North Carolina Has Strong Infrastructure to Get Even Better on Childhood Vaccines

Committed Pediatricians and Other Health Professionals

This commitment shows up in the data. Vaccine rates for North Carolina children are often at the 90% mark or even better, according to the Centers for Disease Control and Prevention (CDC) [3]. For example, the most recent data show that in 2017, of 35-month-olds, 90% had the hepatitis A vaccine, 96% had 3 or more doses of the tetanus, diphtheria, and pertussis (Tdap/DTP) vaccine, 95% had 3 or more doses of the hepatitis B vaccine, and 94% had 3 or more doses of the vaccine for Haemophilus influenzae type b (Hib) [3]. For kindergarten entry for the 2018-2019 school year, at least 91% of North Carolina students had the measles, mumps, rubella (MMR); Tdap; and hepatitis B vaccines and 2 doses of the varicella (chickenpox) vaccine [4]. In 2019, 93% of teens aged 13-17 had their meningococcal ACWY (MenACWY) vaccine [5], and 96% had one or more varicella vaccines [6]. North Carolina Pediatric Society (NCPeds) survey data show that 70% overall and 75% of primary care physicians (pediatricians and family physicians) in physician-owned practices participate in the Vaccines for Children program to ensure that children, regardless of insurance, are fully vaccinated [7].

Strong State Policy

North Carolina laws and policies support vaccination. North Carolina requires all children attending school—including virtual learning, homeschooling, and private schools—to be up to date on vaccines that prevent 12 different diseases [8]. Most of the vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP) are required in order to attend child care, school, and college/university in North Carolina [9, 10]. The only nonmedical exemption allowed is a religious exemption [11, 12].

For decades, our state infrastructure has supported medical homes through private practices, local health departments, and federally qualified health centers (FQHCs) to ensure that vaccines are part of the whole package of well-child care. Our Health Information Exchange (HIE) is baking into its design ways to ensure that vaccine information is robust. Local health departments and FQHCs assure broad access. The Immunization Branch of the North Carolina Department of Health and Human Services (NCDHHS) provides up-to-date supports for practices.

Professional Societies Promoting Vaccines

NCPeds promotes multiple projects on vaccines. Current activities include multi-practice learning to improve teen vaccination rates and a toolkit based on new American Board of Pediatrics flexibilities for smaller practices to use. The NCPeds practice manager group shared strategies for increasing parking-lot clinics to maximize flu vaccination for the 2020-2021 flu season. NCPeds also offers vaccine-focused educational sessions throughout the year.

The North Carolina Academy of Family Physicians (NCAFP) also has robust vaccine educational programming. They partner with a number of groups to promote vaccines both within the medical community and with families. FQHCs promote vaccines generally, and at the start of the 2020 flu season actively promoted strategies for increasing flu vaccination capacity among members.

Workflow Supports for Practices to Support Vaccines

For decades, Community Care of North Carolina (CCNC) has helped practices identify and contact patients who need reminders to come in for vaccines. The North Carolina Area Health Education Centers (NC AHEC) provide workflow supports to practices, along with provider education opportunities. North Carolina is fortunate to have such strong and collaborative partners to advance vaccines and other strategies for promoting health.

Vaccine Inventory Maximization

In 2020, the Immunization Branch made it easier for practices to use the vaccines they have on hand to maximize ability to vaccinate patients [13].

Strong Partnerships

NCPeds has partnered with NCAFP and the North Carolina Division of Public Health (NCDPH) to promote back-to-school vaccines for several years. The North Carolina Immunization Coalition brings together state agencies, professional societies, vaccine manufacturers, and other stakeholders to talk about innovations in vaccine strategies on a quarterly basis. The North Carolina Medical Society leads efforts together with NCPeds and NCAFP to promote laws to support immunizations in the medical home. NCDPH convenes key stakeholders, including NCAFP and the Cancer Society, around vaccine promotion strategies. The Western North Carolina Shield of Protection Immunization Coalition encourages parents to have peer conversations informed by discussions with medical professionals to change the dialogue and to offer evidence-based information about the benefits of vaccines to individual and community health.

Patients Stayed Home

This spring, while health care professionals and other essential workers went to work, many others stayed at home. A survey of primary care physicians conducted by NCPeds and NCAFP revealed that 85% of pediatricians saw declines in patient visits of 40% or more (Table 1, Figure 1) [7]. While telehealth allowed for some important care to continue, some health care, including vaccines, require an in-person visit.

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FIGURE 1.

Children Have Missed Important Care

Source. Ateev Mehrotra et al., The Impact of the COVID-19 Pandemic on Outpatient Visits: Changing Patterns of Care in the Newest COVID-19 Hot Spots (Commonwealth Fund, Aug. 2020) https://doi.org/10.26099/yaqe-q550.

Practices Changed Patient Flow

Practices pivoted to conducting more visits by telehealth, but also changed the way the waiting room works. Some practices are relying almost solely on care in their parking lots, while other practices are triaging sick care to the parking lot and conducting well visits in the office, having patients wait in the car until texted that an exam room is available, or dedicating one site for sick care and another for well-care when multiple sites are available. These changes are important for helping patients be and feel safe, but alone will not help restore our vaccination rates. Data show that pediatric visits nationally have not returned to pre-COVID-19 rates [14-16]. Anecdotal data from North Carolina suggest that cancellations and no-shows are still a problem, with speculation that some families may remain reluctant to take their children to the doctor during the pandemic.

Disparities Remain High

The unequal toll of COVID-19 is well documented [17]. North Carolina was early among states to collect and disseminate data by race and ethnicity, not just for COVID-19 diagnosis and treatment. Figure 2 shows that North Carolina children of color—especially African American and American Indian children—are less likely to get vaccines than white peers, even before COVID-19. Collecting strong data is part of understanding and addressing barriers to receiving appropriate care.

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FIGURE 2.

Weekly Proportion of Population Receiving Childhood Immunization by Race in NC

Source. NC Department of Health and Human Services, Care Gaps, October 2020.

Supports Matter

Patients have healthier outcomes not only when they get needed health care, but also when they have safe housing, adequate food, and access to other needed resources. Without those basics in place, patients may not prioritize coming to the doctor for routine care such as vaccines. Many groups across North Carolina have worked to make sure that more families have the resources they need in these incredibly difficult times. One support that is linked to the health care system is NCCARE360, a new statewide coordinated care network. While NCCARE360 existed in some counties prior to COVID-19, it quickly ramped up to serve all 100 counties by summer 2020.

Partnerships are Still Critical

NC Medicaid is working with NC AHEC and CCNC on a Keeping Kids Well initiative to help make sure that children get the well-child visits, including vaccines, they missed in 2020. Many partners promote this work. The North Carolina Healthcare Association released a joint statement from two dozen stakeholders encouraging North Carolinians to get vaccines in 2020 [18]. Early childhood groups, such as Smart Start and the Child Care Services Association, are working with NCPeds to promote vaccines and well-child visits to parents.

Trust Matters

“Your” doctor, with a relationship developed through the medical home, is often a trusted and important source of information, including information on the importance of vaccines [19, 20]. Trust especially matters for historically marginalized populations [21]. Remember, for example, the Tuskegee syphilis experiments, in which African American participants were misled and effective treatments were withheld from them, an incident that, along with other experiences of health care inequity, has eroded trust among marginalized communities. Trust also can be an important component for addressing vaccine hesitancy.

Promote the Primary Care Workforce

Together with FQHCs and local health departments, pediatricians and family physicians are often the workhorses when it comes to vaccine administration, but trend lines seem to be moving away from primary care. Some North Carolina counties lack pediatricians or family physicians. A national survey of pediatric residents by the American Academy of Pediatrics shows that the share of medical residents planning to go into primary care has gone from around 65%-70% 20 years ago to about 35%-40% over the past 10 years [22]. The North Carolina Office of Rural Health, NC AHEC, and the North Carolina Medical Society all have strong programs to help incentivize primary care professionals to practice in areas of high need. We must address the supply of primary care physicians to truly ensure ready access to appropriate primary care—including vaccines—across the state while also ensuring that all physicians have the support they need to practice, even in rural and remote areas.

Increase the Diversity of the Primary Care Workforce

A recent study shows that race of the doctor relative to the patient was a factor in infant mortality [23]. This is consistent with research from other professions showing that race of the professional can matter toward outcomes [24, 25]. As a state, we need to improve the diversity of our pipeline of health professionals and the cultural competence of those in practice.

Use Strong Disaggregated Data

NCDHHS has increasingly reported data disaggregated by race, which is critical to understanding the impact of explicit and implicit policy decisions to promote vaccines and more. Electronic health records and other practice supports should be strengthened to include key information such as vaccination rates by race and ethnicity.

Address Vaccine Hesitancy

Research on vaccine hesitancy is still emerging and COVID-19 offers new wrinkles. Strategies such as building on trusted relationships, including with primary care providers and fellow parents, seem promising.

Eliminate Non-medical Exemptions

North Carolina should join other states, such as Mississippi and West Virginia [26], in eliminating non-medical vaccine exemptions for school attendance. The full complement of ACIP-recommended vaccines should be required. This helps protect the most people—children, grandparents, and others—from vaccine-preventable diseases and death. It also helps prevent outbreaks, such as the 2018-2019 chicken pox outbreak in Asheville, which was widely attributed to non-medical vaccine exemptions [27-29].

Expand Medicaid

Reducing the barriers to vaccination, especially for parents and other adults, would be but one of the myriad benefits of expanding Medicaid to cover more North Carolinians.