Ohio Senate Health and Human Services Committee
March 18, 2015
Mary DiOrio, MD, MPH
Good morning, Chairwoman Jones, Vice Chair Lehner, Ranking Member Tavares
and members of the Senate Health and Human Services Committee. My name is
Dr. Mary DiOrio and I am the Medical Director at the Ohio Department of Health.
Thank you for inviting me here to testify today on the important issue of
immunizations. I will review the current childhood immunization rates for Ohio
and I will discuss four key strategies that the Ohio Department of Health takes to
protect Ohioans from vaccine-preventable diseases: we issue the state
requirements for vaccinations that are needed for school entry; we coordinate
outbreak reporting and disease surveillance with our local public health partners;
we operate a statewide immunization registry; and we have program initiatives
aimed at increasing immunization rates.
The Centers for Disease Control and Prevention (or CDC)’s National Immunization
Survey assesses the percent of children that are vaccinated with a particular
number of doses of a given vaccine by a certain age. This report notes that the
percent of Ohio children aged 19-35 months that have received one or more
doses of MMR (or measles-mumps-rubella) vaccine is 86% compared to the
national rate of 91.9%. And the percent of children that have received what is
referred to as the 4 3 1 3 3 1 4 vaccinations is 63.3% compared to the national
rate of 72.7%. The 4 3 1 3 3 1 4 measure looks at the percent of children that have
received four or more doses of diphtheria and tetanus toxoids and acellular
pertussis vaccine (DTaP); three or more doses of polio vaccine; one or more doses
of MMR vaccine; three or more doses of Haemophilus influenzae type b (Hib)
vaccine; three or more doses of hepatitis B vaccine; one or more doses of varicella
vaccine; and four or more doses of pneumococcal conjugate vaccine. When
reviewing a statistical evaluation like this National Immunization Survey, one
needs to consider the “confidence interval” for each item being assessed. A
“confidence interval” is a statistical measure that gives the range of values within
which one is confident to a certain degree that the true value is located. For
Ohio’s MMR vaccination rate of 86%, the 95% confidence interval is plus/minus
5.2% and for Ohio’s 4 3 1 3 3 1 4, the 95% confidence interval is 7.6%. Thus, the
true value may be higher or lower than that which is reported. Because of
confidence intervals, it can also be somewhat challenging to compare states
directly, as overlapping confidence intervals can make these direct comparisons
difficult. However, what is important to note from this survey, is that there is
room for improvement, especially within this young age group. When we
compare the immunization rates of the National Immunization Survey with our
Ohio AFIX rates and the rates that are noted at kindergarten entry, there is an
increase with each of these measurements. For example the MMR rate as noted
in the National Immunization Survey is 86% for children aged 19 to 35 months, in
the Ohio AFIX survey this increases to 88.9% and by school entry, the rate is
96.1%. This illustrates the importance of immunization requirements for school
and how these requirements help get children up-to-date with their
immunizations. As Ohio had been the only state without a childcare vaccination
requirement, until recent passage of House Bill 394, immunization rates of
childcare aged individuals (the exact ages that the National Immunization Survey
is assessing) have not had the benefit of a boost in immunizations due to a
requirement. That should change with the new law.
Administer State Requirements
In regards to immunization requirements for school entry, Ohio law (O.R.C.
3701.13 and 3313.671) requires that at the time of initial entry or at the
beginning of each school year, elementary and high school students are to have
documentation of immunization against several vaccine-preventable diseases.
These diseases include chicken pox, measles, mumps, rubella, polio, diphtheria,
pertussis, tetanus, and hepatitis B. Students may have exemptions for
immunizations under several scenarios, including medical contraindications or for
if the parent or guardian declines an immunization due to “reasons of conscience,
including religious convictions.”
Ohio Revised Code section 3313.67 requires that all schools report a summary of
the immunization status of their pupils to the Ohio Department of Health by
October 15 of each year. Accordingly, ODH surveys all schools in Ohio for the
immunization summaries of preschool, kindergarten, seventh grade and new
pupils in grades 1-12. ODH currently uses an online reporting process for all
schools in Ohio. Immunization rates are public health quality indicators for local
health departments. Thus, local health departments partner with school districts
to increase vaccination rates through collaboration, education, outreach, and
reporting efforts.
This past December, Governor Kasich signed House Bill 394 which strengthened
vaccination requirements in child care settings. The law requires that children
attending state licensed child care facilities be vaccinated according to the
Centers for Disease Control and Prevention’s Advisory Committee on
Immunization Practices’ (ACIP) schedule. A parent must provide the child care
provider with a medical statement within 30 days of enrollment noting that the
child has been vaccinated or is in the process of being vaccinated. Similar to the
elementary and high school requirements, this law allows for exemptions for
medical reasons and reasons of conscience or religious conviction. ODH has been
working in collaboration with the Ohio Department of Job and Family Services and
other stakeholders to implement this new requirement.
Coordinate Outbreak Reporting and Surveillance
As you have read or heard in the media, in the past year Ohio has had several
significant regional vaccine-preventable disease outbreaks related to measles and
mumps. Ohio has also had many local outbreaks of diseases like pertussis and
influenza. These local outbreaks are not as visible, but they are much more
common than the larger regional outbreaks. The state’s communicable disease
surveillance and investigation process to respond to these outbreaks is wellcoordinated and efficient.
Public health is able to monitor certain diseases, like the vaccine-preventable
diseases that we are discussing, because they are required to be reported to
public health. Individual cases (and outbreaks) are reported by clinicians, hospitals
and laboratories. Local health departments investigate each case within their
jurisdiction and enter pertinent information about each case into the state’s
electronic disease reporting system which is known as the Ohio Disease Reporting
System. The Ohio Department of Health provides technical assistance to local
health departments as needed, aids with coordination of multi-jurisdiction
investigations and secures laboratory testing and/or additional vaccine for
outbreak control if appropriate. Communications between local health
departments and ODH often occur on a daily basis, especially when outbreaks are
on-going.
As I mentioned, Ohio experienced two significant regional outbreaks of mumps
and measles last year. The 2014 mumps outbreak involved a total of 482 cases
that occurred between January 1 and September 20, 2014. To assist with
containing the outbreak, ODH provided 1,346 mumps-containing vaccine doses to
local health jurisdictions in central Ohio.
The 2014 measles outbreak involved a total of 382 cases that occurred between
April 21 and July 21, 2014. These cases occurred in a highly unvaccinated
population of the state, with Knox County having the most cases. In response to
this outbreak, the Ohio Department of Health provided local health departments
with approximately 11,000 doses of vaccine. Local health departments
administered the vaccine at their clinics and at approximately 120 independent
vaccination clinics that they established increase their outreach and ensure
additional access to vaccine.
In addition to these large regional outbreaks, in 2014, there were also 44
outbreaks of pertussis and 2 outbreaks of varicella (or chickenpox) reported.
These outbreaks occurred predominantly in schools settings. In addition, during
the current 2014-2015 influenza season, there have been 75 suspected or
confirmed influenza outbreaks reported. These outbreaks have been mostly in
healthcare settings, specifically nursing homes and assisted living facilities. This flu
season has been a challenging one with a significant increase in the number of
hospitalizations reported compared to the previous two seasons. This is due in
large part to a vaccine that was a poor match to the predominantly circulating
strain of influenza virus. As a result,
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To date, there have been 7,985 hospitalizations this influenza season
compared to 4,223 and 2,667 during similar time periods within the
2012-13 and 2013-2014 influenza seasons respectively.
And there have been 6 influenza-associated pediatric deaths this season
compared to zero during the 2013-14 season.
In response to the flu epidemic this season, the Ohio Department of
Health laboratory has tested over 1,100 influenza specimens from
outpatient centers and hospitals across the state to determine which
influenza viruses are circulating.
Statewide Immunization Registry
Another key strategy that the Ohio Department of Health utilizes to address
vaccine-preventable diseases is the maintenance and promotion of a statewide
immunization registry. The Ohio Department of Health uses an interactive system
for recording and tracking immunizations called ImpactSIIS or Statewide
Immunization Information System. As of January 1, 2015, ImpactSIIS held more
than 72 million immunization records on more than 8.5 million individuals. In
2014, more than 2500 separate locations around Ohio contributed immunization
data to ImpactSIIS. These included local health departments, Federally Qualified
Health Centers, hospitals, physician’s offices, pharmacies, schools, and payers.
ImpactSIIS was developed to help achieve complete and timely immunization for
all Ohioans, but especially for the age group most at risk - birth through two
years. It does this:
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By maintaining consolidated, comprehensive immunization records
By making immunization records accessible to those with an appropriate
health care or public health need while preserving the security of
individual information
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By identifying when an individual is due for a vaccination and notifying
the patient and/or the provider about this
And by managing vaccine inventory for immunization providers
As a central data processing point, ImpactSIIS provides an accurate, efficient way
to ensure that children and Ohioans of all ages receive the right vaccinations at
the right times without unnecessary repetition.
A recently passed legislation, House Bill 394 required ODH to prepare a report
detailing the feasibility of requiring all individuals who administer vaccines in Ohio
to submit vaccine administration information to ImpactSIIS. ODH is in the process
of completing that report, and we look forward to working on ways to increase
public health knowledge of vaccination rates around the state in order to better
target our interventions.
Administer Program Initiatives
Finally, I would like to take this opportunity to briefly outline for the committee
the work of the ODH Immunization Program, including program initiatives that
are aimed at increasing immunization rates in Ohio. The Immunization Program
provides education and support to immunization providers to improve
immunization coverage. The program’s goal is to reduce and eliminate vaccinepreventable diseases among Ohio's children, adolescents and adults by working
with health care providers and public health partners to improve immunization
rates and to prevent the spread of vaccine-preventable diseases.
The Ohio Department of Health seeks to prevent 17 vaccine-preventable diseases:
diphtheria, tetanus and pertussis; Haemophilus influenzae type b (Hib); hepatitis
A; hepatitis B; human papillomavirus (HPV); influenza; measles, mumps and
rubella; meningococcal disease; pneumococcal disease; polio; rotavirus; varicella
(chicken pox) and zoster (shingles). To achieve this, ODH administers grants,
distributes vaccine, and provides technical assistance and training.
In addition, the ODH Immunization Program administers the federal Vaccines for
Children Program or VFC. The VFC program provides vaccines at no cost to
children who might not otherwise be vaccinated because of an inability to pay.
Ohio estimates that 50.5% of Ohio children are eligible for VFC vaccine. Ohio has
approximately 1,100 VFC providers including private providers, local health
departments, Federally Qualified Health Centers and Rural Health Centers.
VFC providers administer VFC-provided vaccine to the eligible children from birth
through age 18 years of age. Eligible children are those on Medicaid, American
Indians/Alaskan Natives, and un- and under-insured children.
Immunization Billing
Before I close, I would like to mention language in the proposed budget that
addresses immunizations. There is an increased number of Ohioans who have
coverage through Medicaid or private health insurance for immunizations. Local
health departments and other providers can bill private insurers to recoup the
cost of providing vaccinations. Thus, the Fiscal Years 2016-17 biennial budget
proposes discontinuing the use of General Revenue Funds beginning January 1,
2016, to purchase vaccines for distribution to local health departments and other
providers to vaccinate individuals who are now eligible for vaccinations through
private health insurance. ODH will continue to provide funding to local health
departments and other providers for vaccines for the first half of 2016 to give
them sufficient time to develop their billing capabilities and build up their vaccine
inventory. In addition, the federal VFC (Vaccines for Children) Program for will not
be affected by this proposal.
In closing, preventing and controlling the spread of infectious diseases,
particularly vaccine-preventable diseases, is a core priority and a pillar of public
health. The dramatic decrease in vaccine-preventable diseases that occurred in
the twentieth century is a public health success story. To refocus on core public
health activities, ODH has recently realigned its structure. ODH’s new
organizational structure aligns the agency to promote collaboration, operate
more effectively and efficiently, and better plan for and manage the changing
health care landscape.
As I have mentioned, we work very closely with local health departments, health
care providers, and other state and local partners to achieve our public health
goals. Our immunization partners are numerous and include pediatricians, family
physicians, internists, obstetricians and gynecologists, nurse practitioners, school
nurses, public health nurses and pharmacists. All contribute to Ohio’s
commitment to improve vaccination rates across the lifespan.
Thank you again for this opportunity and I would be happy to answer any
questions you may have.