THE NEED TO FOCUS ON STRATEGIES TO INCREASE
IMMUNIZATION LEVELS
Vaccine-preventable disease rates are at their lowest level ever.
In 2002 there were U.S. reports of only 44 cases of measles,
18 cases of rubella, 1 case of diphtheria, 25 cases of tetanus,
and no wild polio. Given these immunization successes, why
is there continued interest in strategies to increase immunization
levels? The three chief reasons relate to concerns about current
immunization levels, costs, and the sustainability of the
immunization delivery system.
Disease levels, while they are one of the chief outcomes of interest,
are a late indicator of the soundness of the immunization system.
Immunization levels are a better indicator than vaccine-preventable
disease rates to determine if there is a problem with immunization
delivery.
Concerns about U.S. immunization levels include:
Childhood immunization rates are still suboptimal. For
example, in 2002 only 82% of children 19 to 35 months of age
had received four doses of DTaP vaccine.
For other age groups, immunization rates are considerably
lower. According to National Health Interview Survey data from
2002 (early release data) only 66% of people 65 years of age and
older received the flu vaccine in the past twelve months and 56%
of seniors had ever received pneumococcal vaccine.
Economic and racial disparities exist. Low-income and
minority children and adults are at greater risk for under-immunization.
"Pockets of need" exist in our nation's inner cities.
Uptake is lagging for some antigens. For example, in 2002
81% of children had received varicella vaccine by their second
birthday. Immunization rates in general seem to be lagging for
healthcare workers. The 2002 National Health Interview Survey
results indicate only 38% of healthcare workers received influenza
vaccine in the previous year.
Improvements in adult immunization rates have tapered off.
According to data from the National Health Interview Survey, after
a consistent increase in rates during the 1980s and early 1990s,
improvements in influenza vaccination rates for adults >65 years of
age have been tapering off since 1997.
Cost effectiveness is also of great concern. We need to know
which strategies increase immunization levels with the least expenditure
so they can be prioritized.
Sustainable systems for vaccinating children, adolescents, and
adults must be crafted. It has been recognized that high immunization
rates cannot rest upon one-time or short-term efforts.
There is interest in understanding strategies to increase immunization
levels in order to create lasting, effective immunization delivery
systems.

MATCHING STRATEGIES TO EXISTING PROBLEMS
Many available strategies work to increase immunization, but some
do not. The value of a strategy depends upon its implementation,
its potential effectiveness, and how well it is matched to existing
problems. Some do not work because they are ill-conceived from
the beginning. Some strategies do not work because they are
implemented badly. Some are simply misdirected - they address
the wrong problems.
School entry laws have been shown to effectively increase client
demand for vaccines, although the effectiveness of other common
strategies (e.g., advertising) is less well documented. Similarly,
there are proven strategies well suited to the problem of low access
to immunization services (e.g., reducing costs,WIC, home visiting).
When considering what new strategies to implement, proposed
solutions must be carefully matched to current problems. At present
in the U.S., most people have sufficient interest in and access
to healthcare and are seen, at least periodically, in healthcare systems.
Those that remain unvaccinated do so largely because
healthcare practices and providers do not always perform optimally
in delivering vaccines. So this chapter focuses on immunization
strategies for healthcare practices and providers.
The purpose of the approach discussed below is to move
healthcare personnel from a state of unawareness about the problem
(low immunization rates in their practice) to one in which they
are aware, concerned, and knowledgeable; motivated to change;
ready to try new behaviors (strategies); and capable of sustaining
the new behavior.
The acronym used by the National Immunization Program (NIP)
for this approach is AFIX: Assessment of the immunization coverage
of public and private providers; Feedback of diagnostic
information to improve service delivery; Incentives (or recognition)
for improved performance; and eXchange of information
among providers. After discussing each of these steps, the chapter
highlights specific practice-based strategies and details where to
find more resources on this topic.

THE AFIX APPROACH
OVERVIEW
Routine assessment and feedback of vaccination rates obtained at
the provider site – whether public or private – is one of the most
effective strategies for achieving high, sustainable vaccine coverage.
Georgia was the first state to implement AFIX in all public clinics.
From 1986 to 1999 median series-completion rates among
Georgia's public clinics for 4 DTPs, 3 polio vaccines, and 1
measles-containing vaccine (the 4:3:1 series) at 24 months of age
increased from 40% to 91%. In a recent analysis of the Georgia
public clinic experience, several factors were found to have significant
positive influence on immunization rates: the lead nurse participated
in the feedback session after assessments and received an
incentive to raise clinic coverage; the site used a phone system for
patient reminders, used WIC voucher incentives, and conducted
home visits for children who fell behind in the series.
The Georgia experience is not unique. Other states and localities
that have used AFIX strategies for three or more years have shown
gradual and consistent improvement in public sector coverage levels.
In a private sector study, involving pediatricians, the median
up-to-date coverage for 4:3:1 at 24 months of age improved in participating
practices from 78% at baseline to 87% at the second
assessment. The Together for Tots program, a 10-state effort to
improve immunization practices in Community/Migrant Health
Centers using continuous quality improvement, saw levels rise from
54% to 84% for 4:3:1 between 1996 and 2000.
AFIX enjoys wide support. One of the Standards for Child and
Adolescent Immunization Practices recently updated and revised
by the National Vaccine Advisory Committee (NVAC) calls upon
providers to do annual assessments of coverage levels. In 1996,
following the success of the Georgia AFIX strategy, a congressional
mandate was passed which stated that all grantees receiving federal
funds for vaccination programs were required to conduct annual
assessments of vaccination rates in all their public health clinics.
The Advisory Committee on Immunization Practices (ACIP)
issued a statement endorsing the AFIX process and recommending
that it be used by all public and private providers. One of the goals
in The Healthy People 2010 report emphasizes that 90% of immunization
providers undergo assessments of childhood immunization
level in their practices, a key component of AFIX, ever two years.
In 1998, the American Academy of Pediatrics (AAP), the American
Academy of Family Physicians (AAFP), state health department
staff and pharmaceutical company representatives agreed that coverage
assessments of private practices using the AAP and AAFP to
help gain access was the most effective way of raising and sustaining
immunization coverage.
AFIX is also an evidence-based strategy shown to improve vaccination
coverage among adults. One of the recently revised Standards
for Adult Immunization Practices issued by NVAC calls upon
providers of adult immunization to do annual assessments of coverage
levels. Although the use of AFIX among providers who serve
adults is still in its infancy and is not as widely disseminated compared
to childhood AFIX, this strategy can be a powerful tool to
improve rates among the adult population.
3
VFC - AFIX INITIATIVE
In order to extend the benefits of AFIX to private providers, which
now vaccinate nearly 80% of children in the US, NIP launched an
initiative in 2000 to incorporate measurement and feedback activities
during Vaccines for Children (VFC) provider site visits.This
initiative links AFIX with the VFC program and focuses on
increasing vaccine management practices and immunization services
within provider offices.
VFC is a federal program that purchases vaccines for eligible children
who meet one of the following requirements: qualify for
Medicaid, have no insurance, are Native American or Alaska
Native, or have insurance but it does not cover immunizations
(underinsured). Those children that are underinsured may receive
VFC vaccines at Federally Qualified Health Centers (FQHC) or
Community/Migrant Health Centers.
All states participate in this popular program, which serves approximately
44,000 provider sites, primarily in the private sector. The
VFC program benefits providers as well as children by reducing
cost as a barrier and encouraging children to stay in a medical
home. VFC provider site visits are conducted to review compliance
with VFC eligibility screening requirements and to evaluate vaccine
storage and handling procedures. These VFC site visits provide an
excellent opportunity to expand assessment and feedback activities
in the private sector.
AFIX has some important characteristics that deserve emphasis.
Focus on outcomes – AFIX starts with assessment. Assessment
data helps pinpoint the processes that need to be initiated or remedied.
The AFIX approach helps providers focus on specific
improvements.
Focus on providers - AFIX focuses on changing healthcare
provider behavior. Strategies implemented do not have to be of a
sweeping governmental scope, nor do they need to be attempts to
change the hearts and minds of every individual client.
Both personal and technological - AFIX depends on the wholehearted,
intense, and subtle union of technology (in the form of
assessment methodology and diagnostics) with art (in the form of
persuasive feedback, moving incentives, and stimulating exchange
of information). Both the message and its delivery are critical to
the success of the AFIX approach. An artful, dynamic delivery can
be informative as well as motivational.

ASSESSMENT
Assessment refers to the evaluation of medical records to ascertain
the immunization rate for a defined group of people as well as to
provide targeted diagnosis for improvement. This step, along with
feedback of the results, is essential because, while most healthcare
providers share the vision for high immunization rates, they do not
see their own practice's immunization rates for what they really are.
This lack of awareness has been documented in several studies
showing that pediatricians greatly over-estimated the proportion of
fully immunized children in their practices. Assessment increases
awareness.
The primary assessment tool that CDC offers and supports is the
Clinic Assessment Software Application (CASA) and the Adult
Clinic Assessment Software Application (ACASA). In addition to
the traditional Classic CASA methods, CDC has created two other
assessment options which reduce the amount of time required to
conduct an assessment in private provider offices: Mini-CASA and
Hybrid CASA. The level of detail desired from the CASA reports
will help guide the choice of an assessment method. (See Appendix
B for a description of the 3 assessment methods: the Classic
CASA, which requires a minimum of 100 records; the Mini-
CASA, which requires 50 records; and the Hybrid CASA, which
requires 30 records.)
The Classic CASA/ACASA and the Mini-CASA assessment methods
provide detailed reports, which diagnose specific problems. For example,
the report results could indicate whether children start their series
on time, whether and when patients drop out of the system, whether
recall is used effectively, whether vaccines are given simultaneously,
and whether record keeping and documentation are adequate.The
Hybrid CASA does not offer the same level of detailed reports, though
it requires the least amount of time. Depending on the chosen assessment
method and the organization of the medical records, the time
spent reviewing immunization records and entering the immunization
data into the software program could take between 2 and 8 hours.
CASA/ACASA are easy to use and can be downloaded from the NIP
website (listed in the resource directory) or obtained on disc from NIP.
There are many special features, including:
• error-checking to ensure that the immunization dates occurred
after the date of birth, before the review date, and after the previous
doses;
• capability of capturing useful, nonimmunization information by
including data fields such as WIC, AFDC, Head Start, EPSDT,
HEDIS information, and date of last visit;
• capability of exporting data to other software applications by saving
to an ASCII text, dBase file, or an Excel spreadsheet;
• ability to generate a mailing list and a reminder or recall
letter/postcard; and
• an easy to use sampling feature that shows the number of records
that should be reviewed in order to achieve a statistically relevant
estimate of vaccination levels if a fixed number of records, i.e., 100
for Classic CASA, 50 for Mini-CASA, and 30 for Hybrid CASA.
• an ability to capture (in ACASA) high risk conditions including
behavioral, medical, and occupational for those younger adults
with indications to receive hepatitis B, influenza, or pneumococcal
vaccine.

FEEDBACK
Feedback is the process of informing immunization providers
about their performance in delivering one or more vaccines to
a defined client population. The work of assessment is of no
use unless the results are fed back to people who can make a
change. Assessment together with feedback creates the
awareness necessary for behavior change.
Strong evidence of the positive effects of provider feedback has
been shown in a range of settings (private practice, managed care,
public clinics and community health centers, academic, and VA settings),
for a range of providers (resident and staff physicians, nonphysician
providers, internal medicine, family medicine, and general
practice), for adults and children (although there are no completed
studies to date on adolescents), and for most universallyrecommended
antigens.
Feed back the data to everyone who can make a change. The data
should be presented to the entire team of people who can make a
change – not only to policymakers, but also to policy implementers.
In a practice, this includes the medical and nursing staff as well as
the office manager and receptionist. It is best if they are all presented
with the data simultaneously to minimize inter-professional
blaming.
Feed back the data with feeling. Feedback is not a pale, passionless
out-pouring of data. Well-designed feedback is tantalizing and
challenging. The most effective "AFIXers" are those emotionally
involved with the "FIX."
Feed back the data with precision. Data should not be sent to the
healthcare providers without explanation or analysis. Within a
CASA Summary Report there are data on immunization levels and
there are more detailed diagnostic data. Diagnostics isolate a single
component of immunization delivery and serve as clues to the
source of the systemic problem. They include, for example, data on
the percent of patient records that reflect clients who are "lost"
(i.e., eligible for vaccine, but not seen in the past year), who were
not given all needed vaccines simultaneously on the last vaccination
visit, or who "dropped-out" of the immunization schedule.
(For more information on CASA reports, see "How to Read a
CASA Summary Report: Just for Starters" in Appendix B.)
Because of the diagnostic capabilities of CASA, one does not need
to "fish around," asking a practice if they implement this strategy
or that. For example, a practice with a 50% drop-off rate need not
be asked if they have an effective recall system. We know by the
data what the office is (not) doing or how (in)effectively they are
doing it. Once you have established the accuracy of the method,
the only issue that remains to be discussed is how to best improve
those specific areas that are below the norm.
Feed back the data as data, not as judgment. There are no bad people,
only bad systems.That is, the problem is not the individuals
employed at the site, it is their immunization delivery system.You
need not scold the people, just help them improve the system.
Feed back the data with respect for confidentiality. The acceptance of
an outside assessor depends upon trust that the data will be used in
a pre-arranged, circumscribed way. Don't violate that trust.
Feed back the data as a challenge. The dedication to confidentiality
should never be compromised. However, in some circumstances,
offices agree to allow their data to be used publicly, either in association
with their name or not. By comparing an office's immunization
rates with national goals or, preferably, with the rates of
peers, competitive spirit can be stirred. Those at the top struggle
to keep or attain first place; those at the bottom scramble to avoid
last place. Graphic representation of relative standing – such as
comparing providers anonymously – is useful, as is wide public dissemination
of the assessment results, when appropriate.

INCENTIVES AND RECOGNITION
People who enter the healthcare profession are likely to be motivated
by an intrinsic desire to prevent disease and its complications.
Immunization is primarily dependent upon this intrinsic motivation.
However, as a supplement, extrinsic rewards, or incentives,
are often useful. It should be noted that incentives will not overcome
significant barriers (e.g., if your practice loses $15 every time
you vaccinate someone, framed certificates of appreciation are
unlikely to sway you to immunize).
An incentive is something that incites or has a tendency to incite to
determination or action. This necessitates prearranged performance
standards (“if I do X, I will get Y”). Recognition is special notice or
attention, and is a powerful motivator. Prearranged performance
standards are not necessary for recognition. When a recognition
program has been in place for a while, people begin to expect it, so
it becomes, in a sense, an incentive program.
What makes an incentive useful? Incentive programs should:
• Reward achievement on the basis of a fair, credible, well-communicated
assessment.
• Be positive; the motivating effect of carrots exceeds the motivating
effect of sticks.
• Reward achievement in a timely fashion.
• Offer something the individual values. Not everyone values
the same things, so discuss the incentives in advance of kick-off.
• Professional recognition is often motivating. Food is (almost)
always motivating. Money is 'iffy': it may be motivating, but it
may be insulting or encourage cheating.
• Be aimed to all levels of involved personnel (e.g., clerical and
nursing staff).
• Create team spirit and/or utilize the competitive nature of
Americans.
• Be publicized. When a professional shares his/her success story
with another professional, you make two friends. Having it in writing
seems quite powerful.
• Reward achievement of attainable goals. Incremental goals
help; complicated goals don't.
• Reflect desired outcomes (e.g., immunization rates) or process
(e.g., putting a reminder system in place) or both. "Most
improved" is a useful category to keep everyone in the running.
• Be inexpensive because these are usually more sustainable.
• Be related to mission (e.g., the reward for letting us do a
CASA is that at the end we'll give you a list of children at your
practice who are behind on immunizations).
• Create a bond between the public and private sectors (e.g., the
prize for letting us do an assessment is that at the end we'll call
the children at your practice who are behind on immunizations).
• NOT dictate methods. Leave the innovation about "how to" up
to the practice. Of course, you can be there as a resource if they
have questions or want suggestions.
• NOT be stale ("Been there, won that.")
• NOT reward winners with more unwelcome work.
The costs of an incentive program may be shared with other
immunization and/or community partners. Various organizations
and private enterprises are available to help fund creative incentive
ideas. For example, local professional organizations may allocate
space in their newsletter to acknowledge immunization accomplishments.
Businesses, service organizations, or vaccine manufacturers
may wish to donate food, gifts, gift certificates, and/or
plaques for an awards luncheon or banquet. A well-known public
official or immunization advocate may be willing to hand out
achievement awards at a meeting. Finally, continuing education
credit could be offered at meetings at which the assessment program
is discussed.
Strategies for Healthcare Practices & Providers
eXchange OF INFORMATION
When healthcare providers have moved from being unaware of
their site's low immunization rates to being aware, concerned, and
knowledgeable as well as motivated to change, they are then ready
to try new strategies. The exchange of information among
healthcare providers is an important next step because peer education
is the best way to learn what new strategies to try.
Why should the exchange of information among providers be supported?
Discussion with fellow workers or education from peers seems to
help most adults learn new things, or recognize they need to stop
doing old things. This exchange helps to educate, motivate, and
coordinate in a way that is powerful because it is believable and relevant.
• Education. The exchange of information gives people access to
more experience than they have time to accumulate individually.
People learn from their peers what strategies work and what
strategies don't. The educational aspect of these conversations can
dispel myths and negative attitudes (e.g., inflated coverage estimates,
the number of shots that parents will accept), clarify true
contraindications, and foster better understanding of assessment
data as a diagnostic tool. During the cross-pollination some new
ideas may even be generated.
• Motivation. By publicly acknowledging success, providers are
informed of the shifting norm. This stimulates competition and
motivates improvement which, in turn, establishes the need for
follow-up assessments. The exchange of information about practices'
relative immunization rates is an incentive to change.
• Coordination. Once the participants' common mission to prevent
disease has been clarified, people may begin to see how they
can use and share common resources, improve communication
within and between practices, and, possibly even coordinate with
the registry and public health department. Increased communication
often leads to improved rapport.
What forums are appropriate for exchange among providers? Meetings
of healthcare providers may be state-wide, regional, or local. They
may be convened solely with the practice members - physicians,
nurses, office managers, and clerical staff - or with sections of professional
organizations such as the American Academy of
Pediatrics, American Academy of Family Physicians, American
Nursing Association, or the Public Health Association. Meetings
of healthcare providers within a managed care plan are another
excellent setting for this kind of exchange. Award ceremonies serve
as a particularly pleasant and supportive forum to open the
exchange.
What type of information should be exchanged among providers?
Information on both immunization levels and on the process of
increasing immunization levels should be exchanged. Sharing
information on immunization levels - whether that is limited (e.g.,
coverage levels, rank ordered by the type of service to increase
comparability if possible) or more extensive (e.g., specific antigen
coverage levels, drop off levels, non-simultaneous vaccination levels)
- will keep the group focused on the desired end-point. Data
can be presented as blinded coverage levels or comparing a
provider's rates to an anonymous average or an anonymous bar
graph of other provider coverage rates. Sharing data on the process
of getting there will confirm that providers are establishing sustainable
systems. If awards are given, a category for "most improved"
keeps even late bloomers in the running.
Peer reports are usually more influential than official reports. Peer
reports on their successful documentation methods, vaccination
practices, and office protocols are often interesting. Discussions of
processes used in practices to educate staff and to streamline procedures
are also useful. Information on true vaccine contraindications,
ACIP recommendations, the Standards for Child and
Adolescent Immunization Practices, and the Standards for Adult
Immunization Practices should supplement peer reports, but they
are often too dry to stand alone. Testimonial success stories are
useful to show that, while we all start out flawed, improvement is
an attainable goal. Indeed, almost all practices can be made better
by better practices.

BETTER PRACTICES
What are the strategies that lead to high immunization levels in a
practice? In this section we will discuss well-studied strategies that
are applicable within most public and private sector practices.
Additionally, we will discuss some strategies that simply enjoy
tremendous intuitive appeal (e.g., good immunization records).
The strategies are summarized under the following headings:
• Records that are accurate, understandable, and available
• Recommendations to parents and reinforcement of the need to
return
• Reminder and recall messages to patients
• Reminder and recall messages to providers
• Reduction of missed opportunities
• Reduction of barriers to immunization within the practice
It has been noted anecdotally that many healthcare practices that
successfully implement these strategies do so because there is an
Immunization Champion among them. Immunization Champions
are highly motivated and find creative ways to solve problems.

RECORDS THAT ARE ACCURATE, UNDERSTANDABLE,
AND AVAILABLE
Easy-to-read immunization records that are available at the time of
the visit are essential. Adult medical records often lack a front
sheet that reflects the important preventive services. Pediatric
patients often have a front sheet from which one cannot, at a
glance, assess age-dependent immunization status. Putting in place
a system that ensures the front sheet is kept current also helps.
Immunization records must be accurate. The active medical
records must reflect who is actually in the practice. Charts of people
who have moved or are going elsewhere for services should be
clearly marked accordingly or removed. Conversely, charts should
not be archived simply because a patient has not presented for a
prolonged time.
Patients often receive vaccines at more than one provider office, so
communication between sites is needed to produce complete and
accurate immunization records. Specifically, it is important for
school-based, public health, and community-based immunization
sites to communicate with primary care personnel through quick
and reliable methods (e.g., telephone, fax, and, if possible, email).
Someday immunization registries may make this communication
seamless. We should work toward, but not wait for, this day to
implement efficient communication between vaccine providers.
Unfortunately, the effectiveness of patient-held records on immunization
rates is difficult to estimate because of the small number
of studies, limitations in study design, and inconsistent results.

RECOMMENDATIONS TO PARENTS AND
REINFORCEMENT OF THE NEED TO RETURN
The recommendation of a healthcare provider is a powerful
motivator. One study demonstrated that when the healthcare
provider's opinion of influenza vaccine was positive, even adults
whose initial opinion of influenza vaccination was negative
were likely to receive the vaccine. Similarly, other work has
shown that parents of pediatric patients are very likely to follow
vaccine recommendation of the child's doctor.
It has been found that, irrespective of true immunization status,
most parents believe their child is fully vaccinated. Parents may
not have been told or may not have understood that return visits
were necessary. Anecdotally, patients often find it useful to have
the next appointment date in hand upon departure from the current
visit. As a supplement to this, the timing of the return visit
can be linked to some calendar event (e.g., "Return for your next
flu vaccine in a year, right before Halloween." "Your child will
need her next set of vaccines in two months. That's her 6-month
birthday...right after Valentine's day.")

REMINDER AND RECALL MESSAGES TO PATIENTS
Definitions. Patient reminders and recall messages are messages
to patients or their parents that recommended immunizations are
due soon (reminders) or past due (recall). The messages vary in
their level of personalization and specificity and in their medium
(e.g., postcard, letter, telephone) and their degree of automatization.
The effectiveness of patient reminders and recall. Both
reminders and recall have been found to be effective in increasing
attendance at clinics and improving vaccination rates in various
settings. This is probably because multiple healthcare visits usually
are needed for patients to be fully vaccinated and these visits are
sometimes missed. Clients can be quite variable in their attendance
for vaccination appointments.
During the past 20 years, many studies of the effectiveness of mail
or telephone appointment reminders/recall have shown consistently
important increases in patient compliance for vaccination as well as
a variety of other scheduled health visits. Generally, mail and telephone
reminders are equally effective.
Costs. Many health providers have been reluctant to institute
aggressive reminder/recall systems because of perceived costs.
Tracking systems that generate reminder and recall messages do
not have to be expensive, elaborate, or computerized. A card-file
box with weekly dividers can work as a tickler system.
In many provider settings, the costs of establishing an aggressive
notification system may be minimized by the use of automated
dialing technology (autodialers). In a recent study conducted by
CDC NIP and the Colorado Immunization Program, computergenerated
telephone calls and letters resulted in a 14% increase in
immunization coverage at a cost of $5.37 per child after start-up.
Support for and wide-spread usage of patient reminders and
recall. Both the Standards for Child and Adolescent
Immunization Practices and the Standards for Adult Immunization
Practices call upon providers to develop and implement aggressive
tracking systems that will both remind parents of upcoming immunizations
and recall children who are overdue. The Advisory
Committee on Immunization Practices supports the use of
reminder/recall systems by all providers. The National
Immunization Program provides state and local health departments
with ongoing technical support to assist them in implementing
reminder and recall systems in public and private provider
sites.
Immunization and beyond: additional benefits of patient
recall and reminder systems. Three trials conducted by the
National Immunization Program and the Georgia Department of
Human Resources have demonstrated that computer-generated
telephone reminders and recall messages, in addition to positively
affecting the "on-time" rate of immunizations, bring a significant
number of children who have dropped out back into the public
health delivery system. Studies in the private sector show that a
key benefit of patient reminder/recall systems is that they increase
utilization of other preventive measures. We are not improving one
preventive measure at a cost to the others. When we institute
patient reminder and recall systems for immunization, we increase
tuberculosis, lead, and anemia screening. Improvements in one
system leads to improvement in others.
Strategies for Healthcare Practices & Providers
REMINDER AND RECALL MESSAGES TO PROVIDERS
Provider reminders and recall messages are communications from
healthcare personnel (or computers) to healthcare providers that,
for individual clients, routine immunizations are due soon
(reminders) or past due (recall). Provider reminder/recall is different
from "Feedback" in which the provider receives a message
about overall immunization levels for a group of clients. Examples
of reminder/recall messages include:
• a computer-generated list that notifies a provider of the children
past-due for vaccines who are to be seen that clinic session,
• a red note "No Pneumococcal Vaccine on Record" that a receptionist
stamps on a senior's chart where the nurse will write the
vital signs,
• an "Immunization Due" clip that a nurse attaches to the chart of
an adolescent who has not had hepatitis B vaccine.
The content of the provider reminders and recall messages vary as
do the techniques to deliver them. To be effective, the information
must be conveyed to the provider before or at the time of the
patient's office visit. Some offices have found that it is productive
to have one knowledgeable and determined "gate keeper" who
checks and updates immunizations at each visit.
Provider reminders and recall systems have been found to be effective
in increasing immunization levels when used alone or in combination
with related strategies such as provider education or
patient recall.
REDUCTION OF MISSED OPPORTUNITIES TO VACCINATE
Definitions. A missed opportunity is a healthcare encounter in
which a person is eligible to receive a vaccination, but is not vaccinated
completely. Missed opportunities occur in settings that routinely
offer immunization, such as primary care offices or public
health clinics, and settings that do not routinely offer immunizations
including healthcare settings (e.g., emergency departments,
inpatient wards) and public health settings (e.g., WIC program
sites).
Why are there missed opportunities to vaccinate? Many nurses and
physicians avoid simultaneous administration of four or even three
injectable vaccines. Frequently stated reasons for resistance to
simultaneous administration have included concern about reduced
immune response, adverse events, and parental objection. These
sources of resistance are not supported by scientific data.
Providers also may be unaware that a child is in need of vaccination
(especially if the immunization record is not available at the
visit), or may follow invalid contraindications (see Chapter 2 for
more information).
Some of the reasons for missed opportunities relate to larger systems
- e.g., a clinic that has a policy not to vaccinate at any visits
except well child care, or not to vaccinate siblings. And some of
the reasons relate to very large systems, like state insurance laws
that deny reimbursement if a vaccine is given during an acute visit.
The degree of difficulty in eliminating the missed opportunity may
vary directly with the size of the system that has to be changed.
Strategies to rid practices of missed opportunities. Several studies have
shown that eliminating missed opportunities could increase coverage
by up to 20 percent. Strategies designed to rid practices of
missed opportunities have included several modalities alone or in
combination. Examples include:
• Standing orders – These are interventions in which non-physician
immunization personnel vaccinate clients by protocol without
direct physician involvement at the time of the immunization.
This may occur in a variety of settings such as clinics, hospitals,
and nursing homes. When used alone or in combination with
other interventions, standing orders have had positive effects
among adults in a range of settings.
• Provider education – Giving immunization providers information
has been attempted with written materials, videos, lectures,
and computerized software. Providing only knowledge may have
limited impact on provider behavior, while implementing multicomponent
interventions that incorporate both knowledge and
other strategies (e.g., feedback, incentives) show more convincing
evidence of effectiveness.
• Provider reminder/recall systems – These are discussed
above. While provider reminder/recall systems generally work to
increase immunization levels, they may not be effective in
decreasing missed opportunities if they are implemented in an
inconsistent way or if providers strongly adhere to invalid contraindications.

REDUCTION OF BARRIERS TO IMMUNIZATION WITHIN
THE PRACTICE
Time and space are two of the chief barriers to vaccination.
Attempts have been made to decrease the distance people must
travel or the time they must spend to get vaccinated. Expanding
hours or access in clinical settings is one example of this approach.
Although data are insufficient to support such an intervention by
itself, strong evidence exists that this intervention is a valuable
component of a multicomponent intervention.
Psychological barriers to healthcare are often more subtle, but may
be just as important. Unpleasant experiences (e.g., fear of immunizations,
being criticized for previously missed appointments, difficulties
leaving work for a clinic appointment) may lead clients to
procrastinate about receiving needed vaccination. Health care
practices should provide a supportive and safe atmosphere for
clients.

SUMMARY
Immunization delivery systems must be improved for people in all
age groups, and especially for the poor and minorities. Strong evidence
exists that this improvement can be achieved through practice-
based assessment of immunization rates and feedback of those
rates to all the people involved. The use of incentives - even if they
are simple recognition of a good job - are useful for enhancing
motivation. The exchange of information among providers is useful
for maintaining motivation, as well as for aiding education and
coordination. The facilitators of this exchange should encourage
discussion of immunization levels, but also of the system changes
that lead to improved immunization levels.
We have to get out the word that we have strong evidence about
what system changes are needed. We have to get out the word that
there are benefits beyond increased immunization rates; these system
changes can lead to improvement in a wide range of clinical
prevention services. And we need to find (or become) the prevention
Champions who will lead the work of improving immunization
records, recommending vaccines, creating aggressive reminder and
recall systems, and ridding practices of immunization missed
opportunities and barriers. We know we can do it and our children
and our parents deserve it.

THE GUIDE TO COMMUNITY PREVENTIVE SERVICES
This chapter has benefitted considerably from the Guide to
Community Preventive Services, the definitive, evidence-based
source on strategies to increase immunization levels. The Guide,
developed under the auspices of the U.S. Public Health Service,
summarizes data on the effectiveness and, when possible, the costeffectiveness
of population-based interventions for prevention and
control. The Guide provides recommendations on these population-
based interventions and methods for their delivery. The
Guide's chapter on vaccine preventable disease provides information
about a wider range of strategies to improve coverage than are
included here and provides more of the evidence on which some of
the conclusions in this chapter are based.

SELECTED REFERENCES
CDC. Programmatic strategies to increase vaccination rates -
assessment and feedback of provider-based vaccination coverage
information. MMWR 1996; 45:219-220.
CDC. Recommendations of the Advisory Committee on
Immunization Practices (ACIP), the American Academy of
Pediatrics, and the American Academy of Family Physicians: Use
of reminder and recall by vaccination providers to increase vaccination
rates. MMWR 1998; 47:715-717.
Dietz VJ, Baughman AL, Dini EF, Stevenson JM, Pierce BK,
Hersey JC.Vaccination practices, policies, and management factors
associated with high vaccination coverage levels in Georgia public
clinics. Arch Pediatr Adolesc Med 2000; 154:184-189.
Dini EF, Linkins RW, Sigafoos, J. The impact of computer-generated
messages on childhood immunization coverage. Am J Prev Med
2000; 18(2):132-139.
LeBaron CW, Chaney M, Baughman AL, Dini EF, Maes E, Dietz
V, Bernier R. Impact of measurement and feedback on vaccination
coverage in public clinics, 1988-1994. JAMA 1997; 277:631-635.
LeBaron CW, Mercer JT, Massoudi MS, Dini EF, Stevenson JM,
Fischer WM, Loy H, Quick LS,Warming JC,Tormey P,
DesVignes-Kendrick, M. Changes in Clinic vaccination coverage
after institution of measurement and feedback in 4 states and 2
cities. Arch Pediatr Adolesc Med 1999; 153: 879-886.
Lieu T, Black S, Ray P. Computer-generated recall letters for
underimmunized children: how cost-effective? Pediatr Infect Dis J
1997; 16:28-33.
Lieu T, Capra A, Makol J, Black S, Shinefield H. Effectiveness and
cost-effectiveness of letters, automated telephone messages, or both
for underimmunized children in a health maintenance organization
[Abstract]. Pediatrics 1998; 101:690-691.
Massoudi MS,Walsh J, Stokley S, Rosenthal J, Stevenson J,
Miljanovic B, Mann J, Dini E. Assessing immunization performance
of private practitioners in Maine: impact of the Assessment,
Feedback, Incentives, and eXchange (AFIX) Strategy. Pediatrics,
1999; 103: 1218-1223.
National Vaccine Advisory Committee. Standards for Child and
Adolescent Immunization Practices. Pediatrics 2003;112:958-63.
Poland GA, Shefer AM, McCauley M, et al. Standards for Adult
Immunization Practices. Am J Prev Med 2003;25:144-150.
Yawn BP, Edmonson L, Huber L, Poland GA, Jacobson RM,
Jacobsen SJ. The impact of a simulated immunization registry on
perceived childhood immunization status. Am J Man Care 1998;
4:186-192.
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