Oral Health – Children (FY 2021 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, to receive dental care.

The Healthy People 2020 goal is to have 28.1% of children ages 6-9 with one or more dental sealants in place. Between 2005 and 2016 there has been 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! MI 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 and a School Oral Health Consultant to manage SEAL! Michigan at the state level. 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.

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 with each individual program expanding into more schools annually. Currently the program has eight grantees across the state, with two more programs planned to begin in the summer of 2020. Although the program provided service to 202 schools in FY 2019, 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 is collected annually and efficiently entered through Teleform software where it is cleaned and analyzed by the oral health epidemiologist. Annual reports are written in a timely manner and released for each local program as well as aggregated into a statewide report. Data can illustrate program success through annual increases in number of schools and students served and through number of sealants placed. Ultimately, 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 worked with an intern in the oral health unit to create a year-end infographic which will be posted on the MDHHS Oral Health webpage. The infographic shares data highlights of each individual program for the fiscal year and can be used by each program to share accomplishments to stakeholders, school administrators, and additional funders. The infographic was also created for the OHP to highlight the cumulative outcome of SEAL! Michigan. The infographic will be updated annually.

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 developed by professional health literacy specialists and is written at a third-grade reading level to accommodate varying literacy levels. 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.

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.

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

Detroit Public Schools Community District 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 Detroit Public Schools Community District (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 region in Michigan. The City of Detroit also reported the highest percentage of children who had a toothache in the past six months. The National Survey of Children’s Health (2016-2018) indicates that Black children ages 1-17 are between 10-22% less likely than non-Hispanic White children to have had a recent preventive dental visit. Black children are also likely to have dental caries than Non-Hispanic White children (NSCH, 2016-2018). 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.

In the years prior to 2018, several SEAL! Michigan grantees provided services to numerous Detroit Public Schools buildings. However, in October 2018 the school system halted all oral health work as a result of having too many different providers of oral health services. Administrators took the opportunity to pause and create an oral health plan that provides more clarity on which providers are servicing the schools. The new process involves contracting with four different providers (two restorative and two preventive) and assignment of two to each school (one restorative and one preventive). This improvement enables DPSCD to have more control over which programs are coming in and out of each school building; however, DPSCD lacks a designated position to oversee all oral health activities and lacks the oversight to ensure that students are receiving preventive and restorative care as well as urgent follow up care. Thus, the OHP has worked extensively with DPSCD to create and fund a half-time Oral Health Coordinator (OHC) that will oversee work relating to oral health in all DPSCD buildings.

The first strategy to achieve this objective is to hire a qualified Oral Health Coordinator in FY 2021 to oversee oral health related work in DPSCD. This person will be the point of contact for all four assigned providers. The OHC will be onsite with the providers continuously throughout the school year and will work closely with the four designated providers to ensure safe and appropriate care is provided and that students with urgent needs are followed up with until their needs are met. Having a place-based OHC will help to ensure that the DPSCD oral health initiative is being responsive to individual school and community needs.

The second strategy is for the OHC to organize parent and student focus groups to assist with family engagement and with developing a more successful oral health program in DPSCD. The groups will support inclusion to ensure families and students have a voice in the program and that program development and evaluation is informed by these stakeholders. This strategy will also enable an increased ability to create culturally and linguistically appropriate health education materials. Involving parents and students will assist in gathering qualitative data and a better understanding of what parents and students need in their school-based oral health program—and conversely, what may not be working. This knowledge will likely lead to an increase in positive parental consent forms and result in a higher utilization of services. Findings will also be shared with SEAL! Michigan programs outside of DPSCD so all programs can benefit from the outcomes of the focus groups.

The third strategy is to increase reporting requirements for all DPSCD oral health providers. Currently, no data are collected from the four contracted programs, thus there is no understanding of what exactly is being provided to students participating in the school-based oral health programs. All contracted oral health programs in DPSCD will be required to complete data forms on each student served to aid in program evaluation and improvement. The data collected will provide a better understanding of delivery of care, patient services, patient outcomes, and follow up. Once these data are collected and examined it will provide guidance as to where program improvement should be implemented.

Lead Poisoning Prevention (FY 2021 Application)

A state performance measure (SPM) was established to address lead poisoning prevention and intervention as a result of the 2015 needs assessment. In the 2020 needs assessment, the SPM was determined to still be a critical need for Michigan. Michigan has made significant progress over time in reducing the percentage of children who have elevated blood lead levels, and Michigan’s rate of children under the age of six with an elevated blood lead level is less than the US rate (3.6% in comparison to 4.0% in 2016). 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 Forces of Change Assessment found that environmental toxins (including lead) disproportionately affect vulnerable populations such as racial and ethnic minorities, those living in poverty, and children. The provider survey and focus groups also identified concerns related to environmental contaminants (especially lead and PFAS) and their impact on health equity. Therefore, prevention and intervention can help to achieve equitable health outcomes, especially among vulnerable populations.

The SPM 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). Title V funding currently 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.

Three main 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 local health departments (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 4.5 micrograms per deciliter of blood (µg/dL). Children with an EBLL should have interventions such as 1) in-home nursing case management and 2) environmental investigations to mitigate health effects of lead exposure and identify and remove sources of lead in their environments.

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 the completion of the risk assessment. That creates a barrier of not being able to accurately determine the number of providers who are conducting the risk assessment with their patients.

A strategy to increase blood lead screening is to 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 2021, CLPPP will work 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. Calling specific 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 throughout Michigan. Health care providers play a vital role increasing screening, testing, and confirmatory testing rates in Michigan. CLPPP will undertake several efforts to educate and connect with health care providers.

• Development 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 overall 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. Content of the training focuses on understanding how children are exposed to lead, the health impacts of lead, blood lead testing requirements and the risk assessment questions, understanding the importance of working with local health departments and other resources.
• 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’s important that these partnerships are developed ahead of time and both parties recognize the services and resources each other offer.
• Public Health Detailing done by an MDHHS nurse consultant. This will include the nurse consultant visiting 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.
• Material development and mailing to area health care providers, specific to health care providers that work with children under six years old, including pediatricians, family practitioners, and OBGYNs.
• Key informant interviews with health care providers to get input on resources, tools, ways CLPPP can assist in increasing blood lead screening and testing and identifying barriers that need to be addressed.

The third strategy is partnering with agencies to provide culturally appropriate lead education to at-risk populations.

• Eastern Michigan University Center for Health Disparities Innovations and Studies has a lead program that works with underserved Asian Americans. CLPPP will work with and support this program in developing culturally appropriate materials, outreach plans, and education/awareness strategies to decrease lead exposure for this population.
• 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 will work with the MDHHS Community and Faith Engagement Office to engage faith-based communities, specifically in areas of the state that are at highest risk for lead exposure. Engagement will include obtaining feedback from community members and faith-based leaders about the community’s needs and what kind of messaging will be most effective in the community. The focus of this partnership will be to educate about lead poisoning and the various sources of lead exposure.
• CLPPP plans to continue to have lead poisoning prevention materials developed and translated into commonly used languages including Spanish, Arabic, and Bengali. CLPPP will work with a group in the Division of Environmental Health (DEH) called Culturally Appropriate Services for All (CASA). CASA is a group of DEH employees who come from various cultural background and speak different languages. The group reviews materials to ensure that they are both linguistically and culturally appropriate. Also, specific to Bengali translations, in partnership with Eastern Michigan University Center for Health Disparities Innovations and Studies, CLPPP will work with representatives from the Bangladeshi community to review materials and get feedback.

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 to be 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 baseline data for this objective is 27.1% in 2019.

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 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.

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. This objective will use MDHHS data warehouse data to track progress through 2025. The baseline data is 45.8% in 2019.

The first strategy for Objective C is 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. CLPPP is working with the University of Michigan to develop these quarterly reports in a format that is easy to use for local health departments. 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.

The second 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 here, specific to encouraging that all elevated blood lead test results from a capillary test are followed up with a venous confirmation test.

Immunizations – Children (FY 2021 Application)

Based on the 2020 Title V needs assessment, the state performance measure (SPM) created in 2015 was retained, 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).” In the 2020 needs assessment, 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 identified an increasing focus on individual choice versus community benefits (including vaccine refusal) as a factor that impacts population health.

Additionally, while the needs assessment was completed before the COVID-19 pandemic, Michigan is currently experiencing 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, it is anticipated that recovering from the impact of COVID-19 will create new, unique challenges.

Additionally, within some populations, Michigan has experienced declining immunizations rates and has not met the Healthy People 2020 goal of 80% for child immunizations. For example, 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 73.6% based on Michigan Care Improvement Registry (MCIR) data. The 2018 National Immunization Survey data shows Michigan at 76.0% for childhood vaccination coverage among children two years old for Michigan for birth years 2011 through 2016 for the same vaccine series. Furthermore, two dose hepatitis A vaccination rates for children are low in Michigan. The Advisory Committee on Immunization Practices (ACIP) routinely recommends two doses of hepatitis A, and Michigan has started tracking completion rates for children to measure progress. If two doses of Hepatitis A vaccine are added to the full series of vaccines for children ages 19-35 months the compliance rate drops to 58.2%.

Parent vaccine hesitancy has also 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 and the need to talk with parents about their concerns. 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 benefits and risks of not vaccinating. MDHHS has also worked with the Franny Strong Foundation 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 National Immunization Surveys (NIS) are a group of telephone surveys sponsored and conducted by the CDC National Center for Immunization and Respiratory Diseases (NCIRD). In 1994, the NIS began to monitor child immunization coverage in all 50 states and select local areas for sampling. The NIS is the only standardized sampling method that can show differences and disparities between states. The NIS uses random-digit-dialing to identify households with children ages 19 through 35 months. In 2018 the methodology was changed to reflect birth years (those children 2 years of age during 2018) as opposed to those who were 19-36 months of age at the time of the survey. This change enhances the power of the survey to provide a more accurate estimate of vaccine coverage. A parent or guardian is interviewed on child immunization status and vaccination providers are mailed a survey to verify immunizations. NIS currently measures: 4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 HepB, 1 Varicella, 4 PCV (4313314). The most recent NIS data from 2018 shows that the point estimate for Michigan is 76.0%.

The Division of Immunization operates the Michigan Care Improvement Registry (MCIR). The MCIR is a regionally based, statewide immunization registry that contains over 149 million shot records administered to 10 million individuals residing in Michigan. MDHHS is currently working through subcontracts with six MCIR regions to enroll and support every immunization provider in the state. Current enrollments include: 6,535 health care providers and pharmacies; 4,142 schools; and 3,943 licensed childcare programs. MCIR is used routinely by nearly 33,000 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. In addition, over 3 million reports were generated by users of the MCIR system in 2019.

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 show that 73.6% of children who reside in Michigan have received the routinely recommend 4313314 series by the time they reach 36 months of age. MCIR rates have experienced gradual decreases in compliance rates for children enrolled in Medicaid and WIC. The current vaccination rate for children enrolled in Medicaid is 71.5% and the vaccination rate for children enrolled in WIC is 76.9%. The overall statewide vaccination level of 73.6% is short of the Healthy People 2020 goal of 80%.

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. By seven months of age, only 54.2% of children in MCIR are current with all recommended vaccines. 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. An assessment of NIS data shows that only 23% of children 24-35 months of age were vaccinated with the primary 4313314 series on time. A Michigan study of vaccine timeliness at age 24 months of children born from 2006 to 2010 shows that only 13.2% of children were vaccinated on time. There are no known benefits to delaying vaccinations. Image 1 illustrates immunization rates by age when vaccines should have been completed. There are small increases in most ages but rates still remain low.

Image 1. Percentage of Michigan Children Vaccinated at Milestone Ages

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 system level to determine any children who need vaccines. To increase vaccination rates, the Division of Immunization has initiated an effort to notify parents of all children 6 months through 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. 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 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 based on race. The City of Detroit has among the lowest immunization rates in Michigan for the 4313314 series at 57.2%. Rates are even lower for people of color. In FY 2021, the Division of Immunization epidemiologist and nurse educators will conduct a root cause analysis for the City of Detroit to attempt to identify causes of these disparities. This root cause analysis will help to target future immunization efforts around strategies to reduce disparities.

Objective B: Assist local health departments in targeting outreach to under-vaccinated populations in their jurisdiction.

The Immunization Program will continue to distribute population-based county “report cards” for local health departments to better understand immunization issues and areas for improvement in their communities. The MCIR epidemiologist will generate county report cards on a quarterly basis, which will be posted on the MDHHS website. The 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 vaccine drop-off report. As discussed earlier, this report shows how well children are staying on schedule for all recommended vaccines. The 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. Slight increases have been seen in the uptake of childhood vaccines, but the rates still show much work needs to be done to keep children on schedule. Image 2, below, shows immunization rates over time by age when vaccines should have been completed.

Image 2. Percentage of Michigan Children Vaccinated with the Recommended Series

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 70.89% for the 4313314 series. 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 Immunization Program will create reports on a semi-annual basis 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.

Objective C: Implement the I Vaccinate Campaign.

Parental vaccine hesitancy has been an increasing concern in Michigan. Vocal and organized groups have continued to push back on school vaccine requirements and vaccines in a broader sense. This trend is affecting not only the school reporting process but parents who may have questions about vaccines. Organized social media issues concerning vaccines circulate broadly throughout the state and the impact is that more parents are questioning the value and safety of vaccinating their children.

In an effort to make positive vaccine messages available to the public, MDHHS partnered with the Franny Strong Foundation in 2017 to launch the I Vaccinate Campaign. The campaign went live in March 2017 to provide information and tools based on research and medical science to help Michigan parents protect their children through vaccinations. MDHHS and the Franny Strong Foundation have partnered to provide financial and program support for the campaign. Approximately 17 other state and national groups are supportive of the campaign, including the Michigan Association of Health Plans, the Michigan Association of Local Public Health, the Michigan Chapter of the American Academy of Pediatrics, and the Michigan Health and Hospital Association.

The I Vaccinate Campaign uses several media platforms to reach target populations of women of childbearing years since they often have a primary role making decisions related to the health of their children. Television and radio ads are purchased during this campaign to promote vaccinations to protect all children. Social media messages are used throughout the state with real life stories of individuals affected by vaccine preventable diseases. A website assists parents in the decision-making process about vaccines for their children. The website is built on fact-based information presented in a user-friendly forum from a parent’s viewpoint. In FY 2021, the Immunization Program will continue to assess the I Vaccinate campaign to identify ways to strengthen its message and broaden its reach. In particular, the Immunization Program will consider ways to obtain feedback and recommendations from parents and community members. Better understanding barriers to immunizations will enable the Immunization Program and its partners to craft messages that build trust and confidence in the effectiveness and safety of vaccines. Parent and community input will also help to ensure that vaccine messages are culturally sensitive and linguistically appropriate, which may include different messages targeted to different population groups or geographical regions.