1 WIC Immunization Screening and Referral Staff Training Guide Developed by The National...

WIC Immunization Screening and Referral

Staff Training GuideDeveloped by

The National WIC-Immunization Workgroup

USDA/Food and Nutrition Service CDC/National Immunization Program National WIC Association American Academy of Pediatrics Association of State and Territorial Health Officials Association of Immunization Managers Every Child By Two

OCTOBER 2002

Training ObjectivesThis training will help you to:

Understand how vaccines can help prevent life-threatening diseases

Understand the recommended childhood immunization schedule

Relate the importance of immunizations to keeping WIC infants/children healthy and to WIC program goals

Understand the the new USDA Immunization Screening and Referral policy and identify policy requirements

Screen immunization records using an easy tool: “Easy IZ Guide”

Talk to parents about their child’s immunization status

Determine effective ways to refer patients to immunization services

Module 1

Communicable Diseases and Vaccines

Why Immunize Infants and Children?

Not long ago, parents lived in fear of diseases we can now prevent

The vaccine became available in 1955; now no polio in the U.S.!

Polio still exists in other parts of the world; easily imported

In 1916, polio killed 6,000 people & paralyzed 27,000

Measles Today, many do not know measles can be

serious For every 1,000 infants/children who have

measles:– 50 get pneumonia– 1 gets brain inflammation– 1 or 2 die

During the U.S. outbreak in 1989-91 there were– Almost 56,000 cases– 123 deaths

Vaccines Prevent Serious Childhood Diseases

Diphtheria Tetanus (lockjaw) Pertussis (whooping

cough) Measles Mumps Rubella (German measles)

Hib Pneumococcus Hepatitis B Hepatitis A Polio Varicella

(chickenpox)

Even chickenpox is a serious illness

Before the vaccine, almost everyone got chickenpox

Six out of every 100,000 infants who get chickenpox die.

Vaccines Prevent Diseases that have no cure

Some diseases prevented by vaccines cannot be treated when a person gets the disease

Tetanus can be prevented by vaccine, but there is no medication that cures tetanus disease

We have (almost) forgotten some diseases like diphtheria

During the 1920’s about 150,000 cases/year and 15,000 deaths occurred

Now in the U.S. a few cases occur, but there are outbreaks in countries of former Soviet Union

Complications from Hepatitis B infection can come later in life

Hepatitis B virus invades the liver causing cirrhosis and cancer

Infected infants are at greatest risk for serious complications

No cure In 1996, 4,000 to 5,000 deaths/year in

Pertussis (whooping cough): After 1-2 weeks of ‘cold’

symptoms, 1-6 weeks of coughing bouts

Complications /1,000 cases:– Pneumonia 95– Seizures 14– Brain inflammation 2– Death 2

– Hospitalization 320

All Preventable Diseases in Children are Serious

Diphtheria Tetanus (lockjaw) Pertussis (whooping cough) Measles Mumps Rubella (German measles)

1950 54 58 62 66 70 74 78 82 86 90 94 98

00 1st Measles VaccineLicensed in 1963

Vaccines are Key to Prevention Measles, 1950-2000

Why not wait? Infants and young children are very

vulnerable to infectious diseases

An outbreak can be anywhere.

Disease is a plane ride away.

If there’s an outbreak, it may be too late.

You don’t always know when a child has been exposed to a disease. …Protect them first rather than wait!

Immunizations are one of the most important ways to protect children!

Module 2

Recommended Childhood Immunization Schedule

Vaccines that prevent disease

Hib Pneumococcus-PCV7 Hepatitis B Hepatitis A Polio-IPV Varicella (chickenpox)

Recommended Childhood Immunization ScheduleUnited States, 2002

VaccineAge

Birth1

Hepatitis B1

Diphtheria, Tetanus, Pertussis2

Haemophilus influenzae Type b3

Inactivated Polio4

Measles, Mumps, Rubella5

Varicella6

Pneumococcal7

Hepatitis A8

Influenza9

Hep B #1

Hep B #2

4-6 yrs

11-12 yrs

13-18 yrs

Hep B #3

DTaP DTaP DTaP DTaP TdDTaP

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2

Varicella

PCVPCVPCVPCV

Hepatitis A series

Influenza (yearly)

This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2001, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible. Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations.

Vaccines below this line are for selected populations

range of recommended ages catch-up vaccination

Hep B series

MMR #2

Varicella

PPVPCV

only if mother HBsAg ( - )

preadolescent assessment

Hepatitis B vaccine Dose #1 - Birth or up to 2 months Dose #2 - 1 to 2 months Dose #3 - 6 to 18 months

Catch up as soon as possible.

The series never needs to be restarted when there has been a long time between doses.

VaccineAge

Birth1

Hepatitis B1

Inactivated Polio4

Varicella6

Pneumococcal7

Hepatitis A8

Influenza9

Hep B #1

Hep B #2

4-6 yrs

11-12 yrs

13-18 yrs

Hep B #3

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2

Varicella

PCVPCVPCVPCV

Hepatitis A series

Influenza (yearly)

Hep B series

MMR #2

Varicella

PPVPCV

DTaPDTaP stands for: “Diphtheria, Tetanus, & acellular Pertussis”

The first 4 doses are usually given at ages:– Dose #1 - 2 months– Dose #2 - 4 months– Dose #3 - 6 months– Dose #4 - 15 to 18 months (or 12 months)

The first booster is usually given before school when the child is 4-6 years of age.

VaccineAge

Birth1

Hepatitis B1

Inactivated Polio4

Varicella6

Pneumococcal7

Hepatitis A8

Influenza9

Hep B #1

Hep B #2

4-6 yrs

11-12 yrs

13-18 yrs

Hep B #3

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2

Varicella

PCVPCVPCVPCV

Hepatitis A series

Influenza (yearly)

Hep B series

MMR #2

Varicella

PPVPCV

VaccineAge

Birth1

Hepatitis B1

Inactivated Polio4

Varicella6

Pneumococcal7

Hepatitis A8

Influenza9

Hep B #1

Hep B #2

4-6 yrs

11-12 yrs

13-18 yrs

Hep B #3

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2

Varicella

PCVPCVPCVPCV

Hepatitis A series

Influenza (yearly)

Hep B series

MMR #2

Varicella

PPVPCV

VaccineAge

Birth1

Hepatitis B1

Inactivated Polio4

Varicella6

Pneumococcal7

Hepatitis A8

Influenza9

Hep B #1

Hep B #2

4-6 yrs

11-12 yrs

13-18 yrs

Hep B #3

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2

Varicella

PCVPCVPCVPCV

Hepatitis A series

Influenza (yearly)

Hep B series

MMR #2

Varicella

PPVPCV

VaccineAge

Birth1

Hepatitis B1

Inactivated Polio4

Varicella6

Pneumococcal7

Hepatitis A8

Influenza9

Hep B #1

Hep B #2

4-6 yrs

11-12 yrs

13-18 yrs

Hep B #3

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2

Varicella

PCVPCVPCVPCV

Hepatitis A series

Influenza (yearly)

Hep B series

MMR #2

Varicella

PPVPCV

VaccineAge

Birth1

Hepatitis B1

Inactivated Polio4

Varicella6

Pneumococcal7

Hepatitis A8

Influenza9

Hep B #1

Hep B #2

4-6 yrs

11-12 yrs

13-18 yrs

Hep B #3

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2

Varicella

PCVPCVPCVPCV

Hepatitis A series

Influenza (yearly)

Hep B series

MMR #2

Varicella

PPVPCV

VaccineAge

Birth1

Hepatitis B1

Inactivated Polio4

Varicella6

Pneumococcal7

Hepatitis A8

Influenza9

Hep B #1

Hep B #2

4-6 yrs

11-12 yrs

13-18 yrs

Hep B #3

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2

Varicella

PCVPCVPCVPCV

Hepatitis A series

Influenza (yearly)

Hep B series

MMR #2

Varicella

PPVPCV

VaccineAge

Birth1

Hepatitis B1

Inactivated Polio4

Varicella6

Pneumococcal7

Hepatitis A8

Influenza9

Hep B #1

Hep B #2

4-6 yrs

11-12 yrs

13-18 yrs

Hep B #3

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2

Varicella

PCVPCVPCVPCV

Hepatitis A series

Influenza (yearly)

Hep B series

MMR #2

Varicella

PPVPCV

Module 3

Facts about Vaccines & Answers to Common Vaccine Questions

Everyone should know key vaccine information!

Vaccines are one of the most important ways to protect children!

Vaccines are safe

Many billion vaccinations have been given safely

Every vaccine that is made meets strict safety requirements.

Disease risks outweigh Vaccine risks

Vaccines have common side effects (such as fever or soreness at the injection site). These are mild.

Vaccines can have more severe side effects (such as an allergic reaction). These are rare.

The potential harm from the diseases far outweighs the potential for vaccine side effects

Waiting can be Risky

Vaccinate early! You never know when an exposure

or outbreak may occur Once an outbreak has been

identified, it may be too late

Not vaccinating is risky

The decision not to vaccinate is

a choice to remain at risk for

disease

Do vaccines overload the immune system?

Infants/children are exposed to germs every day.

The number of “germs” they get from vaccines is small compared with what they get from their daily environment.

Does MMR vaccine cause autism?

Dales, et al, JAMA, Vol 285, No. 9, March 2001

The apparent rise in autism didn’t happen with the increase of MMR.

% of Children receiving MMR vaccine; Caseload of autistic children by year of birth, California, 1980-94

Some parents may have questions about vaccines

Module 4

WIC’s Role: Helping Kids Stay Healthy

Did you know that…

Many low-income infants/children don’t receive their immunizations on time or at all?

WIC is an adjunct to health care– WIC supports immunization services

WIC refers and educates– WIC helps parents understand their child’s

need for immunizations– WIC shares information on where

infants/children can get their immunizations

Infants/children who are up to date on their shots are less likely to suffer from other health problems like anemia and lead toxicity

Good nutrition and immunizations go hand in hand to help WIC children stay healthy

Breastfeeding and ImmunizationsSome interesting facts:

Breastfeeding: babies’ “first immunization” Mothers who intend to breastfeed are more

likely to get infant immunized Breastfed babies have better responses to

vaccines Breastfeeding babies handle shots better

while breastfeeding (less pain)

Breastfeeding and Immunizations

WIC helps babies get their first immunization – breastfeeding

WIC can help babies further strengthen their immunity against disease by helping them get properly vaccinated

Breastfeeding and Immunizations

WIC helps mom breastfeed. WIC helps kids get immunized. What a great combination!

Module 5

New WIC Immunization Screening and Referral Policy

Overview of December 2000 White House Memorandum

Low-income infants/children are not as well immunized as higher income infants/children

WIC has access to the largest number of low-income infants/children and holds great potential to improve immunization rates

Immunization screening and referral should become a standard part of WIC certification. Screening should be conducted using a documented record of immunizations.

WIC benefits are never to be denied for lack of immunization records or shots.

Overview of USDA Policy Memorandum (2001)

Outlined a minimum immunization screening and referral requirement in WIC

To be implemented in all WIC agencies by March 1, 2003

WIC Minimum Requirement for Immunization Screening and Referral

Advise parents of any infant or child under two years of age to bring immunization records to certification

Screen using a documented immunization record, rather than parent’s memory or verbal assurance

Determine the child’s age, then count the number of doses of DTaP vaccines the child has received

Provide information on recommended immunization schedule

Provide referral if needed

Encourage parent to bring the immunization record to next certification visit

Diagram of the WIC Minimum RequirementFor Immunization Screening and Referral

Module 6

Using Documented Immunization Records for Screening and Referral in WIC

What is a documented immunization record?

It is a record that has details of each immunization dose given

Acceptable records are:– A personal immunization record carried by the

parent that has been prepared by the provider

– A printout from an official source such as a registry, the health department, doctor’s office or clinic

Why is it important to use a documented immunization record?

A documented record of shots is more accurate than the parent’s memory.

When asked, parents typically overestimate their child’s immunization status

Advise parents to bring immunization records

Make certification appointment Instruct parent/caregiver to bring the

immunization record Explain importance

WIC benefits are not tied to immunization records

Reassure parents that immunization records are requested as part of the WIC certification and health screening process, but are not required to obtain WIC benefits

Sample Script

“Please bring Miguel’s shot record to your

appointment. Immunization records are

not required to obtain WIC benefits, but

they are an important part of the health

screening WIC provides. We want to

help you make sure your child is up to

date on shots.”

Help Parents Remember to Bring RecordHelpful Tips:

Phone call indicating time of appointment and reminder to bring the shot record.

Postcard indicating time of appointment and reminder to bring the shot record.

Promotional posters in the waiting room reminding parents to bring shot record to WIC appointments.

Thank parent each time they bring record!

Module 7

Counting DTaP Vaccinations

What are the advantages of counting

DTaP doses?

How do I count DTaP doses?

What is a DTaP vaccine?

The vaccine contains a combination of:– D = Diphtheria Toxoid– T = Tetanus (Lockjaw) Toxoid– aP = Pertussis Vaccine

(Whooping cough)

Why was DTaP selected?DTaP was selected to screen theimmunization status of WIC infants/children under two years of age because:

It is a good reflection of the up-to-date status of the child’s other immunizations

It is easier and quicker than counting the doses of all 11 vaccines

Up-To-Date Means….DTaP Vaccine

By Age Minimum Number of Doses

Birth through 1month 0

3 months 1

5 months 2

7 months 3

19 months 4

Personal / Hand Held Records

Variations on DTaP Vaccine

DTaP (Diphtheria, Tetanus, acellular Pertussis)

DTP (Diphtheria, Tetanus, Pertussis) DT (Pediatric Diphtheria & Tetanus) DTaP/Hib (Diphtheria, Tetanus, acellular

Pertussis & Hib)

Td (Adult Tetanus & Diphtheria)

Close up View of an Infant/Child’s Record

Vaccine Type Mo/Day/Yr of dose

Health Provider Date Next dose due

DTaP/DTP

DT/TdDiphtheria

Tetanus

Pertussis

(Specify Type)

1 Tripedia

9/3/02 A.Coulter, MD/Kids Clinic

11/3/02

2Tripedia

01/14/03

3 Infanrix

10/21/03

4 Daptacel

10/21/03 Cordova Co. H.D., AZ

7/3/06

Module 8

Talking to parents about their child’s immunization status

Congratulate ParentSample Script “You’re doing a great job of protecting your [baby/child] against very serious diseases like whooping cough. Please remember that there may be other vaccines, besides the one protecting him/her against Whooping Cough that your [baby/child] may not yet have received. Congratulations! Keep up the good work and remember to get each immunization on time.”

Urgency MessageSample script

“Your [baby/child] has not received all the shots [he/she] needs to be protected from Whooping Cough and other very serious, and sometimes deadly diseases. You need to contact your doctor right away to schedule an appointment for immunizations.”

Providing Education Provide copy of recommended

immunization schedule Provide other educational materials

if desired

Module 9

Making Effective ReferralsReferring WIC participants for

Immunizations

Barriers to Childhood Immunizations

No health care provider Cost (money) Transportation (no car or bus) Waiting time for appointment Waiting time in office Not knowing what shots are due or when

they are due

Effective referrals Identify providers who offer

immunizations Establish relationships with providers Help clients choose a provider

Identify providers who offer immunizationsWith assistance from Immunization program,

develop list of:

Private providers (pediatricians/family practice doctors)

Walk-in clinics Appointment only clinics Mobile vans On-site immunization services

Medical Home

Why important?

Comprehensive care in one location Child and family develop relationship

with physician Better follow-up

Vaccines for Children (VFC) Program

Provides no-cost vaccines for children if they are at least one of the following: – Medicaid eligible– Without health insurance or under-insured– American Indian or Alaska Native

Allows infants/children to receive immunizations at their medical home

Establish Relationships Establish relationships with local

providers, especially office staff

Discuss appointment procedures and obtain other necessary information

Be Specific

Provide address, phone number, days/hours open

Tell parent what to expect− requires well child exam?− has bilingual staff?− appointment only?

Follow-up with WIC parent if possible

Ask if child received shots

If no, find out if there was a barrier.

Ask for assistance from immunization staff at local health department

Help problem-solve

Share what clients are telling you about barriers encountered

Let the immunization program know about the barriers that WIC clients are facing.

Diagram of the WIC Minimum RequirementFor Immunization Screening and Referral

Module 10

Hands-On Practice

Screening Immunization Records and

Comparing to the Recommended

DTaP Schedule

Hands-On Practice During the practice use the Easy IZ

Tool or an Immunization Schedule Compare an immunization record to

the recommended Easy IZ Tool or schedule

Determine if the infant/child is likely to be underimmunized.

Easy IZ Tool1. Ask for the infant/child’s immunization record.2. What is the age of the infant/child in months?3. Count the number of entries in the DTaP, DTP,

DT and DTaP/Hib sections on the infant/child’s immunization record.

4. Look at the DTaP doses column of the Easy IZ tool

5. Does the infant/child have all of the doses due now for his or her age?

6. Look at the Action column and follow the actions described on the back side of the form.

Back of Easy IZ Tool Urgency Message Congratulate Parent Refer for Immunizations Remind parent to bring immunization

record to WIC visits Provide immunization schedule to

parent

Example One of an Infant/Child’s Record

#1 - Close up view of Infant/Child’s record

# DTaP DT DTP Mo Day Yr Name of provider or Health Department

Date Next dose due

Example Two of an Infant/Child’s Record

#2 - Close up view of Infant/Child’s record

Vaccine Type Mo/Day/Yr of dose

Health Provider Date Next dose due

DTaP/DTP

DT/TdDiphtheria

Tetanus

Pertussis

(Specify Type)

Module 11

Hands-On Practice

“What To Do When…”

Situations and Possible Responses

What To Do When…Parent forgets to bring record

Educate about importance Encourage to bring next time Provide immunization schedule Provide referral

When parent forgets to bring recordSample Script

“The WIC program is required to screen

immunization records for all infants/children under

age two at WIC certifications. Vaccines can help

prevent serious diseases. We want to make sure

your child is up to date. Please bring your child’s

shot record to your next WIC appointment.”

Important Reminder

WIC benefits are never to be denied for lack of immunization records or shots.

What To Do When…Parent cannot find record

Educate about importance Encourage parent to talk to provider Provide immunization schedule Provide referral

Sample Script“It is important to have a personal record of your child's vaccinations. If you don't have a record, ask your child's health care provider to give you one. Bring this record with you every time you seek medical care for your child. Make sure your health care provider records all your child's vaccinations on the record. Your child will need it to enter daycare, kindergarten, junior high, etc.”

What To Do When…Parent skips WIC appointment because of no IZ record

Encourage parent to always come to her scheduled appointments even if she can’t locate the immunization record.

Assure her that WIC benefits will never be denied for lack of immunization records.

What To Do When…Parent brings multiple records

Encourage her to talk to her provider about consolidating the records onto one.

Provide referral

What To Do When…Record lists incomplete dates

Screen record for appropriate number of DTaPs

Encourage parent to review record with health care provider

What To Do When…Entries are hard to read

Encourage parent to talk to provider Do not screen record Make referral

What To Do When…Parent does not want WIC to screen child’s record

Educate about importance Provide referral Provide appropriate materials

What To Do When…Records are from another country

Encourage parent to talk to child’s health care provider.

Do not screen record if hard to interpret. Provide referral.

Congratulations!

You’ve completed the immunization screening and referral training.

Thank you for all you do for WIC participantsWe appreciate your hard work and dedication to the infants and young children served by WIC.

Your efforts will help improve immunization rates and keep kids healthy.

1 WIC Immunization Screening and Referral Staff Training Guide Developed by The National...

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