2013-2017 Oklahoma State
Department of Health
Strategic Immunization Plan
9/11/2012
OKLAHOMA STATE STRATEGIC PLAN TO INCREASE IMMUNIZATION RATES
AMONG CHILDREN, ADOLESCENTS and ADULTS
INTRODUCTION
One-in-four of Oklahoma’s children are inadequately protected against the basic series of
vaccine preventable diseases, as defined by the Centers of Disease Control and Prevention
(CDC). A recent analysis of Oklahoma’s immunization data by the National Immunization
Survey (NIS) reveals that just one more dose of the recommended 4:3:1:3:3 vaccination (4
DTaP, 3 Polio, 1 MMR, 3 Haemophilus influenzae b, 3 Hepatitis B) series would have a
significant increase on the coverage rate of Oklahoma children. Findings from the National
Immunization Survey (NIS) and analysis of OSIIS data will be reviewed as they become
available to determine vaccine coverage trends by antigen type, age group and other variables.
2012 NIS results reported that 77.3% of Oklahoma's two year olds were up-to-date with the 4-31-3-3-1 series compared to the national average of 79% up-to-date.
The Oklahoma State Department of Health (OSDH) Immunization Strategic Targeted Action
Team (STAT) was created in January 2010 and charged with developing objectives and an
action plan to improve immunization coverage rates among children 19-35 months of age. The
Team, in conjunction with the Oklahoma State Immunization Advisory Committee developed the
Oklahoma State Strategic Plan to Increase Immunizations among Children 19-35 Months of Age
and continues to addresses the following components: improving legislative and state agency
policies, creation of a redesigned Oklahoma state immunization registry (OSIIS), efforts to
improve parental outreach and access to immunization services, engaging communities with the
lowest immunization rates to initiate improvement strategies, and improved public education and
marketing. Consideration of vulnerable populations (racial and ethnic) is also included in the
plan.
Strategic Goal:
Increase 4:3:1:3:3:1 immunization rates of children 19-35 months from
77% to 85 % by 2017.
Existing Policies Impacting Children age 0-35 Months
Oklahoma has set in place several policies designed to enhance and support immunization
coverage improvement, including:


Oklahoma Childcare Rules – All children attending licensed childcare must be ageappropriately vaccinated. Current rules cover the primary 4:3:1:3:3:1:4 series (includes
one varicella and 4 pneumococcal conjugate). The OSDH is responsible for establishing
rules but enforcement is provided through the Oklahoma Department of Human Services
(ODHS). The OSDH Immunization Service also conducts vaccine assessments in at
least 600 daycare centers annually.
Oklahoma First Dollar Coverage Law – Enacted in 1997, this statute provides that health
benefit plans cover all state required vaccines for their members who are <19 years old.
This law also stipulates that required immunizations must be offered in the absence of
co-pays and deductibles. Companies that participate in self-insured plans are exempted
under this law.
2




OK By One Immunization Schedule – Implemented in 2004, the OK by One schedule
was adopted to “simplify” the childhood schedule for parents and providers and promote
children receiving the 4th DTaP as early as 12 months of age as an acceptable practice.
This campaign also stresses that it takes just 4 visits and immunizes against 13 vaccinepreventable diseases by 12 months of age. This schedule is compatible with the
recommendations of the Advisory Committee on Immunizations Practice (ACIP) of the
US Centers for Disease Control and Prevention (CDC), the American Academy of
Pediatrics (AAP) and the American Academy of Family Physicians (AAFP).
A vaccine for Children Program Delegated Authority – Beginning in 1995, Oklahoma was
the first state to designate underinsured children as eligible for Vaccines for Children
(VFC) vaccine in county health department clinics through a delegated authority
arrangement with a Rural Health Clinic. This practice will continue to affect thousands of
children statewide each year due to a new agreement with county health departments
recently signed in April, 2012.
Temporary Aid to Needy Families (TANF) – The current national policy is to restrict
financial assistance if children are not up-to-date on vaccinations. This policy is
enforced by Oklahoma Department of Human Services (ODHS). TANF clients will
receive a 25% reduction in benefits if their children's immunization status is not current
at the time of recertification.
VFC Participation among Medicaid Providers – In 2006, the Oklahoma Health Care
Authority (OHCA) adopted a policy requiring that all Medicaid participating primary care
providers serving children will be enrolled in the VFC program.
Participation in Oklahoma State Immunization Information System (OSIIS) among
Medicaid Providers – In 2009, the OHCA required their immunization service providers
to document all childhood vaccinations in the OSIIS registry.
Objective 1: Reduce or eliminate coverage disparities by race,
ethnicity, and socioeconomic status. Increase the 4:3:1:3:3:1 rates
among children 19-35 months old in identified areas of disparities to
align with the national average.
Reports will be developed through the Oklahoma State Immunization Information System
(OSIIS) to analyze zip code specific data to identify areas of disparities with 4:3:1:3:3:1 rates for
children 19-35 months old below the state average and target these areas with strategies for
improvement. Operation Buzzer Beater and OSIIS reminder RECALL activities will be
implemented in these identified areas. These reports will be delegated to the respective
Immunization Field Consultants (IFCs) and to the seven agencies under contract with the OSDH
to attempt contact with the parents. A phone call reminder will be made; if no phone contact is
accomplished or a working number is unavailable, a mail vaccination reminder will be sent. This
will be an ongoing monthly activity. The Oklahoma State Immunization System (OSIIS) will be
used to determine the percent of children at least four months old and under six years of age
that are complete for all age-appropriate ACIP-recommended vaccinations, primarily using
4:3:1:3:3:1 criteria complete by 35 months of age.
Objective 2: Increase the number of providers using the Oklahoma
Immunization Information System (OSIIS) to automatically generate a
reminder RECALL for all clients not current in the registry from 75%
to 85% by 2017.
3
Considerable effort will be devoted to increasing provider participation in the use of reminder
RECALL system in the Oklahoma State Immunization Information System (OSIIS) to
automatically send postcard reminders to guardians of clients that are not current on their
reported immunizations. This can be completed from the central office with the provider’s
permission which should be a big boost to increased coverage of infants and adolescents
statewide.
Objective 3: Promote evidence-based strategies. Decrease the
number of missed opportunities on annual Oklahoma State
Immunization Information System (OSIIS) missed opportunities
reports overall by 10% by 2017.
All Immunization Field Staff will begin to document (to ensure consistency of message) that
they emphasized at least four office practices providers can implement to eliminate missed
opportunities and ensure children receive all recommended vaccines during their office visit.
These points will be emphasized beginning in 2012 during AFIX feedback sessions (80% of all
VFC providers targeted each year). Enhanced training will initiate at the provider's annual AFIX
feedback session and continue during quarterly provider temperature check site visits.
Immunization Field Staff will continue to emphasize efforts to reduce missed opportunities.
Evaluation data will be generated from the state immunization registry (OSIIS) which can
produce missed opportunity reports on VFC Providers every 3 months. At the end of the first
year of this intervention, missed opportunity reports will be analyzed to determine if there has
been a reduction in missed opportunities statewide.
Objective 4: Work with VFC providers on quality improvement
processes to increase coverage levels and decreases missed
opportunities using AFIX components, as appropriate, and move
toward use of OSIIS as the primary source of data for provider
coverage level assessment by the end of the project period.
Assessment procedures and protocols for conducting AFIX visits will be revised and maintained
annually along with reporting requirements for documenting assessment findings. QA/AFIX
visits will be conducted annually in 80% of all VFC provider offices emphasizing education on
decreasing the number of missed opportunities to vaccinate in provider offices. A database will
be maintained annually to monitor changes in coverage levels and missed opportunities for
providers that receive AFIX visits to assess immunization coverage levels. A plan to use OSIIS
as the primary source from which records are used to assess immunization coverage levels with
goals for each year of the five-year project period will be emphasized annually with providers.
In 2012, 83% of children < 6 years of age in the immunization registry (OSIIS) have at least two
or more immunizations recorded. During VFC/AFIX site visits, OSIIS users will be encouraged
by Immunization Field Consultants to enter immunization records for non-VFC eligible children
into OSIIS. Work towards developing a Master Person Index (MPI) and the reduction of
duplicate records is continuing, but will not be achieved in 2013. Work towards OSIIS data
exchange procedures using HL7 standards is ongoing although completion is still a few years
away.
Objective 5: Track school vaccination and exemption requirements.
4
An electronic statewide assessment of school-specific coverage levels for each vaccine
appropriate for kindergarten entry will be conducted each year using a CDC-approved
methodology and submitted in PAPA by the April 30th deadline. Reports indicate that 94% of
public kindergartners are up-to-date on required immunizations at the time of the self-reported
survey in 2012. Public and private kindergartens will be reported separately. A total of 84% of
reported private kindergartners were up-to-date in 2012. The number of medical, religious and
philosophical exemptions will be monitored each year in an effort to track the distribution of
philosophical exemptions throughout the state and enable educational interventions in areas
with increasing rates.
Objective 6: Improve adolescent immunization coverage levels; Tdap
from 66% to 72% by 2017; Meningococcal from 55% to 65% by 2017,
and HPV >3 doses from 28% to 40% by 2017.
Trends in NIS data will be annually reviewed to evaluate adolescent rates to identify and target
interventions to improve rates. Oklahoma State Immunization Information System (OSIIS) data
will be analyzed annually to monitor changes in vaccine rates at the county level. Work will
continue with partners to support the establishment of an adolescent platform for adolescent
immunizations. Meetings will be held at least twice yearly with key partners to discuss ways to
increase adolescent immunizations and to monitor and document progress. (Oklahoma
Immunization Advisory Committee, Immunization Program Staff, OSDH Adolescent Staff)
Continued enrollment of all practices that see VFC-eligible adolescents in the VFC program will
be a high priority in the next five years. The new requirement for Tdap vaccine for students
entering the 7th grade was implemented in the 2011-2012 school year. Public awareness
activities will continue to be conducted and materials related to the school requirement for Tdap
vaccination will be distributed to VFC Providers, local health departments, and parents each
year. Vaccination coverage and exemption levels for Tdap at 7th grade entry will continue to be
assessed each year according to state requirements, using a CDC-approved survey
methodology. The statewide 7th grade level for compliance with the Tdap requirement was 65%
for the 2011-2012 school year. The proportion of adolescents aged 11-17 years that have 2 or
more immunizations recorded in OSIIS is at 45%.
Objective 7: Enroll and sustain a network of VFC and other providers
to administer federally funded vaccines to program-eligible
populations according to CDC/ACIP and NVAC standards.
Written policies and protocols to recruit and enroll new VFC Providers will be updated each
year. In 2006, the Oklahoma Health Care Authority (OHCA) adopted a policy requiring that all
Medicaid participating primary care providers serving children be enrolled in the VFC program.
New providers, including non-traditional providers, providers serving adolescents, and newly
licensed providers or newly established in areas serving VFC-eligible children will continue to be
identified and recruited in the VFC Program. Collaboration with medical societies, state licensing
boards, and the OK Medicaid agency will continue to assist in identifying providers to recruit and
enroll in the VFC Program. VFC providers will also be required to complete and submit provider
enrollment and profile forms annually.
Objective 8: Monitor and ensure administration of the hepatitis B birth
5
dose and HBIG to all infants born to HBsAG+ mothers including case
management to ensure that at least 85% percent of infants born to
HBsAG+ mothers receive hepatitis B vaccine and HBIG within 12
hours of birth.
Continue to work with Oklahoma birthing hospitals to achieve universal hepatitis B birth dose
coverage in infants born to mothers with HBsAG+ and/or HBsAG unknown status within 12
hours of birth and document the birth dose of hepatitis B in the Oklahoma Immunization
Information System (OSIIS) in compliance with Oklahoma Statue 310:667-13-5 (Universal birth
dose hepatitis B vaccination). Continue to work with public and private providers to ensure the
receipt of the complete series of hepatitis B in children born to HBsAG+ and HBsAG unknown
status mothers by 15 months of age through comprehensive case management directed by the
OSDH Perinatal Hepatitis B Coordinator.
Objective 9: Encourage OSIIS participation among VFC providers to
ensure 90 percent of public/private and complementary immunization
provider sites routinely submit immunization events to the OSIIS.
OKLAHOMA STATE IMMUNIZATION REGISTRY (OSIIS) ENHANCEMENTS
The Oklahoma State Immunization Information System (OSIIS) is a statewide registry for
persons of all ages. Implemented in 1995, OSIIS is utilized by 955 full service providers and
1,411 ‘read-only’ providers (including over 1,100 schools and 200 childcare facilities). The
Oklahoma Immunization Service has achieved the Healthy People 2010 objective of two or
more vaccines recorded in OSIIS for over 90% of the population under 6 years of age. An
estimated 57% of Oklahoma children less than 6 years of age have 14 or more vaccines
recorded in OSIIS.
The OSIIS registry provides multiple benefits to clinical practices utilizing the system including
vaccine forecasting, ability to print an immunization record, automatic vaccine ordering for VFC
providers and reminder/recall for children due or past due for vaccines. Additionally, the system
is used as the primary management tool by the OSDH Immunization Service for vaccine
accountability, provider quality assurance, immunization coverage assessment, policy
development, billing, and targeting pockets in need of immunization services.
OSIIS System Modifications
Although OSIIS is nationally acknowledged as a premiere immunization registry, it currently
lacks some interoperability capabilities that would allow for the electronic exchange of
immunization records among providers utilizing electronic medical records or other alternative
systems that capture immunization data. A new .net OSIIS system is currently being developed
that will include the following enhancements:




Modules for childcare and school tracking;
Immunization scheduling/forecasting software for children, adolescents and adult
vaccines;
Modules that would allow for improved monitoring and evaluation of immunization
interventions (i.e. – Operation Buzzer Beater and Missed Opportunities Evaluation
Project);
Development of a data warehouse that allows for direct assessment of vaccine
coverage levels for children, adolescents and adults at the practice, regional and state
6




levels; vaccine uptake and vaccine forecasting;
Improved processes for de-duplication;
Interoperability between other Immunization data systems and OSDH systems (i.e. VACMAN, Comprehensive Clinic Assessment Software Application {CoCASA}, Public
Health of Oklahoma Client Information System {PHOCIS}, Vital Records, C-1, WIC)
Development of modules for documenting immunization exemptions and adverse
reactions; and
Expanded reminder/recall system for adolescents and adults.
The new OSIIS registry is scheduled to be completed in the spring of 2013 and implemented
statewide by the end of 2013. Continue to promote and encourage the use of the new
Oklahoma State Immunization Information System (OSIIS) by providers for record entries of
non-VFC eligible children and by VFC providers who are identified as not using OSIIS for record
entries during QA/AFIX/VFC site visits conducted by Immunization Field Consultants targeting
85% of all VFC providers each year. Continue to incorporate dose-level accountability into
OSIIS functionality so that information can be received and stored. (Dose-level accountability
includes assigning a provider-determined program eligibility category for a patient to each
administered dose of vaccine.) Continue to collect data through the registry (OSIIS) to
accurately account for all publicly purchased vaccine. Continue to monitor this information using
standardized protocols to assure that provider’s vaccine orders are consistent with the
provider’s annual profile and to determine the amount of vaccine lost or wasted on an annual
basis. Continue to provide technical assistance to providers when problems are identified by the
IFCs and Regional Immunization Coordinators (RICs), and implement corrective action plans as
needed during VFC site visits. Develop a written five-year OSIIS strategic plan (2013- 2017) to
include a needs assessment, vision and goals, compliance with NVAC functional standards, and
a monitoring and evaluation plan by March 31, 2013.
Objective 10: Develop a new immunization information system (OSIIS)
that has full capacity for electronic data exchange.
Currently OSIIS is undergoing a significant transition to a .net platform which is not scheduled
for full operation until June, 2013. OSIIS supports 2.5.1 VXU message format and accepts test
messages and Production messaging from providers seeking to attest to meaningful use Stage
One. Immunization service staff will continue to collaborate with the Interoperable Public Health
Information System (IPHIS) in strategic planning. The IPHIS will include solutions for assigning
unique identifiers, integration, and interoperability. Short term goals for the next five years
related to immunization and electronic data exchange include maintaining national data
standards; deduplication of individuals and immunizations across all data systems containing
immunization data including the VXU repository; implementing interoperability across OSIISweb, OSIIS-PHOCIS, and the VXU repository; to develop and implement a provider registry;
and incorporate inventory management into electronic messaging.
To support providers, hospitals, and other partners in electronic data exchange, OSDH supports
a website for eligible providers and hospitals to register to submit immunization test messages
for Meaningful Use Stage 1. OSDH is collaborating with the three local Health Information
Exchanges to receive electronic immunization messages through the HIEs. In addition, a new
start-up HISP-like company has approached OSDH to collaborate in working with providers and
EHR vendors to submit immunization messages.
Objective 11: Work with preparedness programs to assure
7
preparedness for influenza pandemics and other events requiring a
vaccination response and work with new and existing partners to
increase demand for seasonal influenza vaccine to improve
preparedness for an influenza pandemic, including school-located
vaccination to increase the annual influenza vaccination rates among
the state's 3 to 5 year old population from 60% to 85% by 2017;
increase the state's school age annual influenza vaccination rates
from 35% to 60% by 2017 and increase the influenza vaccination rate
for Oklahomans age 65 and older from 65% to 90% by 2017.
Trends in school-based influenza coverage will be discussed with Community Health Services
in scheduled monthly meetings and targeted initiatives will be developed annually, including
promoting school-located clinics to assist in vaccinating this age group. Continue to work
collaboratively with the Oklahoma Immunization Advisory Committee, Immunization Coalitions,
community stakeholders and VFC providers to address policy and procedure needs and to
educate and promote seasonal influenza vaccination of all ages. Oklahoma State Immunization
Information System (OSIIS) data and Behavioral Risk Factor Surveillance System (BRFSS)
data will be reviewed annually to assess the percentage of school aged children (5-17 years
old) that receive annual influenza vaccination and coverage patterns by county health
department administrative region.
Oklahoma Administrative Code Title 310, Chapter 675, Section 9-31 requires that all nursing
and specialized facilities document evidence of the offering of annual influenza vaccination to
each resident and employee as well as the offering of pneumococcal vaccination to facility
residents according to ACIP guidelines. The regulation also states that attending physicians
may establish standing orders for the administration of influenza and pneumococcal vaccination
in all licensed Oklahoma long-term care facilities. Increased collaboration with the OSDH
Protective Health Services to promote standing orders for influenza and pneumococcal
vaccination in all Oklahoma hospitals and long-term care facilities is anticipated during the next
five years as well as increased collaboration with the Oklahoma Foundation for Medical Quality
in identifying and intervening with facilities that are reporting low vaccination rates.
Objective 12: Implement a private insurance billing system statewide
in county health departments by June 30, 2013 and provide ongoing
evaluation of project success through process evaluation and
cost/benefit ratios.
The Oklahoma State Department of Health (OSDH) secured “Preventable and Public Health
Fund (Affordable Care Act) Immunization Program” grant funds in 2012 from the Centers for
Disease Control and Prevention (CDC) to develop infrastructure and implement a system for
billing insurance carriers for privately insured individuals who access public health services. The
objective of the grant is to recoup the costs of immunizations and other services from the private
insurance plans of insured individuals who access Oklahoma Public Health Network services.
(County Health Departments)
The primary focus of the grant funding is directed at strengthening the ability of grantees to bill
private insurers for immunization services. The system implemented to bill for immunization
services is expected to be used to submit claims to insurance carriers for all eligible services
8
provided to their members by the Network using the Public Health Model of service
delivery. The system may also be used to submit Medicaid and Medicare claims.
Continue to implement a private insurance billing system in county health departments with the
top ten health plans by June 30, 2013. Monitor implementation results thereafter, identify risks
and barriers for claim denials, and develop processes to minimize risks and barriers. Provide
monthly and annual review of claims submissions, resubmissions, errors, and finance. Utilize
project income to support the public health infrastructure.
Objective 13: Continue to work with the three state immunization
coalitions and six community agencies under contract to promote
community based strategies to improve immunization rates for
residents of all ages.
Continue to collaborate with the Oklahoma Caring Foundation, Inc. in support of the
Oklahoma Caring Van Program, providing VFC Program immunizations to eligible
children across the state. Established in 1994, the foundation is a 501(c) 3 organization,
funded by community contributions and administered by Blue Cross and Blue Shield of
Oklahoma as an in-kind donation. The caring van administers over 22,000 doses of
vaccine each year to residents 0 to 18 years of age.
The Oklahoma County Immunization Coalition, the Tulsa Area Immunization Coalition,
and the Cleveland County Immunization Coalition all act as catalysts for achieving local,
state and national immunization goals. They strive to increase coverage rates by working
with community organizations in setting up local vaccination clinics and other local health
events and in the distribution of educational materials geared to parents of young
children encouraging timely vaccinations. They receive partial funding from the OSDH,
Immunization Service each year and submit annual reports highlighting their activities.
OSDH also maintains a contractual arrangement with five community clinic providers and
one community organization to provide vaccines to high risk VFC-eligible children and
conduct immunization outreach activities in underserved areas. OSDH, Immunization
Service will be placing greater accountability on the monthly performance reports in
future contractual arrangements to ensure that these providers are fulfilling their
commitments to the service delivery terms of their contracts.
9