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

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


1
Immunization in the Medical Home by David Wood,
MD, MPH, FAAP AAP Council on Community
Pediatrics AAP Childhood Immunization Support
Program
2
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.

3
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

4
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.

5
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6
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7
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

8
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
9
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

10
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

11
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
12
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

13
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

14
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

15
Immunization Accessible Care
  • Accessible Physically and economically
  • accessible to all patients
  • Immunizations are available and administered
    according to the harmonized immunization schedule

16
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

17
Patient Barriers to Accessible Care
  • Problems scheduling appointments
  • Cant get off work, long office wait times
  • Lack of transportation
  • Costs of immunization/administration fees

18
Patient Barriers to Accessible Care
  • Uncertainty about how to access free vaccines
  • Confusion about the vaccination schedule
  • Vaccine safety concerns or misconceptions

19
Physician Barriers to Accessible Care
  • Increasingly complex immunization schedule
  • Increased staff time for documentation and
    patient education
  • Large uninsured and/or underinsured patient
    populations

20
Physician Barriers to Accessible Care
  • Low or delayed reimbursement
  • Missing/lost patient immunization record
  • Lack of centralized immunization registry
  • Vaccine delays or shortages

21
Strategies to Provide Accessible Care
  • Financially Accessible
  • All forms of insurance are accepted, including
  • Medicaid
  • SCHIP
  • Practice participates in Vaccines for Children
    (VFC) program

22
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

23
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

24
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

25
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

26
  • 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.

27
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.

28
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?

29
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.

30
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.

31
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.

32
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

33
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

34
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

35
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

36
Who Is Part of a Medical Home for Immunizations?
37
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
38
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.)

39
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

40
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

41
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

42
Strategies to Provide Coordinated 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

43
Strategies to Provide Coordinated 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

44
  • 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.

45
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.

46
Case Study 2 Coordinated Care
  • Question What should the school nurse do? What
    should Billys pediatrician do?

47
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.

48
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

49
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.

50
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.

51
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.

52
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

53
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

54
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

55
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

56
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

57
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

58
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

59
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

60
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

61
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

62
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

63
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

64
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

65
Reasons for MOs
  • Physician reluctance to give multiple vaccines
    simultaneously7
  • Vaccine delays/shortages8
  • Practice requirement to receive physical
    examination prior to vaccination

66
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

67
Valid Contraindications vs Precautions
Condition Allergy 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.
68
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

69
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

70
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

71
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

72
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

73
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

74
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

75
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

76
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

77
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

78
Barriers to Family-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

79
Barriers to Family-Centered Care
  • Patient and physician have access to both
    accurate and inaccurate immunization resources
  • Poor communication (i.e., differing
    education/literacy levels, language barriers)

80
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)

81
Common Parental Concerns About 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)

82
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

83
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)

84
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

85
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

86
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

87
The Importance of the Hepatitis B Vaccine
  • Before the vaccine was introduced, 20,000
    children under age 10 became infected each year

88
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

89
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

90
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

91
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

92
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

93
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

94
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

95
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

96
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

97
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 3 Family-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 800/433-9016 ext 4271 Fax
847/228-9651 E-mail cispimmunize_at_aap.org
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