Colorado Circle of Protection Tdap Program

State: CO Type: Model Practice Year: 2011

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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.

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Tri-County Health Department
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Colorado Circle of Protection Tdap Program
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.
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.
Agency Community RolesTCHD 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. ImplementationThe goal of the Colorado Circle of Protection program is to cocoon infants from pertussis by vaccinating the adults around them with the tetanus, diphtheria, and pertussis vaccine (Tdap). To achieve this goal, the program has the following three primary objectives: 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 increase awareness of the dangers of infant pertussis and to increase vaccination rates in hospital health care workers within the Tri-County Health Department (TCHD) three county area, the public health nurse from TCHD leading the project contacted the birthing unit directors at each hospital within the health department jurisdiction to inquire if the hospital had a Tdap program to vaccinate mothers postpartum and health care workers per the Advisory Committee for Immunization Practices (ACIP) guidelines. Hospitals were invited to partner with the health department to protect infants from pertussis. Free Tdap vaccine was given to hospitals to vaccinate health care workers in direct contact with infants and for mothers postpartum. The public health nurse coordinated and conducted educational trainings for hospital nurses and physicians on the dangers of infant pertussis, public health impacts of the disease, and the economic burden of pertussis. To increase Tdap vaccination rates in parents of infants, hospital nurses educated mothers about the dangers of infant pertussis and administered Tdap postpartum. Fathers and other close contacts of the infant were provided a coupon to access free or discounted Tdap vaccine at the local health department. The public health nurse also conducted educational presentations for divisions within the health department to raise awareness of the need for adult Tdap vaccinations for infant close contacts. Coupons were given to Women, Infant, and Children (WIC) offices within TCHD to educate new mothers and to distribute to clients receiving WIC services. A taskforce for the Colorado Circle of Protection program was formed in December 2008. Public Health Nurses from the local and state health departments as well as a pharmaceutical company representative met to discuss ways to raise awareness of the need for adult Tdap vaccinations to protect infants from pertussis within TCHD’s jurisdiction. A large birthing hospital was chosen to pilot the program. The Colorado Department of Public Health and Environment provided free Tdap vaccine to the hospital through TCHD in exchange for vaccinating hospital health care workers in direct contact with infants as well as mothers postpartum. The hospital began vaccinating health care workers in October of 2009, and began vaccinating mothers postpartum in November 2009. With the success of the pilot program, eight additional birthing hospitals in the TCHD area received invitations to participate in the program. The remaining hospitals implemented Tdap programs between July and November 2010. The children’s hospital and a large pediatric practice were also invited to participate in the Colorado Circle of Protection Program, both starting in September 2010.
The Colorado Circle of Protection program has the following three primary objectives: 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. For the first objective, to increase awareness of the dangers of infant pertussis and the need for adult Tdap, the program collected data on a program output related to the number of individuals trained. As hospitals in the Tri-County jurisdiction joined the program, the program nurse provided trainings for staff nurses and others who would have contact with infants. This training included the importance of understanding how pertussis affects adults and children, how young infants are the most adversely affected by pertussis, and how infants can be protected by vaccinating those around them. The nurse assigned to the program conducted the trainings with staff at five of the ten hospitals in the health department’s jurisdiction and the physician on the team has conducted trainings at three of the hospitals. Training opportunities have been offered to the remaining two hospitals. To date, the program nurse has trained 170 hospital nurses and other hospital staff on educating new families, 110 health department staff and 130 community partners. TCHD learned a great deal from the process of implementing this new program. First, for the success of a program of this kind, it is imperative for individuals involved to be passionate and committed to the long term success of the program goals. It was helpful not only to have people on the taskforce fully behind the program, but to recruit other community professionals equally impassioned about pertussis prevention at each of the hospitals and/or medical clinic. Having at least one program ‘champion’ in each facility increased the success of the Tdap programs at each facility, since peers are more likely to encourage and remind each other about educating patients. Staff educational trainings for hospital staff were found to be a great way to increase nurse advocacy about the need for pertussis prevention through vaccination. It was found that most adults, both physician and nurses included, don’t fully realize the current prevalence of pertussis, nor fully understand the dangers to infants when they contract pertussis. Sharing personal stories using parents’ comments and experiences in dealing with an infant in the NICU or losing an infant to pertussis helped to raise awareness for the importance of pertussis prevention and increased nurse advocacy in recommending Tdap to their postpartum patients. Feedback for the program was gathered in several ways. In order to determine the effectiveness of the educational trainings for hospital staff, pre and post surveys were given to staff nurses. Pre-presentation surveys indicated the majority of nurses had a neutral attitude or a somewhat strong belief in the importance of pertussis prevention. The majority of the nurses claimed to not routinely educate new mothers about the dangers of pertussis in infants and the importance of Tdap vaccinations. Post-presentation surveys showed a large increase in the nurses strongly in favor of pertussis prevention and in educating new moms about pertussis and the need for a Tdap vaccination. Many nurses also gave verbal feedback after the pertussis educational trainings. They indicated that the sound of the infant with a pertussis cough played during the training changed their mind about the importance of pertussis prevention and now they were planning on becoming vocal advocates for the Tdap program. Others gave feedback that hearing the stories of mother’s experiencing pertussis moved them to want to be better advocates for their patients. The pertussis educational training has been changed several times to include feedback after presentations. Changes to initial training presentati
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.
 
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