2019 AIM Leadership In Action Conference · Leadership in Action Conference Association of...
Transcript of 2019 AIM Leadership In Action Conference · Leadership in Action Conference Association of...
2019 AIMLeadership In
Action Conference
#AIM2019
Thank you to AIM’s Corporate Alliance Program members
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Conference Planning Committee
#AIM2019
• Shannon Bennett (NV)• Shauntrelle Chappell (CDC)• Aaron Dunn (OR)• Phil Griffin (KS)• Tim Heath (SD)• Jan Hicks-Thompson (CDC)• Molly Howell (ND)• Sarah Leed (ID)
• James Lutz (Philadelphia)• Tom McCleaf (PA)• Dave McCormick (IN)• Tonya Philbrick (ME)• Gred Reed (MD)• Mark Ritter (TX)• Lynn Treferen (CO)
Leadership Institute Advisory Board
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• Shannon Bennett (current PM Nevada)
• Marcelle Bobinsky (Executivedirector, KV Foundation, LC; former PM, New Hampshire)
• Steven Bors (current PM New Jersey)
• Lorraine Duncan (former PM, Oregon)
• Michele Roberts (current PM, Washington state)
• Laurel Wood (IAC; former PM, Alaska
Stacy HallProgram Manager, Louisiana
#AIM2019
Welcome to Louisiana
Purple matches everything
Gold is a neutral color
Welcome AIM!
Dear America,
I suppose we should introduce ourselves:
We’re South Louisiana … You probably already know that
we talk funny and listen to strange music and eat things
you’d probably hire an exterminator to get out of your
yard. We dance even if there’s no radio. We drink at
funerals. We talk too much and laugh too loud and live
too large and, frankly, we’re suspicious of others who don’t.
--Chris Rose
Welcome home!
Second Lines
Gumbo of cultures: Native American, French, Spanish, German
African, Irish, Acadian…
All the words run together
Howsyamommaanem?
Sounds like “homonym”
What you’re being asking is: “How is your momma and them?”
The “them is your family, but your momma’s the important one.
Never “getting ready” to do something
You’re “fixin’ to”
You don’t “grocery shop”
You go “make groceries”
“What ya’ doin’ today?”
“I’m gonna go make groceries.”
“I’m fixin’ to do that too.”
“Come see” means “come here”
“Put up” the toys, not “pick up”
“Take off the lights” instead of “turn off the lights”
In other places they’re: sneakers, trainers, or tennis shoes,
Here they’re just “tenny shoes”
Bet I know where you got those shoes?
Don’t say “how’s it going?” we ask “where y’at?”
You may want to say I’m standing right in front of you, but that
would be incorrect
You’re really being asked, “Where are you in your life?”
“Marie, I ain’t seen you in ages, where y’at?”
Don’t “cheer,” you yell, “who dat?!
Phrase has a long origin that was revived when the Saints won the
Super Bowl in 2009
It can be used as any exclamation!
Supervisor: “You’re being promoted.”
Employee: “Who dat?!”
Beaucoup (boo-koo) means “big” or “a lot”
French word "Cher" means dear one
"Sha" means exactly the same thing. It's used interchangeably with:
dear, honey, babe, sweetheart or with anyone…
You don’t get something extra as thanks from a merchant, you get
“lagniappe” (lan-yap)
Saying: Y’all come back now.”
“Dressed”
This has nothing to do with clothing and everything to do with
how you want your po’boy (a sandwich served on French bread)
When you order, you’ll be asked if you want it dressed, which
means with lettuce, tomatoes, pickles, and mayo
Shrimp, oyster, catfish, sausage, debris (leftovers of roast beef),
rabbit, duck, potato po’boy which are thick french fries with
generouse gravy….
Don’t say ‘this is good”
Say “It’ll make you slap your momma.”
“ya granma” is interchangeable, but please keep in mind there
isn’t any real slapping involved
Means you actually like something
Customer: “Is the gumbo good?”
Server: “It’ll make you slap yo mama.”
“Louisiana has the best food on the planet if you don’t really ask
too much about what you’re eating.”—Jeff Foxwood
“Fais-do-do” (fay-DOUGH-DOUGH) is a Cajun dance party. It
literally means “to go to sleep,” and it originates from parties
lasting so late into the night that the children would fall asleep
on their own without being told.
A baby being put to sleep is told “go do-do.”
Let's say a friend gives you home and you want to invite him
inside for a beer or a Coke. You would not ask him to come in, but
rather “Ya get down?”
Gris gris (gree gree) is a Voodoo term, but normally used in fun
with an undertone of warning. You may hear, “You better do
what your momma tole you or she’s gonna put a gris gris on you.”
Challenges
Subsidence
½” per year, 4 times higher than the global average
6’ below sea level
Poverty
1/5 people in Louisiana live in poverty
Childhood poverty is almost twice the national average
Some parishes, it’s about half of the children
Here your zip code matters as much as your genetic code
Directions
French Quarter
Borders: Mississippi River, Rampart,
Canal Street, and Esplande
East Bank of the Mississippi River
West Bank, last exit is Tchoupitoulas
(chop-ah-TOO-liss)
Marigny: MA-ruh-nee
Treme: trem-MAY
Calliope: CAL-ee-ope
Burgudy: ber-GUN-dee
Euterpe: YOU-terp
Melpomene: MEL-poe-meen
Terpsichore: TERP-suh-kore
French Quarter aka Vieux Carre (voo-kuh-RAY)
Brieux Carre Brewing in the Marigny on Decatur Street
Crawfish: CRAW-fish
Praline: PRAW-leen
Muffaletta: muff-ah-LOTTA
Beignet: BEN-yay
Café au lait: hot milk with chicory coffee
Pecan: (pah-kahn)
New Orleans
Name of this city is:
noo OAR-linz
noo-AW-lins
Never, noo-oar-LEENZ
So the parish is…?
“New Orleans makes it possible to go to Europe and
never leave the United States.”—Franklin Roosevelt
“Pass a good time”
means to have fun
Stacy Hall
504-232-9622
Michele RobertsProgram Manager, Washington
#AIM2019
Dr. Melinda WhartonDirector
Immunization Services Division, National Center for Immunization and
Respiratory Diseases,Centers for Disease Control and
Prevention
#AIM2019
Dr. Walter OrensteinAssociate Director
Emory Vaccine Center
#AIM2019
A Diagonal Approach – Eliminating Measles and Building Health Systems
Walter A. Orenstein, M.D.Professor of Medicine, Pediatrics, Epidemiology, and Global HealthAssociate Director, Emory Vaccine CenterDirector, Emory Vaccine Policy and Development
Leadership in Action ConferenceAssociation of Immunization Managers (AIM)New Orleans, LA
December 10, 2019
No conflicts to disclose
Comparison of 20th Century Annual Morbidity and Current Morbidity: Vaccine-Preventable Diseases
Disease
20th Century
Annual Morbidity†
2018
Reported Cases † †
Percent
Decrease
Smallpox 29,005 0 100%
Diphtheria 21,053 1 > 99%
Measles 530,217 273 > 99%
Mumps 162,344 2,251 99%
Pertussis 200,752 13,439 93%
Polio (paralytic) 16,316 0 100%
Rubella 47,745 5 > 99%
Congenital Rubella Syndrome 152 0 100%
Tetanus 580 20 97%
Haemophilus influenzae 20,000 27* > 99%
† JAMA. 2007;298(18):2155-2163† † CDC. National Notifiable Diseases Surveillance System, Week 52 (2018 Provisional Data), Weekly Tables of Infectious Disease Data. Atlanta, GA. CDC Division of Health Informatics and Surveillance, 2019. Available at: www.cdc.gov/nndss/infectious-tables.html.Accessed on January 4, 2019.* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 11 cases of Hib are estimated to have occurred among the 221 notifications of Hi (< 5 years of age) with unknown serotype.
2/27/2019CDC: Sandra Roush
Comparison of Pre-Vaccine Era Estimated Annual Morbidity with Current Estimate: Vaccine-Preventable Diseases
47
DiseasePre-Vaccine Era Annual
Estimate2016 Estimate
(unless otherwise specified)
Percent Decrease
Hepatitis A 117,333 † 4,000 * 97%
Hepatitis B (acute) 66,232 † 20,900 * 68%
Pneumococcus (invasive)
all ages 63,067 † 30,400 # 52%
< 5 years of age 16,069 † 1,700 # 89%
Rotavirus (hospitalizations, < 3 years of age)
Varicella
62,500 † †
4,085,120 †
30,625 ##
102,128 ###
51%
98%
† JAMA. 2007;298(18):2155-2163†† CDC. MMWR. February 6, 2009 / 58(RR02);1-25* CDC. Viral Hepatitis Surveillance - United States, 2016
# CDC. Unpublished, Active Bacterial Core Surveillance, 2016## New Vaccine Surveillance Network 2017 data (unpublished); U.S. rotavirus disease now has biennial pattern### CDC. Varicella Program 2017 data (unpublished)
1/11/2019CDC: Sandra Roush
Partners in the Immunization Effort
• Academic and other researchers
• Vaccine manufacturers
• Policy makers
• Public and private vaccine deliverers
• Third party payers
• Federal, State & Local agencies
• Political leaders
• Parents
• Many others
Topics to be Covered
• Horizontal, vertical, and diagonal
• Measles background
• US efforts to eliminate measles and it’s impact on overall immunization system
– The role of science and the role of politics
• Why can measles elimination be an incentive for health system strengthening?
• Are we ready for global eradication?
Horizontal, Vertical, Diagonal
Vertical – focused, proactive, disease-specific interventions on a massive scale
Horizontal – more integrated, demand driven, resource sharing health services
Diagonal – proactive, supply-driven provision of a set of highly cost-effective interventions that bridge health clinics and homes
Sepulveda J, et al. Lancet 2006; 308:2017-2027
Horizontal
V
e
r
t
i
c
a
l
Key Characteristics of Measles
• Highly contagious – most infectious of the vaccine-preventable diseases
• Distinct clinical syndrome
• Virtually all cases clinically apparent
• Good diagnostic tests
• Episodic in nature– Epidemics followed by low incidence as susceptibles accumulate
fueling next epidemic
• Substantial complications including hospitalizations and deaths
Making it an indicator disease for immunization programs
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Community Immunity Threshold (%)
=
𝑹𝟎 − 𝟏
𝑹𝟎
Fine PEM, et al. Chap 77 -Community Protection in Plotkin SA, Orenstein WA, Offit PA, Edwards KM, eds. Plotkin’s Vaccines, 7th
edition, Elsevier, 2018, 1512-1531
Complications from Measles
United States Developing World
Otitis Media 7 – 9% Death 2 – 15%
Pneumonia 1 – 6% PneumoniaMost common cause
Diarrhea 8% Diarrhea2nd most common cause
Post-infection encephalitis
1 – 4 per 1,000 – 2,000 cases
Blindness in areas with Vitamin A deficiency
SSPE1 per 2,500 – 10,000 cases
Estimated to cause more than 100,000 deaths annually
Death 1 – 3 per 1,000 casesNeurological complications
1 – 4 per 1,000 cases
From Strebel PM, et al. Measles Vaccine, Plotkin’s Vaccines, 7th edition, Elsevier, 2018
Epidemiologic Basis for Eradication of Measles in 1967†
• Virtually universal infection
• Reservoir is humans, no non-human reservoirs
• Chronic carriers do not exist
• Transmission dependent on balance between immunes and susceptibles
• Transmission dies off before all susceptibles exhausted
• Herd immunity threshold –
estimated to be 55% based on
data from Baltimore
† Public Health Reports1967; 82:253-256
Initial Strategy for Eradication of Measles in 1967 †
• Routine immunization of infants
• Immunization on school entry
• Surveillance
• Epidemic control
† Sencer DJ, Dull HB, Langmuir AD. Epidemiologic Basis for the Eradication of Measles in 1967. Public Health Reports 1967; 82:253-256
The Vision Behind Initial Attempts to Eradicate Measles in the United States
• First new vaccine (licensed in 1963), since establishment of the 317 Program in 1962 legislation
• Desire to build a more vigorous domestic immunization program
• Worldwide eradication not in initial vision
Impact of Initial Measles Eradication Program 1966-1968
• >90% reduction in measles cases
• >500,000 reported cases annually in pre-vaccine era to 22,000 in 1968
• Actual cases in pre-vaccine era in the millions, many unreported
• With improved reporting in the vaccine era, actual reduction likely much greater than 90%
• Funding for measles eradication program switched to rubella
0
50
100
150
200
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300
1965 1967 1969 1971 1973 1975 1977
Re
po
rte
d C
ase
s (T
ho
usa
nd
s)
Year
MEASLESReported cases, by year, United States,
1966 - 1977
Data from CDC, Epidemiology & Prevention of Vaccine Preventable Diseases, 13th Edition, Appendix E-3 (April 2015)
Accumulating Knowledge1969-1977
• Smallpox was being eradicated with “an outbreak control strategy”
– Could measles be eradicated with a similar strategy?
• Demonstrating measles could be eliminated from the US could set the stage for potential worldwide eradication
• School laws make a major difference in controlling measles
• Need for continuous source of funding
• Surveillance documented a change in age pattern with a greater proportion of cases in middle and high schools
• Political leadership critical for success
Key Differences Between Smallpox and Measles
Clinically distinctive illness Yes No
Contagiousness Ro 5 – 7 Ro 12 – 18
Herd immunity threshold 80 – 85% 92 – 94%
Spread prior to rash Rare Common
Effective 1 dose intervention
†††† ††
Differentiate vaccine successes vs. failures
Yes No
Smallpox Measles
Measles, Los Angeles - 1977†
Mid January – outbreak detected
Mid March – 2 deaths, 3 encephalitis cases, multiple pneumonia cases
March 31 – school exclusion order issued for May 2nd, if no measles immunity
April – clinics in most schools, night and weekend clinics
May – ~50,000 / 1.4 million students excluded within days, most back in school
† Orenstein WA, Hinman AR. Vaccine 1999; 17:S19-S24
1978 ‡
Measles in 6 States Strictly Enforcing School Laws vs. Other States*
* MMWR 1978; 27:303-4† per 100,000 < 18 years‡ 1st 31 weeks
‡ ‡ Alaska, Colorado, Hawaii, Maryland, New Mexico, South Dakota
1975-76 1977
6 states ‡ ‡ 47.0 40.6 2.7
Other states 50.4 90.3
Measles incidence †
35.2
Measles Cases by Age Group United States, 1976-2000
0
5
10
15
20
25
30
35
40C
ase
s (t
ho
usa
nd
s)0- 4 yrs
5-19 yrs
>19 yrs
Figure 4
From: Hinman AR et al. JID 2004; 189 (Suppl 1): S17-S22
Political Leadership - 1977
Mrs. Betty Bumpers –First Lady of Arkansas
Mrs. Rosalynn CarterFirst Lady of Georgiaand later First Lady
Senator Dale BumpersSecretary JosephCalifano, Jr.
Childhood Immunization Initiative - 1977
• Attain 90% immunization level in the Nation’s children by October 1979
• Establish a permanent system to vaccinate the birth cohort each year
• Focus on enactment and enforcement of comprehensive school laws
1978 93(3): i2.
Editorial. Childhood immunizationinitiative off to a good start
Establishment of a Measles Eradication Goal - 1978
• School immunization coverage moving toward >90%
• Eliminate indigenous measles by 1982
• 3 component strategy
• High coverage with a single dose
• Disease surveillance
• Prompt response to outbreaks
Experience Between 1977 and 1988
• Measles incidence dropped from 57,000 cases in 1977 to an average of ~3,000 cases during the 1980s, <1% of total prior to vaccination
• A pattern of 2 types of outbreaks was recognized –preschool and school aged
• A one dose strategy was questioned
Median (Range) Median (Range)
Measles Outbreaks, United States, 1985-1986
32
14
Patients’ characteristics (%)
<16 mos of age
Vaccinated at >12 mos
Outbreak Classification (Age)
Preschool(n=40)
School(n=101)
(0-80)
(0-42)
(0-29)
(0-100)2
60
N Engl J Med 1989; 320: 75-81
The Debate about 2 Doses
• Incremental cost
• Incremental cost effectiveness
• We had not achieved high coverage with one dose in preschool children, maybe it only required one dose
Vaccination Status of Measles Casesby Age at Rash Onset, US 1985-88
0
500
1000
1500
2000
2500
3000
<1 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30+
Nu
mb
er
of
Cases
Age of case (years)
Vaccinated unVaccinated
Recommendations for a Two Dose Schedule – 1989 – A Champion Prevails - I
• Failure to respond to 1st dose, not waning immunity
• Large number of college outbreaks
• Revaccination in outbreaks frustrating and difficult
• Most academic experts had bought into a second dose for measles elimination because measles was so contagious it could cause outbreaks in primary vaccine failures
Recommendations for a Two Dose Schedule – 1989 – A Champion Prevails - II
• Public sector resisted because of cost
• New York State Health Officer declares New York State would have a 2 dose schedule
• Opposition melted
• Both ACIP and AAP recommended a 2nd dose
– AAP recommends at entry to middle school, 11-12 years of age
– ACIP recommends at entry to school, 4-6 years of age
Measles Vaccine First Dose Coverage, U.S., 1973-1999
0
10
20
30
40
50
60
70
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1965 1970 1975 1980 1985 1990 1995
Perc
en
t co
vera
ge
Year
USIS (1-4 Y)
NIS (19-35 M)
School (5-6 Y)
Figure 3
From: Hinman AR et al. JID 2004; 189 (Suppl 1): S17-S22
Interest in Children’s Defense Fund (CDF) in Immunization
• Looking for ways to measure access to care and failure of health care system
• Immunization readily measurable
• CDF issued report warning of the dangers of low immunization coverage
• Invited Kay Johnson from CDF to speak at National Immunization Conference
• CDF and CDC Immunization became allies
• CDF Board members playedpivotal roles in future administrations
http://www.childrensdefense.org/ Accessed 22 Oct 2019
Measles Resurgence 1989 – 1991
• >55,000 cases compared to annual averages of 3,000 cases 1980-1988
• 123 deaths
• >11,000 hospitalizations
• Two groups of cases
– unvaccinated preschoolers
– vaccinated older children including college students
From: Katz S and the National Vaccine Advisory Committee. JAMA 1991; 266: 1547-1552
The Measles White PaperNVAC – 1991†
Main contributors to measles
1. Primary cause of measles resurgence was failure to vaccinate young preschool children on time
2. Opportunities for vaccination were missed in physician’s offices and clinics as well as public health programs such as,
• Department of Agriculture’s Supplemental Nutrition Program for Women, Infants and Children (WIC)
3. Children were referred out of private practices to public clinics because they could not afford the cost of vaccines
† National Vaccine Advisory Committee, JAMA 1991; 266:1547-1552
The Measles White PaperNVAC – 1991†
Selected Recommendations - I
1. Provide funds through 317 program to enhance immunization delivery infrastructure
2. Eliminate by legislation, if necessary, underinsurance
3. Develop immunization coalitions at state and community level
4. Issue standards of immunization practices
† National Vaccine Advisory Committee, JAMA 1991; 266:1547-1552
The Measles White PaperNVAC – 1991†
Selected Recommendations - II
5. Develop coordinated interagency plan to assure clients served are immunized (e.g., WIC)
6. Government should reach out to medical societies to help achieve high coverage in patients served
7. Measure immunization coverage – explore ways to do it at state and local level
8. Support research on health services and measles
† National Vaccine Advisory Committee, JAMA 1991; 266:1547-1552
The Childhood Immunization Initiative (CII)
• Achieve 90% coverage
• Implement Immunization Action Plan
• Implement National Immunization Survey
• Disease elimination goals
• Fix vaccine financing system
Vaccine FinancingEstablishment of the Vaccines for Children Program
• Cost established as barrier in private physician’s offices because of uninsuranceand underinsurance
• Multiple groups supported universal government purchase of vaccines to remove cost as a barrier
• Universal purchase opposed by others because of large expenditure of Federal funds and monopsony purchase could be disincentive to R & D
• Compromise – Vaccines for Children Program
Source: Benefits from Immunization during the Vaccines for Children Program Era — United States, 1994-2013 Accessed 22 Oct 2019
Key Features of Vaccines for Children Program
• Entitlement
• Covered 54% of children aged 0-18 years, in 2017, based on the CDC Population Estimate Survey
• Eligibility
• Uninsured, Medicaid, Alaskan Natives, American Indians
• Underinsured at FQHC only
• ACIP recommendations lead to automatic funding
• Supports public-private partnership where health departments provide vaccine to private physicians and have ability to work with providers to enhance performance
Estimated Vaccination Coverage of 4:3:1:3:3 Vaccine Series Among Children Aged 19-35 months
National Immunization Survey – ChildUnited States, January 2017 – December 2017
https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/data-reports/5-series/reports/2017.html Accessed 22 Oct 2019
Reported Measles Incidence, United States, 1950-2001
0.01
0.1
1
10
100
1000
50 55 60 65 70 75 80 85 90 95 2000
Case
s/100,0
00
po
p.
Year
Vaccinelicensed
One dose school
immunization laws started in all states
Second dose strategy
and school laws
Improved first dose preschool coverage
Figure 2
From: Hinman AR et al. JID 2004; 189 (Suppl 1): S17-S22
Measles Cases, United States, 1962 - October 2019*
*data through 3 Oct 2019
0
100,000
200,000
300,000
400,000
500,000
600,000
1960 1970 1980 1990 2000 2010
Nu
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Vaccine
Licensed
1989
2nd Dose
Recommended
2000
Elimination
Declared
0
5,000
10,000
15,000
20,000
25,000
30,000
1985 1990 1995 2000 2005 2010 2015
1993
Vaccines for
Children
Program
2014-2015
Measles
outbreaks
2019
Measles
resurgence
2019
https://www.cdc.gov/measles/cases-outbreaks.htmlAccessed 22 Oct 2019
What was Diagonal about Measles Elimination in the US?
1. School Mandates – impacted other vaccines
2. Immunization Financing – impacted all vaccines
3. National Immunization Survey – measured coverage of all vaccines
4. Need for constant source of immunization funds
US Experience with Focus on Measles & Building the Overall System
• Led to the enactment and enforcement of school and licensed day care immunization mandates covering all vaccines, not just measles
• Led to financing system to remove cost as a barrier for all childhood vaccines
• Led to a National Immunization Survey measuring immunization coverage of all vaccines for preschool children
• Led to two Presidential Initiatives
Measles Elimination –Lessons Learned
• Strong Scientific Base – vaccine science, epidemiology, health services research
• Limited number of measurable goals
• Compare and contrast good and poor performers –accountability
• Develop key partnerships to help build political base
• Focus not only on vertical measles elimination but also building the system
Thank you
Announcements
#AIM2019
• Sign up for dine-arounds• Wear your badge• Visit exhibits and get your passport stamped• Complete the conference evaluation
at www.surveymonkey.com/r/2019AIMconference
Announcements
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• Attend a breakout session• New location: Grand Ballroom
BREAKOUT SESSION LOCATION
From Survivor to Strategic Leader: Creating a
Meaningful Strategic Plan
Choctaw Room
Grand Ballroom
Note: This session will only be offered once
Managing Up: Building a Great Working
Relationship With Your Boss
Regal Suite
Leading Through Turmoil Madewood/ Oak Alley
Room
BREAKOUT SESSION LOCATION
Five Relationship Building Steps That Will Change Your Life
Choctaw Room
Grand BallroomNote: This session will only be offered once
Managing Up: Building a Great Working Relationship With Your Boss
Regal Suite
Leading Through Turmoil Madewood/ Oak Alley Room
TUESDAY: WEDNESDAY: