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Highlights from Immunization Strategies: Using the Evidence and What Works to Improve Practice

Date: 8/22/2012 12:45 PM

Related Categories: Learning Resource Center (LRC), Performance Management and Quality Improvement (PMQI), TRAIN, Workforce Development

Topic: Workforce Development

Tag: Community Guide, Public Health Works, Workforce Development, TRAIN, Quality Improvement, Learning Resource Center (LRC)

Moderated Discussion with Hugh Tilson, MD, DrPH
Questions and Answers with Ray Strikas, MD, MPH, Medical Officer, Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases and Lucy Wells, Quality Manager, MAOM, DHAc, Duval County Health Department, Florida
Thank you for joining the conversation following Immunization Strategies: Using the Evidence and What Works to Improve Practice, a training program from the Public Health Foundation. This training program demonstrates how the Guide to Community Preventive Services (Community Guide) and quality improvement (QI) methods are being used to improve immunization rates in Los Angeles County, California.  We hope the program provided you with relevant information to address immunization gaps in your community.  Below, we have highlighted questions and answers from the program:
What are some challenges to immunization?
Ray Strikas (RS): Nationally, we recognize that during the past 50 years, immunization has led to elimination or near elimination of several vaccine-preventable diseases in the United States (U.S.) and has substantially reduced deaths, disabilities, and illness. A recent economic analysis indicated that vaccination of each U.S. birth cohort with the current childhood immunization schedule prevents approximately 42,000 deaths and 20 million cases of disease, with net savings of nearly $14 billion in direct costs and $69 billion in total societal costs.  Maintaining success depends on sustaining a strong vaccine-delivery system in both public and private sectors, while ensuring adequate surveillance of disease and of vaccine coverage.  We have to overcome concerns among the public about the safety and effectiveness of vaccines.  We also must take advantage of key opportunities to improve access to preventive services, such as vaccines among adults, and performance improvements and efficiency that should result from enhanced use of Immunization Information Systems and electronic health records.  
Lucy Wells (LW): Our biggest challenge in Florida is that we experience childhood and adult immunization levels that are below the recommended Healthy People targets.  An even greater challenge is persuading more providers who administer shots to enter that data into our statewide Immunization Information System (Registry) called Florida SHOTS.

What does the research tell us about using Immunization Information Systems or IIS along with client recall and provider reminders?
RS: IIS are confidential, population-based, computerized databases that record all immunization doses administered by participating providers to persons residing within a given area, such as a state or metropolitan area. In the U.S., most states and several cities have a functioning IIS, with most systems consolidating records of vaccinations delivered to children up to 6 years of age.  The Community Preventive Services Task Force recommends IIS on the basis of strong evidence of effectiveness in increasing vaccination rates. At the point of clinical care, an IIS provides consolidated immunization histories for use by a vaccination provider in determining appropriate client vaccinations. At the population level, an IIS provides aggregate data on vaccinations for use in surveillance and program operations, and in guiding public health action with the goals of improving vaccination rates and reducing vaccine-preventable disease.

For client reminder and recall, there have been two extensive reviews of this strategy by the Community Preventive Services Task Force.  Client reminder and recall interventions involve reminding members of a target population that vaccinations are due, which are reminders or late vaccinations, which are called recall. These messages differ in content and can be delivered by various methods—telephone, letter, postcard, or electronically. Most reminder systems involve a specific notification for a specific client, and may be accompanied by educational messages regarding the importance of immunization for the targeted vaccine.

LW: The immunization schedule is complicated for parents and providers.  At the Duval County Health Department we have implemented a systematic process for client and provider reminder that resulted in an increase in our two-year old immunization rates from 75% in 2009 to 92% in 2012. Utilizing the Florida SHOTS system, we identify which children are overdue and upcoming for shots.  We then make contact with parents by phone, postcard, or letter reminding them to bring the child into the office.  We attempt to make contact at least 30 days prior to the upcoming shot - giving parents ample time to bring the child in.  These reminder reports are generated for each clinic site monthly.
Florida SHOTS is used by VFC and Non-VFC providers throughout all 67 counties in Florida.  VFC refers to the federal Vaccines for Children program, which covers the cost of vaccines.  Currently we have approximately 2000 VFC providers who utilize the system in some capacity.  Each of Florida’s 67 counties has a local county health department.  All immunizations provided at the health departments are required to be entered into the Florida SHOTS registry or IIS.  The system allows parents to print certified 680 forms, the Florida certificate of immunization, at home at their convenience.  It allows providers, school nurses, daycare owners, and other authorized agencies to view the shot records of children accessing their facilities for services.  Most importantly it helps the Duval County Health Department to monitor the health status of the community.
What is AFIX?
RS: AFIX is a QI strategy used by state and local immunization programs to raise immunization rates and improve standards of practices at the provider level.  The acronym for this four-part dynamic strategy stands for ASSESSMENT of the healthcare provider's vaccination rates and immunization practices; FEEDBACK of results to the provider along with recommended strategies to improve processes, immunization practices, and rates; INCENTIVES to recognize and reward improved performance; and EXCHANGE of healthcare information and resources necessary to facilitate improvement. The Community Preventive Services Task Force recommends assessment and feedback for vaccination providers based on strong evidence of their effectiveness in improving vaccination rates in adults and children; when used alone or with additional components; and across a range of settings and populations.
LW: The AFIX model is an important component in creating a common mission among providers and public health.  The Bureau of Immunizations requires visiting at least 50% of Florida’s VFC providers each year to complete an AFIX assessment.  The field staff makes contact with all VFC providers annually.   They review patients’ immunization records, check storage and handling procedures, and provide feedback on opportunities for improvement.  I monitor Duval County Health Department’s immunization levels and compare them to the county levels, and there is a disparity among the rates.  Both health care providers and health departments are privy to the same knowledge and tools; however the health departments have made a conscious effort across the board to use tools such as AFIX.  The QI efforts on the part of Florida health departments throughout Florida are working, because county health department rates are higher than the overall county rates.  For example, the immunization rates for two-year olds in Duval County Health Departments were 90% or better in 2011 compared to the 78% county rates for the same population. 
What do we know about partnering with other community organizations, such as Women, Infants, and Children (WIC) programs to increase vaccination rates?
RS: The Community Preventive Services Task Force recommends coordinated vaccination interventions in WIC settings based on strong evidence of effectiveness in increasing vaccination rates in children. Evidence of effectiveness was strong based on studies in which assessment of client immunization status and referral to a vaccination provider was combined with additional interventions or with the provision of vaccinations on-site or in a co-located health care service. Studies included in this review combined assessment and referral with monthly voucher pickup requirements, tracking and outreach, client reminder and recall systems, or enhanced access to vaccination services.  Please note the Community Preventive Services Task Force found insufficient evidence to determine the effectiveness of assessment and referral in WIC settings when implemented alone or in the absence of other interventions.

LW: In Duval County, we currently have three of our medical sites co-located with our WIC sites.  These sites are strategically located in areas of the county with large populations of underinsured and uninsured residents.   The shot record is checked by the clerk each time the child comes in for certification. If shots are missing, the child is directed to visit the immunization clinic as a walk-in or by appointment.
Funding for this program was provided by the Centers for Disease Control and Prevention to Public Health Foundation under CDC-RFA-HM08-8050301SUPP10.
How can we best increase the amount of those getting immunizations with the limited staff and financial resources?  
RS: a. Work with partners:  private providers, employers, insurance companies, clinical settings (e.g., hospitals, dialysis clinics), and pharmacies, all of whom can either vaccinate patients, or direct them to sources of vaccination.
b. Does your health department bill patients with insurance for vaccination?  You should assess if you can do so, and check here for more information or contact CDC at
How to reach parents who refuse to vaccinate children. 
RS: a. It takes time to do this work, so you have to be ready, as do other healthcare providers, be ready to spend time to ask about their concerns, do not belittle them, and answer with facts, as well as acknowledge there are areas where we lack data on vaccine safety and effectiveness.
b. Here are some resources to help you talk to parents on these issues.
What can I do to help convince parents to give all needed vaccines on one visit, when they don't want to give their children so many 'shots' at once?
RS: a. Check out a useful, detailed resource page from the Children’s Hospital of Philadelphia.
How would you demonstrate to decision makers that vaccinations are a measure of prevention and cost effective as well?
RS: a. Look at this presentation on the cost-effectiveness of the childhood schedule vaccines.
b. Page 28 of these ACIP recommendations for influenza vaccination summarizes available data on cost-effectiveness of influenza vaccination for different populations.   
Best strategies for parents accessing websites with questionable information on vaccines (Anti-vaccine crowd)
RS: a. Suggest they should balance different points of view, e.g., those favoring vaccine avoidance or exemption, with those advocating vaccine use.
b. The Medical Library Association has a valuable webpage about how consumers can find and evaluate health information on the web.  
How do you respond to parents who don't want any vaccine with thimerosol?
RS: a. Tell them all childhood vaccines are available with no, or very little, thimerosal (trace amounts left after manufacturing) except some influenza vaccines.  
b. Thimerosal in vaccines has not been convincingly associated with any adverse outcome in vaccinated children.
Please share your thoughts, opinions, or successes with implementing best immunization practices using the Community Guide or QI methods by adding a comment below.


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Kennetha Scott


I wrote a paper last year about the importance of immunizations for my college course after my niece's child died. Basically, I think it is a civic duty to get the recommended vaccines.

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