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Program Details


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Practice Type: Model
Program Name: Colorado Circle of Protection Tdap Program
Organization: Tri-County Health Department
Web site:
Overview: Colorado Circle of Protection Tdap Program
Year Submitted: 2011
Responsiveness and Innovation: Pertussis is the most common vaccine-preventable disease. According to the Centers for Disease Control and Prevention (CDC), pertussis rates have risen significantly in the U.S. since the 1980’s, with most notable increases since 2004. Mortality rates in infants have also increased. Pertussis remains a prevalent disease due to the fact that immunity wanes five to ten years following DTaP vaccination. In addition, unlike some other childhood diseases, having acquired the pertussis disease does not provide lifetime immunity against the disease. The CDC’s Advisory Committee for Immunization Practices (ACIP) recommends a five-shot series of DTaP vaccinations for all infants at two months, four months, six months, fifteen-eighteen months and another between the ages of four and six years. A booster Tdap dose is recommended for adolescents between the ages of ten and eighteen years of age. Additionally, any adult needing a booster dose of Td is advised to receive a one-time dose of Tdap if between the ages of 19-64 years of age. Because the maximum benefit for protection against pertussis is not achieved until an infant has received at least three doses of DTaP, infants under the age of six months who have not yet begun the vaccination series are most vulnerable to pertussis, as are unvaccinated infants under twelve months of age. Research has shown that infants most often contract pertussis from family members. In order to protect these young infants, the ACIP recommends all adolescent and adult women of childbearing age receive a Tdap booster before becoming pregnant. Pregnant women who were not previously vaccinated should receive a Tdap booster postpartum. All other children in the household should remain up to date with their immunizations. In addition, a booster dose of Tdap is encouraged for fathers of newborns and other close family members. Incidences of healthcare workers spreading pertussis to infants and other patients have been reported. The ACIP and the American College of Occupational and Environmental Medicine (ACOEM) has recommended to hospitals that all healthcare workers (HCW) with direct patient contact be vaccinated with Tdap to decrease the spread of pertussis.
Agency and Community Roles: TCHD has taken the lead role implementing the Colorado Circle of Protection program. It was a TCHD public health nurse who saw the need for education and promotion on pertussis awareness and the need for Tdap vaccinations among hospital personnel. A TCHD nurse manager saw the potential of this idea and approached the state health department to share the idea, eliciting an interest to collaborate on this project. TCHD then formed a taskforce team to begin discussion on ways to implement such a program. TCHD chose the pilot hospital for this program and met with the birthing unit directors and the infection prevention coordinator to discuss participation in this program. After that, the state health department committed to providing 3000 doses of Tdap for the pilot program. Vaccine was sent to TCHD to distribute for the program. TCHD is also the main contact for all of the nine birthing hospitals within their jurisdiction, the Children’s Hospital, and the pediatric clinic participating in the pilot program.
Costs and Expenditures: In response to the increase in cases of pertussis in recent years and the need to protect infants from pertussis, the Colorado Department of Public Health and Environment (CDPHE) and Tri-County Health Department (TCHD) invited area hospitals and physicians to collaborate to address the issue. Through this collaboration, a pilot program was developed in October 2009 called, “The Colorado Circle of Protection.” Knowing that adults caring for infants are most likely to spread pertussis to infants, the goal of this program is to cocoon infants from pertussis by vaccinating the adults around them with the tetanus, diphtheria, and pertussis (Tdap) vaccine. To achieve this goal, objectives were set to increase awareness of the dangers of infant pertussis and the need for adult Tdap; to increase vaccination rates in hospital health care workers working with infants; and to increase Tdap vaccination rates in parents of infants. To address these issues, TCHD initiated a pilot program providing Tdap vaccine to a local birthing hospital to vaccinate health care providers working with infants as well as postpartum moms prior to hospital discharge. In exchange for the free vaccine, the hospital was asked to educate new mothers about the dangers of infant pertussis and the importance of adult Tdap vaccination to prevent infant pertussis. TCHD provided coupons to the hospital to give to the new mothers so that dads, grandparents, and other infant contacts without insurance or family physicians could receive a free Tdap vaccine at a TCHD clinic. All nine birthing hospitals and a children’s hospital within the Tri-County jurisdiction were invited to participate in the program. To date, eight of the nine birthing hospitals are participating in the program, with the remaining hospital scheduled to begin in January 2011. The hospitals are asked to track how many Tdap vaccinations are given each month as well as how many people decline. If a Tdap vaccination is declined, the hospitals track the reasons and include that information in their monthly reports. The hospitals participating in the program since the beginning are averaging 75-85% vaccination rates for new mothers prior to hospital discharge. The program has recently expanded to include a pilot pediatric office and is working on including a pilot OB/GYN office. Future plans are to expand the program to other pediatric and OB/GYN offices in the TCHD area, as well as promoting Tdap use in emergency departments instead of the Tetanus diphtheria (Td) vaccine.
Implementation: Pertussis is the most common vaccine-preventable disease. According to the Centers for Disease Control and Prevention (CDC), pertussis rates have risen significantly in the U.S. since the 1980’s, with most notable increases since 2004. Mortality rates in infants have also increased. Pertussis remains a prevalent disease due to the fact that immunity wanes five to ten years following DTaP vaccination. In addition, unlike some other childhood diseases, having acquired the pertussis disease does not provide lifetime immunity against the disease. The CDC’s Advisory Committee for Immunization Practices (ACIP) recommends a five-shot series of DTaP vaccinations for all infants at two months, four months, six months, fifteen-eighteen months and another between the ages of four and six years. A booster Tdap dose is recommended for adolescents between the ages of ten and eighteen years of age. Additionally, any adult needing a booster dose of Td is advised to receive a one-time dose of Tdap if between the ages of 19-64 years of age. Because the maximum benefit for protection against pertussis is not achieved until an infant has received at least three doses of DTaP, infants under the age of six months who have not yet begun the vaccination series are most vulnerable to pertussis, as are unvaccinated infants under twelve months of age. Research has shown that infants most often contract pertussis from family members. In order to protect these young infants, the ACIP recommends all adolescent and adult women of childbearing age receive a Tdap booster before becoming pregnant. Pregnant women who were not previously vaccinated should receive a Tdap booster postpartum. All other children in the household should remain up to date with their immunizations. In addition, a booster dose of Tdap is encouraged for fathers of newborns and other close family members. Incidences of healthcare workers spreading pertussis to infants and other patients have been reported. The ACIP and the American College of Occupational and Environmental Medicine (ACOEM) has recommended to hospitals that all healthcare workers (HCW) with direct patient contact be vaccinated with Tdap to decrease the spread of pertussis.
Sustainability: Although the program’s free Tdap vaccine funding through the state health department will terminate July 1, 2011, there is sufficient stakeholder commitment to continue this practice in the hospitals without continued state funding. Before implementing their individual programs, all hospitals received evidence-based articles supporting ACIP guidelines for Tdap vaccinations for mothers postpartum and health care workers in direct contact with infants. Many hospitals were already considering implementing a Tdap program for mothers postpartum, so the offer of free vaccine solidified their desire to begin. The educational trainings provided to the hospitals by the TCHD nurse emphasized the dangers of infant pertussis, the public health impacts of pertussis including the average number of days an adult with pertussis misses work, and the financial impacts of nosocomial pertussis transmission in hospitals. Prior to notification of Tdap funding termination, the public health nurse notified each hospital of the total number of Tdap vaccine given at their facility to date. Also included was the financial impact of the potential savings to the community for the vaccines given based on research of the economic burden of pertussis (Forsyth, K.D.; Campins-Marti, M.; Cherry, J.D.; et al, 2004). Each hospital had potentially saved the community significant amounts of money, ranging from $732,732 to $4,465,461 related to number of doses administered to mothers postpartum and health care workers. Feedback from hospitals after receiving the financial impacts indicated that seeing the potential savings for their facility and their community reinforced and validated their efforts. Following notification that free funding for Tdap will end, almost all birthing hospitals indicated that they will continue giving Tdap to mothers postpartum. Many now have standing orders in place that will continue after July 1. Because parents are not the patients at the children’s hospital and the pediatric clinic, sustainability of the program at both facilities is in question since they cannot bill for administering the vaccine to non-patients. While the free Tdap vaccine funding for the Colorado Circle of Protection Program will come to an end on July 1, 2011, the commitment of CDPHE and TCHD to collaborate with hospitals to protect infants from pertussis continues. At least through 2011, the TCHD public health nurse will continue as a liaison and offer public health interventions to the facilities, including offering additional pertussis educational trainings to new staff; providing coupons for close infant contacts without insurance or are underinsured to receive a reduced-cost Tdap vaccine at a TCHD clinic; offering strategies to maximize insurance reimbursement for mothers receiving Tdap postpartum; and continuing to collect data from hospitals on a monthly basis to record number of free Tdap vaccine given versus hospitals billing insurance for the vaccine. In addition, options for health department funding to provide Tdap vaccine to uninsured postpartum women is being considered so that they may continue to receive Tdap prior to hospital discharge. Health department promotion and outreach for cocooning infants from pertussis will continue, as future plans include a survey of TCHD-area obstetricians, nurse midwives, and other birth providers to determine their current Tdap practices and recommendations. Pertussis presentations by the public health nurse will be offered to obstetrical providers and their staff. Other plans to raise awareness include outreach to parent and community groups.
Lessons Learned:

 

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