Public Health Program Plan: H1N1, DTaP, and HIV in LA

Introduction: H1N1 and the Importance of Immunization

Influenza A H1N1 was first detected in the United States in April 2009. Its first widely reported cases came from Mexico and Canada, and the virus spread to other parts of the world primarily through international travelers. Within weeks, thousands more became sick and hundreds died. The Centers for Disease Control and Prevention (CDC) advised the public that Influenza A H1N1 is contagious and spreads from human to human. Health agencies around the world responded by addressing its prevention and control. Nevertheless, this new threat to public health required concrete and systematic steps to contain it.

Influenza A H1N1, while by far the most widely known type of flu at the time, was in fact a new strain of influenza. Each year, seasonal influenza strains are addressed through vaccines that most commonly come in the form of an injection or a nasal spray. These vaccines are developed on a yearly basis, and everyone is encouraged to receive them — especially those in high-risk groups such as children under 5 years old, adults aged 65 and older, pregnant women, and individuals with chronic medical conditions.

Immunization is one of the most effective means of preventing disease. Governments, health agencies, and healthcare practitioners all advocate for vaccination to ensure a healthy population. Immunizations are administered in one or more doses, beginning in infancy and continuing until the full immunization schedule is complete.

The National Immunization goal is to achieve a vaccine coverage level of 90% for preschool-aged children and 90% for teenagers. The National Immunization Survey monitors progress toward these goals, and Los Angeles County (LAC) is included in this monitoring effort.

As of 2008, Los Angeles County had a population of 9,519,338. Of these, 737,631 — approximately 8% — were children under the age of 5.

Trends reported by the National Immunization Survey show that LAC, beginning in 1997, experienced occasional minor declines but generally maintained standard vaccination coverage. MMR, PCV, Hib, Varicella, and Polio vaccines all reached coverage rates above 90%. Only Hepatitis B (Hep B) and DTaP/DTP fell from their 2006 rates. Despite Hep B's rate decline, it remained at 93% coverage. Unfortunately, DTaP/DTP was the only vaccine that remained consistently below the standard 90% coverage rate throughout the entire ten-year period reviewed.

According to the same survey, estimated vaccination coverage data by age revealed a troubling pattern: "the increase in DTaP/DTP coverage levels from 66% at 7 months to 90% at 13 months implies a delay in children receiving the third dose of vaccine. Similarly, the increase from 19 months to 24 months implies that children are also late in receiving their fourth dose of DTaP/DTP vaccine."

DTaP/DTP Vaccination Coverage in Los Angeles County

To address this sub-standard coverage, a logic model plan is proposed below to help increase DTaP/DTP performance among children in Los Angeles County in the coming years.

Section I: Increasing DTaP/DTP Vaccination Coverage in Los Angeles County

The logic model identifies two primary assessment findings: delays in children receiving their third and fourth doses of DTaP/DTP, and an overall low DTaP/DTP coverage level. Three main interventions are proposed.

Intervention 1: Review of Health Providers Administering DTaP/DTP Vaccinations

This intervention involves consultation meetings with healthcare providers, facilitated by the Public Health Team and supported by presentation materials showing DTaP/DTP statistics. The activities will produce records of health providers' views on the vaccine and documented reasons for delays in children receiving it. The expected outcomes include information usable in an Information, Education, and Communication (IEC) campaign, as well as the formation of a coalition among health providers advocating for timely administration of the vaccine to the target group.

Intervention 2: Assessment of Reasons for Delay in Children's Receipt of DTaP/DTP Vaccines

Logic Model Plan to Increase DTaP/DTP Coverage

This intervention uses self-administered questionnaires completed by parents, supported by information officers and volunteers. A Survey on Knowledge, Attitudes, Perceptions, and Practices (KAPP) of parents toward DTaP/DTP vaccination will be conducted. Outputs will include specified reasons for vaccination delays. Expected outcomes are that the Public Health Department will be able to identify parental misinformation or misconceptions about the vaccine and will be equipped to design a targeted IEC/BCC (Behavior Change Communication) campaign addressing prevailing practices and perceptions.

Intervention 3: Information, Education, and Communication (IEC) Campaign

Using DTaP/DTP informational fliers, brochures, and posters, along with resource persons, information officers, volunteers, and provision of free meals and transportation allowances for outreach workers, this campaign will involve:

Expected outputs include a better-informed public about the vaccine and the diseases it prevents, as well as corrected misconceptions or misunderstandings. The anticipated outcomes are that parents will ensure their children receive DTaP/DTP as scheduled, facilitated through peer-to-peer approaches and support group engagement.

The first suggested intervention is to conduct a KAPP survey to establish the following: (1) data on why DTaP/DTP is the only vaccine performing below standard among all others; (2) an assessed level of knowledge and understanding among parents about Diphtheria, Tetanus, and Pertussis and their vaccine; and (3) identified misunderstandings and misconceptions among parents about the disease and the vaccine.

From the data gathered, an IEC campaign will be implemented. Brochures and fliers will specifically address the misconceptions or misinformation prevalent in the population about the disease and the vaccine. Posters will provide correct information, vaccination schedules, and names of clinics or health facilities offering the DTaP/DTP vaccine. Forums, symposiums, and meetings will be conducted in public offices, town halls, and other county social venues to further promote accurate information and address inquiries or concerns that may not be adequately handled during distribution of printed materials. Peer-to-peer communication and the formation of parent support groups will also be pursued to ensure that parents of children due for vaccination are encouraged and supported as needed.

With the implementation, continuous monitoring, and evaluation of the above plan, it is hoped that Los Angeles County's DTaP/DTP coverage will increase in the coming months and that the population will be better protected from the deadly diseases that this vaccine addresses.