Child Health Overview

Meeting the health needs of children requires coordination and strategic action across multiple systems. The Division of Child and Adolescent Health (DCAH) provides leadership in this domain through the Early Childhood Health Section, Child and Adolescent School Health Section, and Oral Health Unit. Oversight of local MCH (LMCH) funding to local health departments is also located within this division. DCAH collaborates with the Michigan Department of Education, the Children’s Service Agency, Division of Maternal and Infant Health, and the Children’s Trust Fund to implement evidence-based home visiting and to strengthen early childhood systems at the state and local level. Through the Preschool Development Grant Birth through Five (PDG), Michigan is working to ensure smooth transitions for families throughout the early childhood system, including home visiting and Part C of IDEA. Michigan strongly supports Infant Mental Health, ensuring social emotional development of the child and family is considered as well as using a trauma-focused lens when working with families. Infant and Early Childhood Mental Health Consultation is available to early care and education providers in 18 of Michigan’s 83 counties. Consultants are available to a limited number of providers. The Oral Health Unit also plays a key role in promoting children’s health and expanding access to dental screening and services for young children as well as school aged youth. The Division of Immunization (housed in the Bureau of Infectious Disease Prevention) tracks immunization rates and improves access to immunization services.

Title V supports programs for children that improve childhood lead screening, increase access to dental care, address fetal alcohol spectrum disorder, and improve immunization rates for children and adolescents. Other federal funding that improves children’s health includes the Early Hearing Detection and Intervention Program (CDC), the State and Local Healthy Homes and Childhood Lead Poisoning Prevention Program (CDC), and the Maternal, Infant, and Early Childhood Home Visiting Program (HRSA). Title V and these other funding streams are implemented in partnership with a variety of state and local organizations, including the Early Childhood Investment Corporation, Great Start System, local health departments (LHDs), Part C of IDEA, Healthy Start, Head Start, the Michigan League for Public Policy, the Michigan Council for Maternal and Child Health, and many others.

At the local level, LHDs expended LMCH funds across four child health performance measures. Three LHDs supported oral health for children (NPM 13) and expended 1.7% of LMCH funds via oral health education, oral health messages in schools and teen health centers, and gap-filling dental services. One LHD selected NPM 6 (developmental screening, originally selected in Michigan’s 2015 needs assessment), expending 3.9% of LMCH funds to provide gap-filling developmental screenings and to educate parents on developmental milestones. Fourteen LHDs worked on SPM 1 (childhood lead poisoning prevention) expending 11.7% of LMCH funds on gap-filling lead screening and case management, venous confirmation follow-up, and community education. Fourteen LHDs selected the original SPM for immunizations (which included child and adolescent immunizations) and expended a total of 18% of LMCH funds, which represents the largest collective expenditure. Agencies facilitated gap-filling immunization services, waiver education, media campaigns, and community and provider education.

Michigan’s approach to improving child health under the Title V block grant emphasizes improving access to care and preventing blood lead poisoning; improving immunization rates; and improving oral health. The percentage of children under age 19 without health insurance declined between 2009 (4.35%, ACS) and 2017 (2.99%) in Michigan, as it has in the nation overall. However, American Indian children (12.03%, ACS 2018) are significantly less likely to have health insurance than any other group of Michigan children. While 88.6% of children are in excellent or very good health as reported by their parents, only 80.0% of non-Hispanic Black children and 73.3% of children living at or below the federal poverty limit are reported to be in excellent or very good health (NSCH, 2017-2018). Regarding vaccination coverage, the percent of children ages 19-35 months who have completed the seven-vaccine series has increased over time from 52.1% (NIS-Child) in 2009 to 70.5% in 2018. However, coverage is lower among non-Hispanic Black children (51.6%) and children living at less than 100% of the poverty level (60.4%). Oral health is also a concern in Michigan where 8.9% of children, including 5.1% of children under five years of age, have tooth decay or cavities (NSCH, 2017-2018). Tooth decay is especially likely among children receiving Medicaid (11.3%), suggesting a lack of access to dental providers who accept this type of insurance, and among children living below the federal poverty line (13.7%). Asian children (27.7%) are also at greater risk of tooth decay. These key indicators of health status suggest that race, ethnicity, and income impact children’s health in ways that are unjust and unfair.

For the purposes of Title V, the age ranges for the child health and adolescent health population domains are determined by HRSA as outlined in the Title V Guidance. For Title V reporting purposes, children are defined as ages 1 through 21. However, for the purpose of Title V state action plans, the 1-21 age range is divided between children and adolescents and considers the age range of the performance measure and its related data source. For example, in the Child Health domain the Oral Health NPM measures the percent of children ages 1 through 17 who have had a preventive dental visit in the past year. However, in the Adolescent Health domain the Bullying NPM measures the percent of adolescents ages 12 through 17 who are bullied or who bully others. Additional details and definitions are available in the Title V Guidance and related Appendices.

Oral Health – Children (FY 2019 Annual Report)

The MDHHS Oral Health Program (OHP) provides population-based oral health prevention efforts and effective utilization of the dental workforce in implementing and improving oral health access. With the increased awareness of the impact of oral health to overall health, the OHP has increased its collaborations with community partners to improve oral health through prevention activities and direct access programs. The activities of NPM 13 in FY 2019, as discussed below, illustrate these strengthened partnerships. Additionally, Title V funding is used to support the activities of the SEAL! Michigan program, primarily through funding of school-based dental sealant programs.

Objective A: Increase the number of students who have received a preventive dental screening within a school-based dental sealant program.

SEAL! Michigan is a school-based sealant program that aims to educate children about dental health and to reduce decay rates. In FY 2019, SEAL! MI experienced challenges as well as several positive achievements. To provide context for FY 2019 activities, the challenges will be explained first.

Toward the end of FY 2018, the Oral Health Program experienced a loss of two significant federal grants (HRSA and CDC) and recovery from this loss impacted FY 2019. The loss of federal funds required the oral health program to find ways to maintain several key staff members to continue the important work. One of the lost funding sources had historically supported a 0.5 FTE water fluoridation coordinator. Although there was a loss of funding, a partnership was quickly formed with the then Department of Environmental Quality (DEQ)—now Michigan Department of Environment, Great Lakes and Energy (EGLE)—to provide funding for this part-time position. In the interim, Title V funding was used to help support this position and thereby ensure continuation of fluoridation oversight and services. Another challenge in FY 2019 due to the reduction in federal funding was a loss of SEAL! MI programs which decreased from 12 programs in FY 2018 to nine programs in FY 2019.

Despite these challenges, significant achievements can be illustrated through year-end data from FY 2019. Overall, the SEAL! MI program served 6,897 students in FY 2019 which was only a slight decrease from 6,964 students served in FY 2018. Additionally, in FY 2018 a total of 19,862 sealants were placed and in FY 2019 a total of 20,571 sealants were placed; thus, an increase in sealant placements occurred despite fewer programs. This achievement speaks to the success and commitment of the nine SEAL! MI programs that were active in FY 2019.

The SEAL! MI program continues to focus on schools with high needs as indicated by 50% or more of the student population participating in the Free and Reduced Lunch Program. Of students seen through SEAL! MI, nearly half (48.1%) had existing dental decay eliminating the possibility of a sealant placement, while 8% needed urgent dental care due to decay, abscess, pain or bleeding.

Of the population served, more than half were white,16.7% were Black and 12.6% were Multiracial. According to the US Census Bureau (July 1, 2018), the population in Michigan is 79.4% white, 14.1% Black and 6.5% combined other races. Therefore, the population served by SEAL! MI reflects Michigan’s population. A quarter of students screened had special health care needs and 89.9% of students received a fluoride varnish treatment (a slight increase from FY 2018). There was a decrease from FY 2018 in the percent of students in need of urgent care, and this decline has been a positive trend (12.9% in FY 2016, 10.1% in FY 2017, 8.9% in FY 2018, 8.0% in FY 2019). Over the last two reporting years, there was no change in the percent of students who had evidence of decay or filled first molars (6.9% in FY 2016, 8.0% in FY 2017, 6.5% in FY 2018, and 6.5% in FY 2019).

In FY 2016, 19.2% of students did not have dental insurance and 35.2% were on the state’s Medicaid program, Healthy Kids Dental (HKD). In FY 2017 there was a decrease in children who did not have dental insurance (17.3%) and an increase in HKD (41.6%). In FY 2018, the number of students reporting no insurance (17.4%) and the number of children on HKD (41.4%) remained about the same as the prior year. However, in FY 2019, over half of the students seen were covered by HKD (56.3%) and 1.1% had Medicaid, whereas 16.5% reported no dental insurance. This trend continues to demonstrate that HKD is working to increase access to dental care to children seen in the school-based dental sealant program. This could be attributed to the program coordinators working with parents to get students enrolled in HKD as it is a component of the SEAL! MI parent education.

In FY 2019, the SEAL! Michigan program continued to reach the target population through family and consumer outreach and engagement. To reach families and consumers, the funded programs attended back-to-school nights, Parent Teacher Organization (PTO) meetings, and some schools allowed information to be distributed via social media. These settings provided an opportunity to share information and answer questions about oral health. Student consent forms were delivered home with an informational brochure on the SEAL! MI program and the benefits of dental sealants. It is shared anecdotally that when schools agree to send out consent forms at the beginning of the school year there is a much higher consent form return rate, and this will be encouraged in following years. A beneficial tactic learned in FY 2019 was to put a sticky “post-it-note” on the parental consent form. The notes are printed and briefly explain, in plain language, that it is important for the consent forms to be completed and returned to the school. This note added to the consent form made a significant impact in the number of returned forms in three of the programs, which experienced an increase of approximately 40% more forms returned. This success tip was shared with other programs and several have implemented the approach. Although not all returned forms are ‘yes’ consent, it is beneficial to receive the ‘no’ forms to know that guardians were able to make an informed decision.

There has been ongoing program management and high-level technical assistance from the School Oral Health Consultant at MDHHS. During FY 2019, the School Oral Health Consultant began working on a certificate in infection control through the Organization for Safety, Sepsis and Prevention (OSAP). The certificate is a brand-new process; to date all possible steps of the program have been completed, and the final step is scheduled to be available in early 2020. The investment in this process has led to the SEAL! MI programs operating in an even safer manner via school-based care. The OSAP organization has also recognized this effort and is sending the School Oral Health Consultant to teach on behalf of OSAP and SEAL! MI on Infection Control in Mobile Programs in February 2020 at the First Annual Mobile Dentistry Conference.  Although infection control has always been a significant focus in SEAL! MI, it has been strengthened even further due to additional training established in FY 2019 in SEAL! MI programs related to water safety and routine testing of water lines to ensure patient safety.

Quality patient care and continual quality management continued to be a focus in SEAL! MI in FY 2019. Although funding is scarce for training opportunities, a goal has been set to provide at least one significant training to SEAL! MI providers annually via an in-person conference and via one webinar. These trainings have occurred since approximately 2010. Ongoing training provides the necessary tools to continually increase quality within each program. It also provides networking opportunities between the program coordinators where collaboration can take place and lessons learned can be readily shared.

Each August, coordinators working in SEAL! MI programs at the local level attend the Annual SEAL! MI Workshop. The day consists of face-to-face training on topics of interest focused on students, oral health care, and school-based services. At the August 2019 workshop, providers learned about airway issues in children, received an update on oral cancer screening in children, and had training on being prepared in the event of an active school-shooter. Following the training, providers are now putting emergency preparedness plans into place for an active shooter, carrying “Stop the Bleed” kits, and are also prepared for other emergencies, such as tornado or fire. These are important precautions because the dental providers visit numerous schools each year and often multiple schools each week, thus the location, policies and procedures are different in each school. Course evaluations from the workshop showed that participants appreciated the education and feel more prepared to handle a school emergency, how to identify an airway issue, and how to identify and refer for suspicious lesions in the oral cavity. In addition to the Annual Workshop, all providers attend the Annual Training in late September via webinar. The training is a requirement for all existing and new staff working in SEAL! MI and covers important parts of the sealant program, such as infection control, data collection, and following up with students with urgent dental care needs.

To further support the growth and acceptance of school-based dental sealant programs, the MDHHS School Oral Health Consultant attended the Michigan School Nurse conference in both the Upper Peninsula and Lower Peninsula and submitted to present at both conferences in FY 2020. Another positive change was in the organizational structure at MDHHS. In FY 2019, the Oral Health Program was moved into the Division of Child and Adolescent Health (DCAH). The Child and Adolescent School Health Section is also located within the DCAH, which houses the consultants in both school wellness programs and school-based health centers, as well as the state School Nurse Consultant. This re-organization was immediately beneficial as now all school-health providers are in the same division and can more easily collaborate and meet monthly to discuss partnership opportunities. In FY 2019, a connection was also made with a Michigan Department of Education staff member focusing on school-nutrition, and the School Oral Health Consultant assisted with adding oral health language to a project focusing on creating written school health plans.

Lead Poisoning Prevention (FY2019 Annual Report)

The Michigan Childhood Lead Poisoning Prevention Program (CLPPP) has carried out mandated blood lead surveillance and lead poisoning prevention activities since 1998. Childhood lead poisoning has declined steadily in Michigan, but elimination has not yet been attained. In Michigan, a blood lead level of 4.5 micrograms per deciliter (µg/dL) or higher is considered an elevated blood lead level (EBLL). At a level of 4.5 µg/dL or greater, lead education, nursing case management, environmental investigations, and additional medical monitoring should be established to lower the blood lead level.

In 1998 (the first complete year of required reporting) among children under the age of six tested for lead, the percentage of children with EBLLs was 44.0% (29,165 of 66,204 children tested). In 2018, of the 142,356 children younger than six years of age that had a blood lead test, 2.9% (4,124) had elevated blood lead levels. This was a decrease from 3.1% (4,711 of 13,335) in 2017.

This report describes CLPPP activities undertaken in FY 2019 to improve testing in general and confirmatory testing specifically. The rate of confirmatory venous testing of EBLL capillary test results in 2018 was 45.8% (1,671 of 3,646 EBLL capillary tests), which was a slight increase from 44.8% in 2017.

Michigan’s CLPPP is within the Division of Environmental Health, which has overall responsibilities for addressing environmental hazards and for administering the state’s Lead Safe Home Program. Sitting within this division strengthens integration of the blood lead surveillance and epidemiology functions within MDHHS’s area of epidemiological, environmental, and lead abatement subject matter expertise. The three main focus areas of CLPPP include surveillance, outreach, and health services. Surveillance activities allow for CLPPP to better target areas of needed outreach and health services. CLPPP outreach activities and health services are supported by Title V funding. In FY 2019, CLPPP’s staff of 11 included a manager, data analysts, technicians, specialists, and epidemiologists. Job responsibilities of the CLPPP public health consultant and nurse consultant include working with local health departments and state and federal lead poisoning prevention programs to increase testing rates, connecting families of children with elevated blood lead levels to resources and services, and providing expertise and education about lead poisoning prevention throughout the state.

Objective A: By 2020, increase by 20% from baseline data the percent of Medicaid-enrolled children under age 6 with an elevated blood lead level (EBLL) from a capillary test who received a venous lead confirmation test.

Objective B: By 2020, increase by 10% from baseline the percent of all children under age 6 with an EBLL from a capillary test who received a venous lead confirmation test.

All Medicaid-enrolled children are considered to be at high risk for lead exposure. Michigan Medicaid policy requires that all Medicaid-enrolled children are tested for blood lead at age 12 and 24 months of age, or between 36 and 72 months of age if not previously tested. Because of this policy, along with the available infrastructure and data, Medicaid-enrolled children remain a focus for increasing testing rates. In addition, all other children served by private insurance carriers or with no insurance coverage should be assessed to determine if they are at risk for lead exposure. Regardless of insurance status, all children with an elevated blood lead capillary test result should be followed up with a confirmatory venous blood lead test.

In an effort to increase capillary to venous testing rates, grants were awarded to local health departments in FY 2019. The Child Lead Poisoning Education & Outreach Grant was awarded to ten LHDs, with the expectation to develop and conduct educational activities for parents of children at risk of lead poisoning, with special attention to high-risk areas. Activities funded by these grants included:

• Educating and building relationships with primary care and pediatric physicians, Great Start collaboratives, WIC offices, Head Start & Early Head Start offices;
• Distributing materials and providing education at community events including health fairs, school meetings, and church gatherings;
• Developing and implementing a protocol to increase confirmatory testing rates by outreach and education to families of children with EBLLs; and
• Developing local awareness campaigns that include public service announcements on the radio and in movie theaters, billboards, and bus signs.

The Childhood Lead Poisoning Prevention Grant was awarded to nine LHDs, to focus prevention efforts in the highest risk communities in Michigan, including Adrian, Detroit, Grand Rapids, Lansing, Jackson, Flint, Hamtramck, Dearborn, Kalamazoo, Muskegon, Muskegon Heights, and Highland Park. These areas were targeted for this grant because they have older housing stock and high levels of poverty, which are risk factors for exposure to lead sources. Activities funded by these grants included:

• Educating and building relationships with area landlord and realtor associations;
• Distributing cleaning kits, lending HEPA vacuums, and providing education about how to safely clean a home with lead;
• Helping families that need home abatement fill out an application for financial assistance through the Lead Safe Home Program; and
• Providing nursing case management for children with an elevated blood lead level who are not enrolled in Medicaid, visits which are not covered under the Medicaid reimbursement program.

CLPPP hosts quarterly conference calls for grantees. Based on feedback from grantees, more in-person meetings were requested to learn from one another. CLPPP hosted a day-long meeting for all grantees in June 2019. Grantees learned strategies for increasing capillary to venous rates such as using a protocol for follow-up on elevated capillary tests and provider education through public health detailing. There was time for grantees to share their successes and talk through solutions to barriers with each other.

There was continued success in the in-home nursing case management program at LHDs. In January 2017, the reimbursement to all LHDs for in-home nursing case management to Medicaid children with EBLLs increased from $75 per visit to $201.58 per visit. This allowed for greater capacity at the LHD level to provide home visits for Medicaid-enrolled children with EBLLs. CLPPP continues to support the LHDs through training and technical assistance. In FY 2019, 1,049 reimbursable home visits were conducted by the 43 participating LHDs for 831 children with EBLLs. A requirement for reimbursement is that the blood lead level must be confirmed with a venous blood lead test. If a child has an EBLL from a capillary test, a venous confirmatory test must be done before the in-home nursing case management can begin.

Although the nursing case management reimbursement is only for Medicaid-enrolled children because funding comes from Medicaid, many LHDs have committed to doing follow-up with non-Medicaid children with EBLLs, including pursuing venous confirmatory tests where indicated, regardless of no reimbursement. In FY 2019, 64 home visits were completed for a total of 42 non-Medicaid children with EBLLs. The Childhood Lead Poisoning Prevention grantees cover the communities with high-rates of EBLLs. They can use grant funds to offset the costs of providing nursing case management services to this population.

In Genesee County, nursing case management activities are conducted by the Greater Flint Health Coalition Child Health Access Program (CHAP). CLPPP staff support case management activities by maintaining a list of all children in Flint with EBLLs, including their testing history and status of their case management, investigations and remediation. Weekly data exchanges of blood lead data and case management activity updates have been shared with CHAP. This close partnership enables all parties to ensure that all children with EBLLs are contacted, enrolled in a medical home, and offered services (including a home environmental investigation, effective water filters, nutrition counseling, child developmental assessment, and other activities).

All efforts and interventions to lower an elevated blood lead level are documented by the nurse case managers and CLPPP in Michigan’s Healthy Homes and Lead Poisoning Surveillance System (Mi-HHLPSS). Mi-HHLPSS is a surveillance system maintained by CLPPP. It is used as a tool to assess homes abated and to prevent future EBLs. CLPPP uses the system to assure children are provided nursing case management by nurses.

In FY 2019, CLPPP continued support of the Governor’s Child Lead Exposure Elimination Commission (CLEEC), established to address the need for coordinated efforts to eliminate childhood lead poisoning. CLEEC’s action plan prioritizes 51 specific action steps to create a state free of lead exposure to benefit the health of Michigan’s children. The action steps were sorted into six key topic areas of enhanced testing, education, data, partnerships, funding, and regulations/law. In alignment with the education key top area, CLPPP developed the “Lead Free Michigan” toolkit as a go-to resource for nursing case managers, health educators, and other public health professionals as they work with and educate varying populations about lead poisoning prevention. Over 1,200 toolkits have been distributed statewide through local health departments and state lead poisoning prevention partners.

CLPPP’s efforts are not possible without partnerships with other federal and state MCH programs. Michigan is one of nine state participants in the Maternal and Child Environmental Health Collaborative Improvement and Innovation Network (MCEH CoIIN), which started in July 2018. The aim of the MCEH CoIIN is to support and improve coordinated systems of care to address the needs of maternal, infant, and child populations that are at risk for or experience exposure to lead. CLPPP’s specific focus within the MCEH CoIIN includes increasing capillary to venous testing rates and developing materials and recommendations for testing pregnant women.

As part of the MCEH CoIIN, Michigan engaged and built relationships with Michigan parents as family partners and experts. At a meeting in September 2019, the CLPPP public health consultant presented with two parents about the importance of family engagement in lead poisoning prevention work and planning. There are several parent groups that are working to prevent lead in their communities, including Parents for Healthy Homes in Grand Rapids, the Detroit Lead Advocacy Group, and several in Genesee County. CLPPP will continue to support the creation of family-led lead poisoning prevention groups throughout Michigan.

Additional programs and activities undertaken in FY 2019 to improve testing and confirmatory retesting in all children (Medicaid-enrolled and non-Medicaid) included:

• Monthly data summary reports of testing status of Medicaid-enrolled children that included data by Medicaid Health Plan are available. These reports are produced in an effort to bring all Medicaid Health Plans in line with the Medicaid goal of 100% of continuously-enrolled children tested by age three.
• Continuation of a quarterly Medicaid-CLPPP workgroup to ensure coordination between Medicaid programs and CLPPP.
• Facilitating requests for blood lead data and Medicaid data by researchers.
• Providing feedback as MDHHS developed their strategic plan for addressing lead hazards in Michigan. The plan includes a pillar on increasing testing of at-risk children.
• Regularly meet with MDHHS WIC leadership to align our programs, provide technical assistance, and troubleshooting problems that arise at local WIC offices around lead testing.
• Coordination with MDHHS drinking water unit and Michigan’s Department of Environment, Great Lakes & Energy to respond to communities with water testing over 15 ppb. When this happens, CLPPP develops data reports, helps with filter distribution, and attends events to ensure accurate information is distributed to residents.
• Development of an online lead poisoning prevention training module for healthcare providers, in partnership with MPHI. This highlights testing recommendations. Continuing education credits are available for nurses, pediatricians, social workers, and physicians.
• Development of an online lead poisoning prevention training module for home visitors, in partnership with MPHI and MDHHS Child Welfare. This highlights lead hazards home visitors can look for and recommendations for referrals to address the lead hazards.
• Establishing a data referent group to get feedback and input on reports, processes, and procedures from frequent users of CLPPP data. One of the initial recommendations from this group is the development of quarterly reports for local health departments, which will include data on testing rates, capillary to venous rates, and blood lead results. LHDs will be able to use this data to target medical providers with low testing rates, target areas of high risk, and evaluate the effectiveness of their efforts.

In an effort to continuously improve CLPPP programs and activities, CLPPP contracts with the Michigan Public Health Institute (MPHI) to conduct an annual evaluation. The evaluation includes a satisfaction survey and key informant interviews with LHDs and lead poisoning prevention partners to collected data about communication, usefulness of resources, and response times/actions of CLPPP. Overall, results suggest satisfaction of participants with their interaction with CLPPP staff.

Critical to the success of CLPPP and LHDs in meeting the objectives of this project were numerous partnerships with community groups, advocacy organizations, families of lead-exposed children, health care provider groups, and local governmental agencies. Partners included the Michigan Environmental Council, Ecology Center, Healthy Homes Coalition of Western Michigan, WIC, Michigan State Housing Development Authority, Genesee County Medical Society, Michigan Association of School Nurses, Michigan Chapter of American Academy of Pediatrics, Children’s Hospital of Michigan, Michigan Public Health Institute, Greater Flint Health Coalition, MDHHS Medicaid, MDHHS Lead Safe Home Program, Early On Michigan, Michigan Head Start, other programs within MDHHS Division of Environmental Health, local county and regional task forces, and many more.

Immunizations – Children (FY 2019 Annual Report)

To address the 2015-2020 state priority need to “Invest in prevention and early intervention strategies,” MDHHS originally developed a two-part SPM related to Immunizations. The SPM included two measures: A) Percent of children 19 to 36 months of age who have received a completed series of recommended vaccines (4:3:1:3:3:1:4 series) and B) Percent of adolescents 13 to 18 years of age who have received a completed series Human Papilloma Virus (HPV) vaccine. Starting in 2018, these measures were split into two separate measures in two population domains (Child Health and Adolescent Health) to align with the revised HRSA population domains and for clarity of reporting.

The first measure, percent of children 19 to 36 months of age who have received a completed series of recommended vaccines, is discussed here. Many efforts were implemented by MDHHS in 2019 to assure children are vaccinated on schedule. On-schedule vaccinations have become increasingly difficult as parents have questions about vaccines and vaccine hesitancy appears to be increasing. A recent national study suggested that only 63% of parents are following the CDC recommended ACIP schedule. Unfortunately, Michigan immunization rates for this SPM (percent of children 19 to 36 months of age who have received a completed series of recommended vaccines) have dropped from 75% to 74% in the reporting year, based on data from the Michigan Care Improvement Registry (MCIR). However, Michigan continues to see lower immunization waiver rates in school children and preschool children due to the requirement that parents receive immunization education on the value of vaccination before receiving a non-medical waiver.

Objective A: Increase the percentage of children 19-36 months of age who receive recommended vaccines.

In FY 2019, Michigan continued to experience a significant problem keeping children on schedule. Only 54.2% of children who were seven months of age were on schedule with all recommended vaccines which is about 0.5% lower than measured at this time last year (see Figure 1). By the time children reach 24 months of age (when they should have completed all pediatric vaccines) MCIR data show that only 52.5% of children in Michigan are up to date with all vaccines. Children are therefore susceptible to diseases for a longer period of time when they are most vulnerable. Data also show that children who fall behind are less likely to complete the schedule.

Figure 1. Percentage of Children Vaccinated at Milestone Ages

To addresses these challenges, the Michigan Immunization program continues to support the statewide media campaign called I Vaccinate (which began in March of 2017). MDHHS also conducted focus groups with young mothers who were hesitant to vaccinate their children. The goal of the focus groups was to learn about mothers’ concerns and what types of information and messaging would most impact their decision to vaccinate their children. These mothers were also asked how they receive information. This information was used to create the I Vaccinate Campaign. The I Vaccinate Campaign ran through 2019 to provide vaccine information to parents with questions about vaccines. The campaign promotes vaccination of children in Michigan using many media methods, including TV ads, radio ads, social media posts on several social media sites, immunization provider materials, and “Mommy Bloggers” promoting vaccines and vaccine safety. More information is available at the I Vaccinate website.

Objective B: Make quality improvement reports (AFIX reports) available to immunization providers using the MCIR.

The Division of Immunization, under the guidance of CDC, has restructured the quality improvement reports available to local health department staff and to immunization providers in an effort to encourage timely vaccination. Past AFIX reports have been replaced with Immunization Quality Improvement (QI) reports. AFIX reports were focused on immunization rates and efforts to be sure children were caught up with their immunizations. The QI reports put a focus on timely vaccinations and assuring that children are staying on schedule. These QI reports have now been programmed into the Michigan Care Improvement Registry (MCIR) and are available. Local health department staff visit immunization providers in their jurisdiction to educate them on their current vaccination rates to keep vaccinations timely and work with the practice on strategies to improve timely vaccination. In 2019, 829 QI visits were completed in provider offices to assist with increasing immunization rates.

Objective C: Enable local health departments to better track successes or shortfalls for their health jurisdiction.

In FY 2017, County Immunization Report Cards were first generated and posted on the MDHHS website on a quarterly basis. The report cards were generated to reflect the immunization rates of each county in Michigan and ranked them against other counties in the state. The report cards have been modified several times to better meet the needs of local health departments. The goals of the report card data are to 1) provide each county with an understanding of vaccination rates in their respective communities and 2) identify areas for improvement. County report cards have been published every quarter and highlighted during several conferences. The state will continue to make that data available to the public to increase awareness of immunization rates in their area.

The Michigan Immunization Program also provides immunization drop-off data to local health departments on a quarterly basis. Data are obtained from the MCIR. These reports track vaccine completeness by the age at which vaccines should be obtained for children. Data show a dramatic drop off in vaccine completeness by seven months of age which reinforces the difficulty of keeping children on schedule for vaccines.