Spotlight on Vaccines: Pandemic May Open Gateway to Improve Vaccination Rates in Texas

The uneven rollout of COVID-19 vaccines in December created at least one bright spot for Texas physicians: It highlighted how the state could make vaccination more efficient.


Problems arose quickly with the COVID-19 vaccines because there were too few doses to go around as well as technical problems with storage and distribution, says Jon Roth, executive vice president and CEO of the Dallas County Medical Society (DCMS). For instance, Pfizer/BioNTech’s vaccine – the first one available – required ultra-cold storage and came in 975-dose lot sizes.


Physicians were among the top groups designated to receive vaccines, but for the most part, only those at hospitals and large medical groups could easily obtain them.

“It wasn’t feasible for our non-hospital affiliated practices to enroll as a [vaccine] provider themselves,” Mr. Roth said. “And that begged the question, how are we going to get our community physicians and their staffs vaccinated?”


Texas – like most other states – doesn’t have the public health infrastructure to handle a mass-vaccination program quickly, he said. Despite this, by mid-January Texas had managed to lead the nation in doses administered, according to the Texas Department of State Health Services (DSHS).


This success was made possible, in part, when in January DCMS set up its own infrastructure by working with the local pharmacies that had received vaccine doses. Together, they began to vaccinate the 35,000 or so physicians and their staff members in Collin, Dallas, Denton, Grayson, and Tarrant counties, Mr. Roth says.


The partnership allowed physicians to easily arrange an appointment in a designated pharmacy or to attend one of several mass vaccinations events, says Christine Becker, MD, an internal medicine specialist. She, the two other physicians in her Dallas practice, and their staff members were able to get COVID-19 shots through DCMS.


“It was a well-oiled machine,” she said. “I got there and got the vaccine in probably less than 5 minutes after I arrived. … I can’t say enough good about the Dallas County Medical Society and the North Texas alliance for getting this together for the physicians and their staffs.”


Unfortunately, physicians in other counties were not so lucky. In many rural areas, even hospitals still had not received vaccine doses by early January. And despite help from county medical societies, physicians in other highly populated areas often struggled to find pharmacies where they could find vaccine doses for themselves, their staffs, and their patients.


This rough debut for COVID-19 vaccines is just the latest among other ongoing hiccups with vaccine distribution and tracking that have frustrated Texas physicians, says Jason Terk, MD, a Keller pediatrician and chair of the Texas Public Health Coalition, which counts the Texas Medical Association as a member.


Those problems start with the state’s vaccine registry, ImmTrac2, Dr. Terk says. (See “Talk to Patients About: What is ImmTrac2?” page 28). Though intended to help physicians, ImmTrac2 can add to the paperwork and hassle of registering and tracking vaccinations.

Other problems include vaccine exemptions for philosophical reasons, which have risen about 350% between the 2005-06 and 2019-20 school years, according to DSHS data.

Despite the pressing need to improve vaccinations rates, physicians will need to keep expectations for widespread reform in check because the pandemic could significantly hamper efforts to pass bills in this year’s Texas Legislature, says Troy Alexander, TMA’s director of legislative affairs. (See “Staying the Course,” January 2020 Texas Medicine, pages 20-27, www.texmed.org/StayingTheCourse.)


“It’s going to be so difficult to pass a bill of any kind that it’s going to be a limiting factor on both sides [of the vaccine issue],” he said.


Nevertheless, the highly visible problems with distributing COVID-19 vaccines seem to have created momentum to make some improvements in the state’s vaccination infrastructure, which remains a legislative priority for medicine, says Dr. Terk, past chair of TMA’s Council on Legislation.

“We’re at the point now where the seriousness of infectious disease outbreaks is manifest,” he said.


Opt-in vs. opt-out

Improving ImmTrac2 tops TMA’s priority list for the 2021 Texas Legislature, and that will require not one but several reforms, Dr. Terk says.

The nation’s 49 vaccine registries, including ImmTrac2, fill an important public health role.

By age 2, more than 20% of U.S. children see more than one health care professional, resulting in scattered medical records, according to the U.S. Centers for Disease Control and Prevention.

Vaccine registries help consolidate that information so physicians, health departments, and others know what diseases an individual is protected against, says Joseph Schneider, MD, a Dallas pediatrician at UT Southwestern Medical School and chair of TMA’s Committee on Health Information Technology. That kind of tracking becomes especially important during an outbreak of a vaccine-preventable disease like COVID-19.

To support those goals, changing ImmTrac2’s opt-in system is one of TMA’s highest vaccine-related priorities, Dr. Terk says. Opt-in means Texans must give consent before having their vaccine information stored in the registry. Most other states use an “opt-out” system in which vaccine information is automatically stored unless patients ask to have that information left out. (See “Opt In vs. Opt Out,” page 24.)


When it comes to emergency situations – like vaccinating people for tetanus after a hurricane or tracking COVID-19 vaccinations – ImmTrac2 registration is mandatory for everyone. Patient records are automatically stored for five years after the event before being expunged, though patients have the option of keeping them in the registry afterward.

Otherwise, Texas’ opt-in system creates added hassle and paperwork for physician practices, patients, and DSHS, says Donald Murphey, MD, pediatric infectious disease specialist at Dell Children’s Medical Center in Austin.


Most vaccine recipients are young children, and Texas’ opt-in system encourages hospitals or those assisting with births to inform families about the need to opt-in. After that, it’s up to physicians and patients to discuss the registry.


Then comes the paperwork: Physicians and hospitals must then process consent forms for the child to forward to DSHS.


Changing ImmTrac2 to an opt-out system would greatly reduce that extra workflow, Dr. Murphey says.


“You’d only have paperwork if someone said they didn’t want to be in the registry,” Dr. Murphey said.


Texas also has three different forms – one each for children, adults, and for disasters – and the adult version has other consent categories for first responders and their relatives. In total, there are five different consent categories, each of which requires a special EMR code.

Those separate forms, categories, and codes are unique to Texas, which presents challenges for physicians and EMR developers, Dr. Schneider says.


“Ideally, there should be one consent form with a single ‘yes’ or ‘no’ field,” he said. “The EMR should be smart enough to be able to send the birth date and whether the individual is a first responder. Forcing physicians to find or store separate forms is another example of a burden that should be removed.”


Texas opt-in system creates other types of problems because patients obtain vaccines at different locations over time.


For example, if one parent of a minor chooses to withdraw that child’s vaccine records from ImmTrac2, that eliminates any record that the child was previously enrolled in the system. If the other parent takes the child to a different physician and gives consent, ImmTrac2 doesn’t know that consent was previously withdrawn. The child’s vaccine information unknowingly would be entered back into the registry and could be incomplete.


That situation could be fixed by allowing ImmTrac2 to hide the patient’s information – not eliminate it – and reactivate the information if the patient chooses to do that, Dr. Schneider says.


It could also be fixed by allowing “hashing,” a notation that someone has previously withdrawn from ImmTrac2. This would ensure the physician sees and can honor a patient’s withdrawal request. All vaccine data would be deleted except for the date of withdrawal.

Even with such changes, switching from opt-in to opt-out still allows patients to protect their privacy by leaving ImmTrac2 if they choose, Dr. Terk says.


“We have a strong interest in protecting privacy,” he said. “But we can balance that priority in a more equitable way that supports the health of Texans by having a more functional registry.”



The registry also is part of TMA’s goal to improve overall vaccination rates in Texas.

An opt-out system would allow ImmTrac2 to do more to help physicians and proactively improve immunization rates, Dr. Murphey says. For instance, many patients fail to get second doses, and an opt-out system could reach a wide swath of patients with reminders to follow up with their physicians.

According to DSHS, however, ImmTrac2 does not have “the functionality on its own to inform the individual clients they need a second dose of a vaccine,” a spokesperson said in an email. “There are no immediate plans at this time to add that, but health care providers can generate those reminders from within ImmTrac2.”

And while physicians’ desire for a single form is understandable, “due to the requirements of ensuring individuals have a full understanding of what their consent entails, each type of consent (child, adult and disaster) must be captured on different forms,” the DSHS spokesperson said. “It would be difficult to combine all required information onto a single page with all the language, links, and data points needed.”

Physicians also want to end the practice of allowing philosophical exemptions from vaccination for school children, Dr. Terk says.

Between September 2019 and September 2020, there were about 73,000 Texas children exempted from vaccination for non-medical reasons, according to DSHS data.

Many of the people claiming exemptions live in the same neighborhoods, attend the same churches, or send their children to the same schools, Dr. Terk says. That makes those areas ripe for outbreaks of vaccine-preventable diseases like measles.

“Birds of a feather flock together, and we will see more and more outbreaks as the exemption rates increase,” he said.

If exemptions stay, TMA will push for greater data transparency from the schools that grant philosophical exemptions. Currently, DSHS is required to report exemptions at the individual school level for private institutions, but only at the district level for public schools.

Many parents with children who are immunocompromised and therefore cannot get vaccinated need to know the specific exemption rate for their child’s school, not just the school district, says Mr. Alexander, TMA’s lobbyist. If their child’s public school has a vaccine exemption rate above 5% to 7% for measles, for instance – the level at which community immunity breaks down for that disease – that school may be vulnerable to an outbreak and no longer safe for that child.

TMA’s other vaccine priorities include:

  • Additional funding and infrastructure for COVID-19 vaccines to accommodate surge capacity in the coming months. This would include funding items like medical supplies and refrigeration units. It might also provide grants to hospitals, medical practices, and local public health entities to improve COVID-19 vaccination.

  • Ensuring public school funding is not withheld from school districts that properly bar unvaccinated students from attending school.

  • Requiring families to have a licensed Texas physician sign off on any medical exemptions from school vaccines. Currently, out-of-state physicians can sign off on them as well.

  • Creating a public-private partnership for vaccine development that resembles the Cancer Prevention and Research Institute of Texas (CPRIT).

  • Providing stronger legal protection for employers who require vaccinations.

  • Requiring all senior care facility residents’ and employees’ vaccine status to be entered into ImmTrac2.

TMA’s efforts to improve vaccination will be bolstered by its new educational campaign, Vaccines Defend What Matters. (See “Vaccines Defend What Matters,” page 23.)

Meanwhile, in the coming months, physicians have a responsibility to talk up the importance of COVID-19 vaccines with patients and the public, Dr. Becker says. Finally getting her shots has helped her feel safer while treating patients.

“You’ve got all the garb on already, so I feel like I have another layer of protection,” she said.

But the shots only work if they’re taken by as many people as possible, she says.

“[We need to] encourage people to take the vaccine,” she said. “Encourage patients and other doctors so we can get this thing dampened down and controlled.”

Tex Med. 2020;117(3):20-25 March 2021 Texas Medicine Contents Texas Medicine Main Page