I want to do some state updates as well as look at some immunization coverage levels at the local level.  Our immunization coverage levels for infants was at its lowest in the last 10 years in regards to our immunizations for infants. Our adolescent rates are pretty good except for HPV and our flu adolescent rates are not good at all. So I kind of want to go over the different immunizations that we have, the different surveys that we have. I also want to go over the VFC program. We have lots of challenges throughout the state, we have a huge state, and when you look at the biggest challenge I think we have in the VFC program is the lack of movement as far as getting providers recruited into the program. So it has been a major challenge, even when I was in San Antonio and when I moved up to the CDC and worked in Austin, I can tell you today that we have no more providers in the VFC program than we had 13 years ago, and that's a big challenge for us. We're running around, we have all these new immunizations to provide, yet we don't have as many providers in the public health infrastructure or the safety net that we like to look at as being has certainly been reduced greatly in all the different cities. So I kind of want to go into that a little bit as well. It's going to go fast paced. I know you guys don't have the slides and I apologize for that. A lot of this data just came out last week and this thing was done about three hours ago. So we're going to kind of go through this and I'll make sure I get this to the collaborative and make sure they can pass it on to you guys. So let me show our agenda for today. We look at going over the Texas population estimates. I want to kind of give you guys a snapshot of what it looks like, the public health program, who's eligible for the program in the state of Texas. I'm going to go over the VFC program and review. Can I get a show of hands of VFC providers and role VFC providers in San Antonio? Okay, so if there's any other clinics that are here or provider sites I'd like for you to really consider joining the VFC program as well. So I'm going to kind of go over an overview of the VFC program. I know some of the challenges you guys have as well. Some of them are directly resulted from the CDC. Looking at policies, looking at changing, you know, things about screening and eligibility and storage and handling. So I want to kind of give you some background as to why these things have come about. Influenza, you know, certainly influenza is very important. I want to kind of give you an update of where we are with influenza and flu vaccine availability for our VFC kids.  So we have a full agenda. A lot of slides coming through. And again, I'll make sure I get these for you guys. So sit back and don't worry about taking notes. We'll make sure that we get these out for you by the end of the week. So the goals of the Texas Department of State Health Services Immunization Unit certainly raise and sustain vaccine coverage levels for infants and children. Primary goal, looking at expanding immunization services and resources. And that's certainly a challenge when we have public health services reducing themselves, providers not enrolling in the program. We're not expanding our adolescent and adult programs. We're not getting additional sites. So that's certainly one of our big challenges, but something that we need to continue to look at. One thing that's good to say is that, you know, in in Texas, we support local health departments and we have continued to fund local health departments at least at the same level. It's one of the few programs that we haven't reduced in the last 15 years. So at least there is infrastructure support to help local health departments like San Antonio, you know, continue to move forward and work towards maybe not so much giving immunizations in clinics, but looking out there to get more providers enrolled, work towards getting the registry, more people in the registry, looking for cases of vaccine preventable diseases, doing immunization initiatives, focusing on adolescents and focusing on adults. So we do have a lot of resources still going into those areas. So when you look at immunizations, at least as one of the state's programs, it really hasn't been reduced at least at the local level from our perspective. Improved adolescent immunizations, coverage levels. You know, over the last 10 years, we've added three or four vaccines to the adolescent schedules. I'll kind of cover that a little bit, but it certainly has made it challenging. You know, Texas is really aggressive in regards to making vaccine requirements for Tdap and meningococcal. We do have flu as an adolescent vaccine. We have HPV as an adolescent vaccine. We have meningococcal B additional, three other additional adolescent vaccines that I want to kind of cover and tell you where we are in regards to those. Improved adult immunizations has been a major challenge for us. It's good to know, and I'll go into the adult safety net in a few minutes, but you know, what we have is one of the most expansive adult safety net programs in the country. So the state legislature as well as funds from the federal government and through the CDC has thrown about $10 billion annually into Texas to make sure that we could develop and have an expansive adult safety net program. And I want to kind of go over and let you know what is available in regards to those vaccines, who's eligible, kind of tell you how we're doing with that. And then again, reducing in just cases of vaccine preventable diseases. So those are our high-level goals up in Austin, the central office. You'd like to think that we don't live in the ivory tower, but we're not out there in the streets like you guys are doing vaccinations. But I think that we look at these goals as shared goals. These are all, these goals should be on your wall and every one of your clinic sites and each one of your healthcare organizations because it's only through accomplishing these goals that we're going to be successful in decreasing vaccine preventable diseases in the state of Texas. So I don't want to spend a lot of time on Texas population estimates, but I think it's important for us to identify who we serve in the state. There are a lot of busy numbers on the slide, but essentially what we're looking at is when you look at children to Texas, people don't understand that, we have over 1,100 babies born every day in Texas. So 11, and I always talk about that, when we go home on Friday, we come back on Monday, there's 2,500 new babies waiting for us. So I mean, it's a huge challenge in San Antonio, it's the same way. People forget that San Antonio is one of the largest cities in the US and we have the same birth rates that we have throughout the state in Texas. So we have huge challenges about the number of kids we have. So I put the numbers up here, it's kind of indotting and those are just kids zero through 18 years of age. So we're looking at almost eight million kids that we're working to protect against vaccine preventable diseases. I broke out the first five categories, so those are your VFC eligible kids. And when you look at it, you're talking about Medicaid, American Indians, Alaskan Natives, the uninsured and unfortunately Texas still leads the way or is one of the highest countries with uninsured kids without immunization coverage in the state. We have federally qualified health centers that carry their own as far as seeing VFC eligible kids and then we have delegated authority where we look at public health departments to help us with this. So when you look at those 7.9 million kids, over 55% of them are eligible for public health program financings for vaccines. That's significant, that's larger than most other states and it's not just larger than most other states, it's a lot of little kids, certainly born every day.  We continue to have all these kids coming, we have new vaccines, new challenges, new education. So just looking at half the kids in Texas alone qualify for assistance programs for vaccines. We do have CHIP as well. We have about 350,000 kids that are in CHIP and we have a really good partnership with the CHIP program in Texas. So all the kids that are in CHIP actually fall under the public health umbrella for vaccinations.  So it's a really good partnership for us and it's really helpful to keep the CHIP kids in the same medical homes that the VFC providers are in. Then you look at the insured population, about 40% is remaining. So everybody kind of goes, wow, those numbers are crazy, how are we ever gonna get to this? And that's why I bring up the next slide is when you really focus down and look at the kids under one. So when you look at the kids under one, you know, the eligibility is half the kids are almost 60% of the kids, but when you look at the babies who receive most of the immunizations in the age cohorts, over 71% of them fall into the VFC program. So the VFC program isn't successful, seven out of every 10 kids will not be appropriately vaccinated of the babies that are born in Texas. Those numbers are higher, again, one to two. Again, when you look at immunization schedules, most of your immunizations are given through the second year of life. You do have your four year olds and your adolescents, but when you're looking at 71% of the VFC kids and then 57% of the one to two year olds, you're looking at a major emphasis in vaccination of the babies in Texas fall into the public assistance programs of the VFC program, which is why it's so critically important for us to find more partners to both promote and educate as well as enroll in the VFC program to help us with this vaccination efforts. Again, now we have a really strong, this is another snapshot of this. So you're looking again at the different populations, insured is only 40%, Medicaid makes up another 40%, the uninsured, and that's the unfortunate part is that we're still struggling with uninsured children in Texas about not having vaccine insurance coverage. We did a little bit better in moving some of the uninsured into an insured status, whether they became part of CHIP or part of Medicaid, but overall, we were about 15, 16%, which was certainly highest in the country, we're about down to 11%, but when you talk 11%, you talk a million kids in Texas have no health insurance. So now you have to find a place for these kids to go and private providers generally aren't really jumping on board to be able to vaccinate a bunch of kids that don't have any health insurance. And I understand that because they have to maintain their practices, but what do we do when the safety net for seeing uninsured kids has dried up quite a bit as local health departments have lost a lot of their clinic sites, yet we still have a million kids, zero through 18 years of age who are uninsured. That's a major challenge for us at the same part with getting those uninsured kids into the registry. In the last 22 years, we've really built a federal BFC program that really helped serve the immunization needs, certainly in children's and infants and adolescents in the state of Texas throughout the United States. It distributes vaccines at no cost. Anyone who's working in the private sector knows what these vaccines cost, especially as adolescent vaccines these days. So all of that is removed as a risk to the private provider's office by participating in the vaccines for children's program. Again, one of the things that's important to remember about BFC is the eligibility is determined by the provider. We don't go and look and make sure these children are eligible, but it is important to make sure that we are serving eligible children by screening eligibility out as part of the beginning of the visit. So we do need to make sure they're unmedicated, uninsured, underinsured. We do need to make sure that the insured kids that come into our practices are using private stock vaccines, and that's one of the most important things that has changed in the last four years in regards to the CDC, is that we have to have mechanisms in place to screen eligibility out at every visit. You're certainly not gonna take financial risk for vaccines and give privately bought vaccines to BFC eligible kids and lose hundreds of dollars per child that comes in because you're not checking eligibility, and it's the same for the vaccines for children's program. These are some of the goals of the Federal Vaccine for Children's Program. Ordering vaccines in the appropriate quantities. We'll talk about that a little bit. Storing and handling of vaccines. So storing, storage of vaccines. Ordering of vaccines and screening eligibility are the three major components within the BFC program. And again, I don't wanna lecture you guys on the different parts of this. I just wanna let you know and be aware of the different parts and some of the challenges we're having within the BFC program. We've talked about recruiting additional sizes, one of our challenges. But we continue to strive and increase how our provider's doing by doing site visits. And we'll also cover that briefly in just a minute. So when you look at the number of providers in Texas, at its peak, we had about 3,500 providers. These are provider sites. Barrett County right now, it's about 177 active provider sites. When I was here, it was about 210. So we've lost out through nutrition, through providers retiring. Honestly, we've lost some providers because they were not able to manage the Vaccines for Children's program correctly. So we've had to disenroll some providers in that. So when you look at it over the last 10 to 15 years, we had about 3,600 roughly on an average. Now we're down about 300 providers. So the recruitment of vaccines for children's providers isn't working. And we need to start looking at trying to get our other private providers to help us partner and join where the BFC program can be successful so that we can make sure we can take care of this. 1,200 kids that are born a day in Texas. We do have an adult safety net site. I'll kind of go over that as well. We have 515 sites actively enrolled in the adult safety net program, but we do have some challenges with that. We do have a few pharmacies, not very many in Texas. The pharmacy laws in Texas don't really work out well in regards to running full immunization programs for kids, infants, and children. It's more targeted towards older adolescents and adults. But it's something we've always looked at trying to recruit additional pharmacists to help us serve adolescent needs of immunizations in Texas. So these are, you guys all sign these things if you're a vaccines for children's provider in regards to what your responsibilities are. So it adheres to the policies, programs, and procedures certainly having a vaccine provider oversight. This looks at vaccine ordering patterns. Really looks at trying to match up the doses that your individual clinics need versus the number of doses that you provide. So this is one of the problems that come up in regards to vaccine inventory is that we have a lot of provider sites in Texas who think that they need enough vaccines to cover 50 to 100 kids and they're seeing 10 to 15 kids. So what they're doing, providers are building up different inventories at large amounts and maintain those inventories each month even though their needs aren't there for those number of kids. So we have months of vaccines in different providers' offices which puts all those vaccines at risk. Also withholds those vaccines from other providers who need it. And the CDC doesn't really mess around with vaccine inventory. They're not giving us a lot of extras so that we can make sure providers have four and five months of inventory. So I'm gonna cover a little bit of that going down the road because we're kind of moving towards a change in regards to provider inventory for those VFC providers and those who joined the program. But it really comes down to maintaining inventory, screening eligibility and making sure those vaccines are viable through the storage handling procedures. We talk about the VFC provider profile. You guys fill this out every year. What we're looking at is for you to identify the number of kids that you serve, both public and private, so that we can help you identify what your vaccine needs to be for those different age groups. So each year you go through and you say, how many kids do I have under one? Well, we know what vaccines you need for a kid under one as do you. So you know you need three hepatitis Bs unless they got the birth dose. You need your three VTACs. When they become one, you need an MMR and a varicella. You need your pneumocauticals. You get vaccines. The rest of your childhood vaccines. So we're really trying to look at maximizing your vaccine needs on a two month basis. So the goal is, and when the CDC is looking at this, we want you to be able to reorder your vaccines at a month's time. So if you're looking at your inventory, we give you two months of inventory. It's kind of simplifying it, but we give you two months of inventory. You give those vaccines during a month.  And that's what we're moving towards. And this is a new process that the expectation has been out there for a long time. What we need to do is make sure and help providers get out of having four and five months of different inventory of products that they're not using so that they're not limited to the number of vaccines they have for the children they need to serve. So it's kind of, it's a little confusing, but it's something we want to go over. We really want to help you, help you identify your clinic needs so that we can take care of this vaccine overstocking as across the state. And I know that a lot of providers have the same issues with running out of vaccines. So this will fix that as well. I mean, if we can help you not run out of vaccines each month by building up a two-month inventory that we work against with a 30-day reorder point, I think it will help us make sure that we're not running out of vaccines and just trying to keep you guys caught up with what you need versus actually fixing what you should have. So a lot of that's done through the provider profile, helping you identify your kids every year that you're gonna serve and let us help you by setting what, you know, essentially looking at your doses administered. If you know what you gave last year and we've built in some room for growth, essentially we should be able to build what you need this year. And what happens, and I'm just gonna use one vaccine as an example is that, you know, we all use IPV and DTAP for our four-year-old doses that we give to our kids who are coming in four. So that's locking up those vaccines for that age group. So if we need more of DTAP and polio and it's locked up to our four-year-olds for our babies, we can't get it because we have so much inventory of a product that's restricted to four-year-olds. So what we're trying to do is try to figure out each provider what they need. And I think this is one of the integrity issues that we're gonna talk about as far as being in the VFC program and also work to help build out better inventories. So that's all coming down the road fairly quickly. I know back to school when there's a lot of issues about, hey, you don't know what I need each month and it fluctuates and we have back to school, we're gonna try to build all that in. So I just wanted to let you know that that's part of using the provider profile. It's part of building your vaccine stock levels as a provider site. So I needed to spend a few minutes going over that as far as building out, you know, these are the vaccines that you need and we need to help make sure that you're not out of vaccines, but also that you're not stocking four or five months of vaccines. Because if we do that again, we're gonna run out of vaccines again and the state is coming here. Additional program responsibilities, again, the recertification we've talked about, provider recruitment, we need so much help in this area. We're starting to partner with private industry to help us. You know, I don't think that we're really good at communicating with the private providers and telling them the benefits of being in the VFC program. So I think it's something that we need to work through our partnerships, through our collaboratives, through our coalitions to help get the message out about the VFC program. So that's something that we certainly need to look at for as well as ensuring consistency on how providers receive information and education from us to the providers, through the CDC, through us to the providers and from the different other stakeholders and partners that we have. As provider education is something we really need to continue to stress. It's not just provider education, it's parent education, public education across the board. So that's my 10 minutes on we're gonna be better in VFC, we're gonna maintain inventory and storage and we're gonna get to where we need to be. Now I wanna go into some brief vaccines for children's updates for you guys. So, beginning with flu. Flu is always kind of disappointing to me and when I look at the number of flu vaccines that we order and the number of children that are eligible for the flu vaccines in the state of Texas. So to make sure you all are paying attention, roughly how many kids in Texas are VFC eligible? Roughly. How many millions, how many millions? About 4.5 million children in Texas are VFC eligible through 18 years of age. When we ask for providers each year how many flu doses that they want to vaccinate these 4.5 million kids? And we ask them, we do a survey, we say, listen, flu vaccines out there, we have it available, how many doses do you think the providers want? It's right there, 1.6 million doses. So for a vaccine need for Texas to vaccinate all of our children with influenza vaccine, this is even counting the baby doses that babies need, the two-dose series, we're ordering at maximum 1.6 million doses for almost 5 million kids. And that number has not changed in five years. So it really goes back to looking at the commitment to provide and have that vaccines for flu being offered by providers. Flu vaccine runs almost 12 months a year now. We get it out and we got it out as early as August this year. Yet our own provider network is not ordering enough vaccine to vaccinate half the kids in Texas. So that's alarming.  I mean, flu season doesn't end. Vaccination needs to continue from the day you get flu vaccine until the day it expires, which is in June. We have plenty of flu vaccine. In fact, last year we had over 200,000 doses of flu vaccine never leave the shelf at CDC that we ordered for Texas providers. We over-ordered because we really want providers to jump up and start giving flu vaccines and flu vaccine is age-indicated for every single kid in Texas six months and older. So how are we gonna get to the point that where our providers are ordered, and this is all of our providers, public health, all the people you saw on VFC are gonna order vaccines to properly vaccinate our kids against influenza. We really jammed out, everybody wants it, they're screaming at us at where it is. Now those are the yells that we need in November, December, and January because any child who comes in up until really, almost up till the summertime gets a vaccine at any age, we just get a flu vaccine. And we never run out. I say that, we haven't had a shortage in a long time, but if you've used your flu vaccine in your pre-book, we can get you more. But the effort has to be there across the board to screen everyone who comes into the clinic for eligibility for the flu vaccine. And we'll order another million doses, but I can't just keep throwing them away every year. And to put 20% of our vaccine on a shelf at CDC that nobody ever orders in the state of Texas is alarming. And that's one of the things that we had to call about. And if we had vaccinated a lot of these children, we might be in a better situation where we are where we're not having so many infant and children deaths in Texas. Because there's a vaccine out there that we have available that is not being used. So it's just a warning.  We let you order more if you need it. We don't want you to run out and we still have two to 300,000 doses that don't have a home today for flu vaccines. So what are we gonna do about that? That we go through and every time somebody walks in, they're asked if they've had their flu vaccine this year. And then not only do that, because if we just wait for them to come in, we're never gonna reach half the adolescents. They don't have a clinic scheduled to visit this year. If they're not 12 and they come back to school when we didn't have flu vaccine, how are we gonna get 11 and 12 up to 18 years of age kids back into the private or public clinic's offices to get a flu vaccine? We can't just rely on, I sent a postcard to the ones who got it last year or I have a flu day that they can all come in for. It's not working and we have a lot of vaccines that's been thrown away because our flu program really isn't anywhere near where it needs to be. So I want to throw that out there as well. Penicill, we've talked about penicill, a lot of you guys use penicill. As you know, it's on allocation now and we remain on allocation. We're doing the best we can with that vaccine. It will probably remain on allocation throughout the rest of the year. Hit vaccine, GSK's new licensed vaccine is now available in the VFC program. Similar to ACTIB, you can use it in the same age groups and indication. MenB came out this year, January. Still kind of confused. ACIP is meeting in a couple of weeks to help us kind of work out some of the kinks with the meningococcal vaccine, meningococcal B vaccine. Two products, one from GSK and one from Visor. There was also some different recommendations that came out as far as dosing between the two products. So we're hoping for some clarity on that in the next two weeks when the ACIP meets again. One of them's a two-dose series. One of them's a three-dose series for VFC, but two-dose series for FDA. So hoping to get some clarity and further recommendations on that. When you look at HPV9 vaccine, there's only one that's out there now for both children and adults, the virus health product, which is good to replace the HPV2 and IV vaccine. And TwinRex, which we used to give 18-year-olds is the GSK vaccine combination A and B is no longer available except in our adult safety net program. So flu, I kind of gave you guys the right act on the flu. This is kind of the numbers in the process. We pre-booked this in March. So unfortunately, the CDC says, how much flu do you need? And I need to know in March. It doesn't make a lot of sense, but it's what it is. So we asked everybody what they need and we have a survey and we give them up to a month to answer it. And that's when the people said that they want 1.6 million doses. So that's what we ordered on behalf of them. But we really look at opening flu ordering for everybody, probably late November, early December. So even if you've used up all your allocation that you thought you might need, you can always get more flu vaccine from us during open ordering. I wanted to put the doses up here. Just make quick note that, as you guys know, the flu-miss vaccine was not available this year. A lot over half a million doses of flu-miss were ordered by Texas providers. So I want to make the assurances that we were able to switch those vaccines out for the majority of a standard B product and some of the GSK product. So the people who ordered flu-miss throughout the VSC program will get their vaccines that they needed. It will just be in a different product for this coming year. So again, I said 1.6 million doses were ordered by providers. Essentially the state took a risk and ordered another 320,000 doses to help us look at new providers that joined the program, as well as those of y'all who looked that you maybe underestimated what your flu vaccine needs were at the time, which replaced the pre-book. One of the things for the VSC providers in the room I wanted to make you aware of is that we allocate this vaccine every week. So every Monday, every dose that we get gets allocated to you guys. So what's important is to go in there and look at the EV and make sure that you check every Tuesday or Wednesday if you have any flu vaccines.  And it's important if you have the storage capabilities there that you pull those vaccines down and start using those vaccines. So when you look at our summary where we are here today, which is great when we're talking about 2,900 providers who are in flu vaccine, 99% of the providers in Texas have at least some flu vaccines on us. I think we forget that most of this product used to come mid to late October and November. Now we have more than half of our doses have already come into Texas that have been self distributed out. So I know there's some issues with I don't have enough or I'm not getting all my doses, but you're looking at generally most of the vaccine, at least half of the vaccine that we have all been distributed out to providers. And as it comes in, we don't know when it comes in, we'll make sure we turn it around and get it right out to you all. We've also about a third of the providers and fourth of the providers actually we've finished their vaccine border pre-beau borders this year already. I hope it's not finished. I hope those providers look at their vaccine, look at the number of people they're gonna vaccinate and project that they need more flu vaccine to get us into the flu season. They're just not looking to run a flu program for a couple of months in late 2016. So that's what I wanted to hit on in regards to kind of the VFC update. I want to go into the how we're doing. This is the report card session of our presentation. So the National Immunization Survey and everyone gets kind of worried. I get worried and my kid brings his report card home and we had it in you. Where's he at? I don't really worry about where he's at with the rest of his kids. I just want to worry about where he's at with where he is today. So the National Immunization Survey comes out once a year. It comes out, there's a National Immunization Survey for children and National Immunization Survey for teens focused on two different age groups, population-based and we're fortunate in Texas that we have a statewide rate. We have different cities that are also included as part. So San Antonio is one of them. San Antonio has its own immunization coverage levels. Houston has its own coverage levels. El Paso, we run their own coverage levels. This year we added Heldago County for their coverage levels. So we have to pay for different sites but in general we have a state of Texas, City of Houston, City of San Antonio and San Antonio has had it since the NIS has been out. When I was here, we can look at and kind of see a provider report card on how we're doing with the rest of the with the rest of the other states throughout the US. So 2014 was a horrific year for us. We had a 10-point percentage drop. So the series that you look at is the 431-3314. That's all the vaccines that you need outside of road or virus, flu and hepatitis A to be completely up to date. So you need your four D-taps, you went through these before, your varicellular MMR, polio, pneumococcal and the rest of them, hepatitis B. So that's what you look at. The gold standard is to make sure you have all of those vaccines by the time you're three years of age which is what you should have. So when you look at last year, we took a significant 10-point drop on how we were doing as a state. So sitting around, we had to kind of, I mean it's what we were, we were 49th in the US for how, this is how we're measured, Texas was 49th. And you looked at all the charts, we were the black state. We were down there with Mississippi and Arkansas and other states who were having really poor immunization coverage levels for babies. So, wasn't a great year for us last year. We went out and talked about, we tried to figure out where are we falling down on our baby immunizations. Where's the disconnect? I mean we're pretty strong on most vaccines up until their age, one years of life. Because you have to have them all in the series, we start looking, well maybe it's one to two. Our kid's falling off a medicator, our kid's not getting back on a medicaid. Are they re-enrolling in the systems? Are they the same with CHIP? Although we don't see a lot of babies in CHIP program. Where are we falling down that our immunization coverage levels, as a state, San Antonio did very much better, dropped 10 percentage points. And we celebrate when we go up one or two points. That's how hard it is to increase with coverage levels in the state of Texas where you have to have a major change in order to get immunization coverage levels to improve. So luckily for us, is that our coverage levels came out last Friday. We just got the data sets on Monday, so we've been trying to put this together for you guys. So according to the survey, we rose from 64%, which is horrible, up to 71%, which isn't great.  So we had a gang and we had a gang that's pretty substantial according to the CDC. So now people are looking at us going, which I'll do. What did we do as a community to work to get our immunization coverage levels up? And it's a lot of the practices that we can kind of go over in a few minutes, but we're still below the national average. So we're better to what almost everybody else is, but we're still nowhere near where we need to be as far as making sure all of our infants are age appropriately vaccinated by three years of age. This chart will be hard to see for you guys. I'll make sure I get this for you all, but this looks at each antigen. So you can see that we're pretty good on polio, pretty good on MMR, sort of good on hip. Hepatitis B strong, it's over 90%. That's just that one vaccine though. We're pretty good on varicella, pneumococcal poor, not so good. Hepatitis B pretty good, 80% birth cohort coverage. We had a little bit of a drop, but most of our babies in Texas get hepatitis B in the hospitals, which is good. It gets them stirred up out of the gate. Hepatitis A is a challenge for us. I want to cover that in a few minutes. Rotavirus, again, we had a little bit of improvement, but still it's the gold standard for us for immunizations, 70% in the state, because that's where we are. Again, better than 60%, and now we're being asked, well, how can we get from 70 up to 80? Because when you look at the next slide, it kind of looks at what our targets are. And generally, you want most vaccine coverage levels to be at 90%. So that means all four D-taps are given to babies to 90% of the time. You're looking at making sure your polio doses are given at 90%. Our coverage levels for some of these are met. Polio we're doing very well at. D-tap, not so much. A lot of that's that poor D-tap we talked about. Again, same with pneumococcal. That pneumococcal that they need after one year of age. Same with the hip vaccine. Those vaccines that we need when our children's from one to two, we are still struggling quite a bit. So we need to start looking at, what are we doing to get our kids back in after we have really pushed immunizations to their first year of life, and then something happens. We have really good school coverage levels, but we can't have all these kids not vaccinated from the time they're 15, 18 months of age until they're four. We can't catch them up two years later. And we have school requirements for vaccines. We have daycare requirements for vaccines. So we really need to look at where our children are going to make sure that we're partnering with right people. We partner with WIC, we partner with other public agencies to increase immunization coverage levels. But if we don't look at it, we're not gonna know where our improvements need to be made. So something we need to look at, the U.S. isn't there as well in some of these vaccines, but it's important to remember where we were and where we are today and where we need to go and what efforts we're gonna do to increase our immunization coverage levels for infants. I did run some individual vaccine series for San Antonio and the other city sites that we're measuring. 72, again, this is the complete series. We're almost there. Bear County had a 67.5%. So when you look at the different projects in the state, San Antonio has the lowest as far as coverage levels for the NIS for this past year. So it's an improvement from what it was the year before, but when you look at, for the entire vaccine series, we have our lowest rates in Bear County. And I know none of us like to look at that. I know all of our providers think we're at 90 to 100% coverage levels, but through the surveys, we're not. And it's collective. I mean, you don't see a lot of kids, a lot of infants going to public health departments anymore. So it's our provider network, making sure that we find places for all these kids, make sure they come back and get vaccinated and across the board. That's the only way we're gonna get our coverage levels up is I don't want to see Bear County down as the lowest and lowest covered immunization site for babies in Texas. You know, when it's four or five points below the state, we don't want to be there. When you look at hepatitis A, I just pulled up a couple of charts for infants. You know, I don't understand how in Texas that our immunization coverage levels for hepatitis A, and especially hepatitis A vaccination started in Bear County. We've had the first daycare requirements. Dr. Garrett did it 15 years ago to make sure that we had a rule that required all daycares to make sure kids were appropriately vaccinated. Our hepatitis A rates, I mean, they're better in some places in El Paso, but generally you would think a state that had a requirement for hepatitis A vaccinations, certainly in the border areas would have higher coverage levels. So a lot of people don't think about hepatitis A that much, but in regards to where a vaccine that we should be very good at, we're not that much better than the rest of the US and most people north of the middle states aren't really focusing on hepatitis A like we should be. So that's something we need to look at as well. The last one I wanted to bring up was a MMR vaccine. Again, we're, okay. MMR vaccine, the reason I bring this up is that both Bear County and we have Hildago as well, border communities as well as El Paso. You know, MMR rates about 90%, not bad. Bear County is almost 90%, but when you look at Hildago about three or four percentage points, you know, I don't want to go plus or minus on confidence intervals and levels, but essentially our border communities that have to maintain what we have, most of our measles cases come down from the border. So you would think that we would have to have strong border communities for measles vaccinations. We don't want those cases coming up through Mexico, up into Hildago, El Paso, into, you know, San Antonio, Houston and Dallas areas. So we need to look at MMR vaccines and see if there's some efforts that we can do in our border areas to help increase those rates. All right, so adolescent vaccines. We're done having our promotional talk on baby doses and we're all gonna do better. So next year we're highest on the chart and not lowest in Bear County. So the adolescent schedule has certainly gotten complicated. There wasn't even adolescent schedule not much more than 10 years ago because the only adolescent vaccine there was before TDAP and then in Chicago was everybody get a TD vaccine. So we've had huge expansions within the adolescent schedule.  And a lot of the CDC funding for special projects is going towards adolescents. So we have five vaccines that are generally recommended, a flu vaccine, which a lot of people forget about, vaccinating your adolescents. Meningococcal, MCV4, we do very well at, TDAP we do very well at, HPV not so good, flu vaccine certainly not so good. But everyone's looking at, how do we increase adolescent vaccine coverage levels for those vaccines that aren't required for school? We don't have a lot of time really to jump into all the issues that go around HPV in this state, but you know, certainly HPV has been a challenge from the day it was licensed in Texas and it initially recommended and almost required to be a school requirement. So we have a lot of bad taste on that, but that taste should be long gone by now. We still have struggles with our HPV vaccination rates in the state.  Just to take one child and get them through all the vaccine series with publicly purchased vaccines. Now it's over almost $2,400 to vaccinate one child with every product. Now they don't need them all at one time, it's just an estimate, but we've seen almost a four times increase in the cost of vaccinating a child over the last 10 years. So there's some things we need to take in consideration with that and a private provider certainly have issues with that with trying to build up inventory for vaccines that are very expensive, but we would never turn any of these vaccines away. So what we need to look at is, you know, an adolescent market is a new thing. I mean, 10 years is new in amuseations, you know, and we need to understand that, you know, higher price vaccines, we're gonna have to look at controlling the inventory on some of these products, but we do not want it, and certainly in the VFC program for strict kids from adolescents from getting these vaccines. But again, we need to recognize that the price is four times increased in 10 years, mainly because we have some really good vaccines out there and we don't want to move from them, but it's something we need to understand when you're looking at provider inventory in the private sector. So the teen survey. So luckily for us, we do, we have immunization requirements for an inch cockle and we have it for TDAF as a 12 year old age group. So Texas exceeds, which is a good thing for us, the coverage levels for healthy people targets as well as the coverage levels against the United States coverage for an inch cockle and TDAF. So that's a good thing. We're doing really good on our vaccine requirements for school at 11 to 12 years of age. Fortunately, last year we had horrific HPV rates in the state of Texas. But this year we were recognized as having one of the greatest increases in HPV rates in Texas, which is good. We put a lot of effort as you guys have with vaccinating against HPV vaccines or providing HPV vaccines for your adolescents. So we have some updated numbers. I want to cover with you guys briefly on the three different vaccines. So the light green is Texas last year. The darker green is Texas this year. So pretty much stayed the same. I'm gonna inch cockle into a little drop in TDAF. And this is for, not every child in Texas unfortunately doesn't go to school. So we're about 90%. When you look at our school coverage levels for TDAF and an inch cockle, it's over 98, 99%. So I think we're pretty good with that one. When you look at HPV, one dose of HPV into females, 13 to 17 years of age, we were down to 50%. That was our score last year. We had a significant increase. 10 percentage points in one year is significant. So a lot of the work that we're doing with identifying and getting HPV into women and men has improved.  You might have another opportunity to provide a flu vaccine as well as, you know, if you have 16 to 18 year olds coming in for that second dose of meningococcal or MenV. So we're increasing adolescent visits by increasing HPV rates. And that's the way we should look at it. I mean, a lot of the things you hear from the CDC is that we need to educate on all adolescents vaccines. Don't just carve out HPV as the one we need to work on. We need to maintain where we are with TDAP and meningococcal, and then we need to expand those second doses of meningococcal, HPV, as well as MenV vaccines. We still have some challenges. You know, this is a 10 year slide. So as you can see, we started in the 40s and it's taken us 10 years to go about 20 percentage points for one dose of HPV. And today, one dose of HPV really doesn't do what, you know, you need to have a complete series. So getting the kids back in for second and third doses, we have those coverage levels as well. First, I wanted to hit on poverty status. I know this is a major challenge for us across the state. So when you look at above and below the poverty line for how we're doing with HPV, we're certainly doing much better for those children above the poverty line than below the poverty line. I mean, I'm sorry, the other way, below the poverty line, we have higher coverage levels. So again, another factor we have to look at is poverty status for the kids in Texas, the adolescents in Texas, as far as how we're doing with coverage levels for them. NIS coverage levels for the cities again. In this slide, Texas or San Antonio is the bright purple. So very good. We're all about the same level. We're looking at 90% coverage levels. This is for the meningococcal dose and the TDAP dose at 12 years of age. When you get down to HPV vaccine, unfortunately we have some breaks in our coverage levels. We're at 60%, it's better than 50. When you look at the difference coverage levels, you look at green as El Paso. El Paso is doing very good way above the national average in regards to having 75% of their adolescents, 13 to 17 starting the series. But unfortunately, Bear County again, is for HPV vaccine is the lowest in the state in regards to the anatis coverage levels. There are a lot of issues around HPV vaccine. We know that, we hear about how we can better message and get adolescents vaccinated for this. We're going and telling them that HPV is one of the other vaccines for adolescents that they'll get today. And I get that Texas is at a challenge with HPV in regards to, you can look at our coverage levels and see this, but certainly we have to do something to increase our HPV coverage levels to at least start women and men on this vaccine series. And Bear County again is struggling behind a little bit on HPV. We have a statewide initiative that's coming out through the legislature who has pretty much told us that we will enact an HPV plan. It's supposed to be launched at the end of this year, first part of next year. We're gonna come back and sit down with San Antonio and work with you guys on what we can do to help us with our adolescent immunization coverage levels, specifically with HPV. When you look at three doses of HPV, this is the complete series. Again, we're not great, 40% is not great by any means. But again, Bear County is the purple line again, lower than all the other project areas in Texas. So if there's a place that we need to look at for an HPV initiative, it's certainly in Bear County. Now, the city of San Antonio recently did get a special CDC grant to help with doing education around HPV. So I think that'll help as well as what we can do as a state to help direct additional resources and education into Bear County for HPV. So I wanna kinda go over what we've been doing for our 2016 CDC HPV evaluation of our HPV project. So this has been going on for two years now. And what we look at is first we see who needs HPV vaccine and where can they get it. Well, HPV is covered for everybody in the VSC program. Medicaid, uninsured chip, Native American, Alaska Natives. Everybody who's public eligible and most if not all insurance companies are covering HPV vaccine. So the barrier and the cost of HPV vaccine for getting our immunization rates shouldn't be one of our challenges that we have to work on. We also have the adult safety net program that I had on a few minutes ago. So right now anybody who's up through 26 years of age which is where the vaccines recommended for and is uninsured in Texas can go to an adult safety net and complete their HPV series if they've started it after age 19 or start the HPV series. We're one of the few states that is putting resources into this vaccine as well as other adult vaccines to give the opportunity for our uninsured adults to be vaccinated. Now that works really well in our state where we have a meningococcal requirement for kids going into college. We wanna make sure that we finish up our series for kids who start HPV vaccinations for meningococcal vaccines when their VFC eligible become 19 and just don't go to get around to finishing their vaccines. We have an adult safety net program for that. It's a $10 million a year project just to give vaccines to adults for the uninsured adults. It's unlike it anywhere else in the US where that much money is going in to make sure that we build a safety net for adult program. So I wanna kinda tell you what we're doing as a project. So each six months we send out an individual letter to each provider in the state of Texas, including all the providers in Baird County that see adolescents. And we're kinda looking at a ratio. The idea, remember we talked about T-DAP.  So we look at a ratio of one T-DAP to three HPV vaccines. And that's what we're measuring providers on. So when you order a T-DAP, you should be ordering three HPV vaccines for that same person to make sure that they have the opportunity to get fully vaccinated. And we're sending out notifications to every providers every six months on how they're doing on their order data. It's not looking at doses administered. It's not going into the registry and seeing actually who gives these doses. It's going, hey providers, let's help you educate you in the fact that if you see someone for T-DAP for that 12 year old visit or 13 through 18, you probably should order two to three doses of HPV vaccine as well. So we're running these ratios for each provider. Obviously the goal is to be at one to three ratio. And right now across the street, we're about one to 1.6. So for every T-DAP dose that's ordered, maybe providers are ordering one and a half doses of HPV. So until it's like two or three doses for every one T-DAP, our HPV rates are never going to improve. It's the same issues that we have with flu. If we don't order flu vaccines enough doses to cover the population, they're never gonna get better. Same thing with this. If our HPV rates, when you look at ordering one to three as a ratio and you look at it's in different regions, 1.4, 1.5, the state average at 1.63, if we don't get up to at least a two or three ratio for every dose of T-DAP ordered, we're never gonna get our HPV rates to increase. And all the issues around why people aren't giving HPV is a separate side note, but certainly you go back to the entitlement of the adolescent now. Where is that adolescent supposed to get the vaccine if their medical provider is not ordering and recommending it for him? And that's an opportunity for us to look at and come in and customize the report. And this is kind of an example of it. So we're sending out an email each six months and says, hey, listen, this guy is doing great job. I know it's hard to see, but he's ordering four doses of HPV for every T-DAP. So he's aggressively going after other kids that may have already received it. So this would be like a gold standard provider and it gives them a customized report. It also looks at meningococcal vaccines and how many doses they've ordered. So we customize this, we send it to every single provider just to kind of let them know where they're at because a lot of times people need to be reminded as to where we're having our challenges. HPV is one of them. We'll send out this customized letter every six months to y'all to each provider and then, and we keep tracking it for you. So hopefully we'll see some movement that you'll be ordering more HPV vaccines. When you look at January to June from last year to this year, we've had some growth. 1.5 to 1.6, it's slow growth, but at least we're having providers at least more order vaccines. We've done multiple papers on this and the CDC's come down to Texas to try to copy this in other states. Where we're looking at data to help us drive providers where we need to educate some providers more where we're doing almost a customized approach for each provider and we send this out to I think 2,200 sites every quarter. So, and the big reports come every half year but we do quarterly updates as well. So when you look at Bear County, we're doing better than we are in other parts of the state. When you look at our order rates of HPV to TDAP. So that's good. We're moving in the right direction in Bear County. So then you start to figure out well, why are our coverage levels not where they need to be? Well, just ordering vaccine doesn't mean it's being administered. So we don't wanna have providers in Bear County stocking up on vaccines to have better scores if they're not gonna administer them. And it's not specific to Bear County but we have a lot of vaccines that expire because almost all the vaccines that providers get in Texas has over a year shelf life. So if you're ordering vaccines to get a higher score and not giving it, you're really not helping our program out. But it's good that we see that doses are being ordered in Bear County at a higher rate than they are in other areas in the state. So again, when you're looking at how we're doing, I mean, when you overall, 65% of the providers in Texas are doing poor. That's under two dose per every dose of TDAP. And that's not good. But at least we're working with education to help them do a little bit better but it still comes back to providers making decisions to vaccinate these folks, these adolescents for HPV. These are our strategies to look at across the board to increase community demand is something we're looking at, adolescent media campaign. Texas puts in about $2 million a year to help promote adolescent vaccines across the state. There's a lot of resources and educational materials out there as well from the CDC, from different partners in Texas. MD Anderson is a great partner from us. Vaccine manufacturers certainly help with education. We work with all of them to help us. Work with system interventions. That's the project that we've talked about looking at trying to inform and educate providers on where they are. So many people think they're doing so well with adolescent vaccines and we are with the ones that are required, not so good with the ones that aren't. And then we need to continue to strengthen our partnerships across the board to get to those individual providers because I'm not saying that people don't listen to the state but it would certainly be better off if we had provider to provider education on adolescent vaccines. Kind of wrapping up real quick for the adult safety net program. Again, we've talked about this a little bit. We have over 515 sites enrolled. The aim is to offer access to vaccines, expensive vaccines for uninsured adults. Right now these are available in DSHS, regional clinics, local health department clinics. We've also partnered with the FQHCs and RHCs throughout the state. We do have some public family planning clinics, substance abuse centers and hospitals enrolled as well. But the majority of the ASM providers that participate are either FQHCs and local health departments and regional clinics. Again, it's for only uninsured adults. So we certainly have medical homes for other people and having a high co-payer deductible does not make you uninsured in the state of Texas. So what insurance plans you have? If you have any insurance at all, whether it covers vaccines or not, fortunately you're not eligible for these vaccines. All vaccines are offered except for influenza and meningococcal B right now. And you know what Zoster is and you know what HPV costs per dose and this is something we're able to buy and provide for uninsured adults throughout the state. When you look at the overview, this is for over the last, from January to August, given about 135,000 doses throughout the state, these are the different vaccines that we've given. In Bear County, we've given about 7,000 doses and the majority of those doses are being given by the health department. So when you look at the number of provider sites, I talked about 511 sites were enrolled. This is where it's unfortunate. Of those 511 sites throughout the state, about 247 or almost half of them are given less than 50 doses this year. So where's our commitment to providing adult vaccines that we provide for free when our own adult sites aren't giving them? I mean, 50 doses in eight months, when you look at that, even how many workdays that is, that's like giving a dose or two doses every week. So that's not a great use of our adult resources providing these vaccines for these sites. Everybody who comes in, who brings an uninsured child in might be eligible for an adult safety net vaccine as being uninsured themselves. Why would we not screen eligibility out like we should be doing for flu for adult safety net vaccines? All FQHC, almost all FQHCs and all local health departments and regional clinics have adult products in. We allow them to take these vaccines on the road. So it's certainly a challenge. We have enough funding available to buy twice this vaccine. So, and as you know, in the state legislature and they're coming up next year, they look at a surplus of money, they're gonna come and take it. So for adult safety net program doesn't do better. There's a decent chance some of our adult safety net funds will be taken away from us. So it's a great opportunity to work with our local health departments and our regions and our FQHCs to send people to these sites to get vaccinated. I know we don't have a VFC program for adults yet, but we do have something that's available for uninsured adults through our public health infrastructure. So when you look at San Antonio, San Antonio has 27 sites that are enrolled in the program right now. When you looked at, I ran the numbers last night, 11 of these sites have given less than 100 doses this year in eight months. So we're talking 10 doses a month, maybe and the health department really skews this because they do a lot of vaccines to the adult safety net program. So something we need to look at is that, 11 out of 27 sites and of those 11 that are given less than 100, half of those are given less than 30. So why are we having, we don't wanna discourage people from being in the program, but we need to look at where we're not being successful and try to work with individual sites on how we can get them to increase taking advantage of this great opportunity. So finishing up barriers. So we don't like that barriers, we have challenges out there.  So these are some challenges to increasing rates in the state of Texas that we've heard across the board. Some of these challenges have come directly from you guys. Certainly having a high uninsured population is a major challenge for us in Texas. Lack of provider participation, I've gone over that in BFC and ASN, certainly a big challenge for us. We don't get more providers, we're not gonna be able to move our needle forward because many providers are seeing all that they can, yet we still have continual growth. We continue to have all these babies born and we need to find more places for them to go to get vaccinated. Complicated schedule, certainly, lots of educational resources out there, but when you bring someone new into the game and immunizations, you have lots of learning to do and lots of background trainings to do. We have a great opportunity to coming up. I wanna talk to you about that at the end of this, but certainly understanding the immunization schedule and getting people on board for the long haul to learn all the vaccines and the schedule and understand them and what doses are needed when with day for age groups is very complicated. Vaccine costs, we talked about that. I really want to throw that number out there. When you go from $600 to $2,400 to vaccinate one person, that's significant. When you expect providers to maintain inventories and all these different products on the private sector, that can be substantial and that's something we need to look at. Our manufacturers work with the private providers and make this easier for them to handle, but overall, I mean, there's a lot of funds out there being locked up in inventory on expensive vaccines and that's something we need to recognize. Other barriers certainly delay in scheduling, the lack of using of the registry, having requiring visits, well, checkup visits as a simple vaccination visits, one of them, long waiting times, not using reminder systems across the board for all kids. Lack of really having educational materials out there for everybody. So these are our strategies across the board. These are what we continue to promote. The slide hasn't changed since I've been at the state office. So promoting the medical home, we have to get our kids somewhere. Whatever it takes, we have to find more providers. We need to have our providers take on more kids. We need to, you know, public health isn't gonna be there at the same level it has been in the last 10 years. So we need to find other places for our kids to go and we need to get more providers. We need to have a better understanding of how we should be educating providers, not just providers, the public and our parents. We need them to understand the importance of vaccines. There's so much bad information out there on immunizations. Every time you look, I know if you pull up immunizations anywhere, the first 100 sites are gonna be negative sites on immunizations. CDC site doesn't come up till further on down the line. The state office site doesn't come up at all in a lot of cases. So a lot of education still needs to be done in regards to that. Increase access points. Again, we've talked about that over and over again. We have to find more sites. Promoting the use of the registry. We certainly have a lot of work to do with getting providers to use the registry. We need to customize our approaches. As we've talked about today, things in Bear County may not be the same type of messaging that we need to use up in Dallas and El Paso and out in Houston. We need to look at that. Is there a different type of messaging we should be using for the folks in Bear County around HPV? Is there different educational efforts we need to do with the providers, with the parents? The assurances of the vaccines, is it out there in the same level in Bear County as it might be in El Paso and where the coverage levels are higher? And we certainly need to continue to look at working with our partners and this type of meeting and having collaborations with coalitions as far as working with our Texas Immunization Stakeholder Working Group, TMA and TPS, other agencies within DSHS, Immunization Coalitions and lastly vaccine manufacturers. Continue to work with these different partners. So I wanted to selfishly promote our last event is we're having the CDC come down in two weeks and doing a live EpiVac training for anybody who wants to come to Austin. Austin's always awesome in late August, I mean late October, coming in for two days and they're coming through and you guys should all know what the pink book is, the Immunization Bible and they're gonna come here for two days and teach all of us about each individual vaccine, vaccine preventable diseases and the vaccines that are made to prevent those vaccine preventable diseases. They essentially spend an hour for two days going over MMR, polio, hepatitis B, hepatitis A, excellent presentation. We have had a live EpiVac course in Texas since I can remember, over 20 years. So we're having them come down, two experts coming down and training all of us through coming to this course and getting CMEs, CME credits as well.  I know we're still, Link is with us as well from the state and he can give you additional information as far as it's on our website. If you're in our VFC program, we've sent it to you multiple times. If you're part of our partnerships, we've sent it out. This is our one chance to really bring CDC in for two days and if at all possible, you should send every one of your folks who works in immunizations to this once in a lifetime opportunity for immunizations. And lastly, National Influenza Vaccination Week is coming up at the end of December. You guys are awesome. You don't know, but you just sat through 75 slides in an hour. I know we covered a lot today. I wanna make these slides available for you all. There's a lot of information in here. I think it's important to look at the good work that you've done and recognize that there's more for us to do. We need to get our infine immunization rates up. We need to continue to increase our adolescent rates. And again, it's the public health partners and the community providers that are gonna make this happen to the VFC program. So thank you again. I appreciate you guys continuing to meet as a group, as a strong coalition. When I was in San Antonio, we had different coalitions that would start up and we do a lot of good things and then they'd kind of drop off and then we'd start up another one. So it's great to hear that this one has survived and continues to champion different issues throughout Bear County. And as I've said, I mean, I grew up in Bear County. I grew up in San Antonio. So I know this community can come together and increase his immunization rates if anyone can. So thank you again.


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