Executive Summary

By the time children in the United States enter school, more than 95 percent of them have received all recommended immunizations, but estimates for 1992 indicate that no more than 70 percent of 2-year-olds have received the recommended three doses of oral polio vaccine (CDC, 1994a). About 80 percent have received at least three doses of the diphtheria-tetanus-pertussis vaccine, but the reported data do not indicate how many have received all four doses recommended by the Advisory Committee on Immunization Practices (CDC, 1994a). Epidemic levels of measles between 1989 and 1991 and subsequent outbreaks of pertussis and other vaccine-preventable diseases have made these unacceptably low immunization rates among preschool children an especially serious concern.

In 1993, the President's Childhood Immunization Initiative substantially increased the visibility of expanded public and private efforts to improve immunization levels among preschool children. It also set 1996 instead of the year 2000 as the target date for achieving the Healthy People 2000 objective that 90 percent of 2-year-olds complete the basic immunization series against the major preventable childhood illnesses (USDHHS, 1991).

This target presents a formidable challenge that requires an urgent response by all states and communities. Although immunization rates are especially low among African-American, Hispanic, and other minority children and children living in poverty, data for 1992 show that more than 70 percent of the 2-year-olds who were not immunized against measles were white; more than 70 percent also were not living in poverty (CDC, 1994a).

Following the President's initial proposals regarding immunization, public attention focused on the cost of vaccines and provisions for purchasing and



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Overcoming Barriers to Immunization: A Workshop Summary Executive Summary By the time children in the United States enter school, more than 95 percent of them have received all recommended immunizations, but estimates for 1992 indicate that no more than 70 percent of 2-year-olds have received the recommended three doses of oral polio vaccine (CDC, 1994a). About 80 percent have received at least three doses of the diphtheria-tetanus-pertussis vaccine, but the reported data do not indicate how many have received all four doses recommended by the Advisory Committee on Immunization Practices (CDC, 1994a). Epidemic levels of measles between 1989 and 1991 and subsequent outbreaks of pertussis and other vaccine-preventable diseases have made these unacceptably low immunization rates among preschool children an especially serious concern. In 1993, the President's Childhood Immunization Initiative substantially increased the visibility of expanded public and private efforts to improve immunization levels among preschool children. It also set 1996 instead of the year 2000 as the target date for achieving the Healthy People 2000 objective that 90 percent of 2-year-olds complete the basic immunization series against the major preventable childhood illnesses (USDHHS, 1991). This target presents a formidable challenge that requires an urgent response by all states and communities. Although immunization rates are especially low among African-American, Hispanic, and other minority children and children living in poverty, data for 1992 show that more than 70 percent of the 2-year-olds who were not immunized against measles were white; more than 70 percent also were not living in poverty (CDC, 1994a). Following the President's initial proposals regarding immunization, public attention focused on the cost of vaccines and provisions for purchasing and

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Overcoming Barriers to Immunization: A Workshop Summary distributing them. But removing the financial barriers will not, by itself, achieve full immunization of preschool children. Reaching and sustaining a commitment to universal and systematic delivery of immunization services will require addressing not only the costs of vaccine and of delivering services but also barriers that lie in the organization and delivery of health care (e.g., the fragmentation of primary care services, the inaccessibility of services, incomplete information about children's immunization status, and the complexities of the immunization schedule); the practices of individual health care providers (e.g., missed immunization opportunities at health care visits); and the knowledge, attitudes, and behavior of children 's families (e.g., apprehensions about the safety of vaccines and lack of appreciation for the risks of vaccine-preventable diseases) (NVAC, 1991, 1992). THE WORKSHOP AND REPORT To examine these other, largely nonfinancial barriers and to identify opportunities to overcome them, the Institute of Medicine (IOM) held a 2-day workshop on December 8–9, 1993, led by an eight-member steering committee. Participants included leaders of programs that have tried various approaches to reducing barriers to immunization, experts in the social and behavioral sciences, and pediatricians and other health care providers, including those familiar with health care for underserved populations. Funding was provided by the Carnegie Corporation of New York, the Centers for Disease Control and Prevention (CDC), and IOM's Board on Health Promotion and Disease Prevention. The National Vaccine Program Office of the U.S. Public Health Service provided nonfinancial assistance. This report, based on the presentations and discussions at the workshop, reflects the committee's assessment of the problem of underimmunization of preschool children. It makes no formal recommendations, but it reviews specific responses that could make a significant difference in the immunization status of preschool children in the short term and in the longer term. Issues of particular importance are accountability for delivery of immunization services, improving and protecting public health resources for providing immunization services, and effective collaboration between public and private providers. Although the report focuses on nonfinancial factors affecting immunization, it also covers important economic issues that were discussed at the workshop. The committee's special concern is those issues that require the attention of state-level decisionmakers, including government officials, public health officials, and leadership in the health professions. The report also addresses issues of importance to local government and public health officials, national leaders in government and the health professions, and public- and private-sector developers of health care reform plans.

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Overcoming Barriers to Immunization: A Workshop Summary THE COMMITTEE'S ASSUMPTIONS The committee's assessments rest on several assumptions about immunization and immunization services. First, all children in the United States should receive the recommended and medically appropriate immunizations at the recommended times to protect their own health and that of the community. Immunization is one of the safest and most cost-effective means of preventing illness. Second, the environment for vaccine delivery is rapidly changing: the introduction of new and reformulated vaccines, federal purchase of vaccines for Medicaid-eligible and uninsured children beginning in October 1994, adoption of managed care plans by state Medicaid programs, and probable passage of health care reform legislation. Third, immunization can best be seen as part of comprehensive primary care. A freestanding “immunization system” is not an appropriate objective. Finally, the United States cannot wait for health care reform to address its immunization problems. No one can be certain when health care reform measures will take effect or what their final form will be. In the meantime, of the more than 4 million children born each year, about 1 million join the pool of underimmunized preschool children who remain susceptible to serious illness. IMPROVING IMMUNIZATION OF PRESCHOOL CHILDREN The committee concluded that efforts to improve immunization rates among preschool children should focus on (1) leadership for action on immunization, (2) accountability and responsibility for providing immunizations, (3) support for improving provider practices, (4) effective communication with families and the community, and (5) development of better information and more effective information tools to support each of the other efforts. Leadership No easily delineated system of primary care exists. Providers in the public and private sectors deliver varying sets of services, under diverse systems of compensation, to which families have differing degrees of access. For immunization in particular, no consensus seems to exist as to how responsibility for ensuring that children receive the appropriate care should be shared among parents, providers, payers, and health departments. This can result in gaps in children's care. To overcome these gaps, stronger leadership is needed at the federal, state, and local levels and in the public and private sectors. When the political will to improve immunization levels exists, many financial and bureaucratic barriers can be overcome.

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Overcoming Barriers to Immunization: A Workshop Summary States' unique legal and organizational responsibilities in public health in general and immunization in particular make state leadership essential. Each state must, however, take into account its particular resources and the organization of its health and social services. To ensure that every child receives needed immunizations at appropriate times, state collaboration with local health departments, private providers, state and local chapters of professional organizations, community groups, and others is essential. States benefit from federal leadership provided by the National Vaccine Program Office and the CDC through channels such as the President 's Childhood Immunization Initiative, funding for states' Immunization Action Plans, and the Standards for Pediatric Immunization Practices (CDC, 1993b). Accountability and Responsibility Accountability and responsibility for immunizing preschool children must exist at many levels. States in particular have special obligations to develop immunization plans to coordinate systematic delivery of immunization services to all children. Those plans should include assessing immunization levels and the availability of providers. In the committee's view, public health agencies must be at the forefront of efforts to establish accountability for immunizing children and to work with private providers to ensure the delivery of services and the assessment of the performance of those services. States can use the newly available federal funding for their Immunization Action Plans to promote greater accountability for the delivery of immunization services. They can also work toward the development of more effective primary care services that can provide immunizations. Because achieving accountability demands good information, states also can encourage the development of data on immunization needs and services. Improving Provider Practices Improving the delivery of immunization services can raise immunization rates. The Standards for Pediatric Immunization Practices (CDC, 1993b) can guide providers in making needed changes. Changes in provider practices can improve immunization levels by making services more available and by reducing the number of missed immunization opportunities during health care visits. Providers need to be able to identify children due for immunizations and should observe only valid contraindications to those immunizations. They also should be encouraged to administer all appropriate immunizations in a single visit. Many providers overestimate their success in immunizing children; they need

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Overcoming Barriers to Immunization: A Workshop Summary better information about their actual performance and tools that can help them monitor their immunization practices. Providers will benefit from more information about new vaccines and changes in the immunization schedule. Academic health centers and other sources of professional training can ensure that the content of their curricula is consistent with current guidelines. CDC and professional organizations can develop materials that help providers learn about and implement practices consistent with the Standards for Pediatric Immunization Practices (CDC, 1993b). Informing Families and the Community More and better efforts should be made to inform families and communities about the importance of immunization and to encourage them to have children immunized appropriately—by 2 years of age rather than when they start school. Individual providers, office and clinic staff, community groups, and public health officials should be able to deliver accurate and effective messages. To have a long-term impact, public information programs must be sustainable and sustained. Strong community support and culturally appropriate messages and materials are essential for both education and outreach efforts. Families' fears and the small but real risks of adverse reactions to vaccines must be acknowledged, but more can be done to communicate the benefits of immunization, particularly in CDC's Vaccine Information Pamphlets. Providers and health educators also may benefit from better risk communication skills and resources. Immunization successes, such as the recent dramatic reduction in meningitis after the introduction of Haemophilus influenzae type b (Hib) vaccines, should be publicized more extensively. Information Resources Information is fundamental to all of the immunization issues discussed in this report, and, in general, better information and better information systems are needed. Activities on two fronts will help. New CDC-sponsored telephone surveys will begin producing data on immunization levels for states and major urban areas by the end of 1994. Immunization registries and tracking systems under development in states and communities across the country also will become important information resources. Health maintenance organizations and individual practices are implementing tracking systems as well. Tracking systems allow children and their families to benefit from individualized outreach and follow-up. They help providers more easily identify children who are due for immunizations and assess their own compliance with immunization

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Overcoming Barriers to Immunization: A Workshop Summary guidelines, and they provide public health authorities comprehensive population-based information on immunization rates. A national system of state-based registries that covers all children and that is used by all providers promises the greatest benefit. A need also exists for a comprehensive and annotated bibliography of studies on immunization practices, which would help providers and public health officials make better use of the research that has already been conducted. The bibliography should focus on studies of who is not immunized and why and of interventions that are succeeding in improving immunization rates. CONCLUSIONS The nation needs an enhanced, broad-based collaboration between the public health system and private medical practice to meet the primary care needs, including immunization, of preschool children. Although some of what should be done is complex or costly, many simple steps can be taken, often without additional funding. In either case, prompt action is needed to achieve the 1996 goal of up-to-date immunization for 90 percent of 2-year-olds. As the nation debates health care reform, experience with immunization serves as a clear reminder that removing financial barriers is not enough to ensure that those who need care will receive it.