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Program Details


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Practice Type: Model
Program Name: Tdap Education and Adminstration Program for Postpartum Mothers
Organization: Independence City Health Department
Web site:
Overview: Pertussis, or whooping cough, has reemerged in adolescents and adults due to the waning immunity of childhood vaccines, subsequently increasing the risk of transmission to susceptible populations, particularly infants. Pertussis in infants can lead to severe complications, increased hospitalizations, and death. The pertussis booster, Tdap, was licensed in 2005 and recommended for use on adolescents and adults ages 11-64 to prevent pertussis and extend immunity. Decreasing pertussis incidence would decrease the risk of exposure and illness in susceptible infants and the general population; however, many adults, including new parents, are not receiving education from providers and therefore are not getting the Tdap vaccine. Goal: Increase Tdap vaccination rates among postpartum women. The use of Tdap vaccine is high priority among public health agencies and should be a high priority in healthcare facilities, especially for new mothers in the immediate postpartum period. A Tdap Education and Administration Program integrated in healthcare facilities would prevent pertussis among adults and adolescents and thus protect the health and safety of infants and the population at large. A recommended program is to provide Tdap education to health care providers and patients and support administration of Tdap vaccine to household contacts of infants, specifically women of childbearing age and new mothers in the immediate postpartum period. Tdap vaccination rate increased; prior to September 2008 the immuization rate was 0%; from September 2008 to December 2008 the rate was 27%; from September 2009 to December 2009 the rate increased to 35%. Nursing staff report a “very positive” response to the program among patients and staff 100% of patients receive education on pertussis and are screened for and offered Tdap Posters and brochures are available on the unit 100% of OB and nursery staff are educated on pertussis and Tdap OB and nursery staff are also vaccinated with Tdap vaccine
Year Submitted: 2010
Responsiveness and Innovation: Despite high vaccination coverage among infants, pertussis continues to circulate in communities and cause infections. Though pertussis is preventable through vaccination, immunity wanes after five to 10 years causing adolescent and adult populations to be vulnerable to pertussis. Decreasing pertussis incidence among adolescents and adults, especially household contacts, could decrease the risk of exposure and illness to susceptible infants. The risk for severe pertussis and complications is highest among infants during the first six months of life and remains elevated until infants have received one to two doses of pediatric DTaP. Infants that are not fully protected from pertussis are at the highest risk for complications including pneumonia and hospitalizations. Infants under 12 months of age make up 19% of cases and 92% of pertussis deaths in the US from 2000–2004. Though there has been high vaccination for the primary series of infant immunizations, pertussis incidence in the infant population has increased from 34.2 cases per 100,000 in the 1980s to 103.5 cases per 100,000 in 2003 (Wendelboe et al., 2007). Since the pertussis vaccination became available in the 1940s, incidence decreased by 80%. However, since the 1980s, pertussis has been slowing increasing, especially among adolescent and adult populations due to waning immunity of childhood vaccines. Additionally, adolescents and adults with pertussis frequently are misdiagnosed leading to multiple medical visits, prolonged infectious periods, and increased potential of transmission to infants and the population. According to the CDC (2006), attack rates among household contacts exposed to pertussis with no immunity can be up to 80-90%. In a study from 1999–2002, 57% of pertussis exposures in infants was unknown; however, 32% of cases were identified as the mother, father, sibling, or grandparent (CDC, 2006). Studies reported by the Texas Children’s Hospital (2008) revealed that greater than 75% of infants get pertussis from infected family members. Results of multiple studies support the need for high rates of Tdap vaccination coverage among adult and adolescent populations in order to protect infants.Pertussis cases continue to be reported in the Independence community and surrounding areas, despite vaccination. Cases are seen in all ages with varying circumstances. Cases have been reported in infants too young for vaccination with a household contact that has had a prolonged cough. Ongoing outbreaks have been reported among adolescents in the local middle school due to their waning immunity. Adults have been diagnosed several weeks after having a cough, been misdiagnosed, and now potentially exposed numerous people and children. Many adolescents and adults do not believe they are at risk for pertussis because they were vaccinated as children. This practice provides the opportunity for education so new parents understand that they are susceptible to pertussis and that by vaccinating themselves, they are protecting their new susceptible infants. This practice addresses the issue by providing education to all postpartum women, as well as the OB staff. New families are educated on pertussis infection, transmission, risk factors, high risk groups, and vaccination. Every new mother will be screened for Tdap vaccine after delivery, and if eligible, vaccination will be provided before they leave the hospital. Pertussis in infants can lead to severe complications, increased hospitalizations, and death. Many women of child bearing age and new mothers are not receiving education from providers regarding Tdap vaccine. Tdap vaccine could be provided to these populations to extend immunity and therefore protect infants. Tdap was licensed in 2005 and recommended for use in adolescents and adults ages 11-64 to prevent pertussis which would decrease exposure to the infant population and decrease healthcare costs (CDC, 2006). Tdap has been recommended for contacts of infants since 2005, but some healthcare facilities have not applied this recommendation to practice. The recommendation is not new but application in the local hospital is. Additionally, there is no practice documented that has public health as the driving force behind hospital policy change related to pertussis prevention. This approach is different because it is a collaborative effort between a local hospital and and the local health department. The local health department took the iniative based on knowledge that vaccination nor education was occurring and known pertussis rates in the area. The local health department reviewed all of the research and CDC guidance and compiled into a quick, easy to read format. The local health department also survey area hospitals to determine their practices, many do not offer Tdap at all, some only for ER patients, and few offer to OB patients, but not as a part of standing orders with fulll physician support. The local hospital welcomed the health department into their quarterly OB/GYN meeting to present the findings and to recommend policy change. The hospital and health department work collaboratively to problem solve issues and write new policy. Additionally, because this new practice is now a part of standing orders. All patients are educated, screened, and offered vaccination. The health department fosters collaboration with the local hospital, physicians, other local health departments and the community. The staff at the Independence Health Department serves on various committees and coalitions with the shareholders to address various health issues including child safety, communicable disease, health and wellness in schools, emergency preparedness, etc. Shareholders have a voice in the health programs that the health department implements. Outcome data is routinely shared with the shareholders, including our Board of Health and City Council, for feedback on successes and input on ways to improve. The health department also sends out quarterly educational newsletters to healthcare providers, pharmacies, school nurses, childcare facilities, businesses, and the local nursing university. These newsletters encourage collaboration by educating them on current topics in public health, upcoming educational opportunities, changes or updates in pertinent laws or regulations, and other topics to improve their practice. Support of the appropriate community shareholders is vital to the success of health programs. With the practice of Tdap education and administration, having the support of the physicians, OB nurses, and hospital policy makers is critical to it implementation. Fortunately, because of the already strong working relationship that hospital and health department have, the recommendations were taken as an improvement measure that can be worked through collaboratively in order to protect patients and their infants.
Agency and Community Roles: The health department identified the problem and proposed development of new policy. The Independence Health Department took the lead in the review of CDC recommendations and current literature to support a policy change for the routine administration of Tdap vaccine to postpartum mothers at the local hospital. The health department partnered with the local university for access to the library in order to obtain current literature and evidence based strategies from peer reviewed nursing and public health journals. The health department also partnered with the Association of Professionals in Infection Control and Epidemiology (APIC) to survey metropolitan hospitals for their practices and policies related to Tdap. The health department compiled all of the information into a concise format and presented it to OB/GYN physicians, nursing and support staff, pharmacy and other policy makers at the hospital. After the policy change was implemented, the health department provided educational materials for patients and nursing staff. The health department has worked to collect data from the hospital on number of births and number of Tdap doses given for purposes of evaluation. The health department also monitors pertussis incidence in the community and state wide. The local hospital welcomed the health department into the quarterly OB meeting, coordinated the presentation and ensured adequate time was available to present and for questions. The hospital physicians and nursing staff were ultimately responsible for the final decision of whether to implement the proposed practice change into policy. Since they were in agreement, they wrote the new standing ordered and ensured appropriate hospital officials were aware of the change. The nursing staff is responsible for providing the education to each patient, screening patients, and administering vaccine. The hospital pharmacy staff provides the data on doses of Tdap given to the health department and the OB Director provides data on number of deliveries for a given time period.
Costs and Expenditures: The Independence Health Department took the lead in the policy change to routinely offer Tdap vaccination to postpartum women. The health department reviewed and compiled CDC recommendations and literature to support a policy change for the routine administration of Tdap vaccine to postpartum mothers at the local hospital. Current literature was reviewed for evidence based strategies with the support of the local univeristy library. In June 2008, the health department presented this information to OB/GYN physicians, nursing and support staff, pharmacy, infection control, and other policy makers at the hospital. Subsequently, in September 2008, a policy change occurred to include routine education and administration of Tdap vaccine to postpartum mothers as a part of standing orders. Public health staff time is provided through the City's General Revenue. Communicable disease investigations and prevention activities are a part of City Charter and therefore fully supported by the City. Vaccine is provided by the local hospital and is reimbursed through their routine reimbursement protocols.
Implementation: Despite high vaccination coverage among infants, pertussis continues to circulate in communities and cause infections. Though pertussis is preventable through vaccination, immunity wanes after five to 10 years causing adolescent and adult populations to be vulnerable to pertussis. Decreasing pertussis incidence among adolescents and adults, especially household contacts, could decrease the risk of exposure and illness to susceptible infants. The risk for severe pertussis and complications is highest among infants during the first six months of life and remains elevated until infants have received one to two doses of pediatric DTaP. Infants that are not fully protected from pertussis are at the highest risk for complications including pneumonia and hospitalizations. Infants under 12 months of age make up 19% of cases and 92% of pertussis deaths in the US from 2000–2004. Though there has been high vaccination for the primary series of infant immunizations, pertussis incidence in the infant population has increased from 34.2 cases per 100,000 in the 1980s to 103.5 cases per 100,000 in 2003 (Wendelboe et al., 2007). Since the pertussis vaccination became available in the 1940s, incidence decreased by 80%. However, since the 1980s, pertussis has been slowing increasing, especially among adolescent and adult populations due to waning immunity of childhood vaccines. Additionally, adolescents and adults with pertussis frequently are misdiagnosed leading to multiple medical visits, prolonged infectious periods, and increased potential of transmission to infants and the population. According to the CDC (2006), attack rates among household contacts exposed to pertussis with no immunity can be up to 80-90%. In a study from 1999–2002, 57% of pertussis exposures in infants was unknown; however, 32% of cases were identified as the mother, father, sibling, or grandparent (CDC, 2006). Studies reported by the Texas Children’s Hospital (2008) revealed that greater than 75% of infants get pertussis from infected family members. Results of multiple studies support the need for high rates of Tdap vaccination coverage among adult and adolescent populations in order to protect infants.Pertussis cases continue to be reported in the Independence community and surrounding areas, despite vaccination. Cases are seen in all ages with varying circumstances. Cases have been reported in infants too young for vaccination with a household contact that has had a prolonged cough. Ongoing outbreaks have been reported among adolescents in the local middle school due to their waning immunity. Adults have been diagnosed several weeks after having a cough, been misdiagnosed, and now potentially exposed numerous people and children. Many adolescents and adults do not believe they are at risk for pertussis because they were vaccinated as children. This practice provides the opportunity for education so new parents understand that they are susceptible to pertussis and that by vaccinating themselves, they are protecting their new susceptible infants. This practice addresses the issue by providing education to all postpartum women, as well as the OB staff. New families are educated on pertussis infection, transmission, risk factors, high risk groups, and vaccination. Every new mother will be screened for Tdap vaccine after delivery, and if eligible, vaccination will be provided before they leave the hospital. Pertussis in infants can lead to severe complications, increased hospitalizations, and death. Many women of child bearing age and new mothers are not receiving education from providers regarding Tdap vaccine. Tdap vaccine could be provided to these populations to extend immunity and therefore protect infants. Tdap was licensed in 2005 and recommended for use in adolescents and adults ages 11-64 to prevent pertussis which would decrease exposure to the infant population and decrease healthcare costs (CDC, 2006). Tdap has been recommended for contacts of infants since 2005, but some healthcare facilities have not applied this recommendation to practice. The recommendation is not new but application in the local hospital is. Additionally, there is no practice documented that has public health as the driving force behind hospital policy change related to pertussis prevention. This approach is different because it is a collaborative effort between a local hospital and and the local health department. The local health department took the iniative based on knowledge that vaccination nor education was occurring and known pertussis rates in the area. The local health department reviewed all of the research and CDC guidance and compiled into a quick, easy to read format. The local health department also survey area hospitals to determine their practices, many do not offer Tdap at all, some only for ER patients, and few offer to OB patients, but not as a part of standing orders with fulll physician support. The local hospital welcomed the health department into their quarterly OB/GYN meeting to present the findings and to recommend policy change. The hospital and health department work collaboratively to problem solve issues and write new policy. Additionally, because this new practice is now a part of standing orders. All patients are educated, screened, and offered vaccination. The health department fosters collaboration with the local hospital, physicians, other local health departments and the community. The staff at the Independence Health Department serves on various committees and coalitions with the shareholders to address various health issues including child safety, communicable disease, health and wellness in schools, emergency preparedness, etc. Shareholders have a voice in the health programs that the health department implements. Outcome data is routinely shared with the shareholders, including our Board of Health and City Council, for feedback on successes and input on ways to improve. The health department also sends out quarterly educational newsletters to healthcare providers, pharmacies, school nurses, childcare facilities, businesses, and the local nursing university. These newsletters encourage collaboration by educating them on current topics in public health, upcoming educational opportunities, changes or updates in pertinent laws or regulations, and other topics to improve their practice. Support of the appropriate community shareholders is vital to the success of health programs. With the practice of Tdap education and administration, having the support of the physicians, OB nurses, and hospital policy makers is critical to it implementation. Fortunately, because of the already strong working relationship that hospital and health department have, the recommendations were taken as an improvement measure that can be worked through collaboratively in order to protect patients and their infants.
Sustainability: Commitment by the hospital is ensured because, after being presented the facts by public health, they agreed with the proposed policy change and made Tdap administration a routine order for all patients. The hospital committed to this policy change; this is not a trial or pilot project. Communicable disease prevention is a core function of the health department and will remain our commitment. This policy change has been incorporated into the postpartum standing orders. Key stakeholders attending the OB meeting made the decision that this was a worthwhile policy change and therefore committed to it as a routine order for all patients. Financial costs to public health and the hospital would be minimal. Public health is committed to disease prevention, community education and partnership building with the hospital and will maintain those responsibilities.
Lessons Learned:

 

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