NYSAFP POLICY ON ADULT IMMUNIZATIONS

Women In Government Roundtable

May 2, 2017

Thank you for including us in this discussion. NYSAFP, representing over 6000 physicians, residents and medical students, develops policy at an annual meeting of representatives in Albany each June. Family physicians are ideally positioned to transfer the processes for improving childhood immunization into the realm of adult care. I am a past president of our academy, and I chair a committee that advises our Board of Directors on vaccine policy.

NYSAFP has advocacy positions relevant to today’s discussion in support of:

  1. single payer health care
  2. universal purchase of all vaccines, flu vaccine, childhood vaccines, any vaccines
  3. a program of vaccines for adults analogous to VFC
  4. universal reporting of all doses given to adults to the NYSIIS.
  5. thorough consideration of the unintended adverse consequences of vaccinating outside the medical home,
  6. and standing orders bear discussion.

12) In a jurisdiction with single payer healthcare, or with universal purchase of vaccines, disparities based on poverty disappear. I just learned that in NYS affluent white teens have lower rates of HPV immunization than their poorer peers of color. Sometimes disparities are counterintuitive.

3) There apparently is an existing VFA program available at some DOH locations, but not in doctors’ offices as is the case with VFC. Disparities exist for adults. Medicare covers some vaccines under part B, but notably does not cover a tetanus booster unless during the care of an injury. Coverage for tetanus is under part D, leaving the patient to get reimbursed later.

4) An informed discussion about adult immunization disparities should be supported by assessment of current successes and failures. Without data we speculate and extrapolate. An amendment to PBH §2168 eased the permission required to submit adult doses to NYSIIS, from written to verbal. Permission is not required to report kids’ vaccines, and any permission requirement for adults is a barrier to reporting. Another amendment required pharmacists to report, but hospital pharmacies, which dispense many of my patients’ inappropriate repeat doses of vaccines, opine the law does not apply to them. Only universal reporting will give a data base that supports proper immunization and the assessment of such immunization. S44 states there are no fiscal implications of the bill, but small practices that are paper based without EMR face a major fiscal burden if such mandate for reporting is not accompanied by relief for such practices, such as an option to report on paper.

5) Our academy opposed pharmacy administration of adult influenza vaccine which became law in 2008. One adverse impact of this policy has been the unpredictability of needed inventory for a small practice, and uneven distribution of supply during a season when flu vaccine has been less available. My patients usually can recall if they have had such an annual dose during this season. For all other vaccines, given once in a lifetime or once a decade, recall is usually incomplete. This results in repeat doses of vaccines leading to waste or harm. For all vaccines other than flu, immunization is an opportunity for a physician to review other elements of preventive care, a visit that is prevented by administration of vaccine outside the medical home.

6) Non-patient specific orders are often listed as a method of increasing immunization rates. Many offices do not employ an RN, and currently in NYS LPNs are not allowed to rely on non-patient specific orders. Our academy does not have policy on such orders. My personal view is that for vaccines other than flu, vaccine schedules are complex, and patient safety is served when the doctor and the administering nurse each review the order in sequence. Such safety from redundant review is the principle underlying the sequence by which the physician prescribes and the pharmacist dispenses. If we are to rely on such orders, the prohibition of LPN reliance on them should be revisited.

Thank you for your attention.

Philip Kaplan, MD

Past President, NYSAFP