March 29, 2022
David Kim, M.D.
Office of Infectious Disease and HIV/AIDS Policy
Department of Health and Human Services
200 Independence Ave. SW
Washington, DC 20201
RE: Vaccines Federal Implementation Plan Public Comment
Dear Dr. Kim:
As participants in the Adult Vaccine Access Coalition (AVAC), we appreciate the opportunity to comment on the Office of Infectious Disease and HIV/AIDS Policy (OIDP) Request for Information (RFI) on the Vaccines Federal Implementation Plan (VFIP). The Vaccines National Strategic Plan (VNSP) presents an important framework of goals, objectives, and recommended vaccine strategies across the lifespan that will guide priority actions for the period 2021–2025. The implementation plan provides important markers to ensure the goals laid out in the VNSP will be measured and achieved.
AVAC consists of over 70 organizational leaders in health and public health that are committed to addressing the range of barriers to adult immunization and to raising awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions that will strengthen and enhance access to adult immunization across the health care system. Our priorities and objectives are driven by a consensus process with the goal of enabling the range of stakeholders to have a voice in the effort to improve access to and utilization of adult immunizations.
We appreciate that the VFIP continues the broad perspective of the NVSP on the entire vaccine enterprise, including the Department of Health and Human Services (HHS) move to adopt vaccine strategies across the lifecourse. The VFIP comes at a critical time as the COVID-19 pandemic has been a stark reminder of the cornerstone role immunizations play in disease prevention, response, and recovery efforts. Vaccines have a demonstrated record of success as a cost-effective means of reducing disease burden and saving lives, particularly among pediatric and older adult populations. Unfortunately, even before the pandemic, access to vaccines was not equal across a person’s lifespan. Indeed, adult vaccination coverage has lagged below federal health objective targets for most routinely recommended vaccines: influenza, pneumococcal, tetanus, hepatitis B, herpes zoster, and HPV. Millions of adults suffer from vaccine-preventable diseases each year, causing them to miss work and leaving some unable to care for those who depend on them. On top of the already low rates, an estimated 37.1 million doses of recommended vaccines were missed during the pandemic.1 Avoidable illness costs individuals, families, communities, and our nation in numerous ways – not only in terms of lives lost, a deterioration in quality of life and increased disability, but also in terms of billions of direct and indirect costs to individuals, families, and our health care system. The VFIP lays out a comprehensive roadmap to achieve improved access to and utilization of vaccines, especially through the reduction of technological, logistical, geographic, socio-economic, and financial barriers to the full complement of ACIP-recommended adult immunizations.
Below we would like to offer a few overall perspectives and then provide specific focus on implementing goals 3 and 4, which fall most centrally as part of the work of our coalition.
Goal Specific Comments:
The objectives and strategies laid out in Goals 3 and 4 should be viewed and pursued in tandem, with close coordination among leads and support staff. Increasing knowledge of and confidence in recommended vaccines will help to increase community demand for immunizations and will be key to implementation success. The third goal highlights a key area where greater attention and concerted effort is desperately needed in the adult population. Education and awareness of the importance of immunizations should be intricately linked with efforts to improve access. While considerable progress has been made towards providing accurate, timely, and transparent information about COVID-19 vaccines through varied communications and partnership efforts, additional tools are needed to disseminate information about other recommended vaccines—including publication of evidence-based recommendations, use of mass media and new media, provider education and training, and support of non-federal stakeholder partners. These tools are essential to educating and increasing community demand for adult immunizations.
Additionally, the VFIP has limited goals for assessing adult immunization status. Despite broad recommendations for more than ten vaccines across the entire adult age range and for specific sub-populations, the VFIP has only four goals, one on immunization information systems, two on pneumococcal (high risk and 65+) and two on influenza (all adults and pregnant persons). Consideration should be given to additional measures, even in a developmental manner, to better capture and track the full range of recommended vaccines across the lifecourse.
Goal 3: Increase knowledge of and confidence in routinely recommended vaccines
3.1.1, 3.1.2, 3.1.3. AVAC recommends additional presence of the Centers for Medicare and Medicaid Services (CMS) to provide additional leadership and support for Goal 3. CMS has a tremendous reach to millions of beneficiaries in Medicare and Medicaid and will be an essential partner in disseminating immunization information to providers and beneficiaries. Under strategy 3.1.1, CMS should play a lead role in the following action item. We would also request that older adults be listed in the group of stakeholders (see bolded language below).
“Develop and disseminate regularly updated communication products (e.g., vaccine and vaccine safety updates and health equity–centered communication strategies for health care providers; fact sheets and other educational materials on vaccines, including those that counter mis- and dis-information) in multiple languages and media outlets to stakeholders, including Veterans, active-duty military personnel, older adults, persons with disabilities, and non-English speaker.”
Additionally, CMS should also play a lead role in the last two action items under Strategy 3.1.1 by encouraging providers across health care settings to report immunization records and incentivizing the adoption of the National Vaccine Advisory Committee Standards for Adult Immunization Practice.2
3.2.1. Increase provider capacity to promote knowledge of the benefits of immunization and increased vaccine acceptance by the public. This objective will be most impactful if barriers to access have also been effectively addressed. It appears 3.21 was not prioritized for a lead activity in the FVIP. AVAC would urge OIDP, CMS and Health Resources and Services Administration (HRSA) jointly lead the coordination and dissemination of information to the range of provider stakeholder organizations responsible for developing medical education curricula and standards. In addition to leveraging the direct lines of communication to their patients, healthcare professionals (HCPs) are trusted sources of information on how beneficiaries can safely receive preventative care. AVAC recognizes the importance of educating and informing HCPs at every stage of their education on the latest vaccine information, to ensure they are well informed, have confidence, and can make a strong recommendation to patients.
3.2.3 Scale up implementation of best practices among health care providers to effectively promote vaccine confidence and vaccination uptake. This goal captures the broad and critical need to promote vaccine confidence and increase vaccine uptake. This specifically calls out evidence-based counseling and technical assistance for health centers and in underserved communities. Although these are all critical populations with high unmet needs, there should be additional actions to target childhood and adult vaccinations across the entire population.
3.3.2. Educate legislators, executive officers, and policymakers in jurisdictions on policies that increase vaccine use. The SAVE Lives Act is only one example of federal legislation to increase vaccine use. Section 3.3.2 should prioritize developing an “all of government” strategy to inform federal vaccine policy development overall. These relationships will go a long way towards demonstrating that the federal government is prioritizing all aspects of immunization policy. There is also a great need for key decision-makers to have research data as well as easy-to-understand and use information on vaccine benefits and risks, economics, and general attitudes towards adult vaccines.
3.4.1. Reduce barriers to data sharing between public health and the community (e.g., schools) to identify under-vaccinated populations. AVAC would encourage OIDP to expand upon its action items under this strategy to include greater emphasis on data collection in addition to reporting and sharing. In addition to challenges in data sharing between public health and communities, gaps in communication between public health, third party payers, and key decision- and policy-makers also persist. AVAC would also recommend the action items under this section of the VFIP include ONC, ASPR, IHS, VA and DOD as supporting partners to assist with managing, strengthening, and maintaining data standards and data sharing that help leverage coverage data to identify socially vulnerable communities.
3.4.3. Further develop, implement, and evaluate metrics to better understand vaccine confidence by age, race, ethnicity, disability, geography, education, and socioeconomic status over time. Special attention must be paid to advancing strategic, evidence-based metrics that measure whether activities are culturally appropriate and reflect the health literacy, language proficiency, and functional and access needs of specific target populations. AVAC therefore recommends that CDC and CMS lead this strategy with strategic support from the HHS and CMS Offices of Minority Health as partners on this strategy.
3.4.4. Engage trusted community members and organizations (e.g., faith-based leaders) within targeted communities to develop effective culturally and linguistically appropriate messages and strategies in those communities. We know that the best messengers within communities experiencing health disparities are the organizations and partners they already trust. Therefore, vaccination education campaigns must rely upon trusted local community leaders to extend health care messages to areas where people are least likely to be reached by traditional health care and where there are known pockets of vaccine hesitancy. It is vital that targeted resources are dedicated on an ongoing basis to enable local leaders to test and tailor proactive messages, while countering mis-and disinformation as well as anti-vaccination sentiments that may infiltrate communities. We recommend that additional actions and lead partners be added to 3.4.4, such as HRSA and the HHS Office of Minority Health, to make sure this important work happens in low access areas across the country.
Goal 4: Increase access to and use of all routinely recommended vaccines
4.1.1. Removing barriers to and incentivizing vaccination in a variety of settings will improve access to recommended vaccines, including in primary care practices, pharmacies, obstetrics-gynecology practices, other specialty health care settings, and non–health care settings such as schools, workplaces, places of worship, and community centers. AVAC recommends additional participation by CMS to help facilitate a diversity of vaccination settings. CMS has an essential role in helping to expand the number of immunizing providers, linking vaccination records, and promoting patient assessments. We urge CMS to serve as a lead partner under all the actions for this strategy.
4.2.3. Increase use of data by public health departments and health care systems to identify and address disparities in vaccination rates in their jurisdictions and patient populations. Efforts to identify and address disparities will only be meaningful if consistent and reliable data is being collected and reported. At present, there is a great deal of variability in data elements being collected at an immunization encounter and the immediate needs for modernization of information technology platforms and software systems are also quite great. AVAC recommends including ONC as a lead partner with CDC and the VA to help improve systems relied upon to gather vaccination rates among sub-populations and to assist public health departments in their efforts to retrieve vaccination data from their Immunization Information System (IIS). We also recommend an additional action be included that is aimed at achieving better quality measurement and data collection.
4.3.1. Improve IIS reporting, its interoperability across jurisdictions, and bidirectional communication with other health data systems. AVAC agrees that the IIS must be improved and enhanced to meet new and changing data standards and access to IIS must be expanded to more providers and settings across the health care system. This expansion should be accompanied by education and technical assistance to facilitate reporting to the IIS. The immunization data collected across settings must also be efficiently and effectively shared with physician practices. As an additional action, AVAC recommends that IIS be fully integrated as a core pillar in the CDC Public Health Data Modernization Initiative and accompanying strategic implementation plan.3
4.3.3. Increase data analytics capacity to conduct disease surveillance and increase enrollment of adult health care providers in immunization information systems. AVAC encourages HHS in their annual budget to Congress to support investments in data analytics capacity to conduct disease surveillance and increase enrollment of adult health care providers in immunization information systems. AVAC recommends that the action accompanying this strategy be broadened to focus on reducing barriers to provider enrollment in the IIS and CMS be added as a supporting partner.
4.4.5. Remove system barriers to implementation of innovative services such as the use of mobile vans and telehealth and support adequate reimbursement for these services. AVAC recommends that community vaccination clinics be leveraged for the administration of recommended routine vaccinations beyond the COVID-19 pandemic to help with catch up doses that have been missed over the past two years. Reporting to the IIS and sharing immunization records across providers should be included as part of the implementation of these innovative solutions to improve care continuity.
4.5.2. Promote adequate payments for vaccines and vaccinations by public and private health plans to incentivize providers to vaccinate, thereby promoting access. AVAC urges OIDP to include an action item for CMS to lead that is centered on building access through public plans based on the vaccine administration payment policy included in the calendar year 2022 Medicare physician fee schedule. AVAC also encourages the addition of an action item led by CMS to issue guidance to state Medicaid directors aimed at providing coverage and adequate provider payment for all routinely recommended vaccines.
- AVAC members are thrilled to see the re-establishment of the Federal Interagency Vaccine Work Group (IVWG) during the creation of the NVSP in 2019. We are pleased members of the IVWG will continue this collaboration and have taken on distinct leadership responsibilities for the implementation of plan. To fully achieve metrics of success, we recommend that one member of the IVWG be chosen as lead for each strategy, with others listed as support for the action. The challenge with more than one lead is that it may not be clear who is on point for following through and achieving each action.
- We appreciate the VFIP prioritizing activities, indicators, and targets to achieve success. However, to fully achieve the elements of the plan, it must also provide budget estimates overall, and for lead partners specifically, so they can account for funds needed to undertake this work.
- The VFIP rightly lays out next steps, including reporting on the progress of activities within the plan. However, AVAC would recommend the inclusion of clear estimates and expectations on timelines between annual reporting cycles. Additionally, while the VFIP notes the first report is expected mid-2023, it does not offer a continued timeline for reporting between 2023 and 2025. We recommend an annual report be provided thereafter.
- AVAC appreciates that the VFIP recognizes the essential partnership between the federal government, immunization partners, and trusted community leaders and organizations. To achieve success, the IVWG members must continue to be proactive, clear, consistent, and highly visible in their communications to keep the public informed of vaccine development, safety processes, and approval and recommendation criteria.
Again, thank you for the opportunity to provide comments on the federal governments’ implementation plan to strengthen and improve the nation’s response to vaccine preventable disease and strategies to address infectious disease through vaccination. Please contact the AVAC Coalition Managers Abby Bownas (firstname.lastname@example.org) or Lisa Foster (email@example.com) if you would like more information about our views, or the work of AVAC.
Alliance for Aging Research
American Academy of Family Physicians
American Immunization Registry Association (AIRA)
American Lung Association
American Public Health Association
Biotechnology Innovation Organization (BIO)
Emily Stillman Foundation
Families Fighting Flu
Hep B United
Hepatitis B Foundation
Infectious Diseases Society of America
Kimberly Coffey Foundation
March of Dimes
Meningitis B Action Project
Merck & Co Inc.
National Association of Nutrition and Aging Services Programs (NANASP)
National Foundation for Infectious Diseases
National Viral Hepatitis Roundtable
The AIDS Institute
The Gerontological Society of America
Trust for America’s Health
WomenHeart: The National Coalition for Women with Heart Disease