Jeffrey Goldhaggen, a developer of Cleveland's All Kids Count project, pointed out that discussions among Cleveland pediatricians revealed a lack of consensus about the relative importance of immunizations. It is likely to be harder to influence the practices of providers who assign immunization a relatively low priority among their health care responsibilities. David Salisbury noted that the immunization program in the United Kingdom relied on the change in the provider payment scheme to make immunization a much higher priority than it had been.

Roger Bernier, with the National Immunization Program at CDC, and other workshop participants felt that the Standards for Pediatric Immunization Practices (CDC, 1993b) could be used more extensively to influence provider practices. The 18 standards provide clear and common reference points and have been endorsed by major professional organizations. They are already being used in immunization promotion efforts, for provider in-service education, and as performance standards. Bernier noted that the table on valid and invalid contraindications to immunizations seems to be especially useful.1

HRSA's Bureau of Primary Health Care is collaborating with CDC to evaluate the effect on immunization rates of implementing the standards. In five community and migrant health centers, immunization levels and provider practices assessed at the beginning of the study will be compared with results after a 1-year period, during which CDC staff are providing technical assistance in making changes in immunization procedures.

Effective presentation of the immunization practice standards remains a concern. They may need to receive more publicity among providers, and those standards that are considered to be the highest priority should be identified so that they receive attention first. Provider education efforts in Massachusetts specifically address application of the standards in the private setting.

Workshop participants agreed that providers' professional organizations should encourage their members to adopt effective immunization practices. AAP and its Committee on Infectious Diseases produce authoritative materials that inform members about vaccines and immunization (e.g., AAP, 1991) as well as educational materials that pediatricians can give to families. Massachusetts has used IAP funding to help the state AAP chapter support an immunization coordinator who is a liaison to other professional groups and to individual providers. In response to a proposal from the NVPO, the Group Health Association of America (GHAA) has agreed to work with its member HMOs and other managed care organizations to develop practices that can improve immunization rates, such as tracking immunization systems. David Siegel, of


The table has been reproduced as a wall chart, which is available from the Immunization Education and Action Committee of the Healthy Mothers, Healthy Babies Coalition.

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