Immunization in the Medical Home Immunization in the Medical Home by David Wood, MD, MPH, FAAP AAP...

Immunization Immunization in the Medical Homein the Medical Home

by David Wood, MD, MPH, FAAP AAP Council on Community Pediatrics &

AAP Childhood Immunization Support Program

This presentation will describe how the Medical Home concept can be applied to immunization practices for all children.

Emphasis will be placed on Medical Home principles such as the family-physician partnership and the pediatrician’s active application of knowledge, AAP policies, and best practice guidelines that apply to immunizations.

About the PresentationAbout the Presentation

Learning ObjectivesLearning Objectives Understand medical home principles vis-

a-vis immunization services Understand the challenges facing

pediatricians administering vaccines in the context of a medical home

Anticipate and overcome barriers and promote the optimal delivery of immunizations in the medical home

Learn how to access additional immunization and medical home resources and tools

American Academy of American Academy of Pediatrics Stance on Pediatrics Stance on

ImmunizationsImmunizations The American Academy of Pediatrics (AAP)

believes that immunizations are the safest and most cost-effective way of preventing disease, disability, and death, and that the benefits of immunizations far outweigh the risks incurred by childhood diseases, as well as any risks of the vaccine themselves.

The AAP urges parents to immunize their children against dangerous childhood diseases.

Understanding the Understanding the Pediatricians’ Role in Pediatricians’ Role in

Vaccine AdministrationVaccine Administration

Primary care practices delivered 80% of vaccine administration1

Vaccines prevent 10.5 million diseases per birth cohort in the US2

For every $1 spent on immunization, up to $29 can be saved3

Comparison of Maximum and Current Reported Comparison of Maximum and Current Reported Morbidity, Vaccine-Preventable Diseases & Vaccine Morbidity, Vaccine-Preventable Diseases & Vaccine

Adverse Events, USAdverse Events, US44

Diphtheria 31,054 1 -99Measles 390,852 86 -99Mumps 21,342 338 -99Pertussis 117,998 7,867 -93Polio (wild) 4,953 0 -100Rubella 9,941 176 -98Cong. Rubella Synd. 19,177 9 -99Tetanus 1,314 35 -97Invasive Hib Disease** 24,856 112 -99

Total 566,706 8,624 -98

Vaccine Adverse Events 0 13,497 ^ +++

Disease Pre-vaccine Era* 2000 % change

* Maximum cases reported in pre-vaccine era + Estimated because no national reporting existed in the prevaccine era^ Adverse events after vaccines against diseases shown on Table = 5,296** Invasive type b and unknown serotype

ReferencesReferences1. Santoli JM, Szilagyi PG, Rodewald LE. Barriers to

immunization and missed opportunities. Pediatric Annals. 1998;27:366-374

2. Centers for Disease Control and Prevention. Ten great public health achievements – United States, 1990-1999. MMWR Morb Mortal Wkly Rep. 1999;48:241-243

3. Centers of Disease Control and Prevention, National Immunization Program Fact Sheet. Available at: http://cispimmunize.org/pro/pdf/ImpactofVaccinesCostSavings_CDC.pdf (Accessed: August 29, 2005)

4. Atkinson W, Wolfe C, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases, 7th Ed. Department of Health and Human Services, Centers for Disease Control and Prevention; 2002

What Is A Medical Home?What Is A Medical Home?

A medical home is not a building, A medical home is not a building, house, or hospital, but rather an house, or hospital, but rather an approach to providing comprehensive approach to providing comprehensive primary careprimary care

Medical Home is a way to provide cost Medical Home is a way to provide cost effective quality health careeffective quality health care

The AAP Medical HomeThe AAP Medical Home**

Accessible Coordinated Continuous Comprehensive Family-Centered Compassionate Culturally Effective

Care is:

* American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110:184-186

Applying Medical Home Applying Medical Home Principles Can:Principles Can:

Improve health monitoring and delivery of preventive services

– Track needed immunizations

– Reduce missed opportunities

– Facilitate practice team efforts to educate families


Improve immunization delivery for children with chronic conditions

– Monitor immunization for children needing special immunizations (Influenza, synagis, pneumococcal polysaccharide, etc.)

Improve patient compliance

Address problems of vaccine delivery:– Address vaccine controversies and

increase parental confidence in vaccines– Partially address vaccine financing and

supply issues– Decrease mortality/morbidity due to

vaccine-preventable diseases by keeping immunization coverage levels high


Immunization: Accessible Immunization: Accessible CareCare

Accessible: Physically and economically accessible to all patients

Immunizations are available and administered according to the harmonized immunization schedule

Immunization: Accessible Immunization: Accessible CareCare

Scope of Problem:– 12.8% of children with special

needs1, some require physical accommodations

– 10.1% of children uninsured2

– 25% of children under 5 have no insurance or no immunization coverage3

– Over 70% of poor children under 18 rely on SCHIP or Medicaid1

Patient Barriers to Patient Barriers to Accessible CareAccessible Care

– Problems scheduling appointments – Can’t get off work, long office wait

times – Lack of transportation– Costs of

immunization/administration fees

Patient Barriers to Patient Barriers to Accessible CareAccessible Care

– Uncertainty about how to access free vaccines

– Confusion about the vaccination schedule

– Vaccine safety concerns or misconceptions

Physician Barriers to Physician Barriers to Accessible CareAccessible Care

– Increasingly complex immunization schedule

– Increased staff time for documentation and patient education

– Large uninsured and/or underinsured patient populations

Physician Barriers to Physician Barriers to Accessible CareAccessible Care

– Low or delayed reimbursement – Missing/lost patient immunization record – Lack of centralized immunization registry– Vaccine delays or shortages

Strategies to Provide Strategies to Provide Accessible CareAccessible Care

Financially Accessible– All forms of insurance are accepted,

including:MedicaidSCHIP

– Practice participates in Vaccines for Children (VFC) program

http://www.cms.hhs.gov/schip


– Changes in insurance are accommodated– Clinicians/AAP chapters work with third-

party payers (public and private) to ensure reimbursement and coverage of vaccine


Physically Accessible to Children with Special Health Care Needs (CSHCN)– Practice strives to meet

Americans With Disabilities Act requirements

Accessible, Flexible Office Hours– Immunizations are available during all

visits, sick or well, regular hours, or weekend clinics

http://www.usdoj.gov/crt/ada/adahom1.htm


– Vaccination-only visits available– The practice increases access during

periods of peak demand (i.e., flu season, back to school, etc.)

– The practice is accessible by public transportation


Health care professionals review the vaccination and health status of patients at every encounter – Staff can review records to determine

if any vaccines were missed by the physician

– Staff can prepare immunizations while patients are with the physician

Maintain and prominently display vaccine storage and handling procedures and protocols

The following case study is The following case study is designed to assist you to designed to assist you to implement the implement the Accessible CareAccessible Care component of the medical home component of the medical home concept during immunization-concept during immunization-related patient encounters. related patient encounters. Strategies to address specific Strategies to address specific issues raised in the scenario are issues raised in the scenario are included.included.

Case Study #1: Case Study #1: Accessible CareAccessible Care

Flu season is just around the corner. Dr Weiss, a privately practicing pediatrician in an urban city, is concerned about the potential increase in children coming in for the flu vaccine due to the changes in the Recommended Childhood and Adolescent Immunization Schedule. Prior to the change in recommendations, Dr Weiss immunized <250 children against influenza. The practice already has pre-ordered vaccine on hand.

http://www.cispimmunize.org/IZSchedule.pdf



Question: How can Dr Weiss ensure that his at-risk and target patient population has adequate access to flu vaccine?


Addressing the problem: Dr Weiss decides to set up a flu clinic, which

will be devoted to providing flu vaccine only. The flu clinic will run for 2 hours every Tuesday afternoon from October –March or until the virus is no longer circulating.

He ensures that all staff are vaccinated and develops vaccine standing orders so nursing staff can give vaccine without him having to see the patient.


Addressing the problem: He uses his computer-based patient

information system to identify children needing flu vaccine.– The system will “flag” children that

would need flu vaccine (e.g., those with asthma, etc.) and identify those currently 6-23 months old.


Dr Weiss assigns 1 staff person to serve as the office Immunization Champion, answering patient questions regarding the flu and flu vaccine(s).

In addition to the flu clinic, office staff will offer the flu vaccine at well child visits for all eligible children/siblings during flu season.

Patients are screened for and enrolled in the state’s VFC program.

References: Accessible References: Accessible CareCare

1. Strickland B, McPherson M, Weissman G, Van Dyck P, Huang ZJ, and Newacheck P. Access to the Medical Home: Results of the National Survey of Children With Special Health Care Needs. Pediatrics. 2004;113:1485-1492

2. Cohen RA, Coriaty-Nelson Z. Health Insurance Coverage: Estimates from the National Health Interview Survey, 2003. Division of Health Interview Statistics, National Center for Health Statistics; 2004

3. Institute of Medicine. Vaccine Financing In the 21st Century. National Academies Press, Washington DC, 2004

4. National Vaccine Advisory Committee. Standards for Child and Adolescent Immunization Practices. Pediatrics. 2003;112:958-963

Immunization: Coordinated Immunization: Coordinated CareCare

Coordinated: All needed immunization services are facilitated through the medical home. Clinicians practice community-based approaches and work with community groups to develop appropriate vaccination services1

Each visit is an opportunity for vaccination Continually educate practice staff Regularly review and update immunization

procedures


Scope of Problem:– 80% of vaccine administration

takes place in a physician office2 – 43% of children <6 years have 2+

immunizations in a registry, 2002 (Healthy People 2010 Goal: 95%)3


– 22% of children receive early preschool vaccinations from more than one health care professional (leading to increased record scattering)4

– 45% of practices had 1 or more documented storage problems5

Who Is Part of a Who Is Part of a Medical Home Medical Home

for for Immunizations?Immunizations?

ImmunizationCoalitionChild

FamilyPediatrician

Registry/State ImmunizationInformation

System/EMR Local, State,

National ImmunizationPrograms (i.e., VFC)

Third Party Insurers/Authorizing Agents

Community

OrganizationsAAP Chapter or State Educational

ProgramsVaccine

Manufacturers

Child Care Centers,Public & Private

Schools

Medical Home

Health Departments

Barriers to Coordinated Barriers to Coordinated CareCare

Parents/physicians may lack knowledge of immunization-related community resources

Poor communication among public and private health care and child care professionals (relevant state/federal agencies, school nurses, child care centers, etc.)

Barriers to Coordinated Barriers to Coordinated CareCare

Children receive immunizations in multiple sites

Lack of state or local immunization registry

Complex and/or multiple vaccine supply sources

Delays and/or disruptions in vaccine supply

When possible, the practice participates in local or state-level immunization registries

Clinicians work with local and state public health departments on quality improvement measures, such as Assessment, Feedback, Incentives, eXchange (AFIX) and Clinic Assessment Software Application (CASA), to increase immunization rates

Strategies to ProvideStrategies to Provide Coordinated Care Coordinated Care

Cooperate with local public health department to monitor disease outbreaks and educate parents

Develop and train staff on vaccine and office protocols

A central immunization record, including immunizations, is maintained at the practice

Strategies to ProvideStrategies to Provide Coordinated Care Coordinated Care

Strategies to ProvideStrategies to ProvideCoordinated CareCoordinated Care

Designate Immunization Champions The practice reports adverse events to

the Vaccine Adverse Events Reporting System (VAERS), and is aware of the National Vaccine Injury Compensation Program (VICP)1

Immunizations are coordinated with routine well-visits, follow-up, and sick visits

Immunizations received outside of the medical home are communicated to the primary care clinician

Strategies to ProvideStrategies to ProvideCoordinated CareCoordinated Care

The following case study is designed to assist you to implement the Coordinated Care component of the medical home concept during immunization-related patient encounters. Strategies to address specific issues raised in the scenario are included.

Case Study #2: Case Study #2: Coordinated CareCoordinated Care

Billy is a healthy 5 year-old Hispanic boy who is starting kindergarten this year. When Billy’s mom drops him off at school and shows the school nurse his immunization record, the nurse informs her that, according to their state’s immunization requirements, Billy is not current on all of his immunizations. His vaccination record indicates that he has received: 3 DTaP, 2 IPV, 1 Hib, 2 Hepatitis B, 3 Prevnar, 1 Varicella, and 1 MMR.


Question: What should the school nurse Question: What should the school nurse do? What should Billy’s pediatrician do?do? What should Billy’s pediatrician do?


What should the school nurse do? Document that Billy is behind and Document that Billy is behind and

send a letter home to his parents.send a letter home to his parents. Refer Billy to his pediatrician.Refer Billy to his pediatrician.


What should Billy’s pediatrician do?

Follow the written vaccination protocols, Follow the written vaccination protocols, including the including the Catch-up Schedule for for children behind on immunizations.children behind on immunizations.

Billy needs:Billy needs:DTaP #4, IPV #3—both final doses DTaP #4, IPV #3—both final doses

because given after age 4because given after age 4PCV #4—because the first 3 doses PCV #4—because the first 3 doses

given before 24 months of agegiven before 24 months of ageHep B # 3—last doseHep B # 3—last doseMMR #2—he’s doneMMR #2—he’s done


Update the child’s immunization Update the child’s immunization record to reflect which vaccinations record to reflect which vaccinations were givenwere given, dates of administration, , dates of administration, number of doses, intervals between number of doses, intervals between doses, and the child’s age.doses, and the child’s age.

If the physician participates in a immunization registry or child health information system (CHIS), enter data into the system.

If necessary, provide parent education at next visit, and/or provide school

with parent handouts.


Continuously monitor state requirements and the recommended schedule to ensure children are up-to-date.

Consider implementing a reminder-recall system to identify and call in children that are behind.


References: Coordinated References: Coordinated CareCare

1. National Vaccine Advisory Committee. Standards for Child and Adolescent Immunization Practices. Pediatrics. 2003;112:958-963

2. Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for Children Program, United States, 1997. Pediatrics. 1999;104(2)

3. Centers for Disease Control and Prevention. Immunization Registry Progress – United States, January-December 2002. MMWR Morb Mortal Wkly Rep. 2004;53:431-433

References: Coordinated References: Coordinated CareCare

4. Stokley S, Rodewald LE, Maes EF. The impact of record scattering on the measurement of immunization coverage. Pediatrics. 2001;107:91-96

5. Bell KN, Hogue CJR, Manning C, Kendal AP. Risk factors for improper vaccine storage and handling in private clinician offices. Pediatrics, 2001;107:100

Immunization: Continuous Immunization: Continuous CareCare

Continuous: The same primary pediatric clinician practice is available from infancy through adolescence and young adulthood

Continuity of care from birth through the second year of life greatly increases immunization levels3

Multiple clinicians leads to scattering of the immunization record1

Immunization: Continuous Immunization: Continuous CareCare

Improper record keeping can lead to increased costs and extra immunizations

Greater continuity of care is associated with higher quality of care as reported by parents2

Review vaccination and health status of patients at every encounter to determine which vaccines are indicated

Strategies to Provide Strategies to Provide Continuous CareContinuous Care

Regularly review patient records and conduct practice-wide vaccination coverage assessments annually– Identify children behind on

immunizations– Implement recall/reminder or other

strategies to increase immunization rates

Utilize standing orders to allow staff to independently screen patients, identify opportunities for immunization, and administer vaccines under physician supervision (in accordance with local regulations)

Promote immunization at both well and sick visits

Strategies to Provide Strategies to Provide Continuous CareContinuous Care

References: Continuous CareReferences: Continuous Care

1. Yusuf H, Adams M, Rodewald L, Lu P, Rosenthal J, Legum SE, Santoli J. Fragmentation of immunization history among clinicians and parents of children in selected underserved areas. Am J Prev Med. 2002 Aug;23(2):106-12

2. Christakis DA, Wright JA, Zimmerman FJ, Basset AL, Connell FA. Continuity of care is associated with high-quality care by parental report. Pediatrics. 2002;109:e54

3. Irigoyen M, Findley SE, Chen S, Vaughan R, Sternfels P, Caesar A, Metroka A. Early continuity of care and immunization coverage. Ambul Pediatr. 2004 May-Jun;4(3):199-203

Immunization: Immunization: Comprehensive CareComprehensive Care

Comprehensive: Care is delivered or directed by a well-trained physician who is able to manage and facilitate all aspects of immunization and other preventive services

Scope of Problem: Immunization coverage rates are

higher for children receiving all or some vaccines within a medical home1

Immunization: Immunization: Comprehensive CareComprehensive Care

Promoting vaccination within the medical home improves both vaccination coverage and receipt of other preventive services1

Errors maintaining cold-chain (improper vaccine placement, inaccurate thermometers, improper temperature) can affect the access to vaccine quality4

Barriers to Barriers to Comprehensive CareComprehensive Care

Improperly deferring vaccination (i.e., not based on valid contraindications)

Increasingly complex vaccination schedule

Lack of reminder-recall system Improper storage and handling

procedures resulting in spoilage of vaccine

Missed opportunities (MOs) to vaccinate (i.e., vaccine-eligible child does not receive needed vaccines)

– Eliminating MOs could increase immunization coverage by up to 30% or more2, 3


MOs are frequently associated with3,4

– Inappropriate contraindications such as minor febrile illness

– Not giving vaccine at acute care visits

– Not giving all the shots needed at a visit


Reasons for MOsReasons for MOs

Deficits in clinician knowledge3,5

Vaccines delayed due to valid contraindication

Incorrect or overcautious interpretation of contraindications5

Failure to review the child’s vaccination status6

Incomplete vaccine records7

Reasons for MOsReasons for MOs

Physician reluctance to give multiple vaccines simultaneously7

Vaccine delays/shortages8 Practice requirement to

receive physical examination prior to vaccination

Differences Between Differences Between Contraindications & Contraindications &

PrecautionsPrecautions Contraindications: Conditions in a

recipient which greatly increases the chance of a serious adverse reaction

Precautions: Conditions in a recipient which may increase the chance or severity of an adverse reaction, or may compromise the ability of the vaccine to produce immunity

Valid Contraindications vs Valid Contraindications vs PrecautionsPrecautions

ConditionAllergy to ComponentEncephalopathyPregnancyImmunosuppressionSevere illnessRecent blood product

LiveC---CCPP

InactivatedCCVVPV

C=contraindication P=precaution V=vaccinate if indicated

Source: General Recommendations on Immunization, Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. Revised December 2004.

Mild illness Antibiotic therapy Disease exposure or convalescence Pregnancy in the household Breastfeeding Premature birth Allergies to products not in vaccine Family history unrelated to

immunosuppression Need for TB skin testing Need for multiple vaccines

InvalidInvalid Contraindications to Contraindications to Vaccination (not even Vaccination (not even

precautions!)precautions!)

Strategies to Improve Strategies to Improve Comprehensive CareComprehensive Care

Clinicians do not use false Clinicians do not use false contraindicationscontraindications to prevent immunizationsto prevent immunizations

Practices adopt and implement the Standards for Child and Adolescent Immunization Practices established by the National Vaccine Advisory Committee (NVAC)

Vaccines are administered according to the Recommended Childhood and Adolescent Immunization Schedule; physician stays up-to-date about potential new vaccines




Use the recommended Catch-up Schedule for children who have missed or delayed immunization– It makes it easier for staff to figure out

who needs what– Proven to get children up-to-date faster

Practice staff who administer vaccines and staff who manage or support vaccine administration are knowledgeable and receive on-going education


Educational resources about all aspects of immunization are made available

Current Vaccine Information Statements (VISs) are provided and explained to patients/parents prior to vaccination


Staff should follow appropriate procedures for vaccine storage and handling

Staff should reduce vaccine liability and ensure proper coding/reimbursement

Health care professionals follow only medically accepted contraindications

http://www.cdc.gov/nip/publications/vac_mgt_book.pdf

http://www.cdc.gov/nip/publications/vac_mgt_book.pdf


Combination vaccines are utilized when appropriate

Practice staff should regularly conduct assessments to determine immunization coverage rates and incorporate quality improvement measures to raise rates

When possible, participate in a comprehensive state/local immunization registry or CHIS

References: Comprehensive References: Comprehensive CareCare

1. Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for Children Program, United States, 1997. Pediatrics. 1999;104(2)

2. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases: 8th Edition; January 2005

3. Szilagyi PG, Rodewald LE. Missed opportunities for immunizations: a review of the evidence. J Public Health Manage Pract. 1996;2:18-25

4. Sabnis SS, Pomeranz AJ, Lye PS, Amateau MM. Do missed opportunities stay missed? A 6-month follow-up of missed vaccine opportunities in inner city Milwaukee children. Pediatrics. 1998;101:1-4

5. Wood D, Halfon N, Pereyra M, et al. Knowledge of the childhood immunization schedule and of contraindications to vaccinate by private and public clinicians in Los Angeles. Pediatr Infect Dis J. 1996;15:140-145

http://www.cdc.gov/nip/publications/pink/default.htm

http://www.cdc.gov/nip/publications/pink/default.htm

6. Ball TM, Serwint JR. Missed opportunities for vaccination and delivery of preventive care. Arch Pediatr Adolesc Med. 1996;150:858-861

7. Szilagyi PG, Rodewald LE, Humiston SG, et al. Immunization practices of pediatricians and family physicians in the United States. Pediatrics. 1994;94:517-523

8. Gindler JS, Cutts FT, Barnett-Antinori ME, et al. Successes and failures in vaccine delivery: evaluation of the immunization delivery system in Puerto Rico. Pediatrics. 1993;91:315-320

9. Rodewald L. Every medical home needs an immunization recall system. AAP News. February 2001:89

References: Comprehensive References: Comprehensive CareCare

Immunization: Family-Immunization: Family-CenteredCentered

Family-Centered: Care that is based on the understanding that the family is the child’s primary source of strength and support and that the child/family’s perspectives and information are important in clinical decision making1

Immunization: Family-Immunization: Family-CenteredCentered

Scope of Problem: Family-centered care can improve

patient/family outcomes, increase patient/family satisfaction, build on child/family strengths, increase professional satisfaction, decrease health care costs, and lead to more effective use of resources1

Barriers toBarriers toFamily-Centered CareFamily-Centered Care

Parental concerns about vaccine safety or refusal to vaccinate

Patient and physician have differing beliefs regarding vaccination– 25% of parents believe immune

systems are weakened by too many vaccines2

– 19% of parents do not think vaccines were proven safe prior to use in the US2

Barriers toBarriers toFamily-Centered CareFamily-Centered Care

Patient and physician have access to both accurate and inaccurate immunization resources

Poor communication (i.e., differing education/literacy levels, language barriers)

Common Parental Concerns Common Parental Concerns About VaccinesAbout Vaccines

1. The use of Thimerosal (an organomercurial) as an additive in vaccines

2. An unsubstantiated link between the MMR vaccine and autism

3. The necessity of vaccinating children against hepatitis B

4. Pneumococcal conjugate (new vaccine to protect against meningitis, blood infections, ear infections)

Common Parental Common Parental ConcernsConcerns

About VaccinesAbout Vaccines5. Meningococcal vaccine (new

meningococcal conjugate vaccine to protect against meningococcal disease)

6. The relative danger of influenza and the need for a yearly vaccination

7. The relative danger of varicella (chickenpox)

The Facts About The Facts About ThimerosalThimerosal

Thimerosal is a preservative that prevents bacterial and fungal contamination in some vaccines and contains a form of mercury (ethylmercury)

There is no evidence that the trace amounts of Thimerosal in vaccines has caused harm to infants, except for minor side effects like swelling and redness at the injection site

The Facts About The Facts About ThimerosalThimerosal

In 1999, the Public Health Service and the AAP recommended that Thimerosal be taken out of vaccines as a precautionary measure. By the end of 2001, all routine pediatric vaccines contained no Thimerosal or only trace amounts (some Influenza and Td vaccines)

The Facts About MMRThe Facts About MMR

Autism spectrum disorder is a common Autism spectrum disorder is a common developmental disability, affecting 1 in developmental disability, affecting 1 in 166 children166 children33

Concerns have been raised about a Concerns have been raised about a possible link between the proximity of possible link between the proximity of the MMR vaccination administration and the MMR vaccination administration and the development of signs of autismthe development of signs of autism

The Facts About MMRThe Facts About MMR

Studies and independent panels in the Studies and independent panels in the US and in Europe, including experts from US and in Europe, including experts from the the Institute of MedicineInstitute of Medicine and the AAP, and the AAP, have found no association between the have found no association between the MMR vaccination and autismMMR vaccination and autism

The Importance of The Importance of the Hepatitis B Vaccinethe Hepatitis B Vaccine

The hepatitis B vaccine is the best protection a child can have against a dangerous disease with lifelong serious health problems

Vaccinating early against hepatitis B assures children’s immunity when they are the most vulnerable to the worst complications of hepatitis B and before they enter the high risk adolescent years

The Importance of The Importance of the Hepatitis B Vaccinethe Hepatitis B Vaccine

Before the vaccine was introduced, 20,000 children under age 10 became infected each year

The Importance of the Pneumococcal Conjugate

Vaccine Pneumococcus bacteria can cause

meningitis and other blood infections. Meningitis is an inflammation of the brain and spinal cord, which can lead to brain damage, mental retardation, and even death

Pneumococcal conjugate vaccine provides superior protection against this serious and deadly infection

The Importance of the Pneumococcal Conjugate

Vaccine Meningitis symptoms in children are

less obvious than in adults. The disease can go undetected and untreated. Vaccination can protect children from this uncertainty

The Importance of the Meningococcal Vaccine

Meningococcal disease is caused by bacteria that infect the bloodstream, lining of the brain, and spinal cord, often causing serious illness.

Ten to 14% of people with meningococcal disease die, and 11-19% of survivors have permanent disabilities

The Importance of the Meningococcal Vaccine

In 2005, a new quadrivalent conjugate vaccine (MCV4) was licensed and recommended for children 11-12 and teens entering high school, as well as college freshman living in dormitories

A quadrivalent polysaccharide vaccine is available in the U.S.; however, it is not recommended for routine vaccination use

The Importance of The Importance of the Influenza Vaccinethe Influenza Vaccine

In an average year, the flu causes 36,000 deaths and more than 226,000 hospitalizations in the US. An annual flu vaccine is the best way to reduce circulation of the flu

The Importance of The Importance of the Influenza Vaccinethe Influenza Vaccine

Annual shots are necessary because flu viruses change from year to year. A vaccine made against flu viruses circulating last year may not protect against the newer viruses

Immunity to the disease declines over time and may be too low to provide protection after 1 year

The Importance of The Importance of the Varicella Vaccinethe Varicella Vaccine

Many people believe that the chickenpox is a harmless illness

In 1999, an average of 1 child a week died in the US from complications of chickenpox

These complications include encephalitis, a brain infection; severe staph and strep secondary infections (flesh-eating strep and toxic shock syndrome); hepatitis; and pneumonia

Helping Families Locate Helping Families Locate Reliable Information on the Reliable Information on the

InternetInternetThe Internet can be a confusing place to The Internet can be a confusing place to navigate! To help parents locate factual navigate! To help parents locate factual vaccine information on the Web, practice vaccine information on the Web, practice staff should provide information and staff should provide information and resources about how to locate and resources about how to locate and evaluate Web sitesevaluate Web sites

Additional Reading: Content and Design Additional Reading: Content and Design Attributes of Antivaccination Web Sites. Attributes of Antivaccination Web Sites. Wolfe RM, Sharp LK, Lipsky MS. JAMA Wolfe RM, Sharp LK, Lipsky MS. JAMA 2002;287:3245-32482002;287:3245-3248

State Exemptions: State Exemptions: Information and Information and

DefinitionsDefinitions As of 2004, all 50 states allow vaccination As of 2004, all 50 states allow vaccination

exemptions for medical reasons, as exemptions for medical reasons, as determined by a physiciandetermined by a physician

48 states (all except Mississippi & West 48 states (all except Mississippi & West Virginia) allow exemptions for religious Virginia) allow exemptions for religious reasons- when immunizations contradict reasons- when immunizations contradict the parent’s sincere religious beliefsthe parent’s sincere religious beliefs

State Exemptions: State Exemptions: Information and Information and

DefinitionsDefinitions 20 states (AZ, AR, ID, LA, ME, MI, MN, MO, 20 states (AZ, AR, ID, LA, ME, MI, MN, MO,

NE, NM, ND, CA, CO, OH, OK, TX, UT, VT, NE, NM, ND, CA, CO, OH, OK, TX, UT, VT, WA, and WI) allow exemptions for WA, and WI) allow exemptions for philosophical reasons- other non-religious philosophical reasons- other non-religious beliefs held by the parents who do not beliefs held by the parents who do not believe their child should be immunizedbelieve their child should be immunized

Additional information on state Additional information on state exemptions is available at exemptions is available at http://www.cispimmunize.org/pro/StateReqhttp://www.cispimmunize.org/pro/StateRequirements.html uirements.html

Strategies to Provide Strategies to Provide Family-Centered CareFamily-Centered Care

Treat the family as a partner in their Treat the family as a partner in their child’s care and promote shared child’s care and promote shared decision-makingdecision-making

Provide the parent with an Provide the parent with an immunization record book to track immunization record book to track their child’s vaccination history and their child’s vaccination history and gain better understanding of which gain better understanding of which vaccines are needed and whenvaccines are needed and when


When necessary, clinicians should document parent’s refusal to vaccinate in the patient’s record. Providers may utilize the AAP Refusal to Vaccinate Form

Provider should be aware of local school and childcare immunization requirements


Be available to answer questions or Be available to answer questions or concernsconcerns

Educate parents about risks versus Educate parents about risks versus benefits of vaccination benefits of vaccination

Warn them about inaccurate Warn them about inaccurate information on the Webinformation on the Web


Use Vaccine Information Statements Use Vaccine Information Statements (available in simple wording, multiple (available in simple wording, multiple languages) languages)

Provide culturally-appropriate Provide culturally-appropriate educational materials at the necessary educational materials at the necessary literacy level literacy level

– Resource: American Academy of Pediatrics and Resource: American Academy of Pediatrics and National Perinatal Association. National Perinatal Association. Transcultural Aspects of Transcultural Aspects of Perinatal Health Care: A Resource Guide. Perinatal Health Care: A Resource Guide. Shah MA, ed. Shah MA, ed. National Perinatal Association; 2004National Perinatal Association; 2004

The following case study is The following case study is designed to assist you to designed to assist you to implement the implement the Family-Centered Family-Centered CareCare component of the medical component of the medical home concept during home concept during immunization-related patient immunization-related patient encounters. Strategies to address encounters. Strategies to address specific issues raised in the specific issues raised in the scenario are included.scenario are included.

Case Study #3: Case Study #3: Family-Centered CareFamily-Centered Care

Jane Smith is a new mom who is bringing Jane Smith is a new mom who is bringing her baby girl in for her first visit with the her baby girl in for her first visit with the pediatrician. Jane has done some research pediatrician. Jane has done some research on the Internet regarding vaccine safety. on the Internet regarding vaccine safety. From this research, Jane has many From this research, Jane has many questions and concerns regarding questions and concerns regarding vaccination, including the risks vs benefits vaccination, including the risks vs benefits of vaccines and possible side effects of of vaccines and possible side effects of vaccination. She is confused about the vaccination. She is confused about the complexity of the vaccination schedule complexity of the vaccination schedule and is concerned about the pain her baby and is concerned about the pain her baby might feel when the vaccine is injected. might feel when the vaccine is injected.


Question: How can Jane’s pediatrician Question: How can Jane’s pediatrician create a partnership with her and create a partnership with her and provide family-centered care?provide family-centered care?

Case Study #3:Case Study #3:Family-Centered CareFamily-Centered Care

Jane’s pediatrician should provide:Jane’s pediatrician should provide: An immunization record book so that An immunization record book so that

she can take partnership in her child’s she can take partnership in her child’s care care

Educational resources regarding the Educational resources regarding the safety of vaccines (Resource: “Compare safety of vaccines (Resource: “Compare the Risks”).the Risks”).

Additional Resources:Additional Resources:–“Evaluating Information on the Web”“Evaluating Information on the Web” fact sheetfact sheet–“Be There for Your Child During Shots” “Be There for Your Child During Shots” fact sheetfact sheet

http://www.immunizationinfo.org/parents/evaluatingWeb.cfm

http://www.cdc.gov/nip/publications/pink/Appendices/G/comft_tearoff.pdf

Jane’s pediatrician should also:Jane’s pediatrician should also:– Review the Review the Recommended Childhood Recommended Childhood

and Adolescent Immunization Scheduleand Adolescent Immunization Schedule to address confusionto address confusion

– Update the patient’s record and remind Update the patient’s record and remind Jane which immunizations will be due at Jane which immunizations will be due at the next visitthe next visit

– Identify practice staff to serve as an Identify practice staff to serve as an Immunization Champion to be readily Immunization Champion to be readily available to answer questions after available to answer questions after shots are givenshots are given


References: References: Family-Centered CareFamily-Centered Care

1.1. American Academy of Pediatrics, Committee on American Academy of Pediatrics, Committee on Hospital Care. Family-centered care and the Hospital Care. Family-centered care and the pediatrician’s role. pediatrician’s role. Pediatrics.Pediatrics. 2003;112:691-696 2003;112:691-696

2.2. Gellin BG, Maibach EW, Marcuse EK.Gellin BG, Maibach EW, Marcuse EK.Do parents understand immunizations? A national Do parents understand immunizations? A national telephone survey. telephone survey. PediatricsPediatrics. 2000;106:1097-1102 . 2000;106:1097-1102

3.3. American Academy of Pediatrics, Autism Expert American Academy of Pediatrics, Autism Expert Panel, Committee on Children with Disabilities. Panel, Committee on Children with Disabilities. Autism A.L.A.R.M. Website: Autism A.L.A.R.M. Website: www.medicalhomeinfo.org (Accessed August 29, www.medicalhomeinfo.org (Accessed August 29, 2005).2005).

Immunization: Immunization: Compassionate CareCompassionate Care

Compassionate:Compassionate: Concern for the well- Concern for the well-being of the child and family is being of the child and family is expressed and demonstrated in verbal expressed and demonstrated in verbal and nonverbal interactions. Efforts are and nonverbal interactions. Efforts are made to understand and empathize with made to understand and empathize with the feelings and perspectives of the the feelings and perspectives of the family and childfamily and child

Immunization: Immunization: Compassionate CareCompassionate Care

A patient that feels understood is more A patient that feels understood is more likely to adhere to the physician’s likely to adhere to the physician’s recommendationsrecommendations11

Patients tend to judge the quality of Patients tend to judge the quality of treatment on the basis of physicians’ treatment on the basis of physicians’ “affective” behavior towards them“affective” behavior towards them22

Barriers to Barriers to Compassionate CareCompassionate Care

Limited time during patient visitLimited time during patient visit Cultural or racial/ethnic differences Cultural or racial/ethnic differences

between patients and physiciansbetween patients and physicians Ignoring or misinterpreting parents’ or Ignoring or misinterpreting parents’ or

patients’ nonverbal cuespatients’ nonverbal cues Operating from a medical modelOperating from a medical model

– ““Us versus them,” paternalisticUs versus them,” paternalistic

Strategies to Provide Strategies to Provide Compassionate CareCompassionate Care

Listen unhurriedly to family concerns Listen unhurriedly to family concerns and respond to them appropriatelyand respond to them appropriately

Honor or validate family experiences, Honor or validate family experiences, beliefs, questions and perspectivesbeliefs, questions and perspectives

Strategies to Provide Strategies to Provide Compassionate CareCompassionate Care

Address specific concerns directly:Address specific concerns directly:– Discuss myths or misconceptions Discuss myths or misconceptions

openly and dispassionatelyopenly and dispassionately– Offer them the pamphlet “Be There for Offer them the pamphlet “Be There for

Your Child During Shots” Your Child During Shots” Ensure privacy/confidentiality for familiesEnsure privacy/confidentiality for families

The following case study is The following case study is designed to assist you to designed to assist you to implement the implement the Compassionate Compassionate CareCare component of the medical component of the medical home concept during home concept during immunization-related patient immunization-related patient encounters. Strategies to address encounters. Strategies to address specific issues raised in the specific issues raised in the scenario are included.scenario are included.

Case Study #4: Case Study #4: Compassionate CareCompassionate Care

As Kristen enters the pediatrician’s office with her baby girl, the pediatrician, Dr Susan, notices a worried look on Kristen’s face. Dr Susan asks Kristen if something is bothering her.

Kristen explains that she is worried about the number of vaccines her daughter will receive in one visit, specifically the effect on her immune system, as well as about the pain that her daughter may experience.


Question: What should Dr Susan do?Question: What should Dr Susan do?


Dr Susan tells Kristen that she Dr Susan tells Kristen that she understands her concerns. She provides understands her concerns. She provides Kristen with verbal and written explanation Kristen with verbal and written explanation about baby’s immune systems capability about baby’s immune systems capability of handling multiple vaccines. She also of handling multiple vaccines. She also leads Kristen toward additional resources. leads Kristen toward additional resources.

Dr Susan explains to Kristen the ways to Dr Susan explains to Kristen the ways to comfort a baby before, during, and after comfort a baby before, during, and after vaccination and provides her with a fact vaccination and provides her with a fact sheet, “sheet, “Be There for Your Child During ShotsBe There for Your Child During Shots,” ,” which describes methods of comfort.which describes methods of comfort.

http://www.cdc.gov/nip/publications/pink/Appendices/G/comft_tearoff.pdf

Dr Susan encourages Kristen to ask Dr Susan encourages Kristen to ask her about any additional concerns or her about any additional concerns or questions.questions.


References: Compassionate References: Compassionate CareCare

1.1. Bellett PS, Maloney MJ. The importance of Bellett PS, Maloney MJ. The importance of empathy as an interviewing skill in medicine. empathy as an interviewing skill in medicine. JAMA.JAMA. 1991;266:1831-1832 1991;266:1831-1832

2.2. Ben-Sira Z. Ben-Sira Z. Stress, Disease and Primary Medical Stress, Disease and Primary Medical Care.Care. Gower, England, 1986 Gower, England, 1986

3.3. Offit PA, et al. Addressing parents’ concerns: do Offit PA, et al. Addressing parents’ concerns: do multiple vaccines overwhelm or weaken the multiple vaccines overwhelm or weaken the infant’s immuneinfant’s immune s system? ystem? Pediatrics. Pediatrics. 2002;109:124-129. Available at: 2002;109:124-129. Available at: http://www.cispimmunize.org/fam/fam_main.html http://www.cispimmunize.org/fam/fam_main.html (Accessed: August 29, 2005)(Accessed: August 29, 2005)

4.4. Offit PA, Jew RK. Addressing parents’ concerns: do Offit PA, Jew RK. Addressing parents’ concerns: do vaccines contain harmful preservatives, vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics. adjuvants, additives, or residuals? Pediatrics. 2003;112:1394-14012003;112:1394-1401

Immunization: Immunization: Culturally-EffectiveCulturally-Effective

Culturally-Effective:Culturally-Effective: The delivery of care The delivery of care within the context of appropriate within the context of appropriate physician knowledge, understanding, and physician knowledge, understanding, and an appreciation of all cultural distinctionsan appreciation of all cultural distinctions

Family’s cultural background, including Family’s cultural background, including beliefs, rituals, and customs, are beliefs, rituals, and customs, are recognized, valued, and respected and recognized, valued, and respected and incorporated into the care plan incorporated into the care plan 33

Immunization: Immunization: Culturally-EffectiveCulturally-Effective

Scope of Problem:Scope of Problem: Immunization coverage rates are Immunization coverage rates are

lower among children living in lower among children living in povertypoverty1 1 and among black and and among black and Hispanic childrenHispanic children22

By 2020, approximately 40% of By 2020, approximately 40% of school-age children will be of non-school-age children will be of non-white racial or ethnic backgroundswhite racial or ethnic backgrounds33

– Cultural Competence:Cultural Competence: the awareness of the awareness of cultural/religious practices, beliefs, and cultural/religious practices, beliefs, and differences, enabling clinicians to adapt health differences, enabling clinicians to adapt health care in accordance with the ethnocultural/religious care in accordance with the ethnocultural/religious heritage of the individual, family, and heritage of the individual, family, and communitycommunity44

– Linguistic Competence:Linguistic Competence: the provision of bilingual the provision of bilingual staff or interpretation services for all clients staff or interpretation services for all clients without English language proficiencywithout English language proficiency44

– Spiritual Competence:Spiritual Competence: the ability to identify and the ability to identify and understand one's own values and spiritual beliefs understand one's own values and spiritual beliefs in the context of a pluralistic society, recognizing in the context of a pluralistic society, recognizing how interactions with patients and families may be how interactions with patients and families may be affected by religious differencesaffected by religious differences44

Important Definitions

Barriers to Barriers to Culturally-Effective CareCulturally-Effective Care

Differences in cultural Differences in cultural backgrounds including backgrounds including differing perceptions and beliefsdiffering perceptions and beliefs

Language and communication barriersLanguage and communication barriers Lack of skilled staff or resourcesLack of skilled staff or resources Lack of appropriate services (i.e., Lack of appropriate services (i.e.,

patients that require interpretation vs patients that require interpretation vs translation services)translation services)

Strategies to Provide Strategies to Provide Culturally-Effective CareCulturally-Effective Care

Immunization clinicians should be aware Immunization clinicians should be aware of any differences between their own of any differences between their own cultural/religious values and those of the cultural/religious values and those of the patient/familypatient/family44

Foster mutual respect and understandingFoster mutual respect and understanding44

Determine the most effective way of Determine the most effective way of adapting professional interpretations and adapting professional interpretations and recommendations to the value system of recommendations to the value system of each familyeach family44


Provide safe and realistic choices to Provide safe and realistic choices to patients/families within the least patients/families within the least restrictive environmentrestrictive environment44

Promote equity for all cultural/religious Promote equity for all cultural/religious backgroundsbackgrounds44


Openly address cultural barriers with respect and demonstrate sensitivity to conflicts with child/family’s cultural patterns

Recognize, value, respect, and incorporate the child/family’s cultural background into care; including beliefs, rituals, and customs


Listen to verbal and nonverbal cues, Listen to verbal and nonverbal cues, using translation or interpretation using translation or interpretation resources if necessaryresources if necessary

Ensure the child/family understands the Ensure the child/family understands the results of the medical encounterresults of the medical encounter

Consider medical, religious, and Consider medical, religious, and philosophical exemptions to philosophical exemptions to immunization (understanding state law immunization (understanding state law and requirements)and requirements)


If possible, have bilingual staff/volunteers If possible, have bilingual staff/volunteers on handon hand

Display culturally diverse pictures, Display culturally diverse pictures, posters, magazines, etcposters, magazines, etc

Learn key words/phrases in the patient’s Learn key words/phrases in the patient’s languagelanguage


Provide written materials, including VISs, Provide written materials, including VISs, in the family’s primary language and at in the family’s primary language and at the appropriate literacy level; supplement the appropriate literacy level; supplement with additional resources (i.e., visual aids, with additional resources (i.e., visual aids, videos) if necessaryvideos) if necessary

Educate and train immunization clinicians Educate and train immunization clinicians at all levels (medical school, residency at all levels (medical school, residency programs, and continuing medical programs, and continuing medical education)education)

The following case study is The following case study is designed to assist you to designed to assist you to implement the implement the Culturally-Culturally-Effective CareEffective Care component component of the medical home concept of the medical home concept during immunization-related during immunization-related patient encounters. patient encounters. Strategies to address specific Strategies to address specific issues raised in the scenario issues raised in the scenario are included.are included.

Case Study #5: Case Study #5: Culturally-EffectiveCulturally-Effective

Derek, a practicing Catholic, has a 5 year Derek, a practicing Catholic, has a 5 year old son, Jack, who will be attending old son, Jack, who will be attending kindergarten in 3 months. Derek and his kindergarten in 3 months. Derek and his son recently relocated from Texas to son recently relocated from Texas to Illinois. Derek takes his son to their new Illinois. Derek takes his son to their new pediatrician, Dr Bob.pediatrician, Dr Bob.

Dr Bob reviews Jack’s immunization Dr Bob reviews Jack’s immunization history and notices that Jack has not history and notices that Jack has not received a varicella vaccine, which is received a varicella vaccine, which is required by law before school entry. required by law before school entry.

Dr Bob asks Derek the reason for this and Dr Bob asks Derek the reason for this and Derek explains that in Texas, he received Derek explains that in Texas, he received a philosophical exemption for varicella a philosophical exemption for varicella vaccine because the vaccination was vaccine because the vaccination was developed using aborted fetuses. developed using aborted fetuses. Derek’s religious beliefs do not permit Derek’s religious beliefs do not permit abortion of any kind.abortion of any kind.

Dr Bob tries to address Derek’s concern by explaining what the vaccine is and does and that its production does not involve aborted fetuses.



Dr. Bob also explains that Illinois law only allows religious exemptions. Therefore, unless he has a religious objection, Jack will need to be vaccinated with varicella vaccine prior to entering kindergarten.

Derek is unhappy with this option and refuses to vaccinate Jack.


Question: What should Dr Bob do to address this cultural difference?


Dr Bob should: Explain to Derek that there is a religious

exemption in Illinois, and given that he is Catholic, perhaps he could talk to his priest about it.

Listen to and respect Derek’s concerns; let Derek know that he is respected and his beliefs are understood.


Explain the state immunization laws to Derek; if Jack is not vaccinated, he cannot attend school.

Explain to Derek the importance of vaccination, including the benefits and risks of varicella vaccine.

Dr Bob should: If, after discussion about the importance of

vaccination and the risks of not vaccinating, Derek still refuses, Dr Bob should document the discussion and consider having Derek sign a statement affirming his decision not to vaccinate (i.e., AAP Refusal to Vaccinate Form).

Continue to make himself available to answer additional questions from Derek as he gains new information.

Case Study #5: Culturally-Case Study #5: Culturally-EffectiveEffective

Provide educational materials regarding the varicella vaccine for Derek to review at home.

Provide parent-focused fact sheets and Web-based resources that explain the importance of vaccines and provide detailed answers to common vaccine concerns.

Case Study #5: Culturally-Case Study #5: Culturally-EffectiveEffective

References: References: Culturally-EffectiveCulturally-Effective

1.1. Klevens RM, Luman ET. US children living in and Klevens RM, Luman ET. US children living in and near poverty. Risk of vaccine-preventable diseases. near poverty. Risk of vaccine-preventable diseases. Am J Prev Med.Am J Prev Med. 2001;20:41-46 2001;20:41-46

2.2. Wood D, Donald-Sherbourne C, Halfon N, et al. Wood D, Donald-Sherbourne C, Halfon N, et al. Factors related to immunization status among inner-Factors related to immunization status among inner-city Latino and African American preschoolers. city Latino and African American preschoolers. Pediatrics.Pediatrics. 1995;96:295-301 1995;96:295-301

3.3. American Academy of Pediatrics, Committee on American Academy of Pediatrics, Committee on Pediatric Workforce. Culturally effective pediatric Pediatric Workforce. Culturally effective pediatric care: education and training issues. care: education and training issues. Pediatrics.Pediatrics. 1999;103:167-1701999;103:167-170

4.4. American Academy of Pediatrics. Preface. In: Shah American Academy of Pediatrics. Preface. In: Shah MA, ed. MA, ed. Transcultural Aspects of Perinatal Health Transcultural Aspects of Perinatal Health Care: A Resource Guide. Care: A Resource Guide. Elk Grove Village, IL: Elk Grove Village, IL: American Academy of Pediatrics; 2004, xv-xxixAmerican Academy of Pediatrics; 2004, xv-xxix

Pediatricians and practice staff should work together to remove perceived vaccination barriers of parents

Pediatricians and practice staff should use multiple strategies to improve delivery of vaccines

Implementing “Immunization in a Medical Implementing “Immunization in a Medical Home” Concepts Home” Concepts

at the Practice-Levelat the Practice-Level

Choices among strategies should be tailored to the individual child/family

Practice staff, should regularly review office protocols and procedures to ensure efficiency & accuracy

Implementing “Immunization in a Medical Implementing “Immunization in a Medical Home” ConceptsHome” Concepts

at the Practice-Levelat the Practice-Level

AcronymsAcronymsAAPAAP American Academy of PediatricsAmerican Academy of Pediatrics

AFIXAFIX Assessment, Feedback, Incentives, eXchangeAssessment, Feedback, Incentives, eXchange

CASACASA Clinical Assessment Software ApplicationClinical Assessment Software Application

CDCCDC Centers for Disease Control and PreventionCenters for Disease Control and Prevention

CHISCHIS Child Health Information SystemChild Health Information System

CSHCNCSHCN Children with Special Health Care NeedsChildren with Special Health Care Needs

EMREMR Electronic Medical RecordElectronic Medical Record

MOMO Missed OpportunityMissed Opportunity

NVACNVAC National Vaccine Advisory CommitteeNational Vaccine Advisory Committee

SCHIPSCHIP State Child Health Insurance ProgramState Child Health Insurance Program

VFCVFC Vaccines for Children programVaccines for Children program

VAERSVAERS Vaccine Adverse Event Reporting SystemVaccine Adverse Event Reporting System

VICPVICP Vaccine Injury Compensation ProgramVaccine Injury Compensation Program

VISVIS Vaccine Information StatementVaccine Information Statement

Vaccine-Preventable Vaccine-Preventable DiseasesDiseases

Diphtheria, Tetanus toxoids, acellular Pertussis Diphtheria, Tetanus toxoids, acellular Pertussis (DTaP/Tdap)(DTaP/Tdap)

Haemophilus InfluenzaeHaemophilus Influenzae type b (Hib) type b (Hib)

Inactivated Poliovirus Vaccine (IPV)Inactivated Poliovirus Vaccine (IPV)

Measles, Mumps, Rubella (MMR)Measles, Mumps, Rubella (MMR)

Meningococcal (Menactra/MCV4)Meningococcal (Menactra/MCV4)

Influenza (LAIV, FluMist)Influenza (LAIV, FluMist)

Varicella (chicken pox)Varicella (chicken pox)

Hepatitis BHepatitis B

Pneumococcal Disease (PCV7/Prevnar)Pneumococcal Disease (PCV7/Prevnar)

Hepatitis A (given in selected areas of the US)Hepatitis A (given in selected areas of the US)

Additional Web-based Additional Web-based ResourcesResources

Childhood Immunization Support Program (CISP) is Childhood Immunization Support Program (CISP) is a joint program of the AAP and CDC. The CISP a joint program of the AAP and CDC. The CISP provides extensive information on immunizations provides extensive information on immunizations for health care professionals and families. Web for health care professionals and families. Web site: site: www.cispimmunize.orgwww.cispimmunize.org (Accessed: August 29, (Accessed: August 29, 2005)2005)

Teaching Immunization Delivery and Evaluation Teaching Immunization Delivery and Evaluation (TIDE) is an internet-based continuing education (TIDE) is an internet-based continuing education program in childhood immunizations. Web site: program in childhood immunizations. Web site: www.musc.edu/tidewww.musc.edu/tide (Accessed: August 29, 2005) (Accessed: August 29, 2005)

Centers for Disease Control and Prevention Centers for Disease Control and Prevention National Immunization Program (CDC NIP) provides National Immunization Program (CDC NIP) provides leadership for the planning, coordination, and leadership for the planning, coordination, and conduct of immunization activities nationwide. Web conduct of immunization activities nationwide. Web site: site: www.cdc.gov/nipwww.cdc.gov/nip (Accessed: August 29, 2005) (Accessed: August 29, 2005)

http://www.cispimmunize.org/

http://www.musc.edu/tide

http://www.cdc.gov/nip

Immunization Action Coalition (IAC) creates and Immunization Action Coalition (IAC) creates and distributes educational materials for health distributes educational materials for health professionals and the public that enhance the delivery professionals and the public that enhance the delivery of safe and effective immunization services. Web site: of safe and effective immunization services. Web site: www.immunize.orgwww.immunize.org (Accessed: August 29, 2005)(Accessed: August 29, 2005)

National Network for Immunization Information (NNII) National Network for Immunization Information (NNII) provides the public, health professionals, policy makers, provides the public, health professionals, policy makers, and the media with up-to-date, scientifically valid and the media with up-to-date, scientifically valid information related to immunization. Web site: information related to immunization. Web site: www.immunizationinfo.orgwww.immunizationinfo.org (Accessed: August 29, 2005)(Accessed: August 29, 2005)

National Partnership for Immunization (NPI) works to National Partnership for Immunization (NPI) works to improve the effectiveness of efforts to reduce vaccine improve the effectiveness of efforts to reduce vaccine preventable disease among infants, children, preventable disease among infants, children, adolescents, and adults. Web site: adolescents, and adults. Web site: www.partnersforimmunization.orgwww.partnersforimmunization.org (Accessed: August (Accessed: August 29, 2005)29, 2005)

Additional Web-based Additional Web-based ResourcesResources

http://www.immunize.org/

http://www.immunizationinfo.org/

http://www.partnersforimmunization.org/

Other ResourcesOther Resources Recommended Childhood and Adolescent Recommended Childhood and Adolescent

Immunization ScheduleImmunization Schedule Recommended Catch-up ScheduleRecommended Catch-up Schedule Guide to Contraindications Guide to Contraindications Summary of Rules for Childhood and Adolescent Summary of Rules for Childhood and Adolescent

Immunization Immunization VISs in over 30 languages VISs in over 30 languages AAP Refusal to Vaccinate FormAAP Refusal to Vaccinate Form Vaccine Management: Recommendations for Vaccine Management: Recommendations for

Handling and Storage of Selected BiologicalsHandling and Storage of Selected Biologicals Vaccines for Children ProgramVaccines for Children Program

Other ResourcesOther Resources Immunization Registry Clearinghouse Vaccine-Preventable Diseases: Improving

Vaccination Coverage in Children, Adolescents, and Adults Report on Recommendations from the Task Force on Community Prevention Services

National Childhood Vaccine Injury Act Vaccine Injury Table

Immunization Coverage in the US, National Immunization Survey Data

About the Training ToolAbout the Training ToolLead Author:

David Wood, MD, MPH, FAAP, Council on Community Pediatrics (COCP) and Childhood Immunization Support Program Childhood Immunization Support Program (CISP) Project Advisory Committee(CISP) Project Advisory Committee

AAP Reviewers: Charles Onufer, MD, FAAP, Medical Home Project Advisory Committee Gilbert Handal, MD, FAAP, COCP and CISP Project Advisory CommitteeEdgar Marcuse, MD, MPH, FAAP, AAP Immunization Advisory Team

AAP Board of Directors Reviewer: Alan Kohrt, MD, FAAP

AcknowledgmentsAcknowledgmentsJill Ackermann, Manager, Medical Home Surveillance and Screening, Department of Community and Specialty Pediatrics

Carmen Mejia, Manager, Immunization Initiatives, Department of Practice

Elizabeth Sobczyk, Program Coordinator, Immunization Initiatives, Department of Practice

*The development of this training tool was supported by a grant from the CDC (Childhood Immunization Support Program, Cooperative Agreement No. U66/CCU524285-01)

About AAP Immunization About AAP Immunization Initiatives Initiatives

In an effort to help pediatricians address the barriers to increasing and maintaining national immunization coverage levels, the AAP, in collaboration with the CDC, established the Childhood Immunization Support Program (CISP). Since 1999, the Academy’s CISP grant has been working to improve the immunization delivery system for children across the nation.

CISP GoalsCISP Goals

Goal 1: Promote quality improvement and best immunization practices in community- and office-based primary care settings and other identified medical homes.

Goal 2: Enable pediatricians and pediatric health care professionals to communicate effectively with parents about vaccine benefits.

Goal 3: Promote system-wide improvements in the national immunization delivery system.

CISP ResourcesCISP Resources

Key Contact Network: A key contact network of immunization clinicians who are instrumental in promoting immunization delivery has been developed.

The AAP Immunization Initiatives Newsletter is disseminated electronically to members of the network. To receive a copy of this monthly publication, e-mail [email protected]


Vaccine Safety Reports: The Measles -Mumps-Rubella Vaccine and Autistic Spectrum Disorder: Report From the New Challenges in Childhood Immunizations Conference, based on the conference convened in June 2000 was published in the May 2001 issue of Pediatrics.

*A variety of AAP Policy Statements, Clinical Practice Guidelines, and Technical Reports on immunizations and related topics are also available.


Technical Assistance: Technical assistance on immunization issues is provided to pediatricians, other health care professionals, and others in an effort to support their efforts to communicate with parents around vaccine safety issues and immunize children within a medical home.

CISP ResourcesCISP ResourcesResource Publications: Fact sheets, brochures, educational posters, AAP policy statements and technical reports, and strategies on a variety of immunization related topics are provided for pediatric office practices.


CISP Web siteCISP Web site: For fast, helpful and : For fast, helpful and accurate information on immunizations accurate information on immunizations for parents, the public, and all health care for parents, the public, and all health care professionals visit: professionals visit: www.cispimmunize.org www.cispimmunize.org or or www.aap.org www.aap.org and click the Immunization Information and click the Immunization Information button on the homepage.button on the homepage.


The AAP Compendium of Immunization Resources and Organizations is an organized listing of national and state-based

organizations and initiatives, including AAP chapter immunization activities. In addition, the resource provides a compilation of immunization educational resources for parents and pediatricians. An on-line version of the Compendium is available on the CISP Web site.

Contact UsContact Us

For more information about the CISP, to receive copies of our materials, or to be added to the CISP key contact network, please contact:

American Academy of Pediatrics

Department of Practice

141 Northwest Point Blvd.

Elk Grove Village, IL 60007

Tel: 800/433-9016 ext 7106 Fax: 847/228-6432

E-mail: [email protected]

Immunization in the Medical Home Immunization in the Medical Home by David Wood, MD, MPH, FAAP AAP...

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