Recall of children who are past due for immunizations is a powerful strategy for a medical home to ensure high immunization coverage both in the practice and in the community. Telephone and mail recall programs are effective,1 but less so for inner city populations that relocate more often.2
To achieve high immunization rates, especially in pockets of need, children who fail general recall efforts should receive case management or be referred to a community outreach program if available. Home visits for immunization delivery may be necessary. It may not be feasible for a practice to have its own outreach program, so linking with other practices or a community-based program is essential. The National Vaccine Advisory Committee recommends that healthcare professionals practice with communitywide protection in mind.3
CASE MANAGEMENT AND OUTREACH
Children requiring special immunization regimens, such as an infant exposed to hepatitis B infection at birth or those on a "catch-up" schedule because of significant delay, should be tracked to ensure vaccine is provided. Because of potential problems with insurance coverage, transportation, and child care, however, the specific needs of families should be identified and assistance or referral provided if feasible. Case management strategies have been shown to improve immunization rates in practice settings.4 This case management function may be provided in the medical home or through a community-based program if available.
CONDUCTING HOME VISITS
When multiple attempts to reach the family by mail and phone are unsuccessful and case management is unsuccessful in bringing the child to the immunization provider, a home visit should be considered, where feasible. Home visitation programs as extensions of case management programs targeting immunizations have been shown to be feasible, to improve community immunization rates (as well as other preventive services), and to reduce geographic, racial, and ethnic disparities in immunization rates.5-8
IDENTIFYING POCKETS OF NEED
Population-based immunization registries have the potential to identify neighborhoods and communities with low immunization rates. Strategies targeting medical providers of children in those communities as well as outreach efforts including delivering vaccines in shopping centers, parks, and via mobile health vans, may help address these "pockets of need."
USING ASSISTANCE PROGRAMS
Another effective community strategy to raise immunization rates is through partnerships with programs serving populations at risk of low immunization rates, such as the Women, Infants, and Children (WIC) program.1 Parents receiving WIC can be reminded about the importance of immunization, have their immunization records reviewed, and be referred to providers or community programs for immunization delivery if vaccines are delayed.
USING IMMUNIZATION REGISTRIES
As described elsewhere in this issue (Kairys, see page 500), immunization registries not only help identify "pockets of need" but also make it easier for multiple immunization providers to view the child's record and document vaccine delivery in one location. This also prevents unnecessary doses from being repeated due to inadequate handheld records, which also saves time and resources for other children. "Extraimmunization" was found to occur in 21% of children in one study.9 The study also found the strongest contributor to a child receiving an extra dose was having more than one immunization provider.
FORMING AN IMMUNIZATION COALITION
An immunization coalition is an effective way to coordinate community-wide efforts to improve immunization rates among various agencies, constituencies, and health care entities. An immunization coalition is a group of collaborating organizations brought together for the purpose of improving immunization rates in a specific community or region. Potential coalition activities are listed in the Sidebar (see page 514).
Characteristics of successful immunization coalitions have been found to include multiple sources of funding, a strategic planning process, strong leadership and a clear organizational structure, consistent, committed membership displaying various backgrounds and skills, and paid staff.10 An immunization coalition can be an effective way for a community to embrace the importance of preventing disease through vaccination by contributing to the effort.
Pediatricians should be knowledgeable about programs available in their community and support efforts to collaborate with other providers, public health departments and immunization coalitions in their community. Through immunization coalitions and widespread use of an immunization registry, together with participating private providers, case management and home visitation programs can improve immunization rates among the highest risk children.
1. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Task Force on Community Preventive Services. Am J Prev Med. 2000;18(Suppl 1):92-96.
2. Kempe A, Lowery N, Pearson K, et al. Immunization recall: effectiveness and barriers to success in an urban, teaching clinic. J Pediatr, 2001;139(5):630-635.
3. National Vaccine Advisory Committee. Standards for child and adolescent immunization practices. Pediatrics. 2003;! 12(4):958-963.
4. Rosen D. Case management improves UTD rates of children 0-2 years of age. Presented at: 39th National Immunization Conference; March 21-24, 2005; Washington, DC.
5. Eberhart M, Barlow B, Chilkatowsky A, et al. Impact of outreach activities on childhood immunization coverage in Philadelphia. Presented at: 40th National Immunization Conference; March 6-9, 2006; Atlanta, GA.
6. Hambridge S, Guttierrez Floyd S, Chandramouli V, et al. A stepped intervention to increase infant preventive health delivery in an inner-city population. Presented at: Pediatrie Academic Societies Annual Meeting; April 29-May 2, 2006; San Francisco, CA.
7. Rodewald LE, Szilagyi PG, Humiston SG, et al. A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. Pediatrics. 1999;103(1):31-38.
8. Szilagyi PG, Schaffer S, Shone L, et al. Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics. 2002;! I0(5):e58.
9. Feikema SM, Klevens RM, Washington ML, Barker L. Extrainununization among US children. JAMA. 2000;283(10):131 1-1317.
10. Bakalian Consulting Group. Immunization Coalition Sustainabilily Project: Final Report. July 2004. Available at: http://www.bakalianconsulting.com/icsp_finalreport.pdf. Accessed May 31, 2006.