Oral Health – Children (FY 2024 Application)

National Performance Measure (NPM) 13.2 focuses on oral health in children and is linked to the state priority need to “Improve oral health awareness and create an oral health delivery system that provides access through multiple systems.” In the needs assessment, focus group participants reported several needs and challenges related to oral health. These included a need for more school-based oral health services; an overall shortage of dental providers that will accept Medicaid beneficiaries; and a lack of access to dental services in communities. The health status assessment also identified a disparity between oral health outcomes for Black children and non-Hispanic White children, as discussed in Objective B of this state action plan.

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 on overall health—which is illustrated by the fact that this NPM is linked to Title V National Outcome Measure 19, the percent of children in excellent or very good health—the OHP has increased its collaborations with community partners to improve oral health through prevention activities and direct access programs.

In Michigan, 58 of the state’s 83 counties have a full, partial or facility Health Provider Shortage Area (HPSA) designation, with 11 counties having less than five dentists. Only 38% of Medicaid-eligible children in Michigan receive dental services. Children under the age of five are the least likely to have visited a dentist. The Michigan Medicaid Program has been addressing access to oral health care by implementing the Healthy Kids Dental program throughout the state. The Healthy Kids Dental program began as a demonstration program through a contract with Delta Dental Plan of Michigan in 22 counties in May 2000. By October 2015, the program had expanded into all 83 counties. The Healthy Kids Dental Plan now utilizes Delta Dental, Blue Cross Blue Shield and DentaQuest network of dentists and provides a higher reimbursement rate to dentists, thereby allowing greater access to dental care for Medicaid-enrolled children. The utilization of dental care within this program has increased to over 50% of enrollees. This program assists children and adolescents, ages 0-21, with access to dental care.

The Healthy People 2030 target goal is to have 42.5% of children ages 3 to 19 with one or more dental sealants in place. Between 2005 and 2016 there was an increase in the percent of third grade students in Michigan with one dental sealant or more. In 2005, 23.3% of third grade students had one or more dental sealants; in 2010 it was 26.6%; and in 2016 it was 37.6%. This increase is attributed in part to the MDHHS SEAL! Michigan school-based dental sealant program which piloted in 2007 and has expanded within the state over the last several years. Until the fall of 2018, SEAL! Michigan was funded through Title V, CDC Cooperative Agreements, HRSA grants (as available), and annual gifts received from the Delta Dental Foundation of Michigan. Beginning in the fall of 2018, the SEAL! Michigan program experienced a loss of federal grants, and is now primarily funded through a Medicaid match, Title V, and annual gifts from the Delta Dental Foundation. This blended funding supports direct services delivered in schools across Michigan, a School Oral Health Consultant to manage SEAL! Michigan at the state level, and a 0.5 FTE Oral Health Coordinator at Detroit Public School Community District (DPSCD). Although less funding is currently available for sealant programs, the loss of federal grant funding did result in the state Medicaid program supporting the Oral Health Consultant position which adds significant sustainability to the program overall.

Historically the SEAL! Michigan program was entirely school-based and/or school-linked, focusing only on permanent molars; additionally, students served were in the first, second, sixth, or seventh grade for all of lower Michigan, minus Wayne County, and all students (K-12) were served in Wayne County and the Upper Peninsula. During the pandemic, SEAL! Michigan programs have been school-based and school-linked when possible, and when not possible, have been allowed to provide services in alternative locations (i.e., daycare centers, WIC, head start centers, YMCA, churches, Boys & Girls Club, sporting arenas, youth homes, group foster homes, community centers, township halls, city halls, food pantries) and can set up external service areas in retail and health center parking lots. Students served are between the ages of 1-21 and it is now allowable to seal both primary and permanent teeth. These changes are in response to so many students in Michigan not having access to preventive dentistry in a dental home or lacking dental services in a school environment. SEAL! Michigan programs have been given the flexibility to think ‘outside the box’ on how, where, and when to provide dental screenings, sealants, and other preventive treatments.

Effective January 1, 2023, MDHHS has expanded dental sealant coverage for beneficiaries under age 21 for the prevention of pit and fissure caries. In addition to fully erupted first and second permanent molars (2, 3, 14, 15, 18, 19, 30, 31), the expanded coverage includes fully erupted first and second primary molars (A, B, I, J, K, L, S, T) and fully erupted first and second permanent premolars (4, 5, 12, 13, 20, 21, 28, 29). This change will increase the number of sealants allowable for SEAL! Michigan programs and improve the oral health of Michigan children. It will also allow for a more fiscally sustainable model for participating SEAL! Michigan programs.

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

This objective aligns with the Oral Health NPM: Percent of children, ages 1-17, who had a preventive dental visit in the past year. Implementing a school-based dental sealant program will support progress toward an increased number of children with a preventive dental visit. SEAL! Michigan is focused on providing preventive oral health care to students through assessment, education, dental sealants, and fluoride varnish application. To best align preventive efforts to highest areas of need, the SEAL! Michigan programs target schools that have 50% or more students enrolled in the Free and Reduced Lunch Program (FRLP).

Dental decay is the leading chronic childhood disease and nationally leads to more than 51 million missed school hours per year. Dental sealants are an evidence-based strategy to prevent dental decay. SEAL! Michigan is a school-based dental sealant program that provides dental screening and places dental sealants for students at no cost to families. In addition to dental sealants, students receive a dental screening, oral health education and (over 90% of the time) fluoride varnish. Although this strategy does not include comprehensive dental services, dental screenings are an effective point of entry to connect to a dental provider, which is increasingly more accessible with the expansion of Healthy Kids Dental.

SEAL! Michigan began in 2007 with a single pilot program serving a handful of schools. Through increased awareness and advocacy, the program has seen consistent growth by adding more programs and schools annually. Currently the program has nine grantees across the state, plus programs operating in DPSCD (which will be determined by DPSCD but ideally will be no less than four programs at a time). Although the SEAL! Michigan program provided service to 193 schools in FY 2020 (before the state shutdown in mid-March 2020), most schools in Michigan do not offer a dental sealant program to students. Dental sealants ultimately decrease dental disease in youth as they are nearly 100% effective in preventing dental decay when they are retained on the tooth. Reaching children through school-based services is efficacious and is a recognized best practice approach by the CDC and the Association of State and Territorial Dental Directors.

Program management and growth significantly rely on data collection. SEAL! Michigan has made ongoing improvement modifications to its data collection efforts. Data are collected annually and entered into software to be cleaned and analyzed by the oral health epidemiologist. Annual reports are written and released for each local program as well as aggregated into a statewide report. Data  illustrates program success through annual increases in number of schools and students served and through number of sealants placed. The data will be captured by the Michigan Basic Screening Survey of third grade students (completed every five years), Count Your Smiles Report, to demonstrate the rates of dental sealant placement and dental decay in children across the state. In FY 2020, the SEAL! Michigan team in the Oral Health Unit created a year-end infographic which will be updated by each individual program annually. The infographic highlights data from each individual program for the fiscal year and can be used to share accomplishments with stakeholders, school administrators, and additional funders. The infographic was also created for the OHP to highlight the cumulative outcomes of SEAL! Michigan.

The SEAL! Michigan program attempts to reach the target population through family and consumer outreach and engagement. As stated previously, programs focus on schools with a high number of children enrolled in the FRLP. The program relies on parent and guardian awareness of the program; thus, parents’ consent for their children to receive the preventive oral health services is a key component of the program. To reach families and consumers, staff from the funded programs attend back-to-school nights and Parent Teacher Organization (PTO) meetings. A satisfactory rate of parental consent is achieved among currently established SEAL! Michigan programs. New programs will assess parent engagement strategies, as discussed in Objective B. All student consent forms are delivered home with an informational brochure on the SEAL! Michigan program and the benefits of dental sealants. The brochure was initially developed by professional health literacy specialists and was written at a third grade reading level to accommodate varying literacy levels. The brochure was updated in the summer of 2020 by the MDHHS Communications Office and will continue to be used in FY 2024. The brochure strives to deliver linguistically and age-appropriate health information.

The first strategy under this objective is to utilize the SEAL! Michigan database to track the number of students receiving an annual preventive dental screening. This strategy reflects the measure’s ESM, which is the number of students who have received a preventive dental screening through the SEAL! Michigan program. Continual updating of the database allows for tracking the number of unique students who receive one or more dental sealants through the program.

The second strategy is to promote dental sealant programs through school health professionals. The growth of the program relies on continual expansion into new schools. The MDHHS School Oral Health Consultant will continue to a) promote dental sealant programs through school nurses and other school health professionals and b) encourage participation with SEAL! Michigan or other school-based dental sealant programs. This strategy will be accomplished through collaboration with internal MDHHS partners, as well as embracing external partnership opportunities via professional organizations, conferences, and educational venues. Ninety percent of the nurses are contracted and will require training on oral health yearly. A plan to provide oral health education will occur during monthly meetings so that newly hired nurses are provided oral health education information.

The third strategy is to monitor evaluations to determine best practices in school sealant programs in schools with high participation. Ongoing evaluation of sealant programs is imperative to overall growth. Learning from all partners involved (students and parents, school administrators, teachers, school nurses, health professionals, social workers etc.) through evaluation will assist in directing the SEAL! Michigan program towards continued success. In FY 2017, a full SEAL! Michigan program evaluation was conducted by the Michigan Public Health Institute, and the final evaluation provided program improvement strategies. Recommendations continue to be implemented by individual programs to the extent possible.

A fourth strategy is to examine ongoing health trends to identify geographic areas experiencing a high burden of disease, and then use the information to identify populations that will benefit from an increase in dental sealant placement in proportion to disease and population. This strategy will help assess whether oral health programs are funded in areas of high need and to maximize access and preventive potential to the populations with the highest need. This strategy will help build the OHP’s capacity to achieve equitable health outcomes. In addition, MDHHS will partner with data and evaluation entities to build systems to measure the impact of increased sealant coverage in the state of Michigan.

Objective B: Increase dental sealant placement on children enrolled in Detroit Public Schools Community District (DPSCD).

Detroit Public Schools has incorporated BLUEPRINT 2020 into their system to help “rebuild Detroit Public Schools.” Oral health is included in the plan and falls under the Whole Child Commitment, as students receiving dental care will have less toothaches and will be more likely to achieve their full potential. The DPSCD system is the largest school district in the state and provides educational services to approximately 50,000 students. According to a report by the Michigan Department of Education, the majority of children (approximately 82%) attending DPSCD are African American.

Michigan’s 2016 Count Your Smiles (CYS) report collected data from open mouth screenings of third grade children across Michigan. According to the report, the City of Detroit data indicated that approximately 82% of third grade children had active dental disease (18.3% had no obvious problems, 59.6% needed early dental care, and 22.1% needed immediate dental care). Additionally, only 28.3% of children had at least one dental sealant, which is the lowest percentage by region in Michigan. The City of Detroit also reported the highest percentage of children who had a toothache in the past six months. Additionally, more recent data from the National Survey of Children’s Health (2020-2021) indicates that in Michigan 78.4% of Non-Hispanic White children received a preventive dental visit in the last year compared to 70.5% Non-Hispanic Black children. Given these disparities in oral health outcomes and access to care, establishing stronger oral health programs and follow-up care coordination in DPSCD will help to improve the oral health of Michigan’s children.

During the COVID-19 pandemic, dental care was not provided in DPSCD school buildings due to school closings. In March 2022, dental service returned full time. Administrators took the opportunity to pause and create an oral health plan that provides more clarity on which providers serve the schools. The new plan involves contracting with four different providers (three restorative and one preventive) and assignment of one to each school. This improvement enables DPSCD to have more oversight over which programs are coming in and out of each school building. Historically, DPSCD did not have a designated position to oversee all oral health activities and lacked the oversight to ensure that students receive preventive and restorative care as well as urgent follow up care. Thus, the MDHHS OHP worked with DPSCD to create and fund a half-time Oral Health Coordinator (OHC) position to oversee work relating to oral health in all DPSCD buildings. This OHC was hired in August 2020 and will continue to be funded in FY 2024 to provide oversight of the dental programs and to help the students in DPSCD receive both preventive and restorative care.

One strategy is for the OHC to provide multiple ways to access a dental consent form. The dental consent form is given to the student to take home for the caretaker to complete and return to the school. However, this delivery method sometimes requires consent to be sent home several times. In FY 2024, the OCH will work with school administration staff, parents, and students to identify alternative methods to help increase receipt of positive consent forms. Delivery methods might include having forms available online and at PTA meetings and/or having dental packages available during 106 open enrollments and open houses.

The second strategy is to have all staff from the Physical Health Department understand oral health prevention and how pain in oral health can limit student participation in school activities and overall academic performance. In FY 2024, the OHC will train Behavioral Health Counselors in oral health education at each school to help provide a better understanding of how children’s behavior can be affected by pain. In addition, the plan will include a DPSCD school specializing in students with developmental disabilities. Research shows that children with developmental disabilities can experience more pain than children without disabilities. Pain can affect not only the physical status of students but also their mental health.

The third strategy is to increase the number of dental providers in DPSCD. At the time of this writing, DPSCD has approximately 46,000 students enrolled. In FY 2024, the OHP will work to increase the number of dental providers by two. The OHP recognizes that it is essential for students to have a positive relationship with healthcare providers. If there are more dental providers whom students can trust and build a positive relationship with, it will offer rewards in the future. A student will experience seeing a dental professional every six months and will learn about quality dental care. In addition, this will increase the number of sealant placements and other dental services. As the number of positive dental consent forms increases, assessing service data will help determine how many additional providers are needed in the future.

Childhood Lead Poisoning Prevention (FY 2024 Application)

Lead poisoning prevention and intervention continues to be a critical need in Michigan. Michigan has made significant progress over time in reducing the percentage of children who have elevated blood lead levels. However, several of Michigan’s cities (including Highland Park, Detroit, Hamtramck, Grand Rapids, and Muskegon) have significantly higher rates of elevated blood lead levels. Additionally, the COVID-19 pandemic has negatively impacted blood lead testing rates due to deferred care and increased use of telemedicine. Children spending more time at home increased the risk of exposure for those living in homes with lead contamination. In addition, blood lead testing rates decreased even more in 2021 due to a recall of LeadCare II capillary test kits. LeadCare II capillary testing is the main method used for majority of capillary testing in Michigan. With that testing method unavailable, testing rates decreased throughout the state. Although the LeadCare II test kits concerns have been resolved, in FY 2024 those tests will continue to be monitored for accuracy and education will be provided to providers concerned about the recall.

The State Performance Measure (SPM) addressed in this state action plan measures the percent of children less than 72 months of age who receive a venous lead confirmation test within 30 days of an initial positive capillary test. The SPM is linked to the state priority need to expand access to developmental, behavioral, and mental health services through routine screening, strong referral networks, well-informed providers, and integrated service delivery systems.

Leadership for Michigan’s lead prevention activities, as they relate to the MCH population, is housed within the Childhood Lead Poisoning Prevention Program (CLPPP). CLPPP resides in the Division of Environmental Health-Lead Services Section to better strengthen the health/housing partnership at the state and local levels. Title V funding supports the childhood lead programs administered by CLPPP. CLPPP staff work collaboratively with MCH staff and Medicaid, particularly on issues related to case management and blood lead testing. In FY 2024, CLPPP will continue to focus on implementing innovative strategies to increase blood lead testing across the state. Strategies will include new partnerships with the Medicaid Health Plans (MHPs) and Federally Qualified Health Centers (FQHCs) as well as continued support of long-standing partnerships with the Women, Infant & Children’s (WIC) program and local health departments (LHDs).

Three focus areas of CLPPP include data surveillance, nursing assistance, and community education and engagement. Title V funding directly supports nursing assistance and community education. Data surveillance allows for CLPPP to better target areas for needed nursing assistance and community education. CLPPP provides statewide community outreach to parents, health care providers, childcare providers, public schools, homeowners, and tenants on the prevention of lead exposure and the importance of blood lead testing. CLPPP also provides technical nursing assistance for LHDs and health care providers to support the management and coordination of services for children with elevated blood lead levels (EBLL).

An EBLL is defined as a blood lead level (BLL) equal to or greater than 3.5 micrograms per deciliter of blood (µg/dL). Children with an EBLL should have interventions such as 1) in-home nursing case management, 2) environmental investigations to mitigate health effects of lead exposure and identify and remove sources of lead in their environments, and 3) referrals to health and human services and appropriate resources.

During FY 2022, the Michigan Department of Health and Human Services updated its definition of an elevated blood lead level for children from 5 µg/dL to 3.5 µg/dL, following the Centers for Disease Control and Prevention updating their blood lead reference value (BLRV). At a level of 3.5 µg/dL or greater, lead education, nursing case management, environmental investigations, and additional medical monitoring should be established to lower the blood lead level.

With a lowered BLRV, we are identifying additional children as having an EBLL, both through capillary and venous testing. Title V funding and support for MDHHS and state local health departments is critical so that resources are available for outreach and services to families that will be identified as having children with EBLLs. Additionally, outreach is needed to health care providers, laboratories, and partners to share the information on the new BLRV and that capillary results at a level of 3.5 µg/dL should be followed up as an EBLL and a venous test is needed.

Objective A: By 2025, increase screening for lead exposure risk factors for children less than 72 months of age.

Blood lead testing of children at risk of exposure to lead in homes or from other sources is critical for targeting interventions to prevent adverse health effects of lead. All children covered by Medicaid are considered at high risk for blood lead poisoning. In Michigan, all Medicaid children are required to receive blood lead testing at 12 and 24 months of age, or between 36 and 72 months of age if not previously tested. MDHHS also recommends targeted testing for other children who are especially at risk of lead exposure. This risk is determined by screening the child using the Michigan blood lead risk assessment tool. Assessment questions include:

• Does the child live in or regularly visit a home built before 1978?
• Does the child live in or regularly visit a home that had a water test with high lead levels?
• Does the child have a brother, sister, or friend that has an elevated blood lead level?
• Does the child come in contact with an adult whose job or hobby involves exposure to lead?
• Does the child’s caregiver use home remedies that may contain lead?
• Is the child in a special population group such as foreign adoptee, refugee, migrant, immigrant, or foster child?
• Does the child’s caregiver have a reason to believe the child is at risk for lead exposure?

If the answer is “yes” or “don’t know” to any of the above questions, then blood lead testing is recommended.

The blood lead risk assessment is a verbal questionnaire that is conducted with family members when they are in a health care provider’s office. Currently, there is not a consistent way to document completion of the risk assessment, which creates a barrier to accurately determining the number of providers conducting the risk assessment with patients.

A strategy to increase blood lead screening is to improve notification to health care providers of patients’ blood lead levels and the need for blood lead testing. Activities include work with the Michigan Care Improvement Registry (MCIR) team. MCIR is the state immunization registry, accessed by local health departments, health care providers, Medicaid health plans, and schools throughout the state. In FY 2022, CLPPP worked with MCIR to determine the best way to add functionality in the registry to flag or alert a MCIR user that blood lead screening should be done by going through the blood lead risk assessment questions. Expanding on this in FY 2023, CLPPP has also partnered with the Altarum Institute to research how to improve provider notification of elevated blood lead results and improve their ability to determine if a child is due for a blood lead test. In FY 2024, in partnership with Altarum Institute, CLPPP will begin a pilot project to develop a direct interface between EHR systems and the CLPPP data to populate blood lead levels and build in alerts when testing or follow-up is necessary. This interface will call attention to any child who has not had a blood lead test, will support health care providers, local health departments, schools, and Medicaid health plans to go through the risk assessment, determine if testing is needed, coordinate care, help arrange transportation as needed, and address any other barriers to blood lead testing.

Another strategy is education and outreach to health care providers in Michigan. Health care providers play a vital role increasing screening, testing, and confirmatory testing rates. CLPPP will undertake several efforts to educate and connect with health care providers, including:

• Expanded outreach to health care providers in Michigan to heighten awareness of the new BLRV and that levels of 3.5 µg/dL are considered elevated.
• Continued connection between the MDHHS physician consultant and public health detailer with health care provider offices across the state to provide education about blood lead testing recommendations, discuss testing options for offices (including point of care testing), and build partnerships.
• Partner with the Michigan Chapter of the American Academy of Pediatricians (MI-AAP) to present to pediatricians at annual conferences and during a webinar series.
• Follow up with health care providers who received a mailing of a resource packet in February 2022.
• Continued dissemination of an online training module for health care providers, in partnership with the Michigan Public Health Institute. Continuing education credits are available for social workers, nurses, physicians, and pediatricians. The goal of the course is to increase knowledge, understanding, and behaviors to reduce the health impacts of lead exposure in children under the age of six. Training content focuses on understanding how children are exposed to lead, the health impacts of lead, blood lead testing requirements and the risk assessment questions, the importance of working with local health departments and other resources.
• Provide grants to local health departments to connect with and build partnerships with local health care providers within their jurisdiction. The coordination of care between local health departments and health care providers is critical when a child has been identified as having an EBLL. It is important that these partnerships are developed ahead of time and both parties recognize the other’s services and resources.

The third strategy is partnering with agencies to provide culturally appropriate and audience-specific lead education to populations at increased risk for lead exposure, as follows:

• CLPPP will continue to provide educational materials to daycare providers throughout the state.
• A project by the Genesee Health Coalition Community Health Access Program to partner with area health care providers, specifically OBGYNs, to recommend testing for pregnant women identified as being at risk for lead exposure and refer them to health and human services and resources.
• CLPPP has partnered with a consultant in Southeast Michigan to provide trainings and equip staff with tools and materials to conduct environmental assessments, screenings, and education in Arabic for immigrant and refugee clients. This work will be based on the CDC’s Lead Poisoning Prevention in Newly Arrived Refugee Children toolkit.
• CLPPP plans to continue to have lead poisoning prevention materials available in commonly used languages including Spanish, Arabic, and Bengali. CLPPP will work with the Culturally Appropriate Services for All (CASA) group in the Division of Environmental Health (DEH). CASA is a group of DEH employees who come from various cultural background and speak different languages. The group reviews materials so they are both linguistically and culturally appropriate. In FY 2024, CLPPP will work to have additional languages available, both electronically and for mailing.

Objective B: By 2025, increase by 10% the percent of Medicaid-enrolled children less than 72 months of age that receive blood lead testing.

As mentioned above, all Medicaid-enrolled children are considered at high risk for blood lead poisoning. Specifically focusing on Medicaid-enrolled children can help to increase equitable health outcomes across the population. Medicaid policy requires blood lead testing at 12 and 24 months of age, or between 36 and 72 months of age if not previously tested. This population is a priority target for CLPPP to increase testing rates overall.

The first strategy for this objective is to provide local health departments with a monthly report that includes all Medicaid-enrolled children within that local health department’s jurisdiction. The report includes all children less than 72 months of age and their blood lead testing status. Local health departments can use this report as a tool to identify children who need follow up to encourage blood lead testing.

The second strategy to achieve Objective B in FY 2024 will be health care provider education and outreach, as discussed under Objective A. The same activities and efforts will be used here, specific to encouraging blood lead testing to Medicaid-enrolled children.

A third strategy to achieve Objective B in FY 2024 is to expand partnerships with other programs serving Medicaid enrolled children.  In FY 2023, CLPPP began meetings with the Michigan Primary Care Association to partner on a Lead Testing Initiative to support increased blood lead testing efforts at Federally Qualified Health Centers across the state. Another important partnership with Medicaid has resulted in CLPPP’s participation in the Medicaid Health Plan focus studies. These focus studies will take place during the summer of FY 2024. A goal of CLPPP’s involvement in the focus studies has been to increase blood lead testing rates and increase education to their provider network. This important partnership has resulted in additional support for local health departments by increasing communication with MHPs about services they provide to families we are both serving. These partnerships will continue and expand in FY 2024.

Objective C: By 2025, increase by 10% the percent of all children less than 72 months of age with an elevated blood lead level (EBLL) from a capillary test who receive a venous lead confirmation test.

Two sample types are used in blood lead testing: a capillary draw and a venous draw. Any blood lead test that is done on a capillary drawn sample must be confirmed by a venous drawn sample. This is because oftentimes a capillary blood lead test can be falsely elevated, and a venous test is needed to confirm that the blood lead level is truly elevated. Additionally, a child who has an elevated blood lead level confirmed with a venous test qualifies for services like nursing case management, the Lead Safe Home Program, and Early On. This objective will use MDHHS data warehouse data to track progress through 2025.

The first strategy for Objective C is to continue to send local health departments quarterly spreadsheets for each county within their jurisdiction. The spreadsheet will include a venous follow-up testing status for all capillary EBLLs, deduplicated by month, as well as a line list of children with a capillary EBLL no venous follow-up. Local health departments will be able to use these quarterly reports to conduct phone calls, mailings, and home visits to encourage the venous confirmatory test.

A second strategy CLPPP plans to implement in FY 2024 is working with the families of those that have received nursing case management, to get feedback and ideas for improving the case management process. Once nursing case management is completed, the child’s BLL has declined, and the family is connected with resources, CLPPP is planning to work with the family to understand how and if nursing case management is helping, whether the service met families’ expectations, and whether the desired outcomes are being achieved.

The third strategy to achieve Objective C is health care provider education and outreach, as discussed under Objective A. The same activities and efforts will be used, specific to encouraging that all elevated blood lead test results from a capillary test are followed up with a venous confirmation test.

An additional strategy to achieve Objective C is a result of our increased partnership with the MHPs as mentioned in Objective B. In FY 2024, CLPPP, Molina and the Detroit Health Department (DHD) will continue monthly meetings to identify how to coordinate case management, education, and outreach efforts among shared clients. A Plan-Do-Study-Act (PDSA) cycle will be implemented to increase the number of children receiving a venous confirmatory test. The DHD is partnering with Molina’s outreach and case management team to reinforce and more closely monitor how many children receive a venous confirmatory test. The DHD will identify current zip codes with the highest rate of elevated blood lead levels. Once the zip code is identified, both the health department and Molina will develop an engagement strategy and decide on the best method to track and share data to measure how many children received a venous confirmatory using the decided upon strategy. CLPPP will assess the progress of this initiative and expand statewide during FY 2024 with other LHDs and additional MHPs.

Immunizations – Children (FY 2024 Application)

Based on the Title V needs assessment, the state performance measure (SPM) created in 2015 was retained in 2020, which is the “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).” The 4:3:1:3:3:1:4 series represents 4 doses of DTaP, 3 doses of Polio, 1 dose of MMR, 3 doses of Hib, 3 doses of HepB, 1 dose of Varicella, and 4 doses of PCV vaccines. In the 2020 needs assessment Provider Survey, when asked “Which of the following healthcare-related needs are most often unmet among the families you serve?” 37.8% of respondents across population domains identified immunizations as an unmet need. The need was identified as highest among respondents who serve CSHCN (46%) and children and adolescents (40.6%). The forces of change assessment also identified an increasing focus on individual choice (including vaccine refusal) versus community benefits as a factor that impacts population health. Notably, those needs assessment findings were obtained prior to the COVID-19 pandemic.

Michigan continues to experience significant impacts on immunization rates. In May 2020, the CDC published “Decline in Child Vaccination Coverage During the COVID-19 Pandemic —Michigan Care Improvement Registry, May 2016–May 2020” in its Morbidity and Mortality Weekly Report. Data from the Michigan Care Improvement Registry (MCIR) showed vaccine coverage declines among most children at milestone ages in May 2020 compared to previous May estimates. For example, from January through April 2020, the number of non-influenza vaccine doses given to children aged <18 years decreased 21.5% compared to the average for the same period in 2018 and 2019. Up-to-date vaccinations have also declined to <50% among most children ≤2 years.

In addition to the vaccine coverage challenges typically experienced in Michigan, the impact of the COVID-19 pandemic has created new, unique challenges. Image 1 indicates falling vaccination rates at several milestone ages over time.

Image 1. Percentage of Michigan Children Vaccinated at Milestone Ages

Michigan has experienced declining immunizations rates and has not met the Healthy People 2030 goal of 80% for child immunizations. As of December 2022, according to the MCIR, the percent of children ages 19-35 months who received a full schedule of age-appropriate immunizations (Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Haemophilus Influenza and Hepatitis B) is at an alarming 66.1%, 7.5 percentage points lower than the pre-pandemic level of 73.6% in January 2020. The COVID-19 pandemic and vaccine hesitancy have contributed to falling vaccination rates.

Parent vaccine hesitancy has greatly increased even though many published scientific articles show that vaccines are safe and effective. Michigan continues to have some of the highest vaccine exemption rates for kindergarten children compared to other states. Michigan has worked hard to educate providers on the importance of immunizations as a standard of care and the importance of talking with parents about any questions or concerns they may have. Michigan has also partnered with a non-profit organization called the Franny Strong Foundation to provide information for parents through the I Vaccinate campaign to learn facts about immunizations and the risks of not vaccinating. MDHHS will continue to work with internal and external partners to provide educational messages to the public to promote timely vaccinations.

The mission of the MDHHS Division of Immunization is to minimize and prevent the occurrence of vaccine-preventable diseases in Michigan. The program seeks to fulfill its mission through coordinated program efforts designed to:

• Promote high immunization levels for children and adults
• Provide vaccines through a network of public and private health care providers
• Facilitate the development, use and maintenance of immunization information systems
• Support disease surveillance and outbreak control activities
• Provide educational services and technical consultation for public and private health care providers
• Promote the development of private and public partnerships to improve immunization levels across the state
• Promote provider and consumer awareness of immunization issues

The vision of the Division of Immunization is to implement effective strategies and to strengthen partnerships with our stakeholders to eliminate vaccine preventable diseases in Michigan.

The Michigan Division of Immunization operates the Michigan Care Improvement Registry (MCIR). The MCIR is a statewide immunization registry that contains over 192 million provider doses administered to 13 million persons in Michigan. MDHHS continues to subcontract with six MCIR regions to enroll and support every immunization provider in the state. MCIR is used routinely by nearly 7,700 users to access and determine the immunization records of children and adults. In 2019, MCIR generated over 203,187 recall letters notifying responsible parties whose children had missed shots and encouraged them to visit their immunization provider to receive needed vaccines.

MCIR can forecast needed doses of vaccine for all children who are contained in the system. All children should have completed the recommended pediatric vaccines by the time the child reaches 19 months of age. Data from MCIR indicate that between 45.5% and 55.4% of children who reside in Michigan have received the routinely recommended 4313314 series by the time they reach 24 months of age. MCIR rates have experienced gradual decreases in compliance rates for children enrolled in Medicaid as illustrated in Image 2.

Image 2. Estimated Pediatric Vaccine Series Coverage, Children 19 through 35 months, Medicaid and Statewide, September 2013 – December 2022

The Immunization Program intends to use Title V funds in FY 2024 to support program work in addressing declining immunization rates and increasing vaccine confidence among providers and parents. The funds will be used to target areas with low vaccination rates, while working collaboratively with internal and external partners to increase vaccination rates through communication campaigns, targeted outreach, and sending vaccine recall letters using the MCIR for those overdue for any vaccine.

Objective A: By 2025, increase the percentage of children 19-36 months of age who receive recommended vaccines to 80%.

Data obtained from MCIR show that children are not receiving vaccines on-schedule, and many of these children never catch up on all needed vaccines, as illustrated in Image 1. This puts children at risk, with nearly half of children susceptible to these serious diseases. From birth to 2 years of age, children are recommended up to 25 vaccinations to prevent 14 infectious diseases. The vaccination schedule is designed to protect children when they are most vulnerable. Recommendations based on ages of vaccines are shown to be safe and effective. There are no known benefits to delaying vaccinations.

MCIR can also assess existing immunization data for children and forecast needed doses. This functionality greatly assists clinicians in determining any needed doses of vaccine during a clinical encounter. This same forecasting functionality can be used at a population level to determine any children who need vaccines. To increase vaccination rates, in FY 2024 the Division of Immunization will notify parents of all children 24 months of age who are overdue for one or more vaccines. In the past, efforts have been targeted at children who are 2 to 3 years of age, but this effort will attempt to impact parents of children less than 2 years of age who are not staying on schedule. Data from MCIR show that children who stay on schedule are twice as likely to complete all needed vaccines as those who fall behind early in life. A central strategy to address this objective is to generate notices to parents of children who are overdue for vaccines. These notices are not intended to replace other efforts that may be underway in provider offices or at local health departments but are meant to enhance existing efforts to remind parents of the importance of immunizations.

In Michigan, disparities exist in immunization rates. The Division aims to use MCIR data to conduct a root cause analysis and identify high social vulnerability index (SVI) areas within the state and conduct targeted vaccine outreach in those areas. It is of the utmost importance that vaccine access is equitable to all Michigan children. Identifying high SVI areas within the state and conducting targeted vaccine outreach in those areas will assist in addressing the disparities in vaccination coverage.

Furthermore, the COVID-19 pandemic has contributed to an increase in vaccine hesitancy for all vaccines. In FY 2024, the Division of Immunization will work with national partners, including Centers for Disease Control and Prevention, as well as internal and external partners to promote vaccine confidence among parents of this age group through resources, media, and presentations. While most parents choose to vaccinate their children according to the recommended schedule, some parents may still have questions about vaccines and getting answers they trust may be hard. It is vital that the Division works with these partners to address any questions or concerns Michigan parents may have with childhood vaccinations and promote vaccine confidence among this group.

Finally, the Division aims to work more directly with the Alliance for Immunization in Michigan Coalition (AIM) to better engage families and communities through education and improvements to the aimtoolkit.org website. AIM is a partnership of public and private sector organizations formed in 1994 to focus on a broad spectrum of immunization issues in Michigan. AIM’s mission is to promote immunizations across the lifespan through a coalition of health care professionals and agencies. The AIM coalition continues its focus on improving all facets of immunization services in Michigan.

As a result of the COVID-19 pandemic, the AIM coalition was essentially put on hold. As immunization rates continue to drop statewide, it is more important than ever to re-ignite this coalition and work collaboratively with private and public stakeholders to address vaccine hesitancy and improve vaccine uptake. AIM’s website, aimtoolkit.org, provides education and promotes vaccination for both healthcare professionals and individuals and families. Harnessing the Division’s partnership with the AIM coalition will better connect the Division’s resources directly with consumers.

Objective B: Assist local health department immunization staff with targeting outreach to under-served populations in their jurisdiction.

The Michigan Immunization Program will continue to distribute population-based county “report cards” for local health departments to better understand immunization barriers and opportunities for improvement in their communities. The MCIR epidemiologist will generate county report cards on a quarterly basis, which will be posted on the MDHHS Immunization website (www.michigan.gov/immunize). The immunization report card will contain coverage level information in several key areas including pediatric, adolescent, and adult coverage levels. Report cards rank each county in the state, so a county can also compare its progress to other counties.

Another key report which will be made available to local health departments is the COVID-19 Impact Report. This report shows how COVID-19 has impacted childhood and adolescent immunization rates, while encouraging providers to catch Michigan children up on recommended vaccines. The Michigan Immunization Program will continue to make the data available to local health departments so they can be better informed on areas for improvement as they work with immunization providers in their jurisdiction. Due to the COVID-19 pandemic, there have been decreases in the coverage levels of childhood vaccines, and much work needs to be done to keep children on schedule. These reports not only identify immunization rates by age but also show immunization rates by age broken down by vaccine types. Local health departments can identify immunization levels by vaccine type to determine areas where immunization providers may not be offering all recommended vaccines.

Michigan has large disparities in immunization coverage rates based on race. Using the same assessment logic being used by the CDC for the National Immunization Surveys, the statewide immunization rate is 66.1% for the 4313314 series, as of December 2022. Image 3 illustrates vaccination coverage among children ages 19-35 months by mother’s race. Black children record the lowest immunization rates (57.71%) as compared to the highest rates of Asian/Pacific Islanders (76.49%).

Image 3. Vaccination Coverage by Mother’s Race

The Michigan Immunization Program will create reports showing immunization rates by race for each local health jurisdiction. These data are being made available to local health departments to bring more focus to issues of health equity and health disparities as a key strategy to achieving equitable health outcomes related to vaccine coverage.  As a result of the COVID-19 pandemic, the MCIR now contains the race of each person. The immunization rates for race had previously been created using the mother’s race information.