Immunization in the Medical Home by David Wood, MD, MPH, FAAP AAP Council on Community Pediatrics

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Immunization in the Medical Homeby David Wood,
MD, MPH, FAAP AAP Council on Community
Pediatrics AAP Childhood Immunization Support
Program
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About the Presentation

• 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 pediatricians active
  application of knowledge, AAP policies, and best
  practice guidelines that apply to immunizations.

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Learning 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

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American Academy of Pediatrics Stance on
Immunizations

• 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.

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Understanding the Pediatricians Role in Vaccine
Administration

• Primary care practices delivered 80 of vaccine
  administration1
• Vaccines prevent 10.5 million diseases per birth
  cohort in the US2
• Administering seven vaccines saves society over
  40 billion a year3

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Comparison of Maximum and Current Reported
Morbidity, Vaccine-Preventable Diseases Vaccine
Adverse Events, US4
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
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References

• Santoli JM, Szilagyi PG, Rodewald LE. Barriers to
  immunization and missed opportunities. Pediatric
  Annals. 199827366-374
• Centers for Disease Control and Prevention. Ten
  great public health achievements United States,
  1990-1999. MMWR Morb Mortal Wkly Rep.
  199948241-243
• Zhou F, et al. Economic Evaluation of the
  7-Vaccine Routine Childhood Immunization Schedule
  in the United States, 2001. Arch Pediatr Adolesc
  Med. 20051591136-1144. Available at
  http//archpedi.ama-assn.org/cgi/content/short/159
  /12/1136 (Accessed August 6, 2008)
• 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

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What Is A Medical Home?

• A medical home is not a building, house, or
  hospital, but rather an approach to providing
  comprehensive primary care
• Medical Home is a way to provide cost effective
  quality health care

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The 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. 2002110184-186
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Applying Medical Home Principles Can

• Improve health monitoring and delivery of
  preventive services
• Track needed immunizations
• Reduce missed opportunities
• Facilitate practice team efforts to educate
  families

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Applying Medical Home Principles Can

• Improve immunization delivery for children with
  chronic conditions
• Monitor immunization for children needing special
  immunizations (Influenza, synagis, pneumococcal
  polysaccharide, etc.)
• Improve patient compliance

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Applying Medical Home Principles Can

• 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

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Immunization Accessible Care

• Accessible Physically and economically
• accessible to all patients
• Immunizations are available and administered
  according to the harmonized immunization schedule

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Immunization Accessible Care

• 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

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Patient Barriers to Accessible Care

• Problems scheduling appointments
• Cant get off work, long office wait times
• Lack of transportation
• Costs of immunization/administration fees

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Patient Barriers to Accessible Care

• Uncertainty about how to access free vaccines
• Confusion about the vaccination schedule
• Vaccine safety concerns or misconceptions

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Physician Barriers to Accessible Care

• Increasingly complex immunization schedule
• Increased staff time for documentation and
  patient education
• Large uninsured and/or underinsured patient
  populations

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Physician Barriers to Accessible Care

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

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Strategies to Provide Accessible Care

• Financially Accessible
• All forms of insurance are accepted, including
• Medicaid
• SCHIP
• Practice participates in Vaccines for Children
  (VFC) program

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Strategies to Provide Accessible Care

• Changes in insurance are accommodated
• Clinicians/AAP chapters work with third-party
  payers (public and private) to ensure
  reimbursement and coverage of vaccine

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Strategies to Provide Accessible Care

• 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

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Strategies to Provide Accessible Care

• 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

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Strategies to Provide Accessible Care

• 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

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

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Case Study 1 Accessible 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 Schedules.
  Prior to the change in recommendations, Dr Weiss
  immunized lt250 children against influenza. The
  practice already has pre-ordered vaccine on hand.

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Case Study 1 Accessible Care

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

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Case Study 1 Accessible Care

• 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.

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Case Study 1 Accessible Care

• 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.

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Case Study 1 Accessible Care

• 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
  states VFC program.

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References Accessible Care

• 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. 20041131485-1492
• 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
• Institute of Medicine. Vaccine Financing In the
  21st Century. National Academies Press,
  Washington DC, 2004
• National Vaccine Advisory Committee. Standards
  for Child and Adolescent Immunization Practices.
  Pediatrics. 2003112958-963

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Immunization Coordinated Care

• 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

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Immunization Coordinated Care

• Scope of Problem
• 80 of vaccine administration takes place in a
  physician office2
• 43 of children lt6 years have 2 immunizations in
  a registry, 2002 (Healthy People 2010 Goal 95)3

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Immunization Coordinated Care

• 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

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Who Is Part of a Medical Home for Immunizations?
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AAP Chapter or State Educational Programs
Community Organizations
Vaccine Manufacturers
Health Departments

Immunization Coalition
Child Family Pediatrician
Medical Home
Child Care Centers, Public Private Schools
Registry/State Immunization Information System/EM
R
Local, State, National Immunization Programs
(i.e., VFC)
Third Party Insurers/ Authorizing Agents
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Barriers to Coordinated Care

• 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.)

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Barriers to Coordinated Care

• 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

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Strategies to Provide Coordinated Care

• 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 Comprehensive
  Clinic Assessment Software Application (CoCASA),
  to increase immunization rates

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Strategies to Provide 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

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Strategies to ProvideCoordinated 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

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Strategies to ProvideCoordinated Care

• 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

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• 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.

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Case Study 2 Coordinated Care

• Billy is a healthy 5 year-old Hispanic boy who is
  starting kindergarten this year. When Billys mom
  drops him off at school and shows the school
  nurse his immunization record, the nurse informs
  her that, according to their states 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.

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Case Study 2 Coordinated Care

• Question What should the school nurse do? What
  should Billys pediatrician do?

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Case Study 2 Coordinated Care

• What should the school nurse do?
• Document that Billy is behind and send a letter
  home to his parents.
• Refer Billy to his pediatrician.

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Case Study 2 Coordinated Care

• What should Billys pediatrician do?
• Follow the written vaccination protocols,
  including the Catch-up Schedule for children
  behind on immunizations.
• Billy needs
• DTaP 4, IPV 3both final doses because given
  after age 4
• PCV 4because the first 3 doses given before 24
  months of age
• Hep B 3last dose
• MMR 2hes done

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Case Study 2 Coordinated Care

• Update the childs immunization record to reflect
  which vaccinations were given, dates of
  administration, number of doses, intervals
  between doses, and the childs age.

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Case Study 2 Coordinated Care

• 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.

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Case Study 2 Coordinated Care

• 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.

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References Coordinated Care

• National Vaccine Advisory Committee. Standards
  for Child and Adolescent Immunization Practices.
  Pediatrics. 2003112958-963
• Santoli JM, Rodewald LE, Maes EF, Battaglia MP,
  Coronado VG. Vaccines for Children Program,
  United States, 1997. Pediatrics. 1999104(2)
• Centers for Disease Control and Prevention.
  Immunization Registry Progress United States,
  January-December 2002. MMWR Morb Mortal Wkly Rep.
  200453431-433

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References Coordinated Care

• Stokley S, Rodewald LE, Maes EF. The impact of
  record scattering on the measurement of
  immunization coverage. Pediatrics. 200110791-96
• Bell KN, Hogue CJR, Manning C, Kendal AP. Risk
  factors for improper vaccine storage and handling
  in private clinician offices. Pediatrics,
  2001107100

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Immunization Continuous Care

• 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

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Immunization Continuous Care

• 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

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Strategies to Provide Continuous 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

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Strategies to Provide Continuous Care

• 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

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References Continuous Care

• 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 Aug23(2)106-12
• Christakis DA, Wright JA, Zimmerman FJ, Basset
  AL, Connell FA. Continuity of care is associated
  with high-quality care by parental report.
  Pediatrics. 2002109e54
• 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-Jun4(3)199-203

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Immunization Comprehensive 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

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Immunization Comprehensive 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

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Barriers to Comprehensive 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

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Barriers to Comprehensive Care

• 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

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Barriers to Comprehensive Care

• 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

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Reasons for MOs

• Deficits in clinician knowledge3,5
• Vaccines delayed due to valid contraindication
• Incorrect or overcautious interpretation of
  contraindications5
• Failure to review the childs vaccination status6
  
• Incomplete vaccine records7

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Reasons for MOs

• Physician reluctance to give multiple vaccines
  simultaneously7
• Vaccine delays/shortages8
• Practice requirement to receive physical
  examination prior to vaccination

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Differences Between Contraindications
Precautions

• 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

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Valid Contraindications vs Precautions
ConditionAllergy to Component Encephalopathy Preg
nancy Immunosuppression Severe illness Recent
blood product
Live C --- C C P P
Inactivated C C V V P V
Ccontraindication Pprecaution Vvaccinate 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.
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Invalid Contraindications to Vaccination (not
even precautions!)

• 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

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Strategies to Improve Comprehensive Care

• Clinicians do not use false contraindications to
  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
  Schedules physician stays up-to-date about
  potential new vaccines

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Strategies to Improve Comprehensive Care

• 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

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Strategies to Improve Comprehensive Care

• 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

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Strategies to Improve Comprehensive Care

• 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

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Strategies to Improve Comprehensive Care

• 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

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References Comprehensive Care

• Santoli JM, Rodewald LE, Maes EF, Battaglia MP,
  Coronado VG. Vaccines for Children Program,
  United States, 1997. Pediatrics. 1999104(2)
• Centers for Disease Control and Prevention.
  Epidemiology and Prevention of Vaccine-Preventable
  Diseases 8th Edition January 2005
• Szilagyi PG, Rodewald LE. Missed opportunities
  for immunizations a review of the evidence. J
  Public Health Manage Pract. 1996218-25
• 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.
  19981011-4
• 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. 199615140-145

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References Comprehensive Care

• Ball TM, Serwint JR. Missed opportunities for
  vaccination and delivery of preventive care. Arch
  Pediatr Adolesc Med. 1996150858-861
• Szilagyi PG, Rodewald LE, Humiston SG, et al.
  Immunization practices of pediatricians and
  family physicians in the United States.
  Pediatrics. 199494517-523
• 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. 199391315-320
• Rodewald L. Every medical home needs an
  immunization recall system. AAP News. February
  200189

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Immunization Family-Centered

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

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Immunization Family-Centered

• 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

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Barriers toFamily-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

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Barriers toFamily-Centered Care

• Patient and physician have access to both
  accurate and inaccurate immunization resources
• Poor communication (i.e., differing
  education/literacy levels, language barriers)

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Common Parental Concerns About Vaccines

• The use of Thimerosal (an organomercurial) as an
  additive in vaccines
• An unsubstantiated link between the MMR vaccine
  and autism
• The necessity of vaccinating children against
  hepatitis B
• Pneumococcal conjugate (new vaccine to protect
  against meningitis, blood infections, ear
  infections)

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Common Parental ConcernsAbout Vaccines

• Meningococcal vaccine (new meningococcal
  conjugate vaccine to protect against
  meningococcal disease)
• The relative danger of influenza and the need for
  a yearly vaccination
• The relative danger of varicella (chickenpox)

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The Facts About Thimerosal

• 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

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The Facts About Thimerosal

• 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)

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The Facts About MMR

• Autism spectrum disorder is a common
  developmental disability, affecting 1 in 166
  children3
• Concerns have been raised about a possible link
  between the proximity of the MMR vaccination
  administration and the development of signs of
  autism

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The Facts About MMR

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

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The Importance of the 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
  childrens immunity when they are the most
  vulnerable to the worst complications of
  hepatitis B and before they enter the high risk
  adolescent years

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The Importance of the Hepatitis B Vaccine

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

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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

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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

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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

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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

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The Importance of the 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

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The Importance of the 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

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The Importance of the 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

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Helping Families Locate Reliable Information on
the Internet

• The Internet can be a confusing place to
  navigate! To help parents locate factual vaccine
  information on the Web, practice staff should
  provide information and resources about how to
  locate and evaluate Web sites
• Additional Reading Content and Design Attributes
  of Antivaccination Web Sites. Wolfe RM, Sharp LK,
  Lipsky MS.  JAMA 20022873245-3248

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State Exemptions Information and Definitions

• As of 2004, all 50 states allow vaccination
  exemptions for medical reasons, as determined by
  a physician
• 48 states (all except Mississippi West
  Virginia) allow exemptions for religious reasons-
  when immunizations contradict the parents
  sincere religious beliefs

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State Exemptions Information and Definitions

• 20 states (AZ, AR, ID, LA, ME, MI, MN, MO, NE,
  NM, ND, CA, CO, OH, OK, TX, UT, VT, WA, and WI)
  allow exemptions for philosophical reasons- other
  non-religious beliefs held by the parents who do
  not believe their child should be immunized
• Additional information on state exemptions is
  available at http//www.cispimmunize.org/pro/Stat
  eRequirements.html

98
Strategies to Provide Family-Centered Care

• Treat the family as a partner in their childs
  care and promote shared decision-making
• Provide the parent with an immunization record
  book to track their childs vaccination history
  and gain better understanding of which vaccines
  are needed and when

99
Strategies to Provide Family-Centered Care

• When necessary, clinicians should document
  parents refusal to vaccinate in the patients
  record. Providers may utilize the AAP Refusal to
  Vaccinate Form.
• Provider should be aware of local school and
  childcare immunization requirements

100
Strategies to Provide Family-Centered Care

• Be available to answer questions or concerns
• Educate parents about risks versus benefits of
  vaccination
• Warn them about inaccurate information on the Web

101
Strategies to Provide Family-Centered Care

• Use Vaccine Information Statements (available in
  simple wording, multiple languages)
• Provide culturally-appropriate educational
  materials at the necessary literacy level
• Resource American Academy of Pediatrics and
  National Perinatal Association. Transcultural
  Aspects of Perinatal Health Care A Resource
  Guide. Shah MA, ed. National Perinatal
  Association 2004

102

The following case study is designed to assist
you to implement the Family-Centered Care
component of the medical home concept during
immunization-related patient encounters.
Strategies to address specific issues raised in
the scenario are included.
103
Case Study 3 Family-Centered Care

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

104
Case Study 3 Family-Centered Care

• Question How can Janes pediatrician create a
  partnership with her and provide family-centered
  care?

105
Case Study 3Family-Centered Care

• Janes pediatrician should provide
• An immunization record book so that she can take
  partnership in her childs care
• Educational resources regarding the safety of
  vaccines (Resource Compare the Risks).
• Additional Resources
• Evaluating Information on the Web fact sheet
• Be There for Your Child During Shots fact sheet

106
Case Study 3 Family-Centered Care

• Janes pediatrician should also
• Review the Recommended Childhood
• and Adolescent Immunization Schedules to address
  confusion
• Update the patients record and remind Jane which
  immunizations will be due at the next visit
• Identify practice staff to serve as an
  Immunization Champion to be readily available to
  answer questions after shots are given

107
References Family-Centered Care

• American Academy of Pediatrics, Committee on
  Hospital Care. Family-centered care and the
  pediatricians role. Pediatrics. 2003112691-696
• Gellin BG, Maibach EW, Marcuse EK.Do parents
  understand immunizations? A national telephone
  survey. Pediatrics. 20001061097-1102
• American Academy of Pediatrics, Autism Expert
  Panel, Committee on Children with Disabilities.
  Autism A.L.A.R.M. Website www.medicalhomeinfo.org
  (Accessed October 11, 2007).

108
Immunization Compassionate Care

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

109
Immunization Compassionate Care

• A patient that feels understood is more likely to
  adhere to the physicians recommendations1
• Patients tend to judge the quality of treatment
  on the basis of physicians affective behavior
  towards them2

110
Barriers to Compassionate Care

• Limited time during patient visit
• Cultural or racial/ethnic differences between
  patients and physicians
• Ignoring or misinterpreting parents or patients
  nonverbal cues
• Operating from a medical model
• Us versus them, paternalistic

111
Strategies to Provide Compassionate Care

• Listen unhurriedly to family concerns and respond
  to them appropriately
• Honor or validate family experiences, beliefs,
  questions and perspectives

112
Strategies to Provide Compassionate Care

• Address specific concerns directly
• Discuss myths or misconceptions openly and
  dispassionately
• Offer them the pamphlet Be There for Your Child
  During Shots
• Ensure privacy/confidentiality for families

113
The following case study is designed to assist
you to implement the Compassionate Care component
of the medical home concept during
immunization-related patient encounters.
Strategies to address specific issues raised in
the scenario are included.
114
Case Study 4 Compassionate Care

• As Kristen enters the pediatricians office with
  her baby girl, the pediatrician, Dr Susan,
  notices a worried look on Kristens 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.

115
Case Study 4 Compassionate Care

• Question What should Dr Susan do?

116
Case Study 4 Compassionate Care

• Dr Susan tells Kristen that she understands her
  concerns. She provides Kristen with verbal and
  written explanation about babys immune systems
  capability of handling multiple vaccines. She
  also leads Kristen toward additional resources.
• Dr Susan explains to Kristen the ways to comfort
  a baby before, during, and after vaccination and
  provides her with a fact sheet, Be There for
  Your Child During Shots, which describes methods
  of comfort.

117
Case Study 4 Compassionate Care

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

118
References Compassionate Care

• Bellett PS, Maloney MJ. The importance of empathy
  as an interviewing skill in medicine. JAMA.
  19912661831-1832
• Ben-Sira Z. Stress, Disease and Primary Medical
  Care. Gower, England, 1986
• Offit PA, et al. Addressing parents concerns do
  multiple vaccines overwhelm or weaken the
  infants immune system? Pediatrics.
  2002109124-129. Available at
  http//www.cispimmunize.org/fam/infant.html
  (Accessed October 12, 2007)
• Offit PA, Jew RK. Addressing parents concerns
  do vaccines contain harmful preservatives,
  adjuvants, additives, or residuals? Pediatrics.
  20031121394-1401

119
Immunization Culturally-Effective

• Culturally-Effective The delivery of care within
  the context of appropriate physician knowledge,
  understanding, and an appreciation of all
  cultural distinctions
• Familys cultural background, including beliefs,
  rituals, and customs, are recognized, valued, and
  respected and incorporated into the care plan 3

120
Immunization Culturally-Effective

• Scope of Problem
• Immunization coverage rates are lower among
  children living in poverty1 and among black and
  Hispanic children2
• By 2020, approximately 40 of school-age children
  will be of non-white racial or ethnic
  backgrounds3

121
Important Definitions

• Cultural Competence the awareness of
  cultural/religious practices, beliefs, and
  differences, enabling clinicians to adapt health
  care in accordance with the ethnocultural/religiou
  s heritage of the individual, family, and
  community4  
• Linguistic Competence the provision of bilingual
  staff or interpretation services for all clients
  without English language proficiency4 
• Spiritual Competence the ability to identify and
  understand one's own values and spiritual beliefs
  in the context of a pluralistic society,
  recognizing how interactions with patients and
  families may be affected by religious
  differences4

122
Barriers to Culturally-Effective Care

• Differences in cultural backgrounds including
  differing perceptions and beliefs
• Language and communication barriers
• Lack of skilled staff or resources
• Lack of appropriate services (i.e., patients
  that require interpretation vs translation
  services)

123
Strategies to Provide Culturally-Effective Care

• Immunization clinicians should be aware of any
  differences between their own cultural/religious
  values and those of the patient/family4
• Foster mutual respect and understanding4
• Determine the most effective way of adapting
  professional interpretations and recommendations
  to the value system of each family4

124
Strategies to Provide Culturally-Effective Care

• Provide safe and realistic choices to
  patients/families within the least restrictive
  environment4
• Promote equity for all cultural/religious
  backgrounds4

125
Strategies to Provide Culturally-Effective Care

• Openly address cultural barriers with respect and
  demonstrate sensitivity to conflicts with
  child/familys cultural patterns
• Recognize, value, respect, and incorporate the
  child/familys cultural background into care
  including beliefs, rituals, and customs

126
Strategies to Provide Culturally-Effective Care

• Listen to verbal and nonverbal cues, using
  translation or interpretation resources if
  necessary
• Ensure the child/family understands the results
  of the medical encounter
• Consider medical, religious, and philosophical
  exemptions to immunization (understanding state
  law and requirements)

127
Strategies to Provide Culturally-Effective Care

• If possible, have bilingual staff/volunteers on
  hand
• Display culturally diverse pictures, posters,
  magazines, etc
• Learn key words/phrases in the patients language

128
Strategies to Provide Culturally-Effective Care

• Provide written materials, including VISs, in the
  familys primary language and at the appropriate
  literacy level supplement with additional
  resources (i.e., visual aids, videos) if
  necessary
• Educate and train immunization clinicians at all
  levels (medical school, residency programs, and
  continuing medical education)

129

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

130
Case Study 5 Culturally-Effective

• Derek, a practicing Catholic, has a 5 year old
  son, Jack, who will be attending kindergarten in
  3 months. Derek and his son recently relocated
  from Texas to Illinois. Derek takes his son to
  their new pediatrician, Dr Bob.
• Dr Bob reviews Jacks immunization history and
  notices that Jack has not received a varicella
  vaccine, which is required by law before school
  entry.

131
Case Study 5 Culturally-Effective

• Dr Bob asks Derek the reason for this and Derek
  explains that in Texas, he received a
  philosophical exemption for varicella vaccine
  because the vaccination was developed using
  aborted fetuses. Dereks religious beliefs do
  not permit abortion of any kind.
• Dr Bob tries to address Dereks concern by
  explaining what the vaccine is and does and that
  its production does not involve aborted fetuses.

132
Case Study 5 Culturally-Effective

• 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.

133
Case Study 5 Culturally-Effective

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

134
Case Study 5 Culturally-Effective

• 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 Dereks concerns let Derek
  know that he is respected and his beliefs are
  understood.

135
Case Study 5 Culturally-Effective

• 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.

136
Case Study 5 Culturally-Effective

• 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.

137
Case Study 5 Culturally-Effective

• 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.

138
References Culturally-Effective

• Klevens RM, Luman ET. US children living in and
  near poverty. Risk of vaccine-preventable
  diseases. Am J Prev Med. 20012041-46
• Wood D, Donald-Sherbourne C, Halfon N, et al.
  Factors related to immunization status among
  inner-city Latino and African American
  preschoolers. Pediatrics. 199596295-301
• American Academy of Pediatrics, Committee on
  Pediatric Workforce. Culturally effective
  pediatric care education and training issues.
  Pediatrics. 1999103167-170
• American Academy of Pediatrics. Preface. In Shah
  MA, ed. Transcultural Aspects of Perinatal Health
  Care A Resource Guide. Elk Grove Village, IL
  American Academy of Pediatrics 2004, xv-xxix

139
Implementing Immunization in a Medical Home
Concepts at the Practice-Level

• 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

140
Implementing Immunization in a Medical Home
Concepts at 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

141
Acronyms
142
Vaccine-Preventable Diseases
143
Additional Web-based Resources

• Childhood Immunization Support Program (CISP) is
  a joint program of the AAP and CDC. The CISP
  provides extensive information on immunizations
  for health care professionals and families. Web
  site www.cispimmunize.org (Accessed August 6,
  2008)
• Teaching Immunization Delivery and Evaluation
  (TIDE) is an internet-based continuing education
  program in childhood immunizations. Web site
  www.musc.edu/tide (Accessed August 6, 2008)
• Centers for Disease Control and Prevention
  National Center for Immunization and Respiratory
  Diseases (NCIRD) provides leadership for the
  planning, coordination, and conduct of
  immunization activities nationwide. Web site
  www.cdc.gov/vaccines (Accessed August 6, 2008)

144
Additional Web-based Resources

• Immunization Action Coalition (IAC) creates and
  distributes educational materials for health
  professionals and the public that enhance the
  delivery of safe and effective immunization
  services. Web site www.immunize.org (Accessed
  August 6, 2008)
• National Network for Immunization Information
  (NNII) provides the public, health professionals,
  policy makers, and the media with up-to-date,
  scientifically valid information related to
  immunization. Web site www.immunizationinfo.org
  (Accessed August 6, 2008)

145
Other Resources

• Recommended Childhood, Adolescent Immunization
  Schedule Catch-up Schedule
• Guide to Contraindications
• Summary of Rules for Childhood and Adolescent
  Immunization
• VISs in over 30 languages
• AAP Refusal to Vaccinate Form
• Vaccine Management Recommendations for Handling
  and Storage of Selected Biologicals
• Vaccines for Children Program

146
Other 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

147
About the Training Tool

• Lead Author
• David Wood, MD, MPH, FAAP, Council on Community
  Pediatrics (COCP) and Childhood Immunization
  Support Program (CISP) Project Advisory Committee
• AAP Reviewers
• Charles Onufer, MD, FAAP, Medical Home Project
  Advisory Committee
• Gilbert Handal, MD, FAAP, COCP and CISP Project
  Advisory Committee
• Edgar Marcuse, MD, MPH, FAAP,
• AAP Immunization Advisory Team
• AAP Board of Directors Reviewer
• Alan Kohrt, MD, FAAP

148
Acknowledgments

• Jill 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)

149
About AAP Immunization 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 Academys CISP grant has been
  working to improve the immunization delivery
  system for children across the nation.

150
CISP 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.

151
CISP 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 cispimmunize_at_aap.org

152
CISP Resources

• 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.

153
CISP Resources

• 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.

154
CISP Resources

• Resource 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.

155
CISP Resources

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

156
CISP Resources

• 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.

157
Contact 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 [phone] ext 4271 Fax
847/228-9651 E-mail cispimmunize_at_aap.org