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Immunizations Barriers and Strategies . David M. Bendich , MD, FAAP President Essex Metro Immunization Coalition. OBJECTIVES. have a better understanding of existing barriers to timely and complete immunization of children

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ImmunizationsBarriers and Strategies

David M. Bendich, MD, FAAP


Essex Metro Immunization Coalition

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  • have a better understanding of existing barriers to timely and complete immunization of children

  • be aware of and have a greater ability to utilize various tools and communication strategies to overcome these barriers

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Percentage of vaccinated children19-35 months old

NJ Nat’l Ranking

% %

2006 76.0 76.9 26

2007 62.3 77.5 39

2008 59.7 68.4 45

2009 64.6 70.9 42

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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

  • 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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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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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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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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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 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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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

  • 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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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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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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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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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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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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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: (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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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: (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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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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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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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: (Accessed: August 6, 2008)

  • Teaching Immunization Delivery and Evaluation (TIDE) is an internet-based continuing education program in childhood immunizations. Web site: (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: (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: (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: 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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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]