the child be removed. 

“I think getting the opt-out proposal should boost [physician] participation some,” Rider says. “A lot of providers have never heard of it, so there’s going to be a lot of provider education necessary.”

David Scott, director of the ImmTrac program, agrees. “There are groups pushing for [an opt-out registry], and that would increase the effectiveness the registry tremendously,” he says.

An incomplete registry, however, is not the only reason why Texas finished last in the 2000 NIS. “The Texas immunization registry is a tool that can be used to help raise immunization rates, but it’s not the cause of low rates nor would it be the cause of high rates,” Scott says. “There are a lot of other factors involved.”

Show me the money

One such factor is the cost of vaccines. Texas does not have universal vaccine purchasing, and the second recommendation is to conduct more research on UVP with the possibility of implementation.

Under UVP, the state would purchase and pay for all required vaccines for all children, regardless of income level or health insurance coverage. Using this program, state-regulated plans would cover vaccines mandated for school entry plus all vaccines recommended by the Advisory Committee on Immunization Practices, a panel of 15 experts chosen by the Secretary of Health and Human Services. This would most likely increase the number of children who receive their immunizations on time.  

In the 2000 CDC survey, seven of the top 10 states with the highest immunization rates used UVP. Of the bottom 25 states, 20 didn’t use UVP.

The Vaccines for Children program offers another opportunity to increase state reimbursement for the administration of vaccines. A vaccine currently costs a physician about $5.83 to administer, but the state only reimburses $5. The Centers for Medicare and Medicaid Services permits a much higher state maximum for administration fees.

Standardizing vaccine abbreviations and coding among public and private payers and pharmaceutical companies might also help end confusion and inconsistencies in the billing of vaccines.

Spreading the Gospel

Another recommendation is to institute a continuous, statewide education campaign, similar to the Shots Across Texas campaign of the mid-90s. A statewide alliance composed of local, regional and state health departments could improve coordination and communication efforts to raise immunization levels among children.

“We really need to push within the first two years of life, to publicize and encourage parents to get their children immunized rather than waiting for them to enter school,” Rider says. Every doctor’s visit should be viewed as “an opportunity to immunize,” she adds.

An education program must do more than convey the importance of immunizations. It has to dispel misconceptions associated with them. “Most of the time, the news points out the negatives of vaccines,” Linville says. “We would like to try to balance some of the negative things that come out.”

A recent TPS report refers to the need of education for vaccine providers, in addition to parents: “Provider vaccine education is extremely important. With ongoing changes in the recommended childhood immunization schedule and the addition of storage and administration requirements for new vaccines, health care providers must be better informed.”

Linville suggests launching education campaigns as well as distributing informative handouts to physicians and parents. Securing funding for immunization education has also proven a challenge, but Phipps says TPS hopes eventually to obtain grants and financial support to reinstate a statewide education program.

Andrew Eisenberg, M.D., chair of the TAFP Commission on Public Health and Clinical Affairs, says that TAFP has been working with TPS and TMA to put together these proposals in time for the 78th Legislative Session next January. “What we’re trying to do is gather together all interested parties…and formulate a plan for how the state can improve the health of all Texans,” he says. “One of the most cost-effective public health measures that we’ve ever come up with in the United States is the advent of vaccines and immunization for vaccine-preventable illnesses. The majority [of vaccines] are given in doctor’s offices and a lot of those are family physicians, so it’s incumbent on us to lead the way.”

The percentage of fully immunized children ages 19 to 35 months is dismally low right now in Texas. Something must be done to remedy this. At least Texans can be proud of their ranking in one area: the immunization rate of school-age children in Texas is actually very high.

“Our school-age kids are well-protected,” Linville says. “They’re 95 and 98 percent [covered] for all those vaccines. Our school-age children are not the ones we’re worried about at all. It’s the younger kids, the pre-schoolers. They’re the most vulnerable.”