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Immunization in the Medical Home by David Wood, MD, MPH, FAAP AAP Council on Community Pediatrics & AAP Childhood Immunization Support Program PowerPoint PPT Presentation


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Immunization in the Medical Home by David Wood, MD, MPH, FAAP AAP Council on Community Pediatrics & AAP Childhood Immunization Support Program. About the Presentation. This presentation will describe how the Medical Home concept can be applied to immunization practices for all children.

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

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


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About the Presentation

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

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


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Learning Objectives

  • Understand medical home principles vis-a-vis immunization services

  • Understand the challenges facing pediatricians administering vaccines in the context of a medical home

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

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


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American Academy of Pediatrics Stance on Immunizations

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

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


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Understanding the Pediatricians’ Role in Vaccine Administration

  • Primary care practices delivered 80% of vaccine administration1

  • Vaccines prevent 10.5 million diseases per birth cohort in the US2

  • Administering seven vaccines saves society over $40 billion a year3


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Disease Pre-vaccine Era* 2000 % change

Diphtheria 31,054 1 -99

Measles 390,852 86 -99

Mumps 21,342 338 -99

Pertussis 117,998 7,867 -93

Polio (wild) 4,953 0 -100

Rubella 9,941 176 -98

Cong. Rubella Synd. 19,177 9 -99

Tetanus 1,314 35 -97

Invasive Hib Disease** 24,856 112 -99

Total 566,706 8,624 -98

Vaccine Adverse Events 0 13,497 ^ +++

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

* Maximum cases reported in pre-vaccine era

+ Estimated because no national reporting existed in the prevaccine era

^ Adverse events after vaccines against diseases shown on Table = 5,296

** Invasive type b and unknown serotype


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References

  • Santoli JM, Szilagyi PG, Rodewald LE. Barriers to immunization and missed opportunities. Pediatric Annals. 1998;27:366-374

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

  • Zhou F, et al. Economic Evaluation of the 7-Vaccine Routine Childhood Immunization Schedule in the United States, 2001. Arch Pediatr Adolesc Med. 2005;159:1136-1144. Available at: http://archpedi.ama-assn.org/cgi/content/short/159/12/1136 (Accessed: August 6, 2008)

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


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What Is A Medical Home?

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

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


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The AAP Medical Home*

Care is:

  • Accessible

  • Coordinated

  • Continuous

  • Comprehensive

  • Family-Centered

  • Compassionate

  • Culturally Effective

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


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Applying Medical Home Principles Can:

  • Improve health monitoring and delivery of preventive services

    • Track needed immunizations

    • Reduce missed opportunities

    • Facilitate practice team efforts to educate families


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Applying Medical Home Principles Can:

  • Improve immunization delivery for children with chronic conditions

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

  • Improve patient compliance


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Applying Medical Home Principles Can:

  • Address problems of vaccine delivery:

    • Address vaccine controversies and increase parental confidence in vaccines

    • Partially address vaccine financing and supply issues

    • Decrease mortality/morbidity due to vaccine-preventable diseases by keeping immunization coverage levels high


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Immunization: Accessible Care

Accessible: Physically and economically

accessible to all patients

  • Immunizations are available and administered according to the harmonized immunization schedule


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Immunization: Accessible Care

Scope of Problem:

  • 12.8% of children with special needs1, some require physical accommodations

  • 10.1% of children uninsured2

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

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


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Patient Barriers to Accessible Care

  • Problems scheduling appointments

  • Can’t get off work, long office wait times

  • Lack of transportation

  • Costs of immunization/administration fees


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Patient Barriers to Accessible Care

  • Uncertainty about how to access free vaccines

  • Confusion about the vaccination schedule

  • Vaccine safety concerns or misconceptions


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Physician Barriers to Accessible Care

  • Increasingly complex immunization schedule

  • Increased staff time for documentation and patient education

  • Large uninsured and/or underinsured patient populations


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Physician Barriers to Accessible Care

  • Low or delayed reimbursement

  • Missing/lost patient immunization record

  • Lack of centralized immunization registry

  • Vaccine delays or shortages


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Strategies to Provide Accessible Care

  • Financially Accessible

    • All forms of insurance are accepted, including:

      • Medicaid

      • SCHIP

  • Practice participates in Vaccines for Children (VFC) program


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Strategies to Provide Accessible Care

  • Changes in insurance are accommodated

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


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Strategies to Provide Accessible Care

  • Physically Accessible to Children with Special Health Care Needs (CSHCN)

    • Practice strives to meet Americans With Disabilities Act requirements

  • Accessible, Flexible Office Hours

    • Immunizations are available during all visits, sick or well, regular hours, or weekend clinics


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Strategies to Provide Accessible Care

  • Vaccination-only visits available

  • The practice increases access during periods of peak demand (i.e., flu season, back to school, etc.)

  • The practice is accessible by public transportation


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Strategies to Provide Accessible Care

  • Health care professionals review the vaccination and health status of patients at every encounter

    • Staff can review records to determine if any vaccines were missed by the physician

    • Staff can prepare immunizations while patients are with the physician

  • Maintain and prominently display vaccine storage and handling procedures and protocols


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


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Case Study #1: Accessible Care

  • Flu season is just around the corner.

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


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Case Study #1: Accessible Care

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


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Case Study #1: Accessible Care

Addressing the problem:

  • Dr Weiss decides to set up a flu clinic, which will be devoted to providing flu vaccine only. The flu clinic will run for 2 hours every Tuesday afternoon from October –March or until the virus is no longer circulating.

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


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Case Study #1: Accessible Care

Addressing the problem:

  • He uses his computer-based patient information system to identify children needing flu vaccine.

    • The system will “flag” children that would need flu vaccine (e.g., those with asthma, etc.) and identify those currently 6-23 months old.


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Case Study #1: Accessible Care

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

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

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


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References: Accessible Care

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

  • 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. 2003;112:958-963


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Immunization: Coordinated Care

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

  • Each visit is an opportunity for vaccination

  • Continually educate practice staff

  • Regularly review and update immunization procedures


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Immunization: Coordinated Care

Scope of Problem:

  • 80% of vaccine administration takes place in a physician office2

  • 43% of children <6 years have 2+ immunizations in a registry, 2002 (Healthy People 2010 Goal: 95%)3


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Immunization: Coordinated Care

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

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


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Who Is Part of a Medical Home for Immunizations?


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AAP Chapter or

State Educational

Programs

Community

Organizations

Vaccine

Manufacturers

Health

Departments

Immunization

Coalition

Child

Family

Pediatrician

Medical Home

Child Care Centers,

Public & Private

Schools

Registry/State

Immunization

Information

System/EMR

Local, State,

National Immunization

Programs (i.e., VFC)

Third Party Insurers/

Authorizing Agents


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Barriers to Coordinated Care

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

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


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Barriers to Coordinated Care

  • Children receive immunizations in multiple sites

  • Lack of state or local immunization registry

  • Complex and/or multiple vaccine supply sources

  • Delays and/or disruptions in vaccine supply


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Strategies to Provide Coordinated Care

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

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


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Strategies to Provide Coordinated Care

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

  • Develop and train staff on vaccine and office protocols

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


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Strategies to ProvideCoordinated Care

  • Designate Immunization Champions

  • The practice reports adverse events to the Vaccine Adverse Events Reporting System (VAERS), and is aware of the National Vaccine Injury Compensation Program (VICP)1


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Strategies to ProvideCoordinated Care

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

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


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


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Case Study #2: Coordinated Care

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


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Case Study #2: Coordinated Care

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


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Case Study #2: Coordinated Care

What should the school nurse do?

  • Document that Billy is behind and send a letter home to his parents.

  • Refer Billy to his pediatrician.


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Case Study #2: Coordinated Care

What should Billy’s pediatrician do?

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

    Billy needs:

    • DTaP #4, IPV #3—both final doses because given after age 4

    • PCV #4—because the first 3 doses given before 24 months of age

    • Hep B # 3—last dose

    • MMR #2—he’s done


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Case Study #2: Coordinated Care

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


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Case Study #2: Coordinated Care

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

  • If necessary, provide parent education at next visit, and/or provide school with parent handouts.


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Case Study #2: Coordinated Care

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

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


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References: Coordinated Care

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

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

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


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References: Coordinated Care

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

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


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Immunization: Continuous Care

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

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

  • Multiple clinicians leads to scattering of the immunization record1


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Immunization: Continuous Care

  • Improper record keeping can lead to increased costs and extra immunizations

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

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


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Strategies to Provide Continuous Care

  • Regularly review patient records and conduct practice-wide vaccination coverage assessments annually

    • Identify children behind on immunizations

    • Implement recall/reminder or other strategies to increase immunization rates


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Strategies to Provide Continuous Care

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

  • Promote immunization at both well and sick visits


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References: Continuous Care

  • Yusuf H, Adams M, Rodewald L, Lu P, Rosenthal J, Legum SE, Santoli J. Fragmentation of immunization history among clinicians and parents of children in selected underserved areas. Am J Prev Med. 2002 Aug;23(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. 2002;109:e54

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


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Immunization: Comprehensive Care

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

Scope of Problem:

  • Immunization coverage rates arehigher for children receiving all or some vaccines within a medicalhome1


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Immunization: Comprehensive Care

  • Promoting vaccination within the medical home improves both vaccination coverage and receipt of other preventiveservices1

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


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Barriers to Comprehensive Care

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

  • Increasingly complex vaccination schedule

  • Lack of reminder-recall system

  • Improper storage and handling procedures resulting in spoilage of vaccine


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Barriers to Comprehensive Care

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

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


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Barriers to Comprehensive Care

  • MOs are frequently associated with3,4

    • Inappropriate contraindications such as minor febrile illness

    • Not giving vaccine at acute care visits

    • Not giving all the shots needed at a visit


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Reasons for MOs

  • Deficits in clinician knowledge3,5

  • Vaccines delayed due to valid contraindication

  • Incorrect or overcautious interpretation of contraindications5

  • Failure to review the child’s vaccination status6

  • Incomplete vaccine records7


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Reasons for MOs

  • Physician reluctance to give multiple vaccines simultaneously7

  • Vaccine delays/shortages8

  • Practice requirement to receive physical examination prior to vaccination


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Differences Between Contraindications & Precautions

  • Contraindications: Conditions in a recipient which greatly increases the chance of a serious adverse reaction

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


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Valid Contraindications vs Precautions

ConditionAllergy to Component

Encephalopathy

Pregnancy

Immunosuppression

Severe illness

Recent blood product

Live

C

---

C

C

P

P

Inactivated

C

C

V

V

P

V

C=contraindication P=precaution V=vaccinate if indicated

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


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Invalid Contraindications to Vaccination (not even precautions!)

  • Mild illness

  • Antibiotic therapy

  • Disease exposure or convalescence

  • Pregnancy in the household

  • Breastfeeding

  • Premature birth

  • Allergies to products not in vaccine

  • Family history unrelated to immunosuppression

  • Need for TB skin testing

  • Need for multiple vaccines


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Strategies to Improve Comprehensive Care

  • Clinicians do not use false contraindications to prevent immunizations

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

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


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Strategies to Improve Comprehensive Care

  • Use the recommended Catch-up Schedule for children who have missed or delayed immunization

    • It makes it easier for staff to figure out who needs what

    • Proven to get children up-to-date faster

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


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Strategies to Improve Comprehensive Care

  • Educational resources about all aspects of immunization are made available

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


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Strategies to Improve Comprehensive Care

  • Staff should follow appropriate procedures for vaccine storage and handling

  • Staff should reduce vaccine liability and ensure proper coding/reimbursement

  • Health care professionals follow only medically accepted contraindications


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Strategies to Improve Comprehensive Care

  • Combination vaccines are utilized when appropriate

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

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


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References: Comprehensive Care

  • Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for Children Program, United States, 1997. Pediatrics. 1999;104(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. 1996;2:18-25

  • 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. 1998;101:1-4

  • 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. 1996;15:140-145


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References: Comprehensive Care

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

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

  • 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. 1993;91:315-320

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


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Immunization: Family-Centered

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


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Immunization: Family-Centered

Scope of Problem:

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


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Barriers toFamily-Centered Care

  • Parental concerns about vaccine safety or refusal to vaccinate

  • Patient and physician have differing beliefs regarding vaccination

    • 25% of parents believe immune systems are weakened by too many vaccines2

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


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Barriers toFamily-Centered Care

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

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


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Common Parental Concerns About Vaccines

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

  • An unsubstantiated link between the MMR vaccine and autism

  • The necessity of vaccinating children against hepatitis B

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


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Common Parental ConcernsAbout Vaccines

  • Meningococcal vaccine (new meningococcal conjugate vaccine to protect against meningococcal disease)

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

  • The relative danger of varicella (chickenpox)


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The Facts About Thimerosal

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

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


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The Facts About Thimerosal

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


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The Facts About MMR

  • Autism spectrum disorder is a common developmental disability, affecting 1 in 166 children3

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


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The Facts About MMR

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


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The Importance of the Hepatitis B Vaccine

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

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


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The Importance of the Hepatitis B Vaccine

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


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The Importance of the Pneumococcal Conjugate Vaccine

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

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


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The Importance of the Pneumococcal Conjugate Vaccine

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


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The Importance of the Meningococcal Vaccine

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

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


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The Importance of the Meningococcal Vaccine

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

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


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The Importance of the Influenza Vaccine

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


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The Importance of the Influenza Vaccine

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

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


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The Importance of the Varicella Vaccine

  • Many people believe that the chickenpox is a harmless illness

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

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


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Helping Families Locate Reliable Information on the Internet

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

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


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State Exemptions: Information and Definitions

  • As of 2004, all 50 states allow vaccination exemptions for medical reasons, as determined by a physician

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


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State Exemptions: Information and Definitions

  • 20 states (AZ, AR, ID, LA, ME, MI, MN, MO, NE, NM, ND, CA, CO, OH, OK, TX, UT, VT, WA, and WI) allow exemptions for philosophical reasons- other non-religious beliefs held by the parents who do not believe their child should be immunized

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


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Strategies to Provide Family-Centered Care

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

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


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Strategies to Provide Family-Centered Care

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

  • Provider should be aware of local school and childcare immunization requirements


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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


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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


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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.


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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.


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Case Study #3: Family-Centered Care

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


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Case Study #3:Family-Centered Care

Jane’s pediatrician should provide:

  • An immunization record book so that she can take partnership in her child’s 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


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Case Study #3: Family-Centered Care

Jane’s pediatrician should also:

  • Review the Recommended Childhood

    and Adolescent Immunization Schedules to address confusion

  • Update the patient’s 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


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References: Family-Centered Care

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

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

  • 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).


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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


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Immunization: Compassionate Care

  • A patient that feels understood is more likely to adhere to the physician’s recommendations1

  • Patients tend to judge the quality of treatment on the basis of physicians’ “affective” behavior towards them2


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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


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Strategies to Provide Compassionate Care

  • Listen unhurriedly to family concerns and respond to them appropriately

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


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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


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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.


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Case Study #4: Compassionate Care

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

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


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Case Study #4: Compassionate Care

  • Question: What should Dr Susan do?


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Case Study #4: Compassionate Care

  • Dr Susan tells Kristen that she understands her concerns. She provides Kristen with verbal and written explanation about baby’s 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.


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Case Study #4: Compassionate Care

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


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References: Compassionate Care

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

  • 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 infant’s immune system? Pediatrics. 2002;109:124-129. 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. 2003;112:1394-1401


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Immunization: Culturally-Effective

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

Family’s cultural background, including beliefs, rituals, and customs, are recognized, valued, and respected and incorporated into the care plan 3


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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


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Important Definitions

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


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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)


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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


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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


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Strategies to Provide Culturally-Effective Care

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

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


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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)


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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 patient’s language


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Strategies to Provide Culturally-Effective Care

  • Provide written materials, including VISs, in the family’s 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)


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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.


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


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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. Derek’s religious beliefs do not permit abortion of any kind.

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


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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.


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Case Study #5: Culturally-Effective

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


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


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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.


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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.


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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.


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References: Culturally-Effective

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

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

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

  • 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


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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


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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


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Acronyms


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Vaccine-Preventable Diseases


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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)


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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)


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Other Resources

  • Recommended Childhood, AdolescentImmunization 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


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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


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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


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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)


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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 Academy’s CISP grant has been working to improve the immunization delivery system for children across the nation.


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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.


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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 [email protected]


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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.


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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.


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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.


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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.orgor www.aap.organd click the Immunization Information button on the homepage.


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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.


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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: [email protected]


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