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. Mental health consultation has been made available for early care and education providers and evidence-based home visiting 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 (FASD), 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 performance measures in FY 2020. Five LHDs supported oral health for children (NPM 13) providing oral health education and gap-filling dental services (when schools were open during the pandemic). One LHD selected NPM 6 (developmental screening, originally selected in Michigan’s 2015 needs assessment) to provide gap-filling developmental screenings and to educate parents on developmental milestones. Fifteen LHDs worked on SPM 1 (childhood lead poisoning prevention) providing gap-filling lead screening and case management, venous confirmation follow-up, and community education as able during the pandemic. Twelve LHDs selected SPM 2 for children immunizations. Agencies facilitated gap-filling immunization services and waiver education during periods when clinics were open in FY 2020.

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 2019 (2.9%) in Michigan, as it has in the nation overall. However, American Indian children (11.3%, 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.

Oral Health – Children (FY 2020 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 2020, 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.

This objective reflects activities to address and support the ESM, which is the number of students who have received a preventive dental screening through the SEAL! Michigan program. SEAL! Michigan is a school-based sealant program that aims to educate children about dental health and to reduce decay rates. In FY 2020, SEAL! MI experienced challenges as well as several positive achievements. To provide context for FY 2020, activities will be explained in chronological order.

To begin the year, the SEAL! Michigan program started with eight programs, which was one less than FY 2019. One program from FY 2019 became financially self-sufficient and moved into the SEAL! Of Approval program, in which the coordinators still collaborate with MDHHS School Oral Health Consultant and participate in all SEAL! Michigan activities, but do not receive funding. When this occurs, a new program is started; the new program identified to launch in FY 2020 was the District Health Department #10 (DHD #10). The first year of any sealant program is primarily a planning year, and this was the plan with DHD #10: to spend most of the year establishing the contract, completing trainings, establishing relationships with the schools, securing equipment, and beginning implementation in the first two schools in late spring 2020.

In the meantime, the other existing eight programs were active and were having a record year in terms of the number of schools they were working in and the number of students they were screening. For example, one program alone added 50 additional schools to their program.

In March 2020, Michigan experienced its first positive COVID-19 test, indicating that the virus was spreading in Michigan. Governor Whitmer launched a series of Executive Orders (EOs) across the state to help mitigate the spread of the virus and to support health care professionals, protect health care systems, and to ultimately save lives. Not only were schools closed, but Executive Order No. 2020-17 restricted non-essential dental procedures starting on March 21, 2020 until May 29, 2020. In the school-based dental sealant program, March to May is a significant period that programs work in schools because of better weather and fewer holidays. Thus, the school closures coupled with preventive dentistry being closed resulted in the inability of sealant programs to work. Additionally, the school calendar ends in late May/early June, so when the EO was lifted schools closed for the summer.

Another challenge in FY 2020 was navigating the novel coronavirus and understanding how to safely re-open the sealant programs in schools and securing the materials and supplies to do so. In June 2020, a SEAL! Michigan Return to School Committee was assembled, which included a total of four people who spent eight weeks developing the Return to School COVID-19 Requirements. The committee members included the MDHHS School Oral Health Consultant, who collaborates closely with the national Organization for Safety Asepsis & Prevention (OSAP) in dentistry, and three other grantees of SEAL! Michigan who had demonstrated leadership in infection control. A plan was created and reviewed by one of the leading infection control experts in dentistry, Kathy Eklund, and then submitted for approval by the MDHHS Community Health Emergency Coordinator Center (CHECC). This document was approved in late August and a training was provided to all individuals who work in a SEAL! Michigan program. The guidelines were a requirement to return to work under SEAL! Michigan to ensure safety was put first as programs returned to schools to see students.

Once the plan was created to safely return to work, another committee was created (which included a member of each SEAL! Michigan program) to identify alternative work settings. This living document was created via collaboration and brainstorming on the numerous alternative locations that mobile dental programs could provide services to children if schools declined dental services or did not open. Some alternative locations included daycare centers, WIC, head start centers, youth groups (YMCA, churches, Boys & Girls Club, sporting arenas), youth homes, group foster homes, community centers, township halls, city halls, food pantries, and external service areas that could be set up in retail and health center parking lots.

In the meantime, over the summer months SEAL! Michigan programs continued to work and support families’ oral health needs in ways that they could. Activities included packing thousands of oral health bags (which included toothbrushes, toothpaste, and oral health education) and distributing them to families via the school free lunch distribution. One program provided “tickets” in the oral health bag for a free electric Spin Brush if the ticket was brought to the dental clinic at the local health department where dental sealants were placed if the student was eligible for sealants. Another program began collaborating with the Women, Infants, and Children (WIC) department at the health department and started drive thru dental screenings and fluoride placement in which children did not leave the car. In addition to reaching out to families in a variety of ways, time was also spent maintaining equipment (e.g., portable dental units and dental busses); engaging in educational programs focused on health equity and social justice; and examining our individual roles in working toward a more equitable social system.

In late August, SEAL! Michigan programs were educated, stocked, and fully prepared to return to work in schools. Between August and the end of September, minimal schools around the state were both open and allowing dental programs to enter, but a few schools were welcoming, and some work was done. For schools that were taking precautions and not allowing outside programs to enter, SEAL! Michigan programs continued to support families by providing oral health bags and worked in alternative settings as possible.

Despite so many challenges, numerous achievements were realized during the year. First and foremost, the work conducted by the SEAL! Michigan colleagues is a testimony to their dedication to children and adolescents in their communities. Collectively the grantees dove into the work and embraced how to come out of the pandemic stronger. In addition, the strong start to the year helped the year-end data. Collectively, 6,203 students were screened and 14,334 sealants were placed across the eight programs. In comparison, 6,897 students were screened and 15,518 sealants were placed in FY2019 across nine programs.

The SEAL! Michigan 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 the students seen, the grades served vary by county. The Upper Peninsula and Wayne County programs serve all students in all grades; however all other counties only serve students in first, second, sixth, and seventh grades. This is because the Upper Peninsula is a severe health professional shortage area and is also rural with small schools. Wayne County has students who are high-risk for dental disease; has a transient population; and past data show that teeth erupt earlier thus it is important to see all students to determine if teeth can be sealed and to screen for urgent issues. Almost half of screened students received at least one sealant on a first molar; 5.8% received one sealant, 9.4% received two sealants, 5.8% received three sealants and 26.1% received sealants on all four first molars.

Of the total population served by SEAL! Michigan, 59.0% were white,12.4% were Black and 16.3% 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! Michigan reflects Michigan’s population. A quarter of students screened had special health care needs and 86.3% of students received a fluoride varnish treatment (a slight decrease from FY 2019). There was a decrease from FY 2019 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, 6.0% in FY 2020). Over the last three reporting years, there was minimal 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, 6.5% in FY 2019, and 5.1% in FY 2020).

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. 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. In FY 2020, 56% of students screened had HKD and 0.8% had Medicaid, while 19.4% reported no 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 positive trend may be attributed to the program coordinators working with parents to get students enrolled in HKD as it is a component of the SEAL! Michigan parent education.

In FY 2020, 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! Michigan program and the benefits of dental sealants. The informational flyer was updated in 2020 by the MDHHS Communication Department. When the flyer was initially developed several years ago, it was developed by a contracted health literacy expert at McMillian’s Health and was written at a third grade reading level. During the revision, nearly all language was kept the same, but the flyer was updated and given a different look. It was made available in English, Spanish, and Arabic and is provided to all programs to attach to their consent forms. The flyer only shows teeth (no people) so it can be used across all grade levels.

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 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 on 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.

In FY 2020, ongoing program management and technical assistance from the School Oral Health Consultant at MDHHS continued. The School Oral Health Consultant completed a certificate in infection control through the Organization for Safety, Sepsis and Prevention (OSAP). The certificate is a new process and took over a year to complete. The investment in this process has led to the SEAL! Michigan programs operating in an even safer manner via school-based care. The OSAP organization has also recognized this effort and has continued collaborating with the MDHHS School Oral Health Consultant to teach other national programs. In February 2020, the School Oral Health Consultant presented on behalf of SEAL! Michigan and OSAP on Infection Control in Mobile Programs at the First Annual Mobile Dentistry Conference. Although infection control has always been a significant focus in SEAL! Michigan, it has been strengthened even further due to additional training in FY 2019 and FY 2020 related to water safety and routine testing of water lines; in FY 2020 training specifically focused on mitigating the spread of SARS-CoV-2 in school settings to ensure patient and provider safety.

Quality patient care and continual quality management continued to be a focus in SEAL! Michigan in FY 2020. Although funding is scarce for training opportunities, a goal has been set to provide at least one annual training to SEAL! Michigan providers via an in-person conference and via one webinar. These trainings have occurred since approximately 2010. Ongoing training provides the 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! Michigan programs at the local level attend the Annual SEAL! Michigan Workshop. Although unable to meet in person, the SEAL! Michigan Workshop still occurred virtually in August 2020. Dr. Katena Cain presented Bridges Out of Poverty, Part II. Dr. Cain presented Bridges Out of Poverty, Part I in 2018. Continuing education focused on understanding poverty and health equity is important for providers. This course was highly interactive, even more so in the virtual format, as participants felt comfortable sharing and asking questions. Many also utilized the chat feature and to add to the conversation. Workshop evaluations were incredibly positive, and one participant said that “it was so good it could have lasted all day!”. As previously mentioned, a training was also provided via webinar, recorded for on-demand learning, regarding infection control requirements expected of SEAL! Michigan programs.

To further support the growth and acceptance of school-based dental sealant programs, the MDHHS School Oral Health Consultant attended the Michigan Association of School Nurses (MASN) conference in both the Upper Peninsula and Lower Peninsula and presented an oral health update at both conferences.

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 consultants in both school wellness programs and school-based health centers, as well as the state School Nurse Consultant. This re-organization was beneficial as now all school health providers are in the same division and can more easily collaborate 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. The MDHHS School Oral Health Consultant also formed a MDHHS COVID Navigation Committee which meets approximately every other month and brings together various consultants at MDHHS managing school-based programs (hearing, vision, sex ed, etc.) to network, share, brainstorm, and support one another on appropriate management techniques during this unprecedented pandemic. Members of this group have reported appreciation of this time to collaborate internally on best practices of supporting individual programs to ensure that the program is able to thrive post-pandemic.

One final success is the implementation of the Oral Health Coordinator position embedded within Detroit Public School Community District (DPSCD). This position is funded under Title V. The idea for the position was first formed in December 2018. According to the 2016 Count Your Smiles report (an open mouth screening with a dental provider and written parent survey), looking specifically at the City of Detroit, approximately 82% of third grade children have active dental disease (18.3% have no obvious problems, 59.6% have early dental care needs, and 22.1% have immediate dental care needs) and only 28.3% have at least one dental sealant (which is the lowest rate by region in Michigan). Looking further into the 2016 CYS report, only 1.5% of third grade students’ parents report their child could not get care in the last year and 0% reported their child never had a dental visit. Evaluation of these data revealed that students in Detroit have a need for quality dental care and follow-up care coordination specific to oral health because almost all students have been to a dentist, yet nearly 82% have active dental decay. This suggests children are being seen by a dental professional but are left with active disease and lack of follow-up care. Upon meeting with DPSCD school health staff, it was also discovered that no data on past oral health services exist.

After extensive collaboration efforts, a highlight in 2020 was that a new DPSCD Oral Health Coordinator began work. This half-time position is fully embedded within the DPSCD organization as a consultant of the Michigan Public Health Institute. The position is managed by the MDHHS Oral Health Director and works closely with the MDHHS School Oral Health Consultant. The DPSCD Oral Health Coordinator has the following responsibilities:

• Oversee dental treatment and providers on-site to ensure the patient experience is safe, complete, and prevention focused;
• Collect and report accurate data per SEAL! MI requirements;
• Evaluate dental providers with a quality indicator tool to conduct annual performance evaluations;
• Collaborate with providers to ensure students and parents receive oral health education;
• Care-coordination of high-risk students with dental needs to relieve students of the burden of disease;
• Organization of parent and student focus groups to learn how to best meet oral health needs and to increase positive consent forms for treatment; and
• Ensure preventative measures (dental sealants and fluoride varnish) are provided to all students with consent.

DPSCD has a total of 110 physical school buildings to which mobile dental providers are assigned. Having an Oral Health Coordinator housed in DPSCD allows for more hands-on oversight of the dental providers who provide school-based care, which was previously overseen by the school nurse. This new structure enables increased oversight to ensure that safe and proper care is being provided and that students with oral health disease are followed up on and placed in dental homes. Part of the agreement between MDHHS and DPSCD is that all dental providers contracted with DPSCD to provide dental care will prioritize placing dental sealants on all eligible teeth and will report data to MDHHS.

This new position is an exciting and promising new partnership to help ensure that kids who need access to dental care receive appropriate assessment and treatment. The position will also bring an enhanced level of oral heath prevention, oral health education, and community partnership around oral health in DPSCD. The current staff member is a life-long resident of Detroit and previously worked as a SEAL! Michigan coordinator for a former program, and therefore has many connections in Detroit to help support students, providers, and the school nurse.

Lead Poisoning Prevention (FY2020 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). When a child has an elevated blood lead level, several activities—including lead education, nursing case management, environmental investigations, and additional medical monitoring—should be initiated to lower the blood lead level.

This report describes CLPPP activities undertaken in FY 2020 to improve testing in general and confirmatory testing specifically. In 1998 (the first complete year of required reporting) among children under the age of six tested for lead, 44.0% of children had EBLLs (29,165 of 66,204 children tested). In 2020, among children younger than six years of age that had a blood lead test, 2.3% (2,134 of 93,655 children tested) had elevated blood lead levels. This was a slight decrease from 2.7% (3,912 of 143,223) in 2019. The rate of confirmatory venous testing of EBLL capillary test results in 2020 was 48.1% (994 of 2,068 EBLL capillary tests), which was an increase from 45.8% (1,671 of 3,646) in 2018.

However, since the start of the COVID-19 pandemic, deferred care and increased use of telemedicine has negatively impacted blood lead testing. The pandemic also results in children spending more time at home, which increases the risk of exposure for children living in homes with lead contamination. MDHHS developed a response plan to address the decrease in testing rates, with strategies around education, outreach, and data surveillance.

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 2020, CLPPP continued support to address priorities in the MDHHS Lead Strategy. The MDHHS Lead Strategy includes five pillars, including financing, compliance, workforce development, data, and screening. A kick-off meeting for the strategy was held in January 2020 with over 70 participants within MDHHS to present the strategy to Medicaid, maternal and child health programs, departmental leadership, and WIC. Several initiatives were started in FY 2019 to support these pillars, specifically the screening pillar. The initiatives are also part of the response plan to address the decreased blood lead testing rates due to the COVID-19 pandemic. These included:

• The development of a postcard to be mailed out to families of children under the age of six in Michigan. The postcard includes information on the sources of lead, health impacts of lead, and the importance of blood lead testing.
• The development of a statewide lead education media campaign that will show the main sources of lead and simple actions to protect against lead exposure.
• The development of a data dashboard that will be available on www.michigan.gov/lead and will include data about nursing case management, testing, and abatement activities.
• Presentations about lead poisoning prevention to internal and external partners, including Medicaid, WIC, and maternal and child health programs.
• Continued distribution of the “Lead Free Michigan” toolkit, a go-to resource for nursing case managers, health educators, and other public health professionals as they work with and provide education to various populations about lead poisoning prevention.

While two distinct objectives were identified for this state action plan, the same strategies were used to make progress on both objectives and thus are discussed in tandem, below.

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 be 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 2016, baseline data indicated that 23.61% of all children under age 6 with an EBLL from a capillary test who received a venous lead confirmation test. In 2020, the original objective was exceeded with 48.1% of all children under age 6 with an EBLL from a capillary test receiving a venous confirmatory test.

In efforts to increase testing rates, partnerships with local health departments are essential for success. MDHHS provides funding to local health departments to focus on projects to increase capillary to venous testing rates, as well as provide nursing case management to children with elevated blood lead levels. In FY 2020, CLPPP focused on improving communication and technical assistance to local health departments through a quarterly newsletter called “CLPPP Notes”; bimonthly phone calls to facilitate conversation among local health departments that are facing similar barriers; and regular trainings to local health department nurses and staff.

In FY 2020, 13 local health departments were awarded grants to focus on provider education, parent education, and outreach to at-risk populations, with the goal of increasing testing rates. Due to the COVID-19 pandemic, grantees had to adjust how they approached these activities. Activities funded by the grants included:

• Developing and implementing a protocol to increase confirmatory testing rates by outreach and education to families of children with capillary elevated blood lead levels.
• Distributing materials, providing education, and presenting at community events (many of which became virtual due to the COVID-19 pandemic).
• Developing messages to distribute to their community via social media, media campaigns, local radio/tv shows, and mailings.
• Supporting lead testing at WIC clinics and local health departments.
• Convening lead poisoning prevention partners to coordinate efforts and messaging.
• Education to health care providers about lead testing recommendations for children and pregnant women.
• Education to students in health care programs.
• Nursing Case Management services for home visits not covered under Medicaid.

There was continued success in the in-home nursing case management program, provided by local health departments statewide and by the Community Health Access Program in Genesee County. Since the increase in reimbursement amounts for in-home visits to Medicaid children with elevated blood lead levels in 2017, more children have received nursing case management services. Due to COVID-19, these services had to be delivered via phone and tele-visits. In FY 2020, 657 reimbursable homes visits were conducted by the 43 participating local health departments for 522 children with elevated blood levels. This is a decrease in visits and children served from previous years, however, still a significant increase from pre-2017. 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 local health departments 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 2020, 222 home visits were completed for a total of 176 non-Medicaid children with EBLLs. This is an increase from years past, however, these numbers were not required to be reported previously.

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.

Due to the COVID-19 pandemic and a move to remote work, coordination with other programs and partners became even more important to CLPPP’s work. This included:

• Work to expand internal state agency partnerships with WIC, Michigan’s Foster Care Program, and Lead Safe Home Program.
• Coordination with other health educators and community engagement specialists in the Division of Environmental Health to ensure that CLPPP educational materials were distributed widely. 
• Coordination with the 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.
• Coordination with community groups, advocacy organization, families of lead-exposed children, local government agencies

In FY 2020, CLPPP focused on identifying health care provider barriers to blood lead testing. In partnership with Altarum Institute, a survey was sent to health care providers statewide to better understand their current knowledge around testing/screening requirements and recommendations. Survey results showed that additional provider education should focus on testing recommendations, how to integrate testing into the clinic workflow, and how data management systems can support blood lead testing. Based on this information, CLPPP started planning for a robust health care provider education initiative. A public health detailer and physician consultant were hired by MDHHS Division of Environmental Health to assist with strategies and implementation. One of first activities was developing a health care provider resource packet that includes information on patient education, testing recommendations, care coordination with local health departments, and an online lead poisoning prevention training module for healthcare providers.

Additional programs and activities undertaken in FY 2020 to improve blood lead testing rates and capillary to venous testing rates in all children included:

• Began a partnership with MDHHS Vital Records to improve race and ethnicity reporting for blood lead testing. The project centers around establishing a data use agreement to link the birth records and blood lead data tables in the MDHHS Data Warehouse. This linkage will provide data to promote testing to populations that are at risk for blood lead exposure and to better address health disparities and inequities.
• Monthly data summary reports of testing status of Medicaid-enrolled children that included data by Medicaid Health Plans 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. Planning began to move this report availability to a Medicaid care coordination online portal, called CareConnect360. This move will allow for LHD and foster care workers to access blood lead testing status for Medicaid children as needed.
• Continuation of a quarterly Medicaid-CLPPP workgroup to ensure coordination between Medicaid programs and CLPPP. A weekly meeting between CLPPP and the Medicaid Managed Care Program was established for more regular coordination about lead data.
• Facilitating requests for blood lead data and Medicaid data by partners and researchers.
• Held a meeting in January 2020 with the CLPPP data referent group to get feedback and input on reports, processes, and procedures from frequent users of CLPPP data.
• Completed the Master Person Index algorithm project to enhance the matching of individuals within the blood lead data and across MDHHS data systems including Medicaid and the Michigan Care Improvement Registry. This improves our reporting abilities and better links blood lead data to alert providers of a child’s blood lead status.
• Contracted with a community advocate to begin outreach to the Arab American community in Southeast Michigan, specifically to parents, providers, and resettlement workers, promoting screening, testing, and education.
• Development of a radio script for Spanish-speaking populations which will be piloted in Kent County and will be available for use in other areas with Spanish-speaking populations.

To continuously improve CLPPP programs and activities, CLPPP contracts with the Michigan Public Health Institute to conduct an annual evaluation. The evaluation includes a satisfaction survey and key informant interviews with local health departments and lead poisoning prevention partners to collect data about communication, usefulness of resources, and response times/actions of CLPPP. Overall, results suggest participant satisfaction in their interaction with CLPPP staff.

Immunizations – Children (FY 2020 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 2020 to assure children receive vaccines on-schedule according to the recommended ACIP (Advisory Committee on Immunization Practices) Immunization schedule. The COVID-19 pandemic has presented numerous challenges to both healthcare and public health. The MDHHS Division of Immunization has been closely monitoring the impact of the COVID-19 pandemic on immunization administration and reporting patterns to the Michigan Care Improvement Registry (MCIR) and the resulting effect on immunization coverage estimates.

In addition to the barrier of the pandemic, many parents still have questions about vaccines and lack vaccine confidence. A recent national study suggested that only 63% of parents are following the CDC recommended ACIP schedule. 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 74% in FY 2019 to 70% in FY 2020, based on MCIR vaccine information. Michigan continues to see a decline in the immunization waiver rates for school-aged children and for preschool children due to the Michigan requirement that parents must receive immunization education at the local health department on the value and safety of vaccination before receiving a non-medical waiver of immunizations for their child.

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

In FY 2020, due to the COVID-19 pandemic, Michigan continued to experience a significant decrease in keeping children on schedule with all vaccines. During the first 6 months of the COVID-19 pandemic Michigan analyzed and distributed data frequently for children 19-36 months old. Michigan statewide coverage for children 19 through 35 months of age for 4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 HepB, 1 Varicella, 4 PCV, 2 HepA (43133142) rebounded from 53.6% in July 2020 to 55.0% in August 2020. For September 2020, the coverage increased to 55.1%. Additionally, for the same series without 2 HepA (4313314), coverage decreased from 70.3% in August 2020 to 70.0% in September 2020. This vaccine series coverage is 2.9% and 3.9% lower than it was in September 2019.

With the demands of COVID-19 response activities and priorities, MDHHS Immunization staff have not generated immunization impact reports after September 2020. Children who are not fully vaccinated remain susceptible to vaccine preventable diseases. MDHHS Immunization did assess the same childhood immunization coverage by Medicaid Status. The disparity in child coverage for the 4313314 series by Medicaid status remains. After gains in child coverage for the 4313314 series in August 2020, the coverage declined from 72.9% in August 2020 to 72.6% in September 2020 for non-Medicaid children and from 67.2% in August 2020 to 67.0% in September 2020 for Medicaid enrolled children. See Table 1 below for more information on the disparities in vaccination coverage by Medicaid status. Michigan children 7 months of age have the largest disparity in vaccination coverage by Medicaid status with coverage 21.6% lower for Medicaid-enrolled children than non-Medicaid children.

To addresses these challenges, the Michigan Immunization program continues to support the statewide media campaign, I Vaccinate, which began in March of 2017. MDHHS also continues to conduct focus groups with mothers of young children 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 continues with funding to run through 2020 to provide vaccine information to parents. The campaign promotes vaccination of children in Michigan using multiple 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.  The I Vaccinate campaign has also been used during the COVID-19 pandemic.

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

The Division of Immunization, under the direction and guidance from CDC, has paused site visits with immunizing provider sides during the COVID-19 pandemic. The quality improvement (QI) reports remain available to local health department immunization staff and to immunization provider offices. QI reports are focused on timely administration of immunizations and assess coverage level rates at the age of 2 years, 13 years, and 17 years old. The QI reports assist with data to support strategies focusing on increasing timely vaccinations of all patients. In 2019, 829 QI visits were completed in provider offices to assist with increasing immunization rates. During 2020 fewer than 200 immunizing providers received a site visit, directly due to COVID-19 activities and priorities.

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. Because of the COVID-19 pandemic the Michigan Immunization report cards have not been generated. As COVID-19 demands decrease, Michigan will again make that data available to the public to increase awareness of immunization rates by county.