NVAC | February 2024 Meeting | Vaccines for Children Program, Public Comment | Part 3

Name: NVAC | February 2024 Meeting | Vaccines for Children Program, Public Comment | Part 3
Uploaded: 2024-03-04T19:43:37.640Z
Duration: 53 min 29 s
Channel: USDOHAHS
Description: The National Vaccine Advisory Committee (NVAC) recommends ways to achieve optimal prevention of human infectious diseases through immunization. You can learn more about this advisory committee by visiting the NVAC website at hhs.gov/vaccines/nvac/index.html.

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The National Vaccine Advisory Committee (NVAC) recommends ways to achieve optimal prevention of human infectious diseases through immunization. You can learn more about this advisory committee by visiting the NVAC website at hhs.gov/vaccines/nvac/index.html.

>> Robert Hopkins, Jr.: Our next panel is Celebrating 30 Years of Saving Lives: The Vaccines for Children Program Now and in the Future. Established in 1993, the Vaccines for Children Program has had a life-saving impact for children and for public health more broadly. The VFC covers the cost of vaccines for children whose parents or guardians may not be able to afford them, saving almost $2.2 trillion in cost between 1994 and 2021 alone. In the same time period, the VFC was found to prevent more than one million deaths. What's more, the program brings crucial pediatric immunizations to almost half of children across the United States, prioritizing underserved communities to improve vaccine equity. In 2022, VFC distributed over 71.5 million doses of pediatric vaccines to participating provider locations. In this session, the speakers will explore the profound impact of this program as we look toward the future. Our speakers in this panel include Dr. Georgina Peacock from the Center for Disease Control and Prevention, Dr. Sean O'Leary from the University of Colorado, and Dave McCormick from the Indiana State Department of Health. Dr. Peacock, welcome back. I see you on video. Your slides are up. You have the floor. >> Georgina Peacock: All right. Well, thanks so much, and I'm glad to be back here again. So, for those of you who weren't on the last session, I'm Dr. Peacock. I'm the director for the Immunization Services Division at CDC. And really, thank you for joining us today to hear about the Vaccines for Children Program Now and in the Future. And I'm actually going to give a little bit of history as well. So, next slide. So, here's a depiction of what it would look like to build a complete, fully funded immunization program throughout the lifespan. And what you'll see on here is, there are a couple of different parts that support vaccinations across the lifespan. The Section 317 program is the funding that allows our foundational piece of our -- of country's immunization program. So, it really supports that infrastructure. And then what it also does is it allows us to administer the Vaccines for Children program, which I'll be discussing in greater detail throughout the next couple of slides. And then you'll see a proposed part here, and I'll talk about this at the end of my presentation. But it's the proposed Vaccines for Adults program which would complete a National Immunization program. And that in the -- started in the 2023 President's budget. It's in the 2024 President's budget. And it is to provide immunization coverage to a subpopulation of adults who are uninsured built upon the Vaccines for Children program. Next slide. So, now, just going back in history just a little bit, and you did hear some of this history. So, in response to a resurgence of measles between 1989 and 1991, legislation was enacted to create the Vaccines for Children program in 1993. And this program was implemented in 1994, 30 years ago. So, it was a funding for -- the Vaccines for Children program is from the Medicaid Trust Fund. And CDC was delegated responsibilities for the vaccine. The Centers for Medicare and Medicaid Services, or CMS, was delegated responsibility for the administration fee. The Advisory Committee on Immunization Practices, or ACIP, is responsible for the VFC formulary. And they vote as new vaccines are recommended by the ACIP vote. They have a resolution, and they vote on that to include the vaccine in the VFC formulary. VFC is an entitlement program for children who meet certain eligibility criteria that I'll go over a little bit later. And the program provides vaccine to approximately, as you heard just before, 50 percent of U.S. children and adolescents. Next slide. When we look at -- you can advance to the next slide. Looking at the VFC program benefits, the VFC program provides federally funded vaccines at no cost to children who might not otherwise be vaccinated because of an inability to pay. It provides cost-savings to states and territories through bulk purchase of vaccines at lower prices using CDC contracts and eliminates state-to-state differences in price. So, when you've heard about Universal Purchase States that's using this bulk purchase mechanism. It reduces referrals of children from private providers to state health departments for vaccination. Because there are providers out in the community, in the medical home that have -- that are vaccine for children providers. And it saves VFC enrolled providers out of pocket expenses for vaccines. It eliminates and reduces vaccine cost as a barrier to vaccinating eligible children. Next slide. So, in this next slide, you'll see that very initially, the advent of the VFC program was not unopposed. So, critics rejected the administrator -- the Clinton administration's claim that cost was a major barrier to childhood vaccination. And they questioned the program's ability to provide necessary oversight, accountability, and evaluation mechanisms. There were also doubts as to whether the federal government's GSA or General Services Administration, which had never stored vaccines, would be able to safely handle and deliver vaccine products. Therefore, the architects of the program changed some of the plans that they initially had for a national distribution warehouse in 1994. And that meant that awardees would manage and store and distribute the vaccines themselves. In 1997, CDC implemented annual reporting requirements and developed a provider site visit protocol that required in-person evaluations of the record keeping vaccine storage and handling procedures. So now, if we move to the next slide, you'll see kind of where we are today. So, VFC is a $5.5 billion program. It distributes -- and you heard an estimate from one of the recent years, but it distributes more than 76 million doses of pediatric vaccine each year. And the vast majority of these are purchased through VFC. There's approximately 600,000 routine vaccine shipments per year, and nearly 38,000 VFC provider locations across the 64 VFC awardee jurisdictions. This includes pediatric providers that make up about 86 percent of VFC providers, other private providers such as family practice. And subspecialty providers, public health clinics, HRSA, associated health centers, and rural health clinics. Indian health service clinics, school health clinics, hospitals, and a small number of pharmacies. Next slide. VFC eligible -- eligibility includes those children that are zero to 18 years of age who meet at least one of the criteria that are listed here. So, being Medicaid eligible, being uninsured, being American Indian/Alaskan Native or being underinsured. And currently, children eligible to receive vaccine that are uninsured can only get that enrolled through a federally qualified health center, a rural health center, or a deputized provider under the delegation of authority. And this table shows the population estimate survey that breaks down VFC eligibility by age group. And in this survey, you'll see that the highest number of eligible children are one to two years of age at 54.8 percent. And the total number of eligibility -- eligible children is 53.6 percent. Next slide. So, how does VFC work? The VFC program works by healthcare providers enrolling in the program through their respective awardee immunization program. The majority of these awardees are state immunization programs. There are some local and territorial programs as well. The providers then order vaccine for their eligible patients through their awardee immunization program. And the participating providers are responsible for appropriate storage and handling of the vaccine, administering the vaccine to eligible children, participating in quality assurance or compliance visits. Participating in quality improvement activities and completing required annual training. Providers can bill parents for an administration fee if they are -- but cannot exclude children whose parents are not able to pay. Next slide. So, here are some of the key successes for the program. So, the healthcare providers who vaccinate children are critical to extending the reach of the VFC program and ensuring that all pediatric patients get vaccinated. These providers increase the potential number of children vaccinated in a jurisdiction by allowing all VFC eligible and other children to stay in their medical homes to provide -- to get vaccinated. We are constantly working through our immunization programs in the states at the local level to increase provider enrollment and retention, as well as continuing to strongly recommend that all ACIP recommended vaccines are provided to all children. With the introduction of new vaccines and immunizations into the VFC program in 2023 and 2024, CDC and the state and local immunization programs have been working and will continue to work with providers to ensure that VFC programs remain efficient and streamlined, but don't compromise the oversight of the program and the vaccines. So, one of the examples that we really worked to do this season was to allow some flexibilities that aren't typically there. So, it was evident from both the introduction of COVID-19 as a commercialized vaccine, as well as the new immunization for RSV Nirsevimab. That there were needed flexibilities, including for COVID, for example, looking at minimum packaging in locations where demand was very low for COVID-19 vaccine. There were also some attempts early in the season. This kind of changed as we saw some of the shortages, but also some attempt to allow borrowing between private and public stock, both for Nirsevimab and COVID. And so, we worked with professional organizations, and we worked with others in the field to try to address some of the challenges that were being seen with the introduction of these new and unique immunization products. So, we continue to hopefully, work with professional organizations and others to explore options to reduce the administrative burden on providers, while continuing to keep those systems efficient and in place so that the oversight of the VFC program can continue to happen with that proper storage and handling of VFC vaccines. Next slide. So, you heard these numbers at the beginning, and I think I'd just like to illustrate them again. So, 2024 is really a year of celebration. I think VFC is probably one of the most successful examples of a health equity program in public health. This is our 30th anniversary. And through the years, the VFC program and the, you know, good work by all of those providers out there, all those vaccinators out there have been able to prevent 472 million illnesses, help provide -- avoid over a million deaths and save nearly 2.2 trillion in societal costs. Next slide. So, as I mentioned before, this is in the president's budget again in 2024. And the vaccines for adults program is really built on the idea -- it's not exactly the same in the way it is structured but built on the success and the idea of the VFC program. And so, this would really complete that national immunization program that I described at the beginning, that includes the discretionary funding for the infrastructure, as well as a Vaccines for Children program and a Vaccines for Adults program that would provide vaccine for those that are uninsured adults. Now, if we move to the next slide. There are obviously -- and I think you're going to hear this from our speakers that come after me. You know, there are lots of opportunities to continue to do future planning and think about opportunities within the VFC program. We do need to think about fresh strategies. We do need to innovate in the way we're doing implementation and adapt some of the things that are happening. We know that, you know, we need to incorporate new systems and technologies. Those can help with increased accountability, but maybe ease of accountability as well. And also, improve vaccine management practices. It's going to be important to continue to work with priority providers. One example of this is with Nirsevimab, the RSV immunization for infants. You know, looking at, for example, enrolling more birthing hospitals in that. So, there's a shared responsibility or a shared -- sharing of that burden of vaccinating infants, or immunizing infants with Nirsevimab, both in the birthing hospital at the time of birth or for those children that are not born within the RSV season. They can be vaccinated in those outpatient settings. We continue to update communication materials that incorporate best practices for provider and parent conversations and look at increasing vaccine confidence. We have seen some reductions in that confidence in vaccines. And so, it's really important for us all to partner together to do that so that we can restore and improve the childhood vaccination rates. If you move to the next slide. I'd just like to thank you for having me today to talk about the VFC program, and also really celebrate this 30 years, and your continued support of vaccination efforts across the lifespan. Thank you. >> Robert Hopkins, Jr.: Thank you very much, Dr. Peacock. Our next presenter is Dr. Sean O'Leary from the University of Colorado. Dr. O'Leary, your slides are up. I see your face. You have the floor. >> Sean O'Leary: All right. Thank you, Dr. Hopkins. And thanks, Dr. Peacock. It's a pleasure to be here. So, I'm going to be wearing kind of two hats here. One is from some of the work we've done here at the University of Colorado in collaboration with CDC on a survey project. And then I'm also going to represent some perspectives from the AAP. Next slide. So, just to start with, I'm showing a slide from last year, Dr. Peacock showed the updated slide on the Vaccines for Children program. The AAP strongly supports the VFC program, and has really, from the very beginning. We've seen vaccination rates increase across all races, ethnicities, and income groups following the introduction of the program. And we've also seen disparities among races and ethnic groups narrow considerably since the advent of the VFC program. So, I do want to start out by just stating our strong support. Next slide. So, what I'm going to do here today is first present results from a nationally representative survey that we did in collaboration with CDC as part of a collaborative agreement. And then I'm going to give some perspectives from the AAP. Next slide. So, this was a study published in 2020 on pediatricians' experiences with and perceptions of the VFC program. Next slide. So, our objectives in this study were to assess among a nationally representative sample of pediatricians, participation in VFC, and consideration of stopping participation, as well as the perceived burden versus benefit of participation among pediatricians. Next slide. So, we conducted this study in 2017. We had a response rate of 79 percent. Next slide. And what this slide is showing on the bars is simply the proportion of pediatricians who reported participating in the VFC program. So, roughly 86 percent reported that they do, nine percent said that they do not, and they never had. And five percent reported that they didn't, but they had previously. Next slide. And then this slide is looking at current participants at the time in the VFC program and asked them the question, have you considered no longer participating in the past year? And the vast majority said -- simply said no. They had never considered or discussed it. Roughly 10 percent had considered or discussed it, but not seriously and 5 percent had seriously considered or discussed no longer participating. Next slide. And so, we wanted to look at those who considered no longer participating in the VFC program. And I'm just going to highlight the reasons that more than half of pediatricians reported. And the first was that the record keeping requirements were too difficult for VFC vaccines. That there was concern about disciplinary action by the program for non-compliance. They were concerned about the supply of VFC vaccine being unpredictable. And then they were concerned about payment for administration fees for VFC vaccine. So, just to be clear, the VFC program provides the vaccines, but administration fees are generally paid by the jurisdictions. Next slide. So, this is just one piece of a much larger report on attitudes, but this is showing a few sort of supporting the prior slides. Regardless of whether or not you are participating in VFC. How strongly do you agree or disagree with the following statements related to providing VFC vaccine. And you can see these are ordered in the -- from strongly agree. The requirements regarding monitoring tracking of VFC storage. Temperatures are a burden. The requirements to replace lost doses is a major burden. Keeping VFC stock separate from private vaccine stock is a burden. And then billing for vaccine administration fees for Medicaid patients is challenging with the VFC program. Next slide. So, all of that said, we also wanted to look at, well, what are pediatricians' overall, attitudes about the VFC program? Next slide. So, what this slide is looking at is, is it more of a burden to participate or more of a benefit? So, we asked the pediatricians, taking all factors into account, to indicate the extent to which participation is a burden or a benefit. And you can see that the vast majority of pediatricians strongly favor that the VFC program is a net benefit for participation. So again, I want to emphasize the strong support despite some of the concerns that I -- that I have voiced in the prior slides. Next slide. So, to summarize, the vast majority of pediatricians participate in VFC believe the benefits outweigh the burdens. However, large percentages identify certain factors as burdensome, including requirements for monitoring and tracking and recording VFC storage temperatures. Lower payments for VFC vaccine administration than from private health plans. The need to keep separate stocks of VFC and private vaccine. And the requirements to replace lost doses. Next slide. And these are simply my collaborators, both at the University of Colorado as well as CDC for this project. Next slide. And now, moving -- shifting gears, moving into the overall AAP perspective. Next slide. So, again, we are strongly supportive, but there are several challenges, some of which I've mentioned and some others that I haven't yet. You know, one is that things are a lot different today than they were when the VFC program was first started in 1993, 1994. We have certainly seen dramatic increases in childhood vaccination rates, but we've also seen an increase in childhood poverty, both pre and post pandemic, and thus VFC eligibility. So, another challenge is that the operational requirements and overhead costs that I've mentioned. Another challenge is that the state programs really vary widely in their levels of program monitoring and compliance activity. Again, I mentioned the low payment for vaccine administration, and I'm going to get a little specific here. They may -- jurisdictions may pay for codes 90460 and 90471 but cannot pay for 90461. And that restricts payment for administering multicomponent vaccines, which is an ACIP and AAP recommendation. They're also bound by maximum -- sorry, maximum regional charges, and these haven't been updated since 2012. Next slide. Some other challenges. There are also, as Dr. Peacock mentioned, restrictions on where underinsured children can receive VFC vaccines. So, currently that's only in federally qualified health centers and rural health centers and deputized VFC providers. There's also variability among states and jurisdictions between Medicaid and CHIP eligibility. So, currently, CHIP enrollees and Medicaid expansion, and combination programs are eligible for VFC, but children enrolled in separate CHIP programs may not be eligible. Also, newer high cost -- we're, I think, all well aware of the newer vaccines that are available, COVID-19. And these are some of the more expensive immunizations that we have ever seen. So, that -- it is a requirement if you are a VFC provider to also stock private stock vaccine. And so, purchasing these vaccines is cost-prohibitive for many practices. And so, some have -- some of the pediatricians within AAP have expressed to AAP leadership that they're considering dropping VFC participation because of the requirement to purchase these vaccines. Another thing that we're hearing from, pretty much all of our primary care members is that they're having longer discussion times with families around vaccine confidence. There have been shifts in demographics of vaccine hesitancy from historically primarily college-educated White to now include all demographics, including those from lower socio-economic status. And there have been miss and disinformation campaigns targeting Black and Hispanic communities, both pre and during the pandemic. Next slide. So, getting into some specific recommendations. One, to increase participation, simply pay the providers, incentivize them. We gave an example of $10,000 to help increase provider participation and help alleviate operational burdens. Also, update the maximum regional charges for vaccine administration, which again have not been updated since 2012. Also, to allow payment for the 90461 code to recognize the time spent on vaccine counseling and education. Also, expand VFC eligibility to all CHIP enrollees regardless of the individual CHIP program structure. Also, to allow underinsured children to receive vaccines at any participating VFC provider, not just the federally qualified health centers and the rural health centers. And then finally to permit payment for standalone vaccine counseling for all VFC enrollees, not just the Medicaid eligible children. Next slide. And I think this is my final slide. This is getting a little bit specific about some of the things Dr. Peacock mentioned. So, we very much appreciate the flexibility for participating VFC providers issued for Covid-19 and Nirsevimab. Under this new guidance, we'll have until the end of March of this year for COVID-19 vaccines for the private stock requirements and August of this year for Nirsevimab. And also, CDC is allowing bi-directional borrowing of these products under certain circumstances for this respiratory season. But both of these flexibilities were affected by the shortage of Nirsevimab this year. So, we're hoping that CDC will continue these flexibilities for the next RSV season. And we also would encourage -- Dr. Peacock talked about this as well. Ease the enrollment process for birthing centers so that we can get more VFC providers, especially -- more hospitals as VFC providers to be able to administer just Nirsevimab and Hep B vaccine, and not have the requirement to stock all ACIP recommended vaccines. And I believe that's my last slide. Next slide. So, thank you very much for your time. And I will pass it on back to Dr. Hopkins. >> Robert Hopkins, Jr.: Thank you very much, Dr. O'Leary. Our final presenter in this panel is Dave McCormick from the Indiana state Department of Health. Dave, your slides are up. I see you on video. You have the floor. >> Dave McCormick: Thank you. And thank you for allowing me to present this afternoon. I was asked to speak about how we've been able to increase access to vaccines, and then some of the successful things that we've done to increase immunization rates. So, I'm going to highlight some things with the Indiana immunization program. Next slide, please. So, I'd be remiss if I didn't start off by talking about the fact that behind our program is a strong immunization information system. There was a time that I would joke that I could have an immunization program without an immunization information system, but that time is no longer. Everything that we do is really tied to our IIS. So, when we started talking about access, I wanted to know what the data showed. Where are we actually missing opportunities, or where are we really with our immunization rates? So, we started looking at not only what our coverage rates were, but also what were the average age that individuals received a vaccine, and were we close to those recommended ages? So, this slide actually illustrates that there are some huge delays that we are seeing now, especially since the pandemic in series initiation. For example, in Indiana, the average age for initiation of the Hep B birth dose is two months of age. Meaning that we're not getting those doses in the hospital. And for MMR, we are approximately six months late. In some of our counties, the average age of an individual receiving their first MMR is over 20 months. So, we started looking what are the root causes of this and how can we make those changes? One of the things that we found is that there is a problem with appointment availability. We have not seen those appointments bounce back from -- prior to COVID. So, right now, for a well child visit, we're still looking somewhere between four to sixty -- four to six weeks for a parent to get an appointment. And so, we really wanted to look and try to find a way that we could increase that. We also looked at our school immunization rates. And we found that one in five kindergartners, one in four sixth graders, and one in three seniors were missing one or more important vaccines. Next slide, please. So, one of the things that we came up with was trying to do a statewide catch-up vaccine. And I know Dr. Peacock talked about the national effort. But I'm going to give you some highlights on the Indiana specific effort that we had. We worked with our Indiana chapter of AAP. We worked with our Medicaid managed care individuals. And we decided that we would look to see how many kids were missing one or more doses of required vaccines for school entry. We also looked at what the age group we were going to talk about. So, in working with AAP, we decided that we would try to take the burden off of the older kids, the school age kids, and let the healthcare providers try to get those younger kids back into the office. We did have a lot of respect for the medical home and wanted to make sure that we maintained that. But we did think that with the back-to-school campaign, we could increase our efforts. So, next slide, please. So, we started out by extrapolating all the data from our registry. How many kids actually needed one or more vaccines? And so, we looked at which individuals were missing one or more school-required vaccines. Again, we focused on the ages of 5 to 18. We did try to engage our healthcare provider network. We sent a letter to healthcare providers two weeks prior to sending anything out to parents or guardians to make sure that they were one, informed before we sent the letter out. And two, could make any kind of preparations for bringing vaccines into their office. We did see quite a few people go to their healthcare provider. And we also saw this as an opportunity to not only address required immunizations for school but also to talk about all of the recommended vaccines including HPV or MenB, flu, and COVID as well. This is a copy of the letter that we sent to parents saying that your child may be missing one or more required vaccines. And to also talk to your provider about other vaccines that may be needed. Next slide, please. The data that we found showed that over half a million children needed one or more required vaccines for school. So, what we came up with is that we decided we would have a vaccination clinic, in addition to any scheduled clinics that were being held in every county in the state of Indiana. We had a six-week campaign that we tracked. We sent these letters out. We did media ads. And we found that in the first six weeks, 144,983 kids received one or more vaccines. We found then the next month an additional 100,000 children received those vaccines. So, the first six-week time period, those were our clinics that we had in every county. That additional month after the campaign was individuals going back into their health care provider. This chart represents the children that had no action taken, those that received one or more vaccines during the campaign, and then one or more vaccines the month after. We had a total of 47 percent of children that were missing one or more required vaccines, have at least one dose administered. Now, I'll be really honest. That doesn't mean that all of these children were properly vaccinated and fully vaccinated by ACIP recommendations. It just means that they had a touchpoint with a provider and received one or more vaccines. We still have children that are missing important vaccines, but this was a good start to this. I mentioned that we are -- next slide, please. I mentioned that we had a clinic in every county in addition to the health care provider clinics. And the way that we did that is we used our mobile units that we had started through COVID to increase our touch points for just routine and immunizations. We have 10 mobile units that are paired in different regions or districts throughout the state. They have staffing for both vaccination and testing. And again, this was something that was started in COVID for both COVID testing and COVID vaccination, [coughs] excuse me. But we were able to quickly tune that over to do routine vaccines and other testing. One of the things that we focused on was school health. So, these mobile units now go into a school, and they do school-located vaccination clinics. But they also do vision and hearing testing as well. They're also very purposely situated throughout the state so that we can use them to respond to an outbreak, which as all of us know, those happen on a routine basis and really needs to be responded to as quickly as possible. So, it helps already having a vaccinator and a mobile unit that can set up a clinic within just hours of being notified of that. And then the last thing. Well, it really isn't what the VFC program, but it is something that we use these mobile units for is our Homebound Hoosiers program. So, individuals that are not able to get out to a healthcare provider, these mobile units will go to their homes and actually offer a vaccine. We do see some under 18 individuals through this program. But most of them are elderly. Next slide, please. So, I love to talk about pharmacies as VFC providers. I will be honest, we're not as successful as we'd like. But we do know that this is an important vaccine touch point in our community, especially in the adolescent space. Bringing on pharmacies as VFC providers provides expanded hours for vaccinations. We have a lot of experience with this through the COVID-19 Bridge Access program. And we're using that same model for enrollment and management that we've had for that process. And we have developed a streamlined process for enrollment. And we're moving to all electronic processes so that we can streamline that process. And then also, if we can bring on large pharmacies, there's a great marketing option. There's a great way to bring in individuals to a pharmacy on a weekend or a weeknight where individuals can be vaccinated, regardless of their health care coverage. One great example of this has been enrolling a small independent pharmacy in a mainly Amish community. They were the trusted source of healthcare in that community for the Amish population. And we have seen a huge increase in vaccination rates in that community through this independent VFC pharmacy. Next slide, please. I also want to talk a little bit about using our IES to do reminder recalls. We talked a lot about routine vaccinations. And ideally, we would like to think of all routine vaccinations. But in most cases in the state of Indiana, when we talk about routine vaccinations, people associate that just with school-required immunizations. So, we really have had some extra focus on reminder recalls, especially around HPV vaccine. Now, what most states I think kind of struggle with is HPV is one of those things and providers and parents don't like to talk about. And we have tried our best to normalize this. But in some states, this is a hot political topic, and Indiana is no different from that. So, what we tried to do is how can we still have a win? And so, we looked at individuals that had started the series but had not completed the series. So, we know that an uncomfortable conversation has already been had. And so, now, it's just making sure that they complete the series. So, we ran a report of all children both VFC and privately insured, that had started the series, but had not completed it, sent a letter to all of the parents and guardians stating that they needed an additional dose. And as a result, we had over 27,000 individuals in a six-month period that received an additional dose or completed the series. So, it's just those little steps that can really push and increase coverage and also access. As part of our letter, we outlined a map that all providers could or -- I'm sorry, all parents could go to that would illustrate all of our VFC providers across the state where they could go and find a vaccine. Next slide, please. That which is measured tends to improve. And so, we have been really big on trying to provide feedback to our VFC providers making sure that they know where they are in their coverage rates and areas to improve on. So, we have created a VFC coverage report. I know many states are doing this as well. We had multiple antigen report cards, if you will, that we were sending out. And we decided that we would combine it all in one, do it once a year, and make sure that all providers were aware of their rates. This actually serves as a couple of other strong points in [coughs], excuse me, as it talks about a data quality measure. So, as we issue these report cards or coverage reports, if you will, providers will say those are not my rates. I know that rate is not as -- or my rate is not as low as that. And so, we then have an automatic conversation about the quality of data that is being submitted to the registry. It gives us an opportunity to not only talk about how we can improve that measure but also great efforts on where they can increase their vaccination coverage rates. So, again, this has become an excellent tool for the program. Next slide, please. And then this is my last slide. But I'll talk about the importance of getting data back out to our community, not only to healthcare providers but to policymakers. We've had a lot of vaccine-hesitant legislation across the nation. And using data to actually show where we are is a great tool to make sure that we are not losing ground in the immunization community. We have these dashboards. These dashboards are based on information that has been requested. We looked at the six most requested information and then created dashboards of what information would be out there. So, in short, we're using all of our data to increase not only access but also trying to increase our coverage rates. So, thank you for this opportunity. Next slide, please. And I will turn it back over to the moderator. Thank you. >> Robert Hopkins, Jr.: Thank you very much, Mr. McCormick. Very nice presentation. I have to congratulate you and your colleagues in Indiana for your efforts. And I also have to congratulate all of the hard work that's going into the VFC program and the impact it's made over these past 30 years. I was a resident before VFC was instituted. It was instituted shortly after I went into practice and certainly, been critical for all of us. Are there any other comments or questions from members of the committee? >> Male Speaker: Dr. Hopkins? >> Robert Hopkins, Jr.: Yes. Go ahead, Mitch. >> Male Speaker: Yeah. Thank you to the panel for the great presentation, and to all providers who have been committed to the VFC program. And I think a couple of our speakers have touched on a couple of things. But I think we really need to look at the compensation or if you want to call it the reimbursement model. While the vaccine is free, the cost of providing the vaccines and the care has gone up on a lot of providers and their ability to absorb uncompensated expenses is harder and harder. And we're seeing an overall, you know, decrease in the number of VFC providers. It's not a large percentage, but it's going in the reverse direction than where we'd like to go. So, I think, as Dr. Peacock said, looking at doing things differently is really going to be important for us to maintain the VFC providers. And I hope that NVAC, along with CDC, can have more discussions on coming up with what a new model would look like. >> Robert Hopkins, Jr.: Thank you. Any comments from any of our panelists? Well, I don't see any other hands raised. I want to thank the members of the panel. Again, VFC has made a big impact, and we look forward to seeing how we can continue to move forward for the next 30 years. At this time, we're going to turn our attention to the report out from the Innovation and Immunization Subcommittee. Dr. Jewel Mullen and Bob Swanson have been the co-chairs of the Innovation and Immunization subcommittee. I believe Dr. Mullen is going to present. And then Bob's also going to be on to help answer questions. Jewel, your slides are up. You have the floor. >> Jewel Mullen: Thank you. Good late afternoon to everybody. Thank you, Doctor -- well. Sorry, Bob. Bob, I always want to call you Dr. Hopkins. Thank you, Bob. And then thank you, my colleague, Bob. I'm going to be really brief. So, I'm going to take an extra moment to save this. The support that we have gotten from Ann and her staff for this work has been fabulous. So, I want to thank them. I also want to say that it's been a pleasure to co-chair this committee, which has continued to, for, I think, about a year now, show up almost every other week late on a Friday afternoon to discuss this work. And it's been a real privilege to be among the brains, the thoughts, the innovative ideas of the committee members. So, because I have a short report, I thought it would be really appropriate to just say that at this moment. And we can go on to the next slide. So, we still have this robust committee, as you see here. I'm not going to list their names. But we've had great representation, not only on paper but through their participation throughout our work thus far. We can go on to the next slide. I'll just remind us that we were charged by Admiral Levine to write a report to provide conventional and promising approaches for vaccine discovery and development. That we should offer recommendations that are high impact and actionable. That we should provide an evidence base for identifying and prioritizing vaccine candidates and immunization technologies. We've been greatly supported by the speakers that we've heard from over the past year and helping determine that we should provide a list of vaccine innovation priorities. A forward-looking approach to introduce vaccines for special patient populations. And a specific scientific agenda outlining a framework of research direction and that identifies scientific needs and gaps that should be addressed over the next four years. We can go on to the next slide. And I can tell you where we are. Since my last update or since our last update, we've heard presentations on novelty cell vaccines, influenza virus case study, the ACIP processes, vaccine innovation law and policy. And then on the next slide. The rolling up the sleeves to develop and refine the report outline has been underway. We're working on finalizing the first draft of the report for editing. Shout out again to Ann and her team, along with a number of committee members who have been contributing to that. We've had group discussions on the potential recommendations, thinking and rethinking, refining what we want to bring forward, and we're developing and reviewing a table of current vaccine-preventable diseases that outline disease severity, the current vaccine efficacy, and that identify opportunities for innovation. Thank you again to staff for helping with what really is a huge task in that regard. The next slide. Here's where we go next. Where we find our recommendations, revising and drafting the table. We will be coming back to NVAC for feedback on our draft. We will revise the draft following that feedback and promise to present our progress again at the next NVAC meeting. Bob Swanson, anything you would like to add? >> Bob Swanson: Jewel, I think you did a great job and I really appreciate it. Thank you. >> Jewel Mullen: Thank you. So, I almost asked staff to put that you were going to present at the next meeting, Bob. And so, I want to stay serious. But I also appreciate your partnership and co-chairing this committee. >> Bob Swanson: Thank you, Jewel. >> Jewel Mullen: You're welcome. >> Bob Swanson: It's been a pleasure working with you. >> Jewel Mullen: Thank you. Last slide, I think. Questions? Comments? Thank you. >> Robert Hopkins, Jr.: I'm going to take the chair's prerogative and just say, Jewel, that the meetings and the activities of this committee have been lots of fun. I think I've learned something from every single one of our sessions. And I appreciate the leadership that you and Bob have put into this effort and look forward to us bringing it home here in the next meeting or two. >> Jewel Mullen: Thank you. >> Robert Hopkins, Jr.: All right. Well, thank you for your presentation. I don't see any other hands raised. I will encourage the members of our committee, as well as our liaisons and ex officios. If you have feedback, if you have comments, please shoot an email to Ann, to me, to Jewel, or to Bob so we can incorporate your thoughts as we bring this to a conclusion. All right. We've now reached the end of our agenda for our presentations. And it's time now for public comment. I understand that we're to have a public comment from Theresa Wrangham. Theresa, are you on the line? >> Theresa Wrangham: Yes. Can everybody hear me okay? >> Male Speaker: You are loud and clear, Theresa. You may proceed. >> Theresa Wrangham: Wonderful. Thank you. My name is Theresa Wrangham. And I'm the executive director for the National Vaccine Information Center. Our co-founders are parents of vaccine-injured children and worked with Congress to draft and pass the National Childhood Vaccine Injury Act of 1986 that created this committee. NVIC supports access to vaccines, and also upholds the right to make voluntary vaccine decisions aligned with the informed consent ethic and does not support coercive laws, policies, and mandates, making a choice not to vaccinate burdensome. According to the CDC's November MMWR report on vaccine coverage for kindergartners for the '22-'23 school year, it reveals that over half of U.S. states provide provisional and grace status for students. In Colorado, the state I live in, and vaccine laws were enforced. And paperwork gathered by schools on vaccine status and exemptions, high vaccination rates existed. This may be true for many of the states with provisional language regarding school vaccination requirements. Some of the presenters today also mentioned that piece. Indeed, the CDC, during a 2018 ACIP meeting, stated clearly the following: vaccination coverage among kindergartners remains high. However, schools can improve coverage by following up with students who are provisionally enrolled in a grace period or lacking complete documentation of required vaccinations. That statement was made by Dr. Nancy Messonnier. Yet the following legislative session, despite state data validating exactly what Dr. Messonnier alluded to, a new law was passed here in Colorado to consolidate the religious and personal belief exemptions into non-medical exemptions, with required education to obtain the exemption. In a nutshell, parents were penalized, and choices made burdensome because schools were not doing their job and following state law. The slab doesn't appear to threaten parents, as the chair noted should be avoided. It does threaten parents. Such action in Colorado or any state violates the informed consent ethic, which is guided not only by research guidelines but the ethical practice of modern medicine since World War II. It is every individual and parent's right to make voluntary, informed vaccine decisions without threat, coercion, or sanction. Additionally, the data presented on measles outbreaks didn't consistently provide vaccination status, nor were any adverse events resulting from measles vaccination. A vaccination I personally had a severe reaction to and to which my mother thought would kill me were discussed today. The vaccine doesn't always prevent measles and also comes with risk, and the medical literature and public health data document that the vaccine can fail to prevent the disease. I think these are important concepts to include in these meetings when discussing coverage and concerns about measles or any other disease. Thank you for the opportunity to provide public comment today. >> Robert Hopkins, Jr.: Thank you, Ms. Wrangham. Ann, do we have any other public comments on the line? >> Ann Aikin: We do not. We can adjourn the meeting. >> Robert Hopkins, Jr.: Right. With that said, thank you all for your participation in our February 22nd day of our February impact meeting. I look forward to seeing all of you all tomorrow for our second day starting at 12:00 p.m. Eastern Time with our call to order from Ann. You'll have a good evening and look forward to seeing you in our virtual meeting tomorrow. Meeting adjourned. >> Male Speaker: Thank you. >> Female Speaker: Thank you and take care.