PROMOTE Vaccination, Everyone, Everyday

Middlesex County NJ is a County in Central NJ with a population of approximately 860,000 residents and 25 municipalities.  Middlesex County office of Health Services is a large Health department that is the health department for 24 of the 25 municipalities.  The county's racial makeup is 41.9% White, 9.8% African American, 0.53% Native American, 26.5% Asian, and 9.06% from two or more races. Hispanic or Latino of any race were 22.4% of the population.   Seventy one thousand (71,000) people fall below the poverty line.  Forty seven percent (47%) of residents have a non English language as their primary language at home.  Over seventy three thousand (8.5%) have no medical insurance.  More than 52,000 are non- citizens (unauthorized population)

Vaccine preventable Outbreaks in adults can be prevented by maintaining high vaccination rates. Despite this relatively easy intervention, vaccination rates for many of these preventable diseases in the United States still remain low. 

Our health department has several public health clinics for uninsured and underinsured.  These clinics are for child health, Child lead clinic,  Adult sexual health (STD) , CEED  (Cancer Education and Early Detection) , and Tuberculosis.   Although every one of these clinics is well attended, they are NOT attended for vaccination and, in fact, most of the population attending is under vaccinated, unvaccinated or behind on their vaccinations. 

Beginning in 2010, a practice of Promoting Vaccines, Everyone, everyday” was implemented to encourage all adults (19 and older)  visiting any clinic to receive any number of vaccines that would get them current on their vaccine status.  This was done on site when the patient arrived, either when bringing a child for treatment or when presenting to an adult clinic for another reason. 

The simple goal of the practice is to bring every visitor's vaccination status to up to date” on all eligible vaccines.  The  goal was to have 80 percent of the eligible adult population receive their outstanding vaccinations. The objectives--Implement a protocol where all clinical staff actively interview and provide education adult visitors regarding their vaccination status and, evaluate every chart regarding missing vaccination, and strongly recommend missing vaccines to every patient.  This protocol became a matter of practice at each visit, regardless of type.

During the ten years of the program evaluation (2010-2020) the data indicates that over 20,000 non scheduled vaccines were given to visitors to our clinics.  These vaccines included were HPV, Shingles, Varicella, Pneumonia, TD or Tdap, Hep A/B combined Hep A, Hep B, and flu. 

The success of the program is largely due to the routine nature of the promotion (every adult 19 and older who enters any clinic is asked about vaccination) and also the trust of the clinic staff.  The staff is multilingual and can communicate well with the client.   When a parent comes in to bring their child/baby to our clinic, we identify the needed and missing vaccination of the parent and can offer vaccines for the parent at that same visit.  The parent didn't come in for vaccines for themselves but leaves fully updated with their own vaccines.  Since the parent is not likely to receive this care for themselves elsewhere due to time or funding constraints, the public health significance of this practice is remarkable. 

While vaccination in children has been one of the tools used in closing some health disparities by preventing childhood diseases, the same drive to improve vaccination rates in adults helps towards achieving health equity for minority and vulnerable adult populations. 

Vaccination coverage for all recommended vaccines for adults in the United States is lower than expected. Raising that rate has always been challenging.  Racial and ethnic disparities persist, and some of these groups experience significant and avoidable illness from vaccine-preventable diseases.   In the National Health Interview Survey(NHIS), disparities were observed in all or some racial and ethnic minority group for  most adult vaccination rates that were reported. 

Under vaccinated and unvaccinated adults contribute to an overall disease burden that has been estimated at $26.5 billion among persons aged 50 years and older for influenza, pneumococcal disease, herpes zoster, and pertussis

Our target population for Vaccines for Everyone, Everyday are underserved minority groups of adults, age 19 and older, at or below poverty levels with limited access to routine healthcare.  They are uninsured or underinsured, often non English speaking, and sometimes without transportation.  About seventy thousand people in our County have no medical insurance (this includes children). While every one of them is not un or under vaccinated, we reach everyone that enters any one of our clinics.   

The practice of Vaccines, Everyone, Everyday” started in 2010 as an informal PUSH opportunity to offer vaccines to every adult visiting, even if they were attending their child's visit.  In 2010, over 2500 additional, non scheduled vaccines were administered to adults.   For us, a critically important step in ensuring vaccine acceptance is to make vaccines as accessible as possible.  Offering the vaccines in a friendly, non-threatening setting, providing education in multiple languages and no cost were valuable parts of this program.    The cost of healthcare and vaccines is a recognized barrier to vulnerable populations.  To address inequity, offering these vaccines free, often and convenient is one way which public health can have a substantial impact.

A study published in 2008, (Johnson DR, Nichol KL, Lipczynski K. Barriers to adult immunization. Am J Preventive Med 2008; 121:S28–35)  to understand why adults did not receive recommended vaccinations, found that 79%–85% of consumers) indicated that they were likely to receive the vaccination if their healthcare provider recommended it.   Strong provider recommendations was correlated with  increased likelihood of receiving a vaccination in another study regarding vaccine hesitancy.  Our Vaccines, Everyone Everyday” protocol follows this guideline.  At every encounter, a nurse or physician at each clinic discusses and makes a strong recommendation for any outstanding vaccines to each adult. 

Vaccination is not new to public health, in fact, we have many single scheduled vaccine clinics to for flu and covid.  Additionally, public health focuses more heavily on childhood vaccination.  The difference in this program, Vaccines for Everyone, Everyday, is that its focus is on adult vaccines and as many as necessary to get each adult current on their vaccines.  As a matter of practice, every single adult over 19, is asked about their vaccine history, regardless of their reason for entering the clinic.  (sometimes they are just accompanying a patient) The success rate is high.  Over 90% of eligible adults who are asked about missing vaccinations leave the clinic with one or more vaccines. 

*An additional note:  we have several contracts with prisons, halfway houses, and referrals for recent immigrants to provide screenings for sexually transmitted diseases.  At these screenings, everyone who is screened is assessed, evaluated and receives full access to free vaccines, bringing their vaccine status current. 

Our initial goal was to have 80 percent of the eligible adult population 19 and older receive their outstanding vaccinations.   (This changed after several years to 80% of eligible adults over 19 receiving all recommended vaccinations)

Objective 1:   Implement a protocol where all clinical staff actively interview and education adult visitors regarding their vaccination status (with a vaccine assessment form) and recommend vaccines.

Objective 2:  Marketing campaign-signs in multiple languages with information on available FREE adult vaccines at each clinic. 

Objective 3: Roll out protocol to each of our health clinics. 

Objective 4: contact/contract with free ride services to insure transportation to clinics. 

Once the clinical staff was trained, the program was implemented. This took place over a 1 month period once vaccine was available in 2010.  The largest group of stakeholders involved were the public.  Those stakeholders were adults 19 or over (and their families)  attending a clinic with their child, an STD clinic, a Cancer clinic or a TB clinic. Another group of the stakeholders were the physicians employed by each of the named clinics.  These physicians had to "buy in" to the program and ensure the patients were properly assessed and evaluated for vaccines. 

The LHD nursing division was the lead in the development and implementation of the program Vaccines, Everyone, Everyday”.  Because the clinics are welcoming, non threatening, multi language,  and because we accept anyone who is uninsured regardless of legal resident status, we have fostered a valid, trusting relationship with the community. Additionally, these adults return at a future date for more vaccines when it is appropriate.    The clinical staff is assertive in recommending current vaccines and they are also educated to be able to answer questions from the public. 

Transportation is often a limiting problem in the vulnerable population.  For our CEED clinics, we have arranged free UBER rides for uninsured residents with cancer screening appointments.  According to the protocol, these patients are also targeted by the staff to get all updated vaccines when they are there for their cancer screening. 

The vaccine was procured first through VFC and then through the Section 317 vaccine funding for uninsured or underinsured adults at no cost to our health department.  There were no additional costs for staff.  The marketing campaign was within budget for our usual expenses. 

Prior to the implementation of Vaccines, Everyone, Everyday”, our emphasis was childhood vaccinations in our child and baby clinics.  The other public health clinics run by our health department for adults-STD, Cancer Screening, and TB- historically did not focus on vaccination of adults.  This program identifies adults who are NOT primarily seeking vaccination and introduces the opportunity.

Seemingly, many adults can get vaccinations at pharmacies, supermarkets, urgent care, and physicians offices.  Adults without insurance (or finances) and adults who have vaccine hesitancy or other barriers to healthcare, can not take advantage of these opportunities.   "Vaccines, Everyone, Everyday" is a solution to this access to care problem for many of our residents.  

Vaccine program Data was collected electronically throughout the years of the program by the Nursing Division.  The data collected was vaccine year, vaccine type, vaccines administered, along with other vaccine identifying and expiration data,  from 2010 to 2020.    The data was analyzed by the Health Dept Epidemiologist using summary statistics, column charts, scatter plot.  The results stayed steadily increased over the 10 years, after an initial surge in 2010.   

Our primary goal in the program Vaccines, Everyone, Everyday” was for 80% of the eligible adult population 19 and older receive their outstanding vaccinations.  Over 90% of eligible adults who are asked about needed/missing vaccinations leave the clinic with one or more vaccines. 

Objective 1:   Implement a protocol where all clinical staff actively interview and education adult visitors regarding their vaccination status and recommend vaccines.

Objective 2:  Marketing campaign-signs in multiple languages with information on available FREE adult vaccines at each clinic. 

Objective 3: Roll out protocol to each of our health clinics. 

Objective 4: contact/contract with free ride services to insure transportation to clinics. 

All objectives were achieved.  The initial program was implemented in child health clinics, STD and cancer screening (CEED) clinic.  After success of these clinics, the program Vaccine Everyone, Everyday” was implemented in the TB program in 2018. 

Despite vaccine preventable disease being relatively easy to control with vaccination,  rates in adults for these disease has been consistently difficult to raise.   The estimated financial burden for these diseases in Under vaccinated and unvaccinated adults has been estimated at $26.5 billion among persons aged 50 years and older for influenza, pneumococcal disease, herpes zoster, and pertussis.  The  Vaccines, Everyone, Everyday program has addressed some of the inequity and access problems by offering FREE vaccines at every visit, multiple languages, and sometimes free transportation.  The success of the program means that 9 of every 10 people who walk in to the clinic today, walk out with one or more vaccines. 

"Vaccines, Everyone, Everyday" is a sustainable practice because it has been imbedded into the routine structure of the clinical assessment at each clinic.  It is more work and time consuming than just a basic interview and we found that some staff include the vaccine assessment better than others.  A gentle reminder was usually enough to remedy the situation.  One of the rare limitations of the program is having enough Section 317 vaccine on hand at all times.    

The cost of the program is time.  It takes more time to be efficient at getting every adult assessed and vaccinated.  There are no costs related to extra staff or equipment. 

Public Health is obligated to provide some health services to populations that may not be eligible to get them through the private sector.   Once we have that connection, once we have someone in our clinic, once we have their attention, we think it's crucial to make sure they've been given the most basic of protections-against vaccine preventable diseases VPDs).  Even when they only came in with their child, or for a TB check up or a mammogram, even if they're resistant or unsure…we want to provide them every opportunity to get protected again VPDs. If we always have enough vaccine, the availability of adequate resources relies on staffing and we are a large and fully staffed health department

The GAO Routine Vaccinations Report to Congress released in September 2022 indicates that national averages for vaccine rates for Shingles and Influenza for adults are 31.6% and 46% respectively.  We NEED to vaccinate more adults with recommended vaccines.   The practice of Vaccine, Everyone, Everyday” is a replicable practice and every public health clinic can be chipping away at the large burden of vaccine preventable diseases by raising the rates of vaccination in the adult population.   

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