Initiative raises awareness of Tdap recommendations

Health plan honored for working to reduce pertussis

A multi-pronged approach to improving immunization rates for members, particularly infants and adolescents, has earned recognition for Independence Blue Cross from the Pennsylvania Immunization Coalition (PAIC).

The Philadelphia-based health plan was honored with the PAIC Immunization Champion Award for its collaborative work with the Pennsylvania Department of Health to reduce the rising instance of pertussis.

"Immunization awareness is just one of the many ways we work to improve access to quality, affordable health care in the region, promote community wellness, and improve the health of our members," says Esther J. Nash, MD, senior medical director of population health and wellness at Independence Blue Cross.

The health plan has promoted immunizations for many years, updates the recommendations each year, and provides coverage for recommended immunizations across all managed lines of business, Nash adds.

"In recent years, there have been changes in the recommendations as well as new recommended vaccines that mean more visits to health care providers. The key issue is to assist the patients and doctors in keeping up with the increasing number and changing recommendations for vaccinations," she says.

Most recently, the health plan has partnered with the Philadelphia Department of Health to create awareness of the expanded recommendations for administering the Tdap vaccine (diphtheria, tetanus, and acellular pertussis).

Barbara Watson, MD, PhD, of the division of disease control at the Philadelphia Department of Health proposed a collaborative effort to combat the rising instance of pertussis (whooping cough) in the Philadelphia area.

"She was concerned about the number of cases in pertussis, particularly among adolescents and adults. We collaborated on ways to ensure compliance with the new recommendations for expanded use of Tdap," Nash says.

When the pertussis vaccine was developed in the 1940s, the number of cases of the disease dropped dramatically, according to Donna Mulgrew, RN, BSN, senior preventative health coordinator for Independence Blue Cross.

"Since the 1980s, the number of reported cases has been creeping up, particularly among adolescents and adults," she adds.

New recommendations call for adolescents between the ages of 11 and 18 to receive a single dose of Tdap, instead of the tetanus and diphtheria booster given in the past, and for adults to receive at least one booster, she says.

"We now recognize that the immunity to pertussis that people develop through their childhood vaccinations wears off in many people as they grow older. How long the immunity lasts cannot be predicted but it can wear off or get to such a low level that people could have pertussis as an adult," Mulgrew says.

Pertussis in adults is a prolonged illness with severe coughing over a long period of time, she adds.

"In the past, it was recommended that adults receive the diphtheria and tetanus booster every 10 years. Now, recommendations call for at least one of those boosters to be the Tdap vaccine," she adds.

Boosting the immunity of adults not only protects them from a lengthy illness, it also prevents them from transmitting the disease to infants with whom they come in contact, who are at serious risk for complications of the disease, she adds.

"Parents and grandparents of infants or adults who care for babies need good immunity to pertussis. Over 60% of infants who develop pertussis have to be hospitalized. The disease is fatal in a significant number of cases," Mulgrew says.

The health plan's educational efforts focused on pregnant women, adolescents and their parents, and health care providers, informing all three groups about new recommendations for the Tdap immunization.

"We are particularly proud of our immunization outreach for adolescents. We took a creative approach to engage this age group and it paid off," Nash says.

The company designed a special web site for adolescent members and offers the chance to win a reward if they receive the vaccination. Families with children in this age group receive regular mailings educating them on the importance of keeping their vaccinations up to date.

"There have been a lot of changes in recommendations for immunizations for adolescents. Now, it's recommended that all adolescents receive the Tdap booster and the meningitis vaccine and that female adolescents receive the human papillomavirus vaccine. It is preferable for adolescents to receive the Tdap booster between 11 and 12 and that's who we target in our mailings," Nash says.

Independence Blue Cross HEDIS data for 2007 show that 81% of adolescents received all necessary immunizations in 2006, which puts the company in the 90th percentile of all health plans.

The health plan's Baby Blueprints program sent out targeted mailings on immunizations to pregnant members, advising them to discuss their immunization status with their health care provider and to make sure that whoever would be in contact with their newborn had received the vaccine.

"Ideally, a woman should receive Tdap before becoming pregnant but if they were already pregnant, we recommended that they receive the vaccine immediately after delivery," Mulgrew says.

Information on the recommended immunizations for infants and their caregivers is provided on the health plan's web site, through telephone outreach and targeted mailings to pregnant women enrolled in the company's Baby Blueprints maternity education program.

Perinatal nurse case managers who work with members in the health plan's high-risk pregnancy program received specialized training on Tdap and educate their clients on the importance of that and other childhood vaccinations.

The health plan sent updates to providers through its Clinical Update magazine, alerting them to the national Advisory Committee on Immunization Practices (ACIP) recommendations for expanding the use of the Tdap vaccine.

In addition, the insurer encourages providers to participate in the Philadelphia Department of Health's KIDS Immunization Registry, an electronic database of pediatric immunizations for children residing in Philadelphia County. The health department uses the information to identify under-immunized children and target them for outreach.