Problem Addressed

• Significant risk of pertussis in infants: In 2007, infants faced a 19 times higher risk of pertussis than did the typical American, with incidence rates of 69.99 cases per 100,000 infants (compared with 3.62 per 100,000 in the general population).¹
• Particularly among Hispanic infants: For unknown reasons, pertussis incidence and mortality are higher in infants of Hispanic ethnicity. In 2007, for example, Hispanic infants accounted for 70 percent of pertussis-related deaths.¹
• Unvaccinated household members as main source of infection: More than three-fourths of affected infants acquire the infection from an unvaccinated household contact, including 33 percent from their mother and 16 percent from their father.¹
• Unrealized potential of pertussis vaccination: A targeted vaccination strategy for pertussis has not been widely implemented, largely because of a lack of necessary infrastructure, a need for education, reimbursement issues, and logistical barriers.¹

Description of the Innovative Activity

• Raising awareness through educational materials: Program posters and print materials placed in antenatal and postnatal areas of the hospital inform mothers and family members about the need for all household members to be vaccinated against pertussis as protection for the newborn. Each mother also receives a family information packet, written in Spanish and English, that includes a description of the cocooning program, information about the hospital-based clinic for free vaccinations (see last bullet), a brochure about pertussis developed by the Texas Department of State Health Services, and a flyer listing community clinics where family members can receive free or low-cost vaccinations.
• Identifying those in regular contact with infant: Nurses and other staff (with the aid of translators, when necessary) speak to mothers about the vaccine, including the need to vaccinate those who will interact regularly with the infant at home. They ask mothers to identify family members (e.g., siblings, grandparents, aunts, uncles) and other caregivers who will be in contact with the infant, and indicate their willingness to speak to them about being vaccinated if they come to the hospital. They also remind mothers about the hospital-based clinic that can provide free vaccinations to these individuals.
• Vaccinating mother before discharge (per standing order): Per Centers for Disease Control and Prevention (CDC) guidelines, physicians working in obstetrics and maternity care add pertussis vaccination to the hospital’s preprinted standing orders for all women who have given birth. With informed consent, trained nurses vaccinate them before they leave the hospital (unless the vaccine is contraindicated for some reason).
• Vaccinating others through free clinic: Two trained, bilingual nurses (one working full-time, one part-time) staff a clinic in the hospital, full time during the week and on weekends. The nurse reiterates the need for the vaccination to those who visit the clinic and provides the vaccination free of charge to family members and others who will be in regular contact with the newborn. Clinic nurses also distribute information about community programs that offer other free or low-cost vaccinations and services.

References/Related Articles

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Innovator Disclosures

Results

• High vaccination rate for mothers: In Phase 1, 75 percent of women (8,334 of 11,174) who had given birth received tetanus, diphtheria, pertussis (Tdap) vaccine. During Phase 2 (June 2009 through December 31, 2010), 84 percent of women (6,157 of 7,312) were vaccinated; another 9 percent (673) had previously received Tdap vaccine, most from this program after the birth of a prior baby. (This increase was due, in large part, to the elimination of a requirement for a minimum 2-year interval since receipt of a tetanus-containing vaccine, before receiving the pertussis vaccine.) Before launching the program, the hospital did not routinely vaccinate these women. Current immunization rates exceed 93 percent.
• High vaccination rate for others: During Phase 2, 4,323 family members and caregivers received vaccinations. Prior to implementation of this program, it is unlikely that these individuals knew they needed to be vaccinated.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

Key steps included the following:

• Designing program in two phases: In response to the CDC’s recommendation and the presence of a large, underserved Hispanic population at Ben Taub, Dr. Healy and her colleagues designed the two-phased program, with the first phase focused on vaccinating women who had given birth and the second focused on family members and other caregivers.
• Obtaining program support and input from hospital staff: Based on the initial program design, Dr. Healy and her colleagues met with the chief of staff at Ben Taub to discuss the program’s feasibility and obtain support for it.
• Developing implementation plan: The program team held numerous meetings with key individuals to develop a comprehensive implementation plan. Participants included the hospital’s chief of staff and director of medicine, along with department chairs and representatives from obstetrics, pediatrics, neonatal care, family practice, nursing, and pharmacy services.
• Obtaining seed funding and donated vaccine: The program team submitted a successful proposal to the Baylor Methodist Community Health Fund, which awards grants for programs that provide heath care to underserved communities. Dr. Healy also contacted representatives of Sanofi Pasteur, the only manufacturer of pertussis vaccine at the time the program was implemented, who agreed to donate pertussis vaccine doses. The team worked with the head of the Ben Taub pharmacy to arrange for storage.
• Educating staff: Program staff educated relevant hospital-based providers (including obstetricians, family practitioners, midwives, nursing personnel, and translators) during regular grand rounds and in small group sessions. During these sessions, staff learned about their role in the program, including how to explain its importance and benefits to mothers and family members.
• Establishing clinic for other caregivers: The hospital allocated separate space for a clinic to provide vaccines to family members and other caregivers. The Center for Vaccine Awareness and Research hired bilingual nurses (fluent in both English and Spanish) to staff the clinic. (Ben Taub policy did not allow hospital staff to provide services to those who are not hospital patients.)

Resources Used and Skills Needed

• Staffing: The program has a part-time director who spent 30 to 50 percent of her time on the program during the 18-month initial development and startup phase, and who now spends 20 to 25 percent of her time on program-related activities. The program also has a part-time research associate (30 percent); who consults on operating issues, maintains the program database, and evaluates outcomes; and an administrator (10 percent). Another faculty member from Baylor College of Medicine donates approximately 2 hours a week to support program-related research. Hospital staff provide program-related services to mothers as part of their regular duties. The hospital-based clinic serving family members and other caregivers is open 8 hours a day during the week and on weekends; it is staffed by one full-time and one part-time nurse.
• Costs: Operating costs consist primarily of the salary and benefits for nurses who staff the clinic, which total roughly $111,000 a year. This cost excludes time spent by other individuals on the program (as outlined above) and vaccine-related costs (because to date the vaccine has been donated). At current market rates, each dose would cost $38.83 if purchased, before overhead and administrative costs are added.

Funding Sources

• Baylor Methodist Community Health Fund ($100,000 in 2007, $75,000 in 2009, and $110,859 in 2011)
• Children’s Health Fund of the Harris County Hospital District Foundation ($35,842)
• Sanofi Pasteur (in-kind donations of vaccine and a research grant to track long-term outcomes related to pertussis incidence at the hospital).

Tools and Other Resources

Getting Started with This Innovation

• Review hospital and state immunization policies: State laws and policies vary on who can provide vaccines and whether hospital staff can immunize nonpatients. Would-be adopters need to consider such laws and policies during the early stages of program design.
• Identify champions to secure buy-in: The program cannot succeed without buy-in at all levels of the organization, including physician and hospital leaders and frontline provider staff. Program champions can help to win such support by touting the program's benefits to colleagues throughout the hospital.
• Identify funding sources: Ongoing funding or in-kind donations will likely be needed to fund program operations, including the cost of vaccines and the nurses to staff the clinic.
• Include translators in training: Hospital translators need to understand all aspects of the program, as they will be responsible for explaining it to patients and others with limited English proficiency.
• Tailor educational materials to participant needs: Consider the reading level and educational background of the target audience when developing program-related educational materials. Materials should offer a straightforward reason for the program, outline the specific action to be taken (vaccination), and clearly explain how to take that action.
• Maintain flexible clinic hours: At Ben Taub, most family and friends come late in the day (often after work or school) or on weekends to visit patients. Consequently, program developers established clinic hours that cater to these visiting patterns. Would-be adopters will need to analyze their own visiting patterns and schedule program services accordingly.

Sustaining This Innovation

• Provide ongoing training: To address turnover and other internal staffing changes, provide inservice training about the program on a quarterly basis.
• Stay abreast of new standards: Monitor CDC recommendations related to standards for pertussis immunizations and adapt the program to any changes.
• Track pertussis infections among infants: Implement a system for tracking cases of pertussis infection among infants born to hospital and clinic patients. Such information will allow leaders to determine the program's impact on patient outcomes (rather than limiting evaluation to process measures, such as vaccination rates).