3

Leadership for Action on Immunization

Ensuring that all children receive the immunizations they need on time is and must be a responsibility shared by public authorities, public health agencies, private health care providers, payers, families, and the entire community, which benefits from comprehensive immunization of preschool children. The unsatisfactory levels of immunization found in cities and states across the United States suggest that the separate parties have not been able to work together effectively to meet that responsibility. The committee believes that stronger leadership must be exercised at the federal, state, and local levels and in the public and private sectors to build a comprehensive and collaborative primary care system that can improve the delivery of immunization services.

Notable advances in immunization coverage rates and disease reduction have been made when strong leadership was exerted at all levels, clear targets were set, a comprehensive strategy was formulated, and accountability in implementation was monitored. For example, the comprehensive immunization program undertaken by the United Kingdom in 1990 has brought immunization rates for children of all ages to well over 90 percent across most of the country. When the program began, about 45 percent of providers had immunization rates in their practices of less than 90 percent. With the success of this program, the national immunization goal has recently been raised from 90 percent to 95 percent coverage.

In the United States in the late 1970s, the federal government successfully led the effort to increase immunization rates among children starting school from approximately 60 percent to 90 percent (Freeman et al., 1993). National leaders also urged the states to enact and enforce laws requiring immunization before a



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Overcoming Barriers to Immunization: A Workshop Summary 3 Leadership for Action on Immunization Ensuring that all children receive the immunizations they need on time is and must be a responsibility shared by public authorities, public health agencies, private health care providers, payers, families, and the entire community, which benefits from comprehensive immunization of preschool children. The unsatisfactory levels of immunization found in cities and states across the United States suggest that the separate parties have not been able to work together effectively to meet that responsibility. The committee believes that stronger leadership must be exercised at the federal, state, and local levels and in the public and private sectors to build a comprehensive and collaborative primary care system that can improve the delivery of immunization services. Notable advances in immunization coverage rates and disease reduction have been made when strong leadership was exerted at all levels, clear targets were set, a comprehensive strategy was formulated, and accountability in implementation was monitored. For example, the comprehensive immunization program undertaken by the United Kingdom in 1990 has brought immunization rates for children of all ages to well over 90 percent across most of the country. When the program began, about 45 percent of providers had immunization rates in their practices of less than 90 percent. With the success of this program, the national immunization goal has recently been raised from 90 percent to 95 percent coverage. In the United States in the late 1970s, the federal government successfully led the effort to increase immunization rates among children starting school from approximately 60 percent to 90 percent (Freeman et al., 1993). National leaders also urged the states to enact and enforce laws requiring immunization before a

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Overcoming Barriers to Immunization: A Workshop Summary child could enter school, which every state did. Federal authorities supported the new requirements with increases in state resources through CDC's Immunization Program, Medicaid, Maternal and Child Health funds, and community health centers to ensure the availability of providers who were willing to complete each child's immunizations prior to school entry. Strategies for comprehensive immunization coverage for preschool children have proved more elusive. Among these children, there is no universal experience equivalent to school entry, and the United States lacks the centrally managed health care system that allows the United Kingdom to exert a strong influence over local providers. Nevertheless, the committee sees ensuring the proper immunization of preschool children as an explicit public health responsibility. In principle, the public health system in the United States—constituted of the many separate federal, state, and local public health authorities—should protect everyone. As the immunization problem demonstrates, this system has gaps that need to be closed. Clear and effective leadership is required to find and close those gaps and to recognize and respond to those that may develop in the future. Private providers must play a greater role in meeting the need for immunization services in all settings, including low-income urban areas. Enhanced cooperation between the public health system and private providers will be needed to achieve this important shift in provider roles. UNIQUE STATE RESPONSIBILITIES The Constitutional authority to act to protect the public's health and safety rests with the states (Freeman et al., 1993). 1 The IOM (1988) has described the mission of public health as assuring conditions in which people can be healthy. Many states delegate some of their authority to local health departments. This does not mean that either state or local public health authorities must provide all services. Depending on the nature and extent of the available private resources, public resources may be needed only to guide public health planning, fill gaps in service, and ensure accountability. The committee believes that it is essential that states understand their unique legal and organizational roles in public health in general and immunization in particular. Given the current level of attention and federal support, the committee feels that this may be a defining moment for immunization and child health, and states need to be prepared to lead effective programs. When the 1   The state's public health powers, which derive from the its “police powers,” are meant to protect the entire community, and the state has authority to design public health measures to ensure that result (Jacobson v. Massachusetts, 197 U.S. 11 [1905]).

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Overcoming Barriers to Immunization: A Workshop Summary political will to improve immunization levels exists, many apparent financial and bureaucratic barriers can be overcome. Governors, legislators, and health officers all need to recognize the importance of immunizing preschool children and the special responsibility that the state has in ensuring that they are immunized. Furthermore, these officials can exercise authority and influence on behalf of new programs that lower-level officials often cannot. David Smith observed that strong support from the Texas governor has made continued progress in immunization efforts possible in that state. Understanding the importance of support at these levels of state government, the Every Child By Two immunization campaign initiated by Rosalynn Carter and Betty Bumpers has targeted governors and other elected officials and their spouses. State officials also need to know that current approaches to immunizing children are not sufficient to reach the 1996 target of 90 percent coverage. To guide the development of new programs and the allocation of funding and other resources, states must have comprehensive information on children's unmet needs for immunizations and on the factors that keep them from receiving those immunizations. Some of this information will come from the CDC diagnostic projects (mentioned in Chapter 1) and other research studies such as those reported on at the workshop, from CDC surveys, and from tracking and other improved information systems. Beginning in 1992, states and 24 major urban areas had the opportunity to obtain supplemental grant funds from CDC to assist them in developing and implementing Immunization Action Plans (IAPs) to improve immunization levels among preschool children.2 These funds give states and urban areas the opportunity to move ahead with reducing barriers to immunization, enhancing the infrastructure for vaccine delivery, and supporting immunization information and education activities. IAPs are intended to support improvements in the delivery of public and private immunization services, but the initial focus has been on the public sector. With the first results of CDC's telephone surveys in November 1994, the IAP areas will have the comprehensive population-based data necessary to assess the need for immunization services and the impact of enhanced service delivery in both the public and private sectors. The committee encourages states and communities to work with CDC to ensure that IAPs promote comprehensive planning across the public and private sectors. The application process for the Robert Wood Johnson Foundation's All 2   The $45 million in awards made in April 1993 represented only 20 percent of the additional funding that states estimated that they needed (Walter Orenstein, CDC, personal communication, December 1993). For fiscal year 1994, funding was increased to $129 million.

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Overcoming Barriers to Immunization: A Workshop Summary Kids Count grants for immunization registry systems illustrates the kind of collaboration needed.3 Committee member Robert Ross, who served on the All Kids Count advisory committee, was impressed by the ability of the foundation to insist on representation from all elements of the public and private health care delivery systems, including physicians, nurses, hospitals, and community organizations, in proposal development and interviews during site visits. No single plan will lead to comprehensive immunization coverage in every state. Common themes may exist, but each state must find a solution that takes into account the specific immunization needs of its children and how its providers and organizational resources can be used to meet those needs. The committee is persuaded that solutions will require state collaboration with local health departments, private providers, state and local chapters of providers' professional organizations, community groups, and others. States should be exploring how to strengthen primary care to meet not only children's immunization needs but also their other important health care requirements. FEDERAL LEADERSHIP States can benefit from the strong federal support for improving immunization levels among preschool children. Political influence on behalf of immunization initiatives as well as funding and technical assistance can come from federal sources. With its responsibility for overseeing the President's Childhood Immunization Initiative (see box), the NVPO has a critical leadership role to play. It is coordinating federal immunization efforts, working with the national leadership of provider organizations, and stimulating awareness of immunization issues among the public health and private provider communities and the public at large. CDC's role includes implementing operational aspects of the President 's Childhood Immunization Initiative, administering major grant programs, providing technical assistance to public health departments in the delivery and monitoring of services, and conducting disease surveillance. CDC also coordinated the development and publication of the Standards for Pediatric Immunization Practices (CDC, 1993b). The standards are an influential tool for 3   In 1992, the Robert Wood Johnson Foundation (1992) established a new grant program called All Kids Count. The program seeks to improve immunization rates among preschool children by supporting the development and implementation of computerized systems that record and monitor children's immunization status. Recipients of 1-year planning grants, awarded in 1992, were eligible to apply for a limited number of larger implementation grants that would provide support for a maximum of 4 years.

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Overcoming Barriers to Immunization: A Workshop Summary THE PRESIDENT'S CHILDHOOD IMMUNIZATION INITIATIVE The Initiative's goals include establishing an effective and sustainable vaccination-delivery system and achieving up-to-date immunization for 90 percent of 2-year-olds by 1996. Specific activities include: enhancing the availability of immunization at the community level by increasing funding for Immunization Action Plans and encouraging the development of state immunization information systems stimulating greater awareness of the importance of immunization through a nationwide health promotion campaign aimed at providers and the public reducing cost barriers through the Vaccines for Children Program, under which the federal government will purchase vaccines for Medicaid-eligible and uninsured children improving disease surveillance and measurement of immunization coverage at the national, state, and local levels and by individual providers coordinating immunization activities among federal departments and agencies and promoting partnerships with private providers and organizations encouraging the development of safer and more effective vaccines, including combination products that can reduce the number of separate vaccine doses required SOURCE: CDC (1994b). communicating with a large audience of public and private health care providers. Endorsement of the standards by professional organizations signals their willingness to collaborate with CDC in promoting the standards. It also involves CDC with providers outside of state and local public health departments. FEDERAL AND STATE COLLABORATION States have specific responsibilities for and operational resources to apply to the immunization of children, but the committee feels that they may benefit from better federal guidance. The President 's Childhood Immunization Initiative has given immunization greater prominence in federal health planning, and it will be important to ensure that activities already in operation are consistent with

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Overcoming Barriers to Immunization: A Workshop Summary new undertakings. The committee was particularly concerned that oversight and implementation of state IAPs be coordinated with the increased federal purchase of vaccines by the federal government under the Vaccines for Children Program. States will face the need to manage large-scale distribution of the federally purchased vaccines. In Washington State, for example, 67 percent of children under 1 year old will be eligible to receive federally purchased vaccines. Walter Orenstein emphasized CDC's desire to move away from auditing and outcomes assessment to providing collaborative assistance to states, communities, and providers. CONFLICTING INTERESTS Efforts to protect the health of children through immunization cannot always proceed along unambiguous paths. In several areas, competing interests need to be recognized and managed by officials with public health responsibilities. Several concerns surfaced during workshop discussions, and others were apparent to the committee. Financial constraints at state and local levels and steady or declining funds from federal sources have made it difficult for health departments to meet the increasing demand for public immunization services caused by referrals from private providers (Schulte et al., 1991). Some assistance should come from an increase of $83 million in federal funding through IAPs in fiscal year 1994 and, beginning in October 1994, expanded purchase of vaccines by the federal government for Medicaid-eligible and uninsured children, including those cared for by private providers. In addition to children who are uninsured or covered by Medicaid, many children with health insurance are immunized in public clinics because their insurance does not provide “first-dollar” coverage for immunizations.4 Alan Kohrt, a Pennsylvania pediatrician instrumental in passage of state legislation mandating insurance coverage for immunizations, explained that such legislation does not resolve the problem. The many employers that self-insure remain exempt from state requirements under the provisions of the 1974 federal Employee Retirement Insurance Security Act (ERISA). An emerging concern for some local health departments is what their responsibilities will be in delivering personal health services, such as immunizations, as Medicaid moves families into capitated and managed care programs that are expected to provide immunizations as part of overall primary 4   Health insurance plans with first-dollar coverage pay for immunizations regardless of the amount of a family's other health care expenditures. Plans without first-dollar coverage pay for immunizations only after a family has incurred a specified level of health care costs (the plan's deductible).

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Overcoming Barriers to Immunization: A Workshop Summary care. Health departments may be able to make more effective use of their available resources if they are not responsible for patient care. Anticipated health care reforms that emphasize the role of private primary care providers will broaden health departments' concerns about what services they will offer. They may still remain providers to the most hard to reach groups in the community. Vaccine purchase also generates conflicts. For example, vaccine companies may feel that they need to offset the low bulk-purchase prices negotiated by federal and state governments with higher retail prices for private purchasers. The vaccine companies are essential contributors to the public health goal of protecting children from vaccine-preventable diseases. They produce most of the vaccines used in the United States and will be the source of new and improved vaccines. They also contribute support to community immunization activities, and companies such as Merck are implementing pilot programs to improve private providers ' access to vaccines that they can afford to administer to their Medicaid patients. Nevertheless, vaccine companies have a financial interest in maximizing sales at the highest prices. TAKING ACTION Workshop presentations and discussions highlighted some steps that are already being taken. To achieve maximum effectiveness, these steps should be part of an overall plan to respond to clearly identified immunization needs. Promoting the effective delivery of immunizations in a primary care setting must be an important element of that plan. Magda Peck, Executive Director of CityMatCH, reported that some urban health departments have increased clinic hours and instituted walk-in immunization services, immunization services in public housing projects, and public information programs. Providing immunizations at a variety of sites can, however, make it difficult to create and maintain accurate records. The various clinic- and community-based registries and follow-up programs that are being implemented can reduce but may not eliminate that problem. Rita Goodman, from the Bureau of Primary Health Care in HRSA, noted that a study of five community and migrant health centers showed better immunization coverage in the center that immediately identified children seeking immunizations and referred them to special providers at the center. Adopting standing orders that authorize nurses to immunize children also is associated with higher immunization rates. Social services such as AFDC or WIC are being used to address immunization needs. Approaches include educating families about immunization; assessing a child's immunization status for referral, if necessary, to an immunization provider; and having immunization services available on site. In some

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Overcoming Barriers to Immunization: A Workshop Summary cases, social service benefits themselves are being altered if children have not had the prescribed immunizations or primary care visits. Herminia Luna, manager of a WIC demonstration project in the Chicago Department of Health, noted that this project requires monthly rather than quarterly visits for food vouchers if a child's immunizations are not up to date. The program also includes education and immunization services at some sites. Maryland has taken a more controversial approach: reducing monthly AFDC grants if children lack evidence of prescribed preventive care visits. Some argue that such penalties are an appropriate way to emphasize parents' responsibility for their children's health (e.g., see Jost, 1993). At the workshop, however, many participants voiced ethical concerns about the impact of reducing benefits on other aspects of the lives of the children that the programs are intended to help, as well as about the state 's use of funds that are not distributed to families. Maryland has imposed many more penalties than anticipated, which suggests that families could not easily obtain the mandated preventive health services for their children (George, 1993). Rose Ann Meinecke, from the Maryland Department of Health and Mental Hygiene, noted that efforts are being made to increase outreach and follow-up services to families whose benefits were reduced and to overcome problems traced to administrative processes. Because of the legislative interest in such programs in other states, the committee emphasizes the need to determine whether they are effective and whether public officials are managing them in the best interests of the children whom the programs are intended to benefit. Many techniques are being used to try to improve immunization rates, and states and communities should expect to find that some efforts are not successful at first. That should not prevent them from experimenting with new approaches or modifying unsuccessful ones that continue to show promise. The effectiveness of all such efforts must be evaluated systematically, however. Magda Peck urged assembling and disseminating information about what has been done and how well it has worked so that similar programs planned in other states or communities do not have to be created from scratch. The inventory obtained from the CityMatCH survey of major urban health departments (Hubbert and Peck, 1993) could be supplemented with information about experiences in smaller communities and rural areas and in state-run programs; results of program evaluations should be included as well. Programs that address immunization within a broader primary care context could be given special attention. An important adjunct to such information would be an annotated bibliography of research studies on immunization practices (discussed later in this report).

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Overcoming Barriers to Immunization: A Workshop Summary THE UNITED KINGDOM'S IMMUNIZATION PROGRAM David Salisbury described the successful program that the United Kingdom has implemented to achieve immunization rates of at least 90 percent for children of all ages and for all vaccines. By 1990, the Department of Health had initiated action on three fronts: (1) provider practices, (2) administrative policies, and (3) public education. Provider practices. Three major steps were taken to encourage providers to immunize as many children as possible. First, the immunization guidelines were revised and distributed to all providers, regardless of specialty. The revised guidelines sanction a minimal set of valid contraindications to immunization. Second, an extensive provider education program introduced the new guidelines and a revised immunization schedule. Third, the Department of Health adopted a new system to pay providers for administering immunizations. Instead of small payments for each immunization, providers receive quarterly lump-sum payments if they meet an overall level of immunization for the children in their practice. Specifically, they receive a minimum payment for immunization rates of at least 70 percent and a larger additional payment if their immunization rates are 90 percent or higher. The new payment scheme makes immunizations a higher priority than in the past and promotes timely reporting on the immunizations that have been administered. Coverage rates are based on all children in a provider's practice who were due for immunizations during the quarter, including any for whom immunization was contraindicated. This policy removes any incentive to attribute missed immunizations to invalid contraindications. Administrative policies. The program made several administrative changes. National health promotion and disease prevention goals were established, including achieving immunization rates of 90 percent. The national goals provided the targets for the new provider payment system. The immunization schedule was standardized and compressed, which increases the chance that children will have completed their immunizations if their families move. Each health district was required to appoint an immunization coordinator who is responsible for the delivery of immunization services in that district. These coordinators work with the providers in their districts and must answer to the Department of Health at the national level. Health districts were also encouraged to improve their computer-based information systems, which are an important factor in the success of the program. Each child is registered at birth, and the system generates notices to primary care providers when newborns are added to their practice. The information system helps in scheduling appointments and identifies children who have not received immunizations. Individual providers and the staff of the health district monitor the system to ensure that it accurately reflects the children in a providers practice (e.g., children who have moved are taken off of a provider 's list).

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Overcoming Barriers to Immunization: A Workshop Summary Public education. The Department of Health developed a coordinated national campaign to promote immunization. This effort relies on funds budgeted specifically for immunization education. Professional advertising agencies developed the television spots used in the campaign. Because the television districts and health districts cover very similar regions, it has been possible to target the immunization message to those districts with lower immunization rates. Follow-up research has been done to test the impact of the advertising. An intensive effort made at the time that the Hib (Haemophilus influenzae type b) vaccine was introduced proved to be very successful.