General Recommendations on Immunization Screening Questions epoiem .Problems with immune system? Tmea8pno8rsgdwh icient.LAIV should no to phe w ntacts of severely immunosuppr sed persons. Blood products in last year? .Pregnant? hamyinthastyer, stion helne MMR and var ons for live fy prbich should peoho havethe women.MMR,varicella,smallpox(vaccinia),and LAIV vaccines should not be given to women know ontact recommend pregnancy testing prior to administration of any vaccine indicationsand deve Immunization Action Coalition,are included in Appendix A. Selected Referen e ed. American Academy of Pediatrics:2003:1-98 Atkinson W,Pickering LK,Watson JC,Peter G.General e203.9112 CDC.General recommendations on immunization:recom- mendations of the Advisory Committee on Immunization emy of amly Physicia CDC.Recom endations of the advisc Immuniation Practices:use of vaccines and immune gobulins 树wR的器及 26
2 Does anyone in your household have a problem with their immune system? Oral polio vaccine should not be given to a healthy person who has household contact with someone who is immunodeficient. LAIV should not be given to household contacts of severely immunosuppressed persons. Has the child received any blood products in the last year, like a transfusion, or immune globulin? This question helps identify precautions for live attenuated MMR and varicella vaccines, which should not be given to persons who have received passive antibody in the last few months. The question may also expose unreported illnesses that might not have been revealed in earlier questions. Are you pregnant, or trying to become pregnant? This question should be asked of all adolescent and adult women. MMR, varicella, smallpox (vaccinia), and LAIV vaccines should not be given to women known to be pregnant or for 4 weeks prior to pregnancy. Persons with a pregnant household contact should not receive smallpox (vaccinia) vaccine in nonemergency situations. ACIP does not recommend pregnancy testing prior to administration of any vaccine. Every person should be screened for contraindications and precautions before vaccination. Standardized screening forms for both children and adults, developed by the Immunization Action Coalition, are included in Appendix A. Selected References American Academy of Pediatrics. Active and passive immunization. In: Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics;2003:1–98 Atkinson W, Pickering LK, Watson JC, Peter G. General immunization practices. In: Plotkin SA, OrentseinWA, eds. Vaccines. 4th ed., Philadelphia, PA: Saunders;2003:91–122. CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices and the American Academy of Family Physicians. MMWR 2002;51(RR-2):1–36. CDC. Recommendations of the Advisory Committee on Immunization Practices: use of vaccines and immune globulins in persons with altered immunocompetence. MMWR 1993;42(RR-4):1–18. 26 General Recommendations on Immunization
General Recommendations on Immunization CDC.Guidelines for unistic infections among hemate recommendations of CDC,the Infectious Disease Society of M() act on AalNMcayg4i484gdhopoutaesAehPediar M.rk RK.S to eggs.N Engl J Med 1995;332:1262-9. Plotkin SA.Vaccines,vaccination and vaccinology.J.Infect Dis2003:187:1349-59. 27
2 CDC. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients: recommendations of CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation. MMWR 2000;49(RR-10):1–128. Dietz VJ, Stevenson J, Zell ER, et al. Potential impact on vaccination coverage levels by administering vaccines simultaneously and reducing dropout rates. Arch Pediatr Adolesc Med 1994;148:943–9. James JM, Burks AW, Roberson RK, Sampson HA. Safe administration of the measles vaccine to children allergic to eggs. N Engl J Med 1995;332:1262–9. King GE, Hadler SC. Simultaneous administration of childhood vaccines: an important public health policy that is safe and efficacious. Pediatr Infect Dis J 1994;13:394–407. Plotkin SA. Vaccines, vaccination and vaccinology. J. Infect Dis 2003;187:1349–59. 27 General Recommendations on Immunization
Immunization Strategies for Healthcare Practices and Providers Immunization Strategies for Healthcare Practices and Providers The Need for Stratedies to Increase Immunization Levels atio r the eed them.While attention toa who tiate administration of vaccinations is essential,it cannot be assumed that these vaccinations are being given to every eligible child at the recommended age.Immunization levels in the Unites States are high,but gaps still exist,and providers can do much to ncm吃n in their practice apter cribes the ne lin ou Vaccine-preventable disease rates in the United states are at their lowest level ever in 2003 only 56 cases of measles 7 cases of rubella,1 case of diphtheria,20 cases of tetanus, and no wild-type polio were reported to CDC.Given these immunization successes,one might question the continued interest in strategies to increase immunization levels. ase ot hr arding vaccination.For several rea -includin resurgence of disease,introduction of new vaccines. suboptimal immunization levels,cost-effectiveness,and gaps in sustainable immunization efforts- the need to focus on ase and deat still ex d mps, ical costs children miss school,parents lose time from work,and illness among healthcare workers can severely disrupt a healthcare system.For many of these diseases,without vaccination.the incidence will rise to prevaccine levels. Although levels of disease mate outc ome interest,thes or o of the ther fo ith nd this increasing immunization levels and the strategies healthcare providers can use to do this. 29
Immunization Strategies for Healthcare Practices and Providers The Need for Strategies to Increase Immunization Levels An important component of an immunization provider practice is ensuring that the vaccines reach all children who need them. While attention to appropriate administration of vaccinations is essential, it cannot be assumed that these vaccinations are being given to every eligible child at the recommended age. Immunization levels in the Unites States are high, but gaps still exist, and providers can do much to maintain or increase immunization rates among patients in their practice. This chapter describes the need for increasing immunization levels and outlines strategies that providers can adopt to increase coverage in their own practice. Vaccine-preventable disease rates in the United States are at their lowest level ever. In 2003, only 56 cases of measles, 7 cases of rubella, 1 case of diphtheria, 20 cases of tetanus, and no wild-type polio were reported to CDC. Given these immunization successes, one might question the continued interest in strategies to increase immunization levels. However, although levels of vaccine-preventable diseases are low, this should not breed complacency regarding vaccination. For several reasons—including possible resurgence of disease, introduction of new vaccines, suboptimal immunization levels, cost-effectiveness, and gaps in sustainable immunization efforts—the need to focus on immunization rates remains crucial. The viruses and bacteria that cause vaccine-preventable disease and death still exist and can be passed on to unprotected persons or imported from other countries. Diseases such as measles, mumps, or pertussis can be more severe than often assumed and can result in social and economic as well as physical costs: sick children miss school, parents lose time from work, and illness among healthcare workers can severely disrupt a healthcare system. For many of these diseases, without vaccination, the incidence will rise to prevaccine levels. Although levels of disease are the ultimate outcome of interest, these are a late indicator of the soundness of the immunization system. Immunization levels are a better indicator for determining if there is a problem with immunization delivery, and this chapter will focus on increasing immunization levels and the strategies healthcare providers can use to do this. 3 Immunization Strategies for Healthcare Practices and Providers 29
Immunization Strategies for Healthcare Practices and Providers mization levels and areas still sub boptimal.In 35 months For other age groups, e considerably 2003.3 median of only 70%of p one 65 and older received the nlue n the pmonths 64.2%had ever received pneumococcal vaccine. nd racial dis arities evist lov munization."Pockets of need"exist in our nation's inner cities. .1n2004.for the nerce age of children who had received varicella vac. cine by their second birthday was 87.5%.Rates of influenza immunization are also unacceptably low among hea ncare th.can whyro muni nization rates ng to d the apered the 1980 .Immunization levels not optimal and.improvements in influenza vaccination eis65endaenahaenadad Sustainable systems needed levelth the least expendire these sege can be Sustainable sustems for va ,adolescents and adults must be developed.High immunization rates ndeorll level delivery systems. Many strategies have been used to incre hizations me,for (advertising)is less well docun ented.Some proven egie 、等高出 30
3 30 Immunization Strategies for Healthcare Practices and Providers Specific concerns about U.S. immunization levels and areas for further study include the following: Childhood immunization rates are still suboptimal. In 2004, for example, only 85.5% of children 19 to 35 months of age had received four doses of DTaP vaccine. For other age groups, immunization rates are considerably lower than those for early childhood. According to Behavior Risk Factor Surveillance System data from 2003, a median of only 70% of persons 65 years of age and older received the influenza vaccine in the past 12 months, and 64.2% had ever received pneumococcal vaccine. Economic and racial disparities exist. Low-income and minority children and adults are at greater risk for underimmunization. “Pockets of need” exist in our nation’s inner cities. Uptake is lagging for some antigens. In 2004, for example, the percentage of children who had received varicella vaccine by their second birthday was 87.5%. Rates of influenza immunization are also unacceptably low among healthcare workers, an important target population for vaccination. Typically, fewer than 40% of healthcare workers receive influenza vaccine. Improvements in adult immunization rates have tapered off. According to data from the National Health Interview Survey, after a consistent increase in rates during the 1980s and early 1990s, improvements in influenza vaccination rates for adults 65 years of age and older have leveled off since 1997. Cost-effectiveness needs more research. More research is needed regarding which strategies increase immunization levels with the least expenditure so these strategies can be prioritized. Sustainable systems for vaccinating children, adolescents, and adults must be developed. High immunization rates cannot rest upon one-time or short-term efforts. Greater understanding of strategies to increase immunization levels is necessary in order to create lasting, effective immunization delivery systems. Many strategies have been used to increase immunizations. Some, such as school entry laws, have effectively increased demand for vaccines, but the effectiveness of other strategies (e.g., advertising) is less well documented. Some proven strategies (e.g., reducing costs, linking immunization to Women Infants and Children (WIC) services, home visiting) are well suited to increasing rates among specific populations, such as persons with low access to immunization services
Immunization Strategies for Healthcare Practices and Providers One key to a successful strategy to increase immunization is 3 present in the providers do not always optimally perform the activities ough a strategi aining high strategies for healthcare practices and providers. The AFIX Approach The National Immunization Program,through state and AFIX a state o bout the Assessment Feedback change their immunization practices;and capable of sustaining new behaviors.The acronym used for this approach is Incentives AFIX:Assessment of eXchange and poicno tochangemmuniatiopacisOrecoeebovi improved or high performance,and eXchange of information eing used n onw and privare 11 nd on provi iders an ntal vaccine programs and medical professional societies. Overview The AFIX process consists of an assessment of an immunization ecoverage rates bya fee immunization grante of th nt to exchange of information and ideas amo providers.Some specific characteristics of this approach have made it one of the most effective for achieving high. sustainable vaccine coverage. First.AFIX focuses on outcomes.It starts with an Special Characteristics of AFIX producing an estimate of immunization coverage levels in a provider's office,and these data help to identify specific ciencies.Outco uses on proFlX 31
3 31 Immunization Strategies for Healthcare Practices and Providers One key to a successful strategy to increase immunization is matching the proposed solution to the current problem. At present in the United States, most persons have sufficient interest in and access to health care and are seen, at least periodically, in healthcare systems. Those who remain unvaccinated are so largely because healthcare practices and providers do not always optimally perform the activities associated with delivering vaccines and keeping patients up-to-date with their immunization schedules. Although a combination of strategies—directed at both providers and the public—is necessary for increasing and maintaining high immunization rates, this chapter focuses on immunization strategies for healthcare practices and providers. The AFIX Approach The National Immunization Program, through state and other grantees, administers a program designed to move healthcare personnel from a state of unawareness about the problem of low immunization rates in their practice to one in which they are knowledgeable, concerned, motivated to change their immunization practices; and capable of sustaining new behaviors. The acronym used for this approach is AFIX: Assessment of the immunization coverage of public and private providers, Feedback of diagnostic information to improve service delivery, Incentives to motivate providers to change immunization practices or recognition of improved or high performance, and eXchange of information among providers. First conceived by the Georgia Division of Public Health, AFIX is now being used nationwide with both public and private immunization providers and is recommended by governmental and nongovernmental vaccine programs and medical professional societies. Overview The AFIX process consists of an assessment of an immunization provider’s coverage rates by a trained representative from the state or other immunization grantee program, feedback of the results of the assessment to provider staff, incentives to improve deficiencies and raise immunization rates, and exchange of information and ideas among healthcare providers. Some specific characteristics of this approach have made it one of the most effective for achieving high, sustainable vaccine coverage. First, AFIX focuses on outcomes. It starts with an assessment, producing an estimate of immunization coverage levels in a provider’s office, and these data help to identify specific actions to take in order to remedy deficiencies. Outcomes are easily measurable. Second, AFIX focuses on providers, those who are key to increasing immunization rates. AFIX requires no governmental policy changes, nor does it