Medicine Wins Passage of Legislation to Improve Immunization Rates
ine Legislative Affairs Feature -- July 2003
By Ken Ortolon
On April 30, 27-day-old Serena King died of pertussis. The Austin infant was too young to have received immunizations that might have protected her from the disease. Her family blamed her death on the fact that someone who should have been immunized came into contact with the child.
"Serena's death was totally preventable, but someone made a bad decision not to get immunized for whooping cough," her grandfather, Troy Richabaugh, said in a letter to newspapers across the state.
While Serena's death is a tragedy for her family, there may be some consolation for them because it focused attention on the need for Texas to do a better job of immunizing its children against vaccine-preventable diseases. Just days after her death, Texas lawmakers sent two bills to the governor that physicians believe will significantly boost the fight to improve immunization rates. And, two other immunization measures that looked like they might bog down in the legislative process also gained final passage during the final week of the Texas legislative session.
Improving Physician Performance
While Texas has made great strides in improving immunization rates over the past decade, it ranked a lowly 42nd nationally in 2001 for children between 19 and 35 months who had received the full schedule of immunizations recommended by the Advisory Committee on Immunization Practices. The Texas rate was 74.9 percent, compared with a national rate of 78.6 percent.
Senate Bills 40 and 43, authored by Sen. Judith Zaffirini (D-Laredo) and sponsored in the House of Representatives by Rep. Jaime Capelo (D-Corpus Christi), sought to improve the Texas rates through educating physicians and the general public. The two bills were part of a larger immunization package backed by the Texas Medical Association, the Texas Pediatric Society (TPS), and numerous other physician and public health advocacy groups. Improving immunization rates was among TMA's top legislative priorities.
SB 43, which was signed into law by Gov. Rick Perry, directs the Texas Department of Health (TDH) to report to the legislature in 2005 the results of a Houston pilot project designed to help physicians improve immunization rates in their practices. TDH also will make recommendations about expanding the program statewide.
The Educating Physicians in Your Community (EPIC) pilot is a joint project of TPS, Baylor College of Medicine, and Texas Children's Hospital of Houston. Funded by grants from TDH and the U.S. Centers for Disease Control and Prevention (CDC), the project is a peer-to-peer initiative to provide quality, practical education to help medical practices identify procedures that will increase immunization rates, including reminder systems to alert parents when their child is due for an immunization and standardized forms that can be placed in the child's chart so the doctor is aware of the child's immunization history at each visit. The pilot also stresses participation in the Vaccines for Children (VFC) program to reduce barriers to immunization for uninsured children. The pilot involves 100 pediatric and family medicine practices in Houston.
Casey Blass, chief of the TDH Bureau of Immunization and Pharmacy Support, says the project seeks to replicate a program that originated in Pennsylvania and showed "promising results." That prompted CDC to fund the Houston project and a handful of others across the nation to see if similar results could be obtained.
"Basically, it is a model that matches peers within an office setting so a physician will work with a physician, a nurse with a nurse, an office manager with someone with that background," Mr. Blass said. "And they help them examine their systems to improve immunization rates within that practice."
San Angelo pediatrician Jane Rider, MD, a member of TMA's Council on Legislation, says educating physicians and their office staffs can have a significant impact in getting more kids immunized.
"Physicians think they're doing a good job immunizing their patients; that's what they want to do," Dr. Rider said. But doctors may not be doing as good a job as they think, she adds.
That was the case in her own practice in 1984, when she allowed her immunization records to be reviewed as part of a research project. "When my records were reviewed, I found out I wasn't doing as good a job as I thought I was."
Dr. Rider says EPIC might be taken statewide in the 2005 legislative session if it is successful in getting more kids immunized.
Getting the Message
While SB 43 targets physicians, SB 40 concentrates on educating parents about the importance of immunizations. The bill, which was still awaiting the governor's signature in late May, directs TDH to carry out a continuous statewide education campaign similar to the Shots Across Texas program of the mid-1990s.
Shots Across Texas was a public-private partnership between TDH and numerous public health stakeholders, including TMA and the TMA Alliance. Local coalitions in all 254 counties participated. Between 1994 and 1996, the campaign helped boost immunization rates from 40 percent to 71 percent.
While the formal campaign ended in 1996, components of it were absorbed into the general work of the TDH immunization division, and funding for the local coalitions decreased.
"I think it's very important that we resume this effort," Dr. Rider said. "We need to constantly remind the public, the mothers and fathers of our children, of the fact that their children are healthy now because we don't face the diseases of the past. In order for that to continue to be true, we need to continue with our immunizations and not forget about them."
Senator Zaffirini says despite the success of Shots Across Texas, state health officials let the program wane. "As soon as our age-appropriate immunization rates started improving, the department dropped it," she said.
Senator Zaffirini, however, says she is encouraged that Commissioner of Health Eduardo Sanchez, MD, has made immunizations one of his top priorities. In fact, TDH already was working to ramp up a new education campaign before SB 40 passed.
Mr. Blass says TDH is working with TMA, the TMA Alliance, and other partners to regenerate the public-private partnerships necessary to carry out the campaign. TDH also has been working with an advertising agency to develop new messages for the public.
The next step is identifying funds and making media buys. The legislature has appropriated no new funds for the project, so success will depend on the partners' ability to attract funding.
"We have in the past year or two begun identifying portions of our federal grant monies to use for this purpose," Mr. Blass said. "We hope to use that as a seed and build on it. As with Shots Across Texas, we will look for more public-private partnerships to build on the resources we already have."
Two other measures that passed with just five days remaining in the session will provide even more help. House Bill 1920, by Representative Capelo and Senator Zaffirini, requires TDH to develop continuing education for physicians and other health care professionals about the VFC program, and makes it easier for them to enroll as VFC providers. Physicians and other health care professionals could enroll in the program on the same form used to apply as a Medicaid provider.
HB 1921, also by Representative Capelo and Senator Zaffirini, would improve the state's immunization registry, known as ImmTrac.
Currently, parents must "opt-in" to have their child's immunization records included in the registry, and either physicians or health plans may verify the parents' consent. TMA lobbyist Stephen Brown says the amount of data going into the registry has been spotty because of the confusion associated with consent verification and the subsequent liability concerns.
Originally, HB 1921 would have changed that to an "opt-out" system, in which all immunization records would go into the system unless a parent specifically asked that they be excluded. Some parents groups concerned about the privacy of their children's medical records opposed that approach. As the result of months of negotiations with House members, modified language was drafted that maintains the opt-in registry but makes it easier for physicians and others to report immunization records.
The bill allows both physicians and health insurance companies to send immunization histories directly to TDH when consent is verified, removes liability for physicians and payers who access or submit information to the registry, provides for one-time consent for inclusion in the registry, and adds a signature line next to the opt-in box on the birth certificate application.
Dr. Rider says that approach takes the burden off physicians to obtain and verify consent for the records to be included in the registry, and it should make it more functional.
"It's only common sense that if we have a registry that's well used, then we can find the areas of the state or the areas within a community where children haven't been immunized adequately and we can focus our resources there," she said. "Having a functional registry enables us to use our resources intelligently."
Senator Zaffirini was disappointed that the opt-out language was removed, saying the compromise "significantly weakened" the bill. Supporters of the measure, however, believe it will increase the amount of data in the registry and ImmTrac's usefulness through increased participation and a simplified consent process.
While passage of the immunization package was a major victory for medicine, the good news was tempered somewhat by a late maneuver by Sen. Craig Estes (R-Wichita Falls) to make it easy for a family to arbitrarily decide not to have a child immunized. Senator Estes succeeded in tacking an amendment onto a bill to reorganize state health and human services agencies that allows families to object to immunization of a child if a sibling had an adverse reaction. The provision contains no definition of adverse reaction, leaving room for something as innocuous and common as a fever to be deemed an adverse reaction.
The provision also allows families to object on grounds of religious tenets, but removes the definition of what constitutes a religion, and allows objections to immunization based on a doctor's opinion, but requires no medical examination. Finally, the provision would allow children who are not immunized to attend school with other children.
Ken Ortolon can be reached at (880) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.