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    Addressing immunizationbarriers, benefits, and risks


    Vaccines have been highly effective in eliminating or significantly decreasing the occurrence ofmany once-common diseases. Barriers to immunization are a significant factor in the risingincidence rates of some vaccine-preventable diseases. Cost, reduced accessibility to immuniza-tions, increasingly complex childhood and adolescent/adult immunization schedules, andincreasing focus on the potential adverse effects of vaccines all contribute to difficulty in meet-ing the 2010 immunization goals. Physicians must not only be knowledgeable about vaccinesbut they must incorporate systems in their offices to record, remind, and recall patients for vac-cinations.They must also clearly communicate vaccine benefits and risks while understandingthose factors that affect an individual's acceptance and perception of those benefits and risks.

    Vaccines have almost eliminated or significantlyreduced the incidence of many diseases, but tensof thousands of children and adults in the UnitedStates continue to develop vaccine-preventable dis-eases. Reported cases of pertussis have increased froma low of 1010 cases in 1976' to 25,827 in 2004,' withthe majority of these cases occurring in adolescentsand adults. Potential reasons for this include geneticchanges in Bordetella pertussis (which make vaccinesless effective), decreased potency of pertussis vaccines,greater awareness of pertussis, and improved diagnos-tic tests.* However, many of these cases are believed tobe caused by waning immunity or inadequate immu-nization. In 2005, only 76.1% of US children aged 19to 35 months had received all of the recommendeddoses of DTaP, Hib, hepatitis B, MMR, polio, and vari-cella vaccines, although rates of those who receivedmost individual vaccines were higher.'' A HealthyPeople 2010 goal is to immunize 90% of young chil-dren and adolescents with age-appropriate vaccines.'

    Barriers to immunization are grouped as systemsbarriers (eg, those involving the organization of thehealth care system and economics), health careprovider barriers (eg, inadequate clinician knowledgeabout vaccines and contraindications to their use), andparent or patient barriers (eg, fear of immunization-

    related adverse events).' These barriers affect immu-nization rates and increase the burden of preventabledisease in our society.

    Systems Barriers to ImmunizationFactors affecting the supply and distribution of vaccinesare among the most noticeable systems barriers. Thesupply of influenza, conjugate pneumococcal, and,most recently, tetravalent conjugate meningococcal(MCV4) vaccines have been inadequate due to a lack ofmanufacturing capacity.' A misdistribution of vaccineshas also occurred. Uninsured and Medicaid-insuredchildren may qualify to receive vaccines through theVaccines for Children program (VFC), but VFC doesnot provide funding to reimburse providers for thecosts of administering those vaccines. Uninsured adultsrepresent another major systems problem.

    Provider Barriers to ImmunizationProviders may lack knowledge about the indicationsfor and contraindications to immunization.Expanded uses for current vaccines such as hepatitisA vaccine for children aged 12 months or older andnew vaccines against rotavirus and zoster make itdifficult for health care providers to stay currentwith immunization schedules. A study of California

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    practices found that knowledge deficits regardingimmunization schedules, vaccine contraindications,and vaccine side effects were present among physi-cians and nonphysician office staff."

    One early study indicated that almost one half ofnurses (as reported by physicians) were resistant togiving children 3 or more injections and that parentsand physicians were also uncomfortable about this.'However, a later study at an inner-city pediatric clin-ic indicated that parents overwhelmingly compliedwith physicians' recommendations for immuniza-tions.'" Thus, the attitude the physician transmits tohis or her staff about the importance of immuniza-tions is crucial. Combination vaccines that decreasethe number of shots administered at a single visitalso enhance compliance.

    Logistical barriers faced by health care providersinclude the cost of immunizations, vaccine storageor capacity, and lack of access to patients' prior immu-nization records. Vaccines with stringent storagerequirements, such as varicella vaccine or live attenuat-ed influenza vaccine, may present a challenge.Fragmentation of patient care makes it more likely thatproviders will not have complete immunization recordsfor patients currently in their care. This can lead toincomplete immunization and overimmunization.

    Missed visits and missed opportunities for immu-nization when necessary vaccines are not administeredat a visit are also notable barriers to timely completionof immunization requirements. When health careproviders have routinely assessed a patient's immu-nization status and notified patients and parents aboutvaccinations that were due (reminders) or overdue(recalls), immunization rates have improved.Reminder/recall systems can be time-consuming andcost-intensive, and they are used infrequently." Greateruse of electronic medical record systems should makereminder/recall systems more efficient.

    Immunization registries are computerized databasesthat consolidate vaccination data from multiple healthcare providers within a defined geographic area andcan generate reminder and recall notices. Currently,48% of children younger than 6 years old participatein an immunization registry.'^ One national healthobjective calls for a participation rate of 95% of chil-dren younger than 6 years old by the year 2010.'

    Patient and ParentBarriers to ImmunizationPatients or their parents or guardians may lackknowledge about immunizations, be fearful of vac-

    cine safety, or lack transportation. They may beunaware of the threat of vaccine-preventable dis-eases or that safe and effective vaccines are availableagainst these diseases. Complicated immunizationschedules, fragmented care records, inconvenientclinic hours, long wait times for immunizations,transportation problems, and cost are other exam-ples of logistical barriers to immunization. Onestudy found that mothers in rural West Virginia weremore likely to have fully immunized children if theyfelt that the clinic they attended was "supportive,"which included variables such as staff who wouldclarify immunization schedules, convenient officehours, and limited wait time for immunizations.'

    The VFC program has funded immunizations foruninsured and Medicaid-insured children since itsinception in 1994, but not all underinsured childrencan visit their usual source of health care and receivethese vaccines at no cost. Even low-income parentsof children who qualify for immunizations through aVFC program at their usual source of care may notbe aware of this program, and these parents contin-ue to cite cost as a barrier to immunization.'^Families who might qualify for free vaccinationsmay face other barriers such as transportation prob-lems. To limit additional patient trips to health careproviders, all eligible physicians should become VFCproviders so that immunizations can be given at thechild's medical "home." However, children who havehealth insurance that does not cover immunizationsmust continue to receive their vaccinations at publicor federally funded health clinics.

    SolutionsDespite the many barriers described above, researchhas shown that some interventions canand doimprove immunization rates (TABLE 1). In diverseadult populations, one of the strongest predictors ofinfluenza immunization is a physician's recommenda-tion to receive the vaccine.'""' In low-income pediatricpopulations, enrollment in the Special SupplementalNutrition Program for Women, Infants and Children(WIC)which offers programs to educate parentsabout the importance of immunizationsimprovesimmunization rates among both urban and nonurbanpediatric populations.'^-'"

    Educational resources for parents who declinevaccination because of antivaccine misinformationcan be found both in print and on the Internet.Providers should tell parents about Web sites thatpresent more balanced and useful information on the

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    TflBIF 1 ,


    Knowledge deficits

    Patients and families


    Fragmented care

    Vaccine shortages

    Missed visits, missed opportunities

    AAFP = American Academy of Family PhysSupplemental Nutrition Program for Wome

    Barriers and solutions to vaccination


    Education through WIC, community outreach, provider recommendation. Web sites

    Recognized sources of information/guidelines (AAFP, AAP, and CDC Web sites, AAP Red Book,

    Shots software from vi/

    Immunization registries

    Improved vaccine infrastructure

    Fair reimbursement for vaccines

    Reminder/recall systems

    Fair reimbursement for vaccination

    Standing orders

    Shared responsibility for identifying needed vaccines with nursing personnel

    during vital signs or through smart electronic records

    Combination vaccines to decrease number of shots required at a visit

    icians; AAP = American Academy of Pediatrics; CDC = Centers for Disease Control and Prevention; WIC = Specialn, Infants and Children.

    risks and benefits of vaccination as well as links toother sources. Among these Web sites are the following:

    American Association of Pediatrics (AAP)

    US Centers for Disease Control and Pre-vention (CDC):

    Society of Teachers of Family Medicine'sGroup on Immunization Education (GIE)

    Vaccine Information Center at the Children'sHospital of Philadelphia:

    Immunization Action Coalition (IAC)

    Parents opposed to immunizations are often dis-trustful of "official" sources but may be more willingto accept information from their personal physicianwho takes time to listen to their concerns andrespond in a thoughtful manner.

    Immunization registries are being developed in allstates and in the District of Columbia.'' In 2002, 43%of all US children had at least 2 immunizations record-ed in a registry. However, about 40% of children in theregistries had incomplete or missing data on adminis-tered doses of vaccine.'' Lack of time or staff to enterdata as well as possible transcription errors may makesome physicians hesitant to use these systems; howev-er, they save time when immunization records arerequested for school or camp forms and improveimmunization rates." Another study also showed thatcomplete computerization of paper immunizationrecords saved both time and money."

    The Task Force on Community PreventiveServices recommended or strongly recommendedimplementation of the following measures toincrease immunization rates' ":

    Reminder/recall systems for patients, families,and providers

    Requirement of vaccination as a prerequisitefor enrollment in school and childcare

    Decreases in out-of-pocket costs for patients/families

    Assessment ofand collection of feedbackregardingimmunization rates for individualproviders

    Issuance of standing orders for adult immunization Provision of immunization services in homes

    and WIC settings Implementation of multicomponent interven-

    tions that expand access to services and provideeducation to target populations.

    Interventions tailored to the culture of aprovider's practice and its patients should increaseimmunization rates. A study of tailored standingorders, reminders, and express vaccination servicesin inner-city clinics found that these measures led toan increase in influenza immunization

    Communicating the Benefitsand Risks of VaccinesThe benefits of immunization are often obvious tohealth care providers; however, patients, parents, andthe general public may have questions or concerns.

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    As knowledge of the devastation caused by manyvaccine-preventable diseases fades from public mem-ory, attention shifts to the occasionally seriousadverse events that may follow immunization. Thedissemination of (mis)information and anecdotalreports of alleged vaccine reactions by the media, theInternet, and antivaccine groups causes parents,patients, and even some health care providers toquestion the justification for immunizations.^^ Somephysicians may be reluctant to administer immuniza-tions because of liability concerns. An Ohio studydemonstrated that liability concerns influenced thedecisions of 9% of family physicians and 23% ofpediatricians in their choice of polio vaccines."Consequently, vaccines have become victims of theirown success. If a loss of confidence in the vaccinedevelops, then an outbreak of disease may ensue,resulting in resumption of vaccine use."

    Public Perceptions of Vaccine SafetyParents of incompletely immunized British childrenwere likely to report that immunization was riskier fortheir child than was nonimmunization due to concernsabout vaccine-related side effects, the belief that theirchild was not at risk for the disease, or the belief thatthe disease was not serious." In the United States, con-cerns about vaccine safety are more common amongparents of underimmunized children, but many par-ents of fully immunized children have also expressedsuch concerns." Most family physicians and almost allpediatricians reported at least 1 vaccine refusal fromparents during the year 2000. " A Canadian studyfound that most mothers would accept a 1:100,000 to1:1,000,000 risk for a severe vaccine side effect; how-ever, 14% would not tolerate any serious risk."

    Common MisconceptionsAbout VaccinesMost parents support immunizations for their chil-dren, but misconceptions do exist. Some parentsbelieve that the administration of too many immu-nizations will weaken their child's immune system^'or cause chronic diseases such as asthma, autism,diabetes mellitus (DM), or multiple sclerosis (MS).^'Some believe that vaccine-preventable diseases hadalready begun to disappear prior to the use of vac-cines or that there are "hot lots" of vaccines thathave a greater frequency and/or severity of adverseevents.^' Others believe that vaccines are not "natu-ral" and thus prefer disease-induced immunity.Individuals often use cognitive shortcuts or heuris-

    tics to simplify complex decisions and judgments."'Parents who are nonvaccinators may believe theycan control their child's su...


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