January 1996
MADISON, Wisc.—No matter how effective a vaccine is, it is useless unless it gets into the child.
Millions of children remain unimmunized or behind schedule; to immunize them, states are experimenting with strategies to get more shots into more arms.
"We try to dream up novel ways of reaching children, and if it works, we do it," said Jeff Berg, Acting Director of the Immunization Program for the Wisconsin Division of Health.
The strategies range from extending clinic hours to having pharmacists administer vaccines, with states using whatever best suits their needs.
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"Our primary effort is to mainstream vaccinations in the context of preventive care," said Loring Dales, MD, Medical Epidemiologist, Immunization Branch of the California Department of Health Services in Berkeley. "We are trying to find health care for everybody."
Public health clinics serve about 20% of California's children, yet they are "starving on the vine" because of funding cuts, Dales said.
Rather than offering immunizations at health fairs and other one-time sites, California prefers to use federal funds to keep its clinics open more days per week, for longer hours, or to open new sites.
"Outreach clinics must operate on a regular basis," Dales said. "They must be there on the same day every week. One-time clinics get a bad response. Even if the response is good once, children may need up to five shots to be fully immunized. What happens then?"
Reaching children in the community requires effort and creativity, and low-income areas present additional challenges. Milwaukee addressed the problem in part by equipping a van to bring vaccines to areas where immunization levels were lowest.
The mobile outreach campaign began during the measles resurgence of 1989-1990, said Jeffrey Davis, MD, Chief Medical Officer, Wisconsin Division of Health.
Although California faces similar challenges in reaching its low-income children, vaccination vans have not been as effective there. As with clinics, vans must keep a consistent schedule, Dales said. Otherwise, their impact is transient.
"There are limitations," he said. "One thing is their size; people have to wait outside. Another problem is security. The van is difficult to secure and we cannot park it on a dangerous street corner or else people will try to steal donations or needles. We have tried them, but vans do not seem to have enough of an edge."
Another method of bringing immunizations to low-income populations is to tie them to other services, such as the Special Supplemental Food Program for Women, Infants, and Children (WIC). These services may act as an access point for low-income families by providing referrals for immunizations and other health care needs.
The intent is to use food vouchers as an incentive. Parents whose children are up to date on their immunizations may be rewarded by receiving a 2- or 3-month supply of food vouchers rather than a single month's supply. Wisconsin has been collaborating with WIC for several years, Berg said. WIC's screening process is being redesigned to emphasize immunizations.
"The child's immunization record in the computer will be available and will be flagged if the child is behind schedule and a referral can be made," Berg said. Some WIC sites may have a provider on site to administer immunizations to avoid referrals to outside providers and missed opportunities.
Language is an obstacle all outreach programs must overcome—and one that spans the economic spectrum. This barrier is especially problematic in California, where 44% of all preschool children in the state are Latino, Dales said.
"Language barriers are a repeated problem," Dales said. "We have many recent immigrants, and they have difficulty with the system, especially if they are from rural areas."
It is imperative that public health clinics include staff members who are not only bilingual but also bicultural, Dales said. By having some member of the staff who can help the patient through the process, the experience will be much more positive.
"There is a huge difference in the willingness of people to return to clinics if they are treated poorly," Dales said. "That is a major disincentive for them to come back, and we lose them."
Community resources are invaluable and may be an essential inroad into a tight-knit neighborhood. An example is the local pharmacy.
The pharmacy's prescription database contains a wealth of information that can target patients who, because their medications signal the presence of a high-risk condition, may need vaccination, said Maj. John Grabenstein, EdD, Clinical Research Pharmacist, U.S. Army Clinical Investigation Regulatory Office, Fort Sam Houston, Texas.
"We put 'take with food or milk' labels on prescriptions," Grabenstein said. "Should we put a label on amoxicillin, 'are your children fully vaccinated'? Should we put an auxiliary sticker on a digoxin prescription saying, 'you might need an influenza shot'?...What can pharmacists do? They can host vaccine clinics, they can screen and identify the people who need vaccines...Maybe they can prescribe or administer [vaccines]. They can certainly warn, encourage, recommend, and be advocates for [their patients]."
The Michigan Pharmacists Association's Immunization Awareness Program takes full advantage of the pharmacist-patient relationship.
"The Immunization Awareness Program provides the opportunity for all pharmacists to become more involved in promoting the importance of age-appropriate immunizations," said Larry Wagenknecht, Chief Executive Officer, Michigan Pharmacists Association. "The level of participation is voluntary—from providing immunization information to conducting immunization clinics within the pharmacy."
Although the program's major push was in the spring, the initiative is continuing. Michigan shared its program information with the pharmacist associations in other states, but Wagenknecht has not received any feedback.
Pharmacists in Washington state are taking their involvement a step further; eight pharmacists have completed a 20-hour credentialing program that enables them to administer vaccines. The state's scope of practice allows pharmacists to administer drugs, including injections, said Rod Shafer, Executive Director of the Washington State Pharmacists Association.
"Pharmacists can address two barriers to immunization in their communities," Shafer said. "Pharmacists are in a unique position, as the most accessible health care providers, to provide both the educational resource and improved access as vaccine administrators. As we develop these innovative programs to make vital public health programs more accessible to the public, it is extremely important that practitioners communicate. Tracking mechanisms need to be developed so that continuity of care is ensured. Innovative pediatric and adult immunization projects are most effective in a cooperative effort with local health departments, health care providers, and patient advocacy groups."
Indeed, strategies to improve immunizations have a dual emphasis. "We can reinforce the importance of having a medical home while reinforcing good immunization practices," Wisconsin's Davis said.
Editor's note: It would be good to hear about creative ideas from our readers.
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