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Immunization Immunization in the Medical Homein the Medical Home
by David Wood, MD, MPH, FAAP AAP Council on Community Pediatrics &
AAP Childhood Immunization Support Program
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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.
About the PresentationAbout the Presentation
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Learning ObjectivesLearning 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 American Academy of Pediatrics Stance on Pediatrics Stance on
ImmunizationsImmunizations 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 Understanding the Pediatricians’ Role in Pediatricians’ Role in
Vaccine AdministrationVaccine 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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Comparison of Maximum and Current Reported Comparison of Maximum and Current Reported Morbidity, Vaccine-Preventable Diseases & Vaccine Morbidity, Vaccine-Preventable Diseases & Vaccine
Adverse Events, USAdverse Events, US44
Diphtheria 31,054 1 -99Measles 390,852 86 -99Mumps 21,342 338 -99Pertussis 117,998 7,867 -93Polio (wild) 4,953 0 -100Rubella 9,941 176 -98Cong. Rubella Synd. 19,177 9 -99Tetanus 1,314 35 -97Invasive Hib Disease** 24,856 112 -99
Total 566,706 8,624 -98
Vaccine Adverse Events 0 13,497 ^ +++
Disease Pre-vaccine Era* 2000 % change
* 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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ReferencesReferences1. Santoli JM, Szilagyi PG, Rodewald LE. Barriers to
immunization and missed opportunities. Pediatric Annals. 1998;27:366-374
2. Centers for Disease Control and Prevention. Ten great public health achievements – United States, 1990-1999. MMWR Morb Mortal Wkly Rep. 1999;48:241-243
3. 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)
4. 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?What Is A Medical Home?
A medical home is not a building, A medical home is not a building, house, or hospital, but rather an house, or hospital, but rather an approach to providing comprehensive approach to providing comprehensive primary careprimary care
Medical Home is a way to provide cost Medical Home is a way to provide cost effective quality health careeffective quality health care
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The AAP The AAP Medical HomeMedical Home**
Accessible Coordinated Continuous Comprehensive Family-Centered Compassionate Culturally Effective
Care is:
* American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110:184-186
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Applying Medical Home Applying Medical Home Principles Can: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 Applying Medical Home Principles Can: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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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
Applying Medical Home Applying Medical Home Principles Can:Principles Can:
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Immunization: Accessible Immunization: Accessible CareCare
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 Immunization: Accessible CareCare
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 Patient Barriers to Accessible CareAccessible 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 Patient Barriers to Accessible CareAccessible 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 Physician Barriers to Accessible CareAccessible 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 Physician Barriers to Accessible CareAccessible 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 Strategies to Provide Accessible CareAccessible Care
Financially Accessible– All forms of insurance are accepted,
including:MedicaidSCHIP
– Practice participates in Vaccines for Children (VFC) program
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Strategies to Provide Strategies to Provide Accessible CareAccessible 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 Strategies to Provide Accessible CareAccessible 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 Strategies to Provide Accessible CareAccessible 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 Strategies to Provide Accessible CareAccessible 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 The following case study is designed to assist you to designed to assist you to implement the implement the Accessible CareAccessible Care component of the medical home component of the medical home concept during immunization-concept during immunization-related patient encounters. related patient encounters. Strategies to address specific Strategies to address specific issues raised in the scenario are issues raised in the scenario are included.included.
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Case Study #1: Case Study #1: Accessible CareAccessible Care
Flu season is just around the corner. Dr Weiss, a privately practicing pediatrician in an urban city, is concerned about the potential increase in children coming in for the flu vaccine due to the changes in the Recommended Childhood and Adolescent Immunization Schedules. Prior to the change in recommendations, Dr Weiss immunized <250 children against influenza. The practice already has pre-ordered vaccine on hand.
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Case Study #1: Case Study #1: Accessible CareAccessible 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: Case Study #1: Accessible CareAccessible 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: Case Study #1: Accessible CareAccessible 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: Case Study #1: Accessible CareAccessible 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 References: Accessible CareCare
1. 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
2. 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
3. Institute of Medicine. Vaccine Financing In the 21st Century. National Academies Press, Washington DC, 2004
4. National Vaccine Advisory Committee. Standards for Child and Adolescent Immunization Practices. Pediatrics. 2003;112:958-963
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Immunization: Coordinated Immunization: Coordinated CareCare
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 Immunization: Coordinated CareCare
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 Immunization: Coordinated CareCare
– 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 Who Is Part of a Medical Home Medical Home
for for Immunizations?Immunizations?
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ImmunizationCoalitionChild
FamilyPediatrician
Registry/State ImmunizationInformation
System/EMR Local, State,
National ImmunizationPrograms (i.e., VFC)
Third Party Insurers/Authorizing Agents
Community
OrganizationsAAP Chapter or State Educational
ProgramsVaccine
Manufacturers
Child Care Centers,Public & Private
Schools
Medical Home
Health Departments
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Barriers to Coordinated Barriers to Coordinated CareCare
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 Barriers to Coordinated CareCare
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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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
Strategies to ProvideStrategies to Provide Coordinated Care Coordinated Care
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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
Strategies to ProvideStrategies to Provide Coordinated Care Coordinated Care
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Strategies to ProvideStrategies to ProvideCoordinated CareCoordinated 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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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
Strategies to ProvideStrategies to ProvideCoordinated CareCoordinated Care
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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: Case Study #2: Coordinated CareCoordinated 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: Case Study #2: Coordinated CareCoordinated Care
Question: What should the school nurse Question: What should the school nurse do? What should Billy’s pediatrician do?do? What should Billy’s pediatrician do?
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Case Study #2: Case Study #2: Coordinated CareCoordinated Care
What should the school nurse do? Document that Billy is behind and Document that Billy is behind and
send a letter home to his parents.send a letter home to his parents. Refer Billy to his pediatrician.Refer Billy to his pediatrician.
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Case Study #2: Case Study #2: Coordinated CareCoordinated Care
What should Billy’s pediatrician do?
Follow the written vaccination protocols, Follow the written vaccination protocols, including the including the Catch-up Schedule for for children behind on immunizations.children behind on immunizations.
Billy needs:Billy needs:DTaP #4, IPV #3—both final doses DTaP #4, IPV #3—both final doses
because given after age 4because given after age 4PCV #4—because the first 3 doses PCV #4—because the first 3 doses
given before 24 months of agegiven before 24 months of ageHep B # 3—last doseHep B # 3—last doseMMR #2—he’s doneMMR #2—he’s done
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Case Study #2: Case Study #2: Coordinated CareCoordinated Care
Update the child’s immunization Update the child’s immunization record to reflect which vaccinations record to reflect which vaccinations were givenwere given, dates of administration, , dates of administration, number of doses, intervals between number of doses, intervals between doses, and the child’s age.doses, and the child’s age.
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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.
Case Study #2: Case Study #2: Coordinated CareCoordinated Care
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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.
Case Study #2: Case Study #2: Coordinated CareCoordinated Care
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References: Coordinated References: Coordinated CareCare
1. National Vaccine Advisory Committee. Standards for Child and Adolescent Immunization Practices. Pediatrics. 2003;112:958-963
2. Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for Children Program, United States, 1997. Pediatrics. 1999;104(2)
3. 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 References: Coordinated CareCare
4. Stokley S, Rodewald LE, Maes EF. The impact of record scattering on the measurement of immunization coverage. Pediatrics. 2001;107:91-96
5. 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 Immunization: Continuous CareCare
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 Immunization: Continuous CareCare
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 Strategies to Provide Continuous CareContinuous 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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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
Strategies to Provide Strategies to Provide Continuous CareContinuous Care
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References: Continuous CareReferences: Continuous Care
1. 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
2. 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
3. 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: Immunization: Comprehensive CareComprehensive Care
Comprehensive: Care is delivered or directed by a well-trained physician who is able to manage and facilitate all aspects of immunization and other preventive services
Scope of Problem: Immunization coverage rates are
higher for children receiving all or some vaccines within a medical home1
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Immunization: Immunization: Comprehensive CareComprehensive Care
Promoting vaccination within the medical home improves both vaccination coverage and receipt of other preventive services1
Errors maintaining cold-chain (improper vaccine placement, inaccurate thermometers, improper temperature) can affect the access to vaccine quality4
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Barriers to Barriers to Comprehensive CareComprehensive 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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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
Barriers to Barriers to Comprehensive CareComprehensive Care
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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
Barriers to Barriers to Comprehensive CareComprehensive Care
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Reasons for MOsReasons 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 MOsReasons 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 Differences Between Contraindications & Contraindications &
PrecautionsPrecautions 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 Valid Contraindications vs PrecautionsPrecautions
ConditionAllergy to ComponentEncephalopathyPregnancyImmunosuppressionSevere illnessRecent blood product
LiveC---CCPP
InactivatedCCVVPV
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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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
InvalidInvalid Contraindications to Contraindications to Vaccination (not even Vaccination (not even
precautions!)precautions!)
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Strategies to Improve Strategies to Improve Comprehensive CareComprehensive Care
Clinicians do not use false Clinicians do not use false contraindicationscontraindications to prevent immunizations 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 Strategies to Improve Comprehensive CareComprehensive 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 Strategies to Improve Comprehensive CareComprehensive 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 Strategies to Improve Comprehensive CareComprehensive 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 Strategies to Improve Comprehensive CareComprehensive 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 References: Comprehensive CareCare
1. Santoli JM, Rodewald LE, Maes EF, Battaglia MP, Coronado VG. Vaccines for Children Program, United States, 1997. Pediatrics. 1999;104(2)
2. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases: 8th Edition; January 2005
3. Szilagyi PG, Rodewald LE. Missed opportunities for immunizations: a review of the evidence. J Public Health Manage Pract. 1996;2:18-25
4. 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
5. 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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6. Ball TM, Serwint JR. Missed opportunities for vaccination and delivery of preventive care. Arch Pediatr Adolesc Med. 1996;150:858-861
7. Szilagyi PG, Rodewald LE, Humiston SG, et al. Immunization practices of pediatricians and family physicians in the United States. Pediatrics. 1994;94:517-523
8. 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
9. Rodewald L. Every medical home needs an immunization recall system. AAP News. February 2001:89
References: Comprehensive References: Comprehensive CareCare
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Immunization: Family-Immunization: Family-CenteredCentered
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-Immunization: Family-CenteredCentered
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 toBarriers toFamily-Centered CareFamily-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 toBarriers toFamily-Centered CareFamily-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 Common Parental Concerns About VaccinesAbout Vaccines
1. The use of Thimerosal (an organomercurial) as an additive in vaccines
2. An unsubstantiated link between the MMR vaccine and autism
3. The necessity of vaccinating children against hepatitis B
4. Pneumococcal conjugate (new vaccine to protect against meningitis, blood infections, ear infections)
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Common Parental Common Parental ConcernsConcerns
About VaccinesAbout Vaccines5. Meningococcal vaccine (new
meningococcal conjugate vaccine to protect against meningococcal disease)
6. The relative danger of influenza and the need for a yearly vaccination
7. The relative danger of varicella (chickenpox)
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The Facts About The Facts About ThimerosalThimerosal
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 The Facts About ThimerosalThimerosal
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 MMRThe Facts About MMR
Autism spectrum disorder is a common Autism spectrum disorder is a common developmental disability, affecting 1 in developmental disability, affecting 1 in 166 children166 children33
Concerns have been raised about a Concerns have been raised about a possible link between the proximity of possible link between the proximity of the MMR vaccination administration and the MMR vaccination administration and the development of signs of autismthe development of signs of autism
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The Facts About MMRThe Facts About MMR
Studies and independent panels in the Studies and independent panels in the US and in Europe, including experts from US and in Europe, including experts from the the Institute of MedicineInstitute of Medicine and the AAP, and the AAP, have found no association between the have found no association between the MMR vaccination and autismMMR vaccination and autism
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The Importance of The Importance of the Hepatitis B Vaccinethe 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 Importance of the Hepatitis B Vaccinethe 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 Importance of the Influenza Vaccinethe 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 Importance of the Influenza Vaccinethe 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 Importance of the Varicella Vaccinethe 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 Helping Families Locate Reliable Information on the Reliable Information on the
InternetInternetThe Internet can be a confusing place to The Internet can be a confusing place to navigate! To help parents locate factual navigate! To help parents locate factual vaccine information on the Web, practice vaccine information on the Web, practice staff should provide information and staff should provide information and resources about how to locate and resources about how to locate and evaluate Web sitesevaluate Web sites
Additional Reading: Content and Design Additional Reading: Content and Design Attributes of Antivaccination Web Sites. Attributes of Antivaccination Web Sites. Wolfe RM, Sharp LK, Lipsky MS. JAMA Wolfe RM, Sharp LK, Lipsky MS. JAMA 2002;287:3245-32482002;287:3245-3248
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State Exemptions: State Exemptions: Information and Information and
DefinitionsDefinitions As of 2004, all 50 states allow vaccination As of 2004, all 50 states allow vaccination
exemptions for medical reasons, as exemptions for medical reasons, as determined by a physiciandetermined by a physician
48 states (all except Mississippi & West 48 states (all except Mississippi & West Virginia) allow exemptions for religious Virginia) allow exemptions for religious reasons- when immunizations contradict reasons- when immunizations contradict the parent’s sincere religious beliefsthe parent’s sincere religious beliefs
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State Exemptions: State Exemptions: Information and Information and
DefinitionsDefinitions 20 states (AZ, AR, ID, LA, ME, MI, MN, MO, NE, 20 states (AZ, AR, ID, LA, ME, MI, MN, MO, NE,
NM, ND, CA, CO, OH, OK, TX, UT, VT, WA, and NM, ND, CA, CO, OH, OK, TX, UT, VT, WA, and WI) allow exemptions for philosophical reasons- WI) allow exemptions for philosophical reasons- other non-religious beliefs held by the parents other non-religious beliefs held by the parents who do not believe their child should be who do not believe their child should be immunizedimmunized
Additional information on state exemptions is Additional information on state exemptions is available at: available at: http://www.cispimmunize.org/pro/StateRequirehttp://www.cispimmunize.org/pro/StateRequirements.html ments.html
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Strategies to Provide Strategies to Provide Family-Centered CareFamily-Centered Care
Treat the family as a partner in their Treat the family as a partner in their child’s care and promote shared child’s care and promote shared decision-makingdecision-making
Provide the parent with an Provide the parent with an immunization record book to track immunization record book to track their child’s vaccination history and their child’s vaccination history and gain better understanding of which gain better understanding of which vaccines are needed and whenvaccines are needed and when
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Strategies to Provide Strategies to Provide Family-Centered CareFamily-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 Strategies to Provide Family-Centered CareFamily-Centered Care
Be available to answer questions or Be available to answer questions or concernsconcerns
Educate parents about risks versus Educate parents about risks versus benefits of vaccination benefits of vaccination
Warn them about inaccurate Warn them about inaccurate information on the Webinformation on the Web
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Strategies to Provide Strategies to Provide Family-Centered CareFamily-Centered Care
Use Vaccine Information Statements Use Vaccine Information Statements (available in simple wording, multiple (available in simple wording, multiple languages) languages)
Provide culturally-appropriate Provide culturally-appropriate educational materials at the necessary educational materials at the necessary literacy level literacy level
– Resource: American Academy of Pediatrics and Resource: American Academy of Pediatrics and National Perinatal Association. National Perinatal Association. Transcultural Aspects of Transcultural Aspects of Perinatal Health Care: A Resource Guide. Perinatal Health Care: A Resource Guide. Shah MA, ed. Shah MA, ed. National Perinatal Association; 2004National Perinatal Association; 2004
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The following case study is The following case study is designed to assist you to designed to assist you to implement the implement the Family-Centered Family-Centered CareCare component of the medical component of the medical home concept during home concept during immunization-related patient immunization-related patient encounters. Strategies to address encounters. Strategies to address specific issues raised in the specific issues raised in the scenario are included.scenario are included.
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Case Study #3: Case Study #3: Family-Centered CareFamily-Centered Care
Jane Smith is a new mom who is bringing Jane Smith is a new mom who is bringing her baby girl in for her first visit with the her baby girl in for her first visit with the pediatrician. Jane has done some research pediatrician. Jane has done some research on the Internet regarding vaccine safety. on the Internet regarding vaccine safety. From this research, Jane has many From this research, Jane has many questions and concerns regarding questions and concerns regarding vaccination, including the risks vs benefits vaccination, including the risks vs benefits of vaccines and possible side effects of of vaccines and possible side effects of vaccination. She is confused about the vaccination. She is confused about the complexity of the vaccination schedule complexity of the vaccination schedule and is concerned about the pain her baby and is concerned about the pain her baby might feel when the vaccine is injected. might feel when the vaccine is injected.
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Case Study #3: Case Study #3: Family-Centered CareFamily-Centered Care
Question: How can Jane’s pediatrician Question: How can Jane’s pediatrician create a partnership with her and create a partnership with her and provide family-centered care?provide family-centered care?
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Case Study #3:Case Study #3:Family-Centered CareFamily-Centered Care
Jane’s pediatrician should provide:Jane’s pediatrician should provide: An immunization record book so that An immunization record book so that
she can take partnership in her child’s she can take partnership in her child’s care care
Educational resources regarding the Educational resources regarding the safety of vaccines (Resource: “Compare safety of vaccines (Resource: “Compare the Risks”).the Risks”).
Additional Resources:Additional Resources:–“Evaluating Information on the Web”“Evaluating Information on the Web” fact sheetfact sheet–““Be There for Your Child During Shots” Be There for Your Child During Shots” fact sheetfact sheet
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Jane’s pediatrician should also:Jane’s pediatrician should also:– Review the Recommended Review the Recommended Childhood Childhood
and and Adolescent Adolescent Immunization Schedules Immunization Schedules to address confusionto address confusion
– Update the patient’s record and remind Update the patient’s record and remind Jane which immunizations will be due at Jane which immunizations will be due at the next visitthe next visit
– Identify practice staff to serve as an Identify practice staff to serve as an Immunization Champion to be readily Immunization Champion to be readily available to answer questions after available to answer questions after shots are givenshots are given
Case Study #3: Case Study #3: Family-Centered CareFamily-Centered Care
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References: References: Family-Centered CareFamily-Centered Care
1.1. American Academy of Pediatrics, Committee on American Academy of Pediatrics, Committee on Hospital Care. Family-centered care and the Hospital Care. Family-centered care and the pediatrician’s role. pediatrician’s role. Pediatrics.Pediatrics. 2003;112:691-696 2003;112:691-696
2.2. Gellin BG, Maibach EW, Marcuse EK.Gellin BG, Maibach EW, Marcuse EK.Do parents understand immunizations? A national Do parents understand immunizations? A national telephone survey. telephone survey. PediatricsPediatrics. 2000;106:1097-1102 . 2000;106:1097-1102
3.3. American Academy of Pediatrics, Autism Expert American Academy of Pediatrics, Autism Expert Panel, Committee on Children with Disabilities. Panel, Committee on Children with Disabilities. Autism A.L.A.R.M. Website: Autism A.L.A.R.M. Website: www.medicalhomeinfo.orgwww.medicalhomeinfo.org (Accessed October 11, (Accessed October 11, 2007).2007).
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Immunization: Immunization: Compassionate CareCompassionate Care
Compassionate:Compassionate: Concern for the well- Concern for the well-being of the child and family is being of the child and family is expressed and demonstrated in verbal expressed and demonstrated in verbal and nonverbal interactions. Efforts are and nonverbal interactions. Efforts are made to understand and empathize with made to understand and empathize with the feelings and perspectives of the the feelings and perspectives of the family and childfamily and child
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Immunization: Immunization: Compassionate CareCompassionate Care
A patient that feels understood is more A patient that feels understood is more likely to adhere to the physician’s likely to adhere to the physician’s recommendationsrecommendations11
Patients tend to judge the quality of Patients tend to judge the quality of treatment on the basis of physicians’ treatment on the basis of physicians’ “affective” behavior towards them“affective” behavior towards them22
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Barriers to Barriers to Compassionate CareCompassionate Care
Limited time during patient visitLimited time during patient visit Cultural or racial/ethnic differences Cultural or racial/ethnic differences
between patients and physiciansbetween patients and physicians Ignoring or misinterpreting parents’ or Ignoring or misinterpreting parents’ or
patients’ nonverbal cuespatients’ nonverbal cues Operating from a medical modelOperating from a medical model
– ““Us versus them,” paternalisticUs versus them,” paternalistic
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Strategies to Provide Strategies to Provide Compassionate CareCompassionate Care
Listen unhurriedly to family concerns Listen unhurriedly to family concerns and respond to them appropriatelyand respond to them appropriately
Honor or validate family experiences, Honor or validate family experiences, beliefs, questions and perspectivesbeliefs, questions and perspectives
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Strategies to Provide Strategies to Provide Compassionate CareCompassionate Care
Address specific concerns directly:Address specific concerns directly:– Discuss myths or misconceptions Discuss myths or misconceptions
openly and dispassionatelyopenly and dispassionately– Offer them the pamphlet “Be There for Offer them the pamphlet “Be There for
Your Child During Shots” Your Child During Shots” Ensure privacy/confidentiality for familiesEnsure privacy/confidentiality for families
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The following case study is The following case study is designed to assist you to designed to assist you to implement the implement the Compassionate Compassionate CareCare component of the medical component of the medical home concept during home concept during immunization-related patient immunization-related patient encounters. Strategies to address encounters. Strategies to address specific issues raised in the specific issues raised in the scenario are included.scenario are included.
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Case Study #4: Case Study #4: Compassionate CareCompassionate 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: Case Study #4: Compassionate CareCompassionate Care
Question: What should Dr Susan do?Question: What should Dr Susan do?
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Case Study #4: Case Study #4: Compassionate CareCompassionate Care
Dr Susan tells Kristen that she Dr Susan tells Kristen that she understands her concerns. She provides understands her concerns. She provides Kristen with verbal and written explanation Kristen with verbal and written explanation about baby’s immune systems capability about baby’s immune systems capability of handling multiple vaccines. She also of handling multiple vaccines. She also leads Kristen toward additional resources. leads Kristen toward additional resources.
Dr Susan explains to Kristen the ways to Dr Susan explains to Kristen the ways to comfort a baby before, during, and after comfort a baby before, during, and after vaccination and provides her with a fact vaccination and provides her with a fact sheet, “Be There for Your Child During sheet, “Be There for Your Child During Shots,” which describes methods of Shots,” which describes methods of comfort.comfort.
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Dr Susan encourages Kristen to ask Dr Susan encourages Kristen to ask her about any additional concerns or her about any additional concerns or questions.questions.
Case Study #4: Case Study #4: Compassionate CareCompassionate Care
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References: Compassionate References: Compassionate CareCare
1.1. Bellett PS, Maloney MJ. The importance of Bellett PS, Maloney MJ. The importance of empathy as an interviewing skill in medicine. empathy as an interviewing skill in medicine. JAMA.JAMA. 1991;266:1831-1832 1991;266:1831-1832
2.2. Ben-Sira Z. Ben-Sira Z. Stress, Disease and Primary Medical Stress, Disease and Primary Medical Care.Care. Gower, England, 1986 Gower, England, 1986
3.3. Offit PA, et al. Addressing parents’ concerns: do Offit PA, et al. Addressing parents’ concerns: do multiple vaccines overwhelm or weaken the multiple vaccines overwhelm or weaken the infant’s immuneinfant’s immune s system? ystem? Pediatrics. Pediatrics. 2002;109:124-129. Available at: 2002;109:124-129. Available at: http://www.cispimmunize.org/fam/infant.html http://www.cispimmunize.org/fam/infant.html (Accessed: October 12, 2007)(Accessed: October 12, 2007)
4.4. Offit PA, Jew RK. Addressing parents’ concerns: do Offit PA, Jew RK. Addressing parents’ concerns: do vaccines contain harmful preservatives, vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics. adjuvants, additives, or residuals? Pediatrics. 2003;112:1394-14012003;112:1394-1401
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Immunization: Immunization: Culturally-EffectiveCulturally-Effective
Culturally-Effective:Culturally-Effective: The delivery of care The delivery of care within the context of appropriate within the context of appropriate physician knowledge, understanding, and physician knowledge, understanding, and an appreciation of all cultural distinctionsan appreciation of all cultural distinctions
Family’s cultural background, including Family’s cultural background, including beliefs, rituals, and customs, are beliefs, rituals, and customs, are recognized, valued, and respected and recognized, valued, and respected and incorporated into the care plan incorporated into the care plan 33
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Immunization: Immunization: Culturally-EffectiveCulturally-Effective
Scope of Problem:Scope of Problem: Immunization coverage rates are Immunization coverage rates are
lower among children living in lower among children living in povertypoverty1 1 and among black and and among black and Hispanic childrenHispanic children22
By 2020, approximately 40% of By 2020, approximately 40% of school-age children will be of non-school-age children will be of non-white racial or ethnic backgroundswhite racial or ethnic backgrounds33
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– Cultural Competence:Cultural Competence: the awareness of the awareness of cultural/religious practices, beliefs, and cultural/religious practices, beliefs, and differences, enabling clinicians to adapt health differences, enabling clinicians to adapt health care in accordance with the ethnocultural/religious care in accordance with the ethnocultural/religious heritage of the individual, family, and heritage of the individual, family, and communitycommunity44
– Linguistic Competence:Linguistic Competence: the provision of bilingual the provision of bilingual staff or interpretation services for all clients staff or interpretation services for all clients without English language proficiencywithout English language proficiency44
– Spiritual Competence:Spiritual Competence: the ability to identify and the ability to identify and understand one's own values and spiritual beliefs understand one's own values and spiritual beliefs in the context of a pluralistic society, recognizing in the context of a pluralistic society, recognizing how interactions with patients and families may be how interactions with patients and families may be affected by religious differencesaffected by religious differences44
Important Definitions
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Barriers to Barriers to Culturally-Effective CareCulturally-Effective Care
Differences in cultural Differences in cultural backgrounds including backgrounds including differing perceptions and beliefsdiffering perceptions and beliefs
Language and communication barriersLanguage and communication barriers Lack of skilled staff or resourcesLack of skilled staff or resources Lack of appropriate services (i.e., Lack of appropriate services (i.e.,
patients that require interpretation vs patients that require interpretation vs translation services)translation services)
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Strategies to Provide Strategies to Provide Culturally-Effective CareCulturally-Effective Care
Immunization clinicians should be aware Immunization clinicians should be aware of any differences between their own of any differences between their own cultural/religious values and those of the cultural/religious values and those of the patient/familypatient/family44
Foster mutual respect and understandingFoster mutual respect and understanding44
Determine the most effective way of Determine the most effective way of adapting professional interpretations and adapting professional interpretations and recommendations to the value system of recommendations to the value system of each familyeach family44
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Strategies to Provide Strategies to Provide Culturally-Effective CareCulturally-Effective Care
Provide safe and realistic choices to Provide safe and realistic choices to patients/families within the least patients/families within the least restrictive environmentrestrictive environment44
Promote equity for all cultural/religious Promote equity for all cultural/religious backgroundsbackgrounds44
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Strategies to Provide Strategies to Provide Culturally-Effective CareCulturally-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 Strategies to Provide Culturally-Effective CareCulturally-Effective Care
Listen to verbal and nonverbal cues, Listen to verbal and nonverbal cues, using translation or interpretation using translation or interpretation resources if necessaryresources if necessary
Ensure the child/family understands the Ensure the child/family understands the results of the medical encounterresults of the medical encounter
Consider medical, religious, and Consider medical, religious, and philosophical exemptions to philosophical exemptions to immunization (understanding state law immunization (understanding state law and requirements)and requirements)
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Strategies to Provide Strategies to Provide Culturally-Effective CareCulturally-Effective Care
If possible, have bilingual staff/volunteers If possible, have bilingual staff/volunteers on handon hand
Display culturally diverse pictures, Display culturally diverse pictures, posters, magazines, etcposters, magazines, etc
Learn key words/phrases in the patient’s Learn key words/phrases in the patient’s languagelanguage
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Strategies to Provide Strategies to Provide Culturally-Effective CareCulturally-Effective Care
Provide written materials, including VISs, Provide written materials, including VISs, in the family’s primary language and at in the family’s primary language and at the appropriate literacy level; supplement the appropriate literacy level; supplement with additional resources (i.e., visual aids, with additional resources (i.e., visual aids, videos) if necessaryvideos) if necessary
Educate and train immunization clinicians Educate and train immunization clinicians at all levels (medical school, residency at all levels (medical school, residency programs, and continuing medical programs, and continuing medical education)education)
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The following case study is The following case study is designed to assist you to designed to assist you to implement the implement the Culturally-Culturally-Effective CareEffective Care component component of the medical home concept of the medical home concept during immunization-related during immunization-related patient encounters. patient encounters. Strategies to address specific Strategies to address specific issues raised in the scenario issues raised in the scenario are included.are included.
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Case Study #5: Case Study #5: Culturally-EffectiveCulturally-Effective
Derek, a practicing Catholic, has a 5 year Derek, a practicing Catholic, has a 5 year old son, Jack, who will be attending old son, Jack, who will be attending kindergarten in 3 months. Derek and his kindergarten in 3 months. Derek and his son recently relocated from Texas to son recently relocated from Texas to Illinois. Derek takes his son to their new Illinois. Derek takes his son to their new pediatrician, Dr Bob.pediatrician, Dr Bob.
Dr Bob reviews Jack’s immunization Dr Bob reviews Jack’s immunization history and notices that Jack has not history and notices that Jack has not received a varicella vaccine, which is received a varicella vaccine, which is required by law before school entry. required by law before school entry.
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Dr Bob asks Derek the reason for this and Dr Bob asks Derek the reason for this and Derek explains that in Texas, he received Derek explains that in Texas, he received a philosophical exemption for varicella a philosophical exemption for varicella vaccine because the vaccination was vaccine because the vaccination was developed using aborted fetuses. developed using aborted fetuses. Derek’s religious beliefs do not permit Derek’s religious beliefs do not permit abortion of any kind.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.
Case Study #5: Case Study #5: Culturally-EffectiveCulturally-Effective
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Case Study #5: Case Study #5: Culturally-EffectiveCulturally-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: Case Study #5: Culturally-EffectiveCulturally-Effective
Question: What should Dr Bob do to address this cultural difference?
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Case Study #5: Case Study #5: Culturally-EffectiveCulturally-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: Case Study #5: Culturally-EffectiveCulturally-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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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.
Case Study #5: Culturally-Case Study #5: Culturally-EffectiveEffective
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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.
Case Study #5: Culturally-Case Study #5: Culturally-EffectiveEffective
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References: References: Culturally-EffectiveCulturally-Effective
1.1. Klevens RM, Luman ET. US children living in and Klevens RM, Luman ET. US children living in and near poverty. Risk of vaccine-preventable diseases. near poverty. Risk of vaccine-preventable diseases. Am J Prev Med.Am J Prev Med. 2001;20:41-46 2001;20:41-46
2.2. Wood D, Donald-Sherbourne C, Halfon N, et al. Wood D, Donald-Sherbourne C, Halfon N, et al. Factors related to immunization status among inner-Factors related to immunization status among inner-city Latino and African American preschoolers. city Latino and African American preschoolers. Pediatrics.Pediatrics. 1995;96:295-301 1995;96:295-301
3.3. American Academy of Pediatrics, Committee on American Academy of Pediatrics, Committee on Pediatric Workforce. Culturally effective pediatric Pediatric Workforce. Culturally effective pediatric care: education and training issues. care: education and training issues. Pediatrics.Pediatrics. 1999;103:167-1701999;103:167-170
4.4. American Academy of Pediatrics. Preface. In: Shah American Academy of Pediatrics. Preface. In: Shah MA, ed. MA, ed. Transcultural Aspects of Perinatal Health Transcultural Aspects of Perinatal Health Care: A Resource Guide. Care: A Resource Guide. Elk Grove Village, IL: Elk Grove Village, IL: American Academy of Pediatrics; 2004, xv-xxixAmerican Academy of Pediatrics; 2004, xv-xxix
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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
Implementing “Immunization in a Medical Implementing “Immunization in a Medical Home” Concepts Home” Concepts
at the Practice-Levelat the Practice-Level
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Choices among strategies should be tailored to the individual child/family
Practice staff, should regularly review office protocols and procedures to ensure efficiency & accuracy
Implementing “Immunization in a Medical Implementing “Immunization in a Medical Home” ConceptsHome” Concepts
at the Practice-Levelat the Practice-Level
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AcronymsAcronymsAAPAAP American Academy of PediatricsAmerican Academy of Pediatrics
AFIXAFIX Assessment, Feedback, Incentives, eXchangeAssessment, Feedback, Incentives, eXchange
CASACASA Clinical Assessment Software ApplicationClinical Assessment Software Application
CDCCDC Centers for Disease Control and PreventionCenters for Disease Control and Prevention
CHISCHIS Child Health Information SystemChild Health Information System
CSHCNCSHCN Children with Special Health Care NeedsChildren with Special Health Care Needs
EMREMR Electronic Medical RecordElectronic Medical Record
MOMO Missed OpportunityMissed Opportunity
NVACNVAC National Vaccine Advisory CommitteeNational Vaccine Advisory Committee
SCHIPSCHIP State Child Health Insurance ProgramState Child Health Insurance Program
VFCVFC Vaccines for Children programVaccines for Children program
VAERSVAERS Vaccine Adverse Event Reporting SystemVaccine Adverse Event Reporting System
VICPVICP Vaccine Injury Compensation ProgramVaccine Injury Compensation Program
VISVIS Vaccine Information StatementVaccine Information Statement
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Vaccine-Preventable Vaccine-Preventable DiseasesDiseases
Diphtheria, Tetanus toxoids, acellular Pertussis Diphtheria, Tetanus toxoids, acellular Pertussis (DTaP/Tdap)(DTaP/Tdap)
Haemophilus InfluenzaeHaemophilus Influenzae type b (Hib) type b (Hib)
Inactivated Poliovirus Vaccine (IPV)Inactivated Poliovirus Vaccine (IPV)
Measles, Mumps, Rubella (MMR)Measles, Mumps, Rubella (MMR)
Meningococcal (Menactra/MCV4)Meningococcal (Menactra/MCV4)
Influenza (LAIV, FluMist)Influenza (LAIV, FluMist)
Varicella (chicken pox)Varicella (chicken pox)
Hepatitis BHepatitis B
Pneumococcal Disease (PCV7/Prevnar)Pneumococcal Disease (PCV7/Prevnar)
Hepatitis A (given in selected areas of the US)Hepatitis A (given in selected areas of the US)
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Additional Web-based Additional Web-based ResourcesResources
Childhood Immunization Support Program (CISP) is Childhood Immunization Support Program (CISP) is a joint program of the AAP and CDC. The CISP a joint program of the AAP and CDC. The CISP provides extensive information on immunizations provides extensive information on immunizations for health care professionals and families. Web site: for health care professionals and families. Web site: www.cispimmunize.orgwww.cispimmunize.org (Accessed: August 6, 2008) (Accessed: August 6, 2008)
Teaching Immunization Delivery and Evaluation Teaching Immunization Delivery and Evaluation (TIDE) is an internet-based continuing education (TIDE) is an internet-based continuing education program in childhood immunizations. Web site: program in childhood immunizations. Web site: www.musc.edu/tidewww.musc.edu/tide (Accessed: August 6, 2008) (Accessed: August 6, 2008)
Centers for Disease Control and Prevention National Centers for Disease Control and Prevention National Center for Immunization and Respiratory Diseases Center for Immunization and Respiratory Diseases (NCIRD) provides leadership for the planning, (NCIRD) provides leadership for the planning, coordination, and conduct of immunization coordination, and conduct of immunization activities nationwide. Web site: activities nationwide. Web site: www.cdc.gov/vaccineswww.cdc.gov/vaccines (Accessed: August 6, 2008) (Accessed: August 6, 2008)
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Immunization Action Coalition (IAC) creates and Immunization Action Coalition (IAC) creates and distributes educational materials for health distributes educational materials for health professionals and the public that enhance the professionals and the public that enhance the delivery of safe and effective immunization services. delivery of safe and effective immunization services. Web site: Web site: www.immunize.orgwww.immunize.org (Accessed: August 6, (Accessed: August 6, 2008)2008)
National Network for Immunization Information National Network for Immunization Information (NNII) (NNII) provides the public, health professionals, provides the public, health professionals, policy makers, and the media with up-to-date, policy makers, and the media with up-to-date, scientifically valid information related to scientifically valid information related to immunization. Web site: immunization. Web site: www.immunizationinfo.orgwww.immunizationinfo.org (Accessed: August 6, 2008)(Accessed: August 6, 2008)
Additional Web-based Additional Web-based ResourcesResources
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Other ResourcesOther Resources Recommended Childhood, Adolescent Recommended Childhood, Adolescent
Immunization Schedule & Catch-up Immunization Schedule & Catch-up ScheduleSchedule
Guide to Contraindications Guide to Contraindications Summary of Rules for Childhood and AdolSummary of Rules for Childhood and Adol
escent Immunization escent Immunization VISs in over 30 languages VISs in over 30 languages AAP Refusal to Vaccinate FormAAP Refusal to Vaccinate Form Vaccine Management: Recommendations Vaccine Management: Recommendations
for Handling and Storage of Selected for Handling and Storage of Selected BiologicalsBiologicals
Vaccines for Children ProgramVaccines for Children Program
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Other ResourcesOther Resources Immunization Registry Clearinghouse Vaccine-Preventable Diseases: Improving Vaccinat
ion 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 ToolAbout the Training ToolLead Author:
David Wood, MD, MPH, FAAP, Council on Community Pediatrics (COCP) and Childhood Immunization Support Program Childhood Immunization Support Program (CISP) Project Advisory Committee(CISP) Project Advisory Committee
AAP Reviewers: Charles Onufer, MD, FAAP, Medical Home Project Advisory Committee Gilbert Handal, MD, FAAP, COCP and CISP Project Advisory CommitteeEdgar Marcuse, MD, MPH, FAAP, AAP Immunization Advisory Team
AAP Board of Directors Reviewer: Alan Kohrt, MD, FAAP
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AcknowledgmentsAcknowledgmentsJill 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 About AAP Immunization Initiatives 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 GoalsCISP 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 ResourcesCISP 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 ResourcesCISP 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 ResourcesCISP 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 ResourcesCISP ResourcesResource 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 ResourcesCISP Resources
CISP Web siteCISP Web site: For fast, helpful and : For fast, helpful and accurate information on immunizations accurate information on immunizations for parents, the public, and all health care for parents, the public, and all health care professionals visit: professionals visit: www.cispimmunize.orgwww.cispimmunize.org or or www.aap.orgwww.aap.org and click the Immunization Information and click the Immunization Information button on the homepage.button on the homepage.
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CISP ResourcesCISP 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 UsContact 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]