Administrative Barriers to Immunization
Compliance
August 13, 2013
Andrew Kroger, M.D., M.P.H.
Medical Officer
Centers for Disease Control and Prevention (CDC)
Agenda Item
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Presenter
Time
Welcome and
Introductions
Janet Gingold, MD, MPH
5 min
Discussion of Barriers
and Strategies
Andrew Kroger, MD, MPH
45 min
Questions and Answers
All
10 min
Housekeeping
 All phones are muted until Q&A at end
 Type questions during the presentation into the chat
box and send to Janet Gingold or everyone or wait
to ask over phone during Q&A
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Attendance Tracker for CME & MOC
 Within 1-2 days of the webinar, please submit a spreadsheet
containing the following information about the webinar
participants from your practice:
Full name (as it
will appear on
your CME
Certificate)
Email address (you
will be sent a
webinar evaluation
after the webinar)
Designation (as
it will appear on
your CME
Certificate)
Full Address (only if this
differs from the
address of the Project
leader’s address)
 Please send this spreadsheet to Liz Rice-Conboy at
[email protected]. An evaluation survey will be sent out via
REDCap. Liz will email a PDF of the CME Certificate directly to
each participant.
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CME Designation
 The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for




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Continuing Medical Education (ACCME) to provide continuing medical education for
physicians.
The AAP designates this live activity for a maximum of 1.00 AMA PRA Category 1
Credit(s)™. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
This activity is acceptable for a maximum of 1.00 AAP credits. These credits can be applied
toward the AAP CME/CPD Award available to Fellows and Candidate Members of the
American Academy of Pediatrics.
The American Academy of Physician Assistants (AAPA) accepts certificates of participation
for educational activities certified for AMA PRA Category 1 Credit™ from organizations
accredited by ACCME. Physician assistants may receive a maximum of 1.00 hours of
Category 1 credit for completing this program.
This program is accredited for 1.00 NAPNAP CE contact hours of which 0.25 contain
pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners
(NAPNAP) Continuing Education Guidelines.
Speaker’s background
 Andrew Kroger, M.D., M.P.H., is a medical officer for the National Center for
Immunization and Respiratory Diseases at the Centers for Disease Control and
Prevention (CDC). As one of the traveling trainers in the Education, Information and
Partnership Branch, Dr. Kroger has given multiple presentations on topics ranging
from immunization updates to pandemic influenza preparedness.
 Most notably, Dr. Kroger is the author of the newest edition of the CDC’s General
Recommendations on Immunization; and he is also involved with some of the new
distance learning activities of the branch, including the Current Issues in
Immunization Series that is delivered through NetConferencing.
 Dr. Kroger trained in pediatrics for two years at Rainbow Babies and Children's
Hospital in Cleveland before transferring to Emory University where he specialized
in public health and preventive medicine. He received joint Doctor of Medicine and
Master of Public Health degrees from Yale Medical School and Yale University School
of Epidemiology and Public Health with a concentration in international health.
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http://www.cdc.gov
/mmwr/pdf/rr/rr60
02.pdf
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Comparison of Immunization Quality
Improvement Dissemination Strategies (CIzQIDS)
CME Disclosure
I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s) and/or
provider of commercial services discussed in this CME
activity.
In the webinar, I may use recommendations based on
evidence that are common practice and supported by the
CDC a leading public entity.
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Learning Objectives
 After completing this course, you should be able to:
a) Identify vaccine-specific strategies intended to
raise vaccination coverage levels
b) Recognize the most common reasons for missed
opportunities to vaccinate.
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Overview
 Administrative barriers to vaccination
 Strategies to overcome administrative barriers
 Other barriers to vaccination
 Other strategies
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Administrative Barriers to Vaccination
 Inconvenient clinic hours
 Clinic distance
 Cost
See Section 6. “Availability of Vaccine
Services” in the Vaccinator Toolkit for
other barriers, QI practices, tools and
resources pertaining to Administrative
Barriers to Vaccination.
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Inconvenient Clinic Hours
 Reducing missed opportunities
 Lack of simultaneous administration
 Unaware child needs additional vaccines
 Invalid contraindications
 Inappropriate clinic policies
 Reimbursement deficiencies
 Alternative vaccination venues (Adult)
 The workplace
 Grocery stores
 Voter registration drives
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Simultaneous Vaccination
 “Simultaneously administering
the most widely used live and
inactivated vaccines have
produced seroconversion rates
and rates for adverse reactions
similar to those observed
when the vaccines are
administered separately”
See Section 4. “Administering
multiple vaccines” in the
Vaccinator Toolkit.
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Simultaneous Vaccination
 King G, Hadler S. Pediatric Infectious Disease Journal 1994
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



MMR + DTP + OPV1
Hib + DTP + OPV
HepB + Hib + DTP + OPV
MMR + Hib

1
Deforest A, et. Al. Pediatrics 1998
Simultaneous Vaccination: – Rotavirus
Vaccines (Package Insert)
 484 infants - RV1 (04/2008) combined with Pediarix,
Prevnar, and Hib compared with RV1 alone
 No evidence of interference with the immune response
 RV5 was administered concomitantly with DTaP, IPV, Hib,
HepB and PCV
 No evidence of reduced antibody response
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Simultaneous Vaccination: Human
Papillomavirus Vaccine (Package Insert)
 Study of 1871 women 16-24 years old demonstrated non-
inferior immune response to HPV and HepB when
administered at same visit or different visit
 Safety was assessed in the same study (presumed also noninferior)
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Exceptions to Simultaneous
Vaccination
 PCV13 and PPSV23 need to be separated by 8 weeks
 PPSV23 generates immunotolerance to PCV13 (and future doses of
PPSV23)
 PCV13 and MCV4-D need to be separated by 4 weeks
 MCV4-D interferes with response to PCV13
 ONLY in children with functional or anatomic asplenia
 ONLY with MCV4-D (not Hib-MenCY or MCV4-CRM)
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Missed Opportunity: Provider
Unawareness of Vaccination Need
 Provider recommendation the strategy most successful in
improving immunization rates
 Assessment, Feedback, Information, eXchange (AFIX)
 Screening an important part of immunization practices
 Every encounter
 Use a standardized form
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AFIX
 Assessment – use systems to determine current provider
practice coverage levels
 Administered at state level
 Feedback – provided in a non-judgmental manner
 Incentives – recognition of programs with high levels and
those that improve
 eXchange – sharing of experiences from other provider
practices
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AFIX
 Task Force on Community Preventive Services –
Strong Recommendation to link services with
education
 14 studies, showed coverage levels rise 16%
(median)
 Can be combined with educational activities
 17 studies showed a rise of 16% (median)
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Screening Questions
 Is the child sick today?
 Does the child have an allergy to any medications, food, or
any vaccine?
 Has the child had a serious reaction to a vaccine in the past?
 Has the child had a seizure, brain or nerve problem?
 Has the child had a health problem with asthma, lung disease,
heart disease, kidney disease, metabolic disease, such as
diabetes, or a blood disorder?
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Invalid Contraindications
 Mild Illness
 Antimicrobial therapy
 Disease exposure or convalescence
 Pregnant or immunosuppressed person in the household
 Breastfeeding
 Preterm birth
 Allergy to products not present in vaccines or allergy that is
not anaphylactic
 Family history of adverse events
 Tuberculin skin test
 Multiple vaccines
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Human Papillomavirus Vaccines: Additional Visits Needed for
Females,
First HPV Vaccine at Well Visit vs.
Any Visit - 24 month window
% of female adolescents
100
Type of visit
1st vaccine
80
60
Well visit
Any visit
40
20
0
0
1
2
# of additional visits needed
3
*Adapted from Dr. Cynthia Rand, Univ Rochester
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Inappropriate Clinic Policies and
Cost Issues
 Not vaccinating siblings
 Not vaccinating during acute illness
 Lack of reimbursement
 Systems changes
 Providers are encouraged to work with insurers, state and
specialty-specific medical organizations, vaccine
manufacturers and other stakeholders to address financial
barriers to achieving high vaccination coverage
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Vaccines For Children (VFC) Program
 Established in 1994 by Section 1928 of
This document can be found on the CDC
website at:
http://www.cdc.gov/vaccines/programs/vfc/dow
nloads/vfc-op-guide/18-appx-2-providerprofile.pdf
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the Social Security Act
 Entitlement program
 Provides free (government-purchased)
vaccines for certain children in their
private provider’s office
 Covers children 18 years and younger
who have no health insurance or are
Native American or American Indian
 Covers children who have insurance that
does not include vaccines
(“underinsured”) but only at certain
Federally Qualified and Rural Health
Clinics
Summary: Strategies for Administrative
Barriers
 AFIX program
 Provider recommendation – screening
 Avoiding missed opportunities – recognizing false
contraindications
 Systems changes – working with insurers, manufacturers,
government
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Other Barriers to Vaccination
 Psychological barriers
 Fear of vaccines
 Criticism for previously missed appointments
 Addressed through communication strategies
See Section 8. “Effective Communication about Risks
and Benefits” in the Vaccinator Toolkit.
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Enhancing Vaccine Communication
 Recognize the challenges
 Meet them where they are
 Share the goal of informed
decision-making in
partnership
 Engage in a dialogue with
trust and open
understanding
For the information resources mentioned in this sheet, and others, look for Provider Resources for Vaccine
Conversations with Parents at http://ww.cdc.gov/vaccines/conversations or call 800-CDC-INFO (800-232-4636).
These resources are free to download and ready for color or black and white printing and reproduction.
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Benefit and Risk Communication
Strategies
Tell real stories of
children/adults who have
suffered from vaccine
preventable diseases
www.immunize.org
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Benefit and Risk
Communication Strategies
 Opportunities for questions should
be provided before each vaccination
 Vaccine Information Statements (VISs)
 must be provided before each dose
of vaccine
 public and private providers
 available in multiple languages
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Other Strategies to Increase
Vaccination Coverage
 Standing orders
 Recordkeeping – Immunization Information Systems
 Patient Reminder/Recall
 Provider Reminder/Recall
See Section 10. “Implementation
of Strategies to Improve
Vaccination Coverage” in the
Vaccinator Toolkit.
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Use Multiple Methods to
Increase Immunization Rates
 Minnesota VA Medical Center
Percent Vaccinated
100
80
60
40
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Pneumococcal
Program
Institution-wide
Program
Standing
Orders
Provider
Education
0
Flu vaccination rate
Pneumococcal vaccination rate
83-84 84-85 86-87
87-88 89-90
91-92 92-93 93-94 94-95
Vaccination Year
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Adapted from Nichol KL. Am J Med. 1998;105:385–392.
96-97
Provider Reminder Systems
 Informs the provider that an individual patient is due for vaccine
 Should require some acknowledgment
 Examples:
 Notation, prompt, or sticker in patient chart
 Standardized checklists
 Computerized database or registry
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Chart Reminders: Implementation
 Design or identify a chart reminder to use
 Make copies to be inserted into all appropriate patient records
 Assign a staff person to place the reminders in a prominent
place in the chart
 Resources needed:
 Staff time
 Chart reminders
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Computerized Record Reminder
 Computer print-out of reminders that appear on a patient’s record
 Use software to determine dates that certain immunizations are due or past due and
then print reminder messages, usually overnight, for patients with visits scheduled
for the next day
 Advantages:
 Inexpensive once computerized system is in place
 Efficient
 Disadvantages:
 Only reaches patients with office visits
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Computer Record Reminder:
Implementation
 Design or identify a computerized reminder system
 Train professional staff in the use of the computerized
reminders
 Resources needed:
 Computer program linked to medical records or billing
data to generate reminders
 Computerized medical records
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Intervention Effectiveness
Intervention
Median Increase in
Vaccination Rate
Standing orders
51%
Provider reminder/recall
17%
Assessment and feedback of vaccine
providers
16%
Patient reminder/recall
8%
Clinic-based education
2%-3%
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Briss PA, et al. Am J Prev Med. 2000;18(1S):97-140.
Questions and Answers
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