DETROIT Private practitioners can make a difference and help raise adolescent immunization rates, and a program in Wisconsin is proving this.
Tom Saari, MD, executive board member and immunization coordinator of the Wisconsin chapter of the American Academy of Pediatrics (WCAAP), helped increase regional and private practitioner participation in the adolescent health care immunization initiative.
Adolescent immunization programs in Wisconsin have evolved over the past two years as a result of private-public partnerships developed through models created by the Wisconsin Statewide Workgroup on Pre-adolescent Vaccination.
"We learned how to develop state and local partnerships with private practitioners by identifying key contacts in the primary care medical organizations that share your goals," said Saari, whose background includes work in pediatric infectious diseases.
Fifty-seven percent of all pediatricians surveyed last fall were identifying and immunizing all sixth graders in their practices with hepatitis B (HepB) vaccine in preparation for the revision of the school immunization requirements. The revisions were implemented July 1.
In the same survey, more than 90% of all pediatricians agreed with the revision of Wisconsin Administrative Rules affecting immunization required for adolescents and more than 80% supported school-based immunization clinics, under certain conditions.
"My role in the adolescent immunization program began by using WCAPP newsletters to establish a communications link with pediatricians and family practitioners," he said. "The WCAAP and the department of health agreed we needed to develop a statewide workgroup to look at the national recommendations and see how they might affect Wisconsin private practices."
Getting adolescents into the office is the first and often hardest step to beginning the health maintenance program, Saari said.
"We wanted practitioners in our state to understand that offering immunizations for hepatitis B, the second dose of MMR [measles, mumps and rubella] and varicella would be a venue to get teens into the doctors office for a complete health maintenance evaluation that dealt with many other adolescent health issues," he said. "We looked at the immunization component as a carrot and school-entry requirement as the stick to affect rapid change in preventative adolescent health."
The programs focus fell upon one disease in particular: hepatitis B. Existing Wisconsin school-entry immunization rules had required since 1994 a second dose of MMR for grades K-12, which eliminated the need to include a second vaccine as part of the Wisconsin initiative.
"Some of our earlier surveys indicated that most of the practitioners in the state were actually more interested in adolescent hepatitis B immunization than they were in a universal infant hepatitis B program," Saari said. "Its something they could relate to better."
There was a preliminary public-private sector agreement that addition of hepatitis B immunization to the school-entry requirements was the best way to ensure universal coverage. By choosing multiple cohorts [day care children, kindergartners and seventh graders], a maximal rate of protection for the population as a whole would be achieved as quickly as possible.
Coordinating efforts between private providers, the state department of health, the governors office and key legislators was a tedious and time-consuming process which extended over 18 months, Saari said. Private providers had to take the lead in pressing for rule changes because the Wisconsin Department of Health would only recommend such changes, but could not lobby for them.
"It was up to us [practitioners] to keep the ball rolling and make sure our government officials understood these rule changes were important to the private sector where 70% of the vaccine administered in the state was given," he said.
Strategies used by the WCAAP to raise adolescent immunization rates included coordinating physician education development programs by co-sponsoring a statewide adolescent immunization workgroup with the Wisconsin Department of Health. The WCAAP also sought endorsements from various sectors of the health care community to impress individual physicians with the broad-based support for adolescent immunization that existed in the medical community.
The WCAAP sent questionnaires to its membership about middle school-based immunization clinics as a viable and necessary component to provide additional access for all teens.
The concept of adolescent health maintenance, supported by the AAP and Immunization Practices Advisory Committee (ACIP), is promoted to practitioners through triennial specialty organization newsletters and continuing medical education courses.
Another part of the programs strategy involves surveying physicians attitudes about adolescent immunization by conducting frequent opinion polls about key elements of implementation that affect a busy practice. The WCAAP then provides feedback to physicians by sharing the results of surveys with the medical community and establishing an acceptable standard of care.
To implement these strategies, the WCAAP established the Preadolescent Hepatitis B Vaccination Statewide Workgroup in the spring of 1996. Coalitions, derived from state government, the pediatric and family practice medical community, the local health department nurses and school nurses and school administrators, were assigned to devise a statewide adolescent immunization plan for Wisconsin that included school-based shot clinics.
Under Saaris supervision, the Wisconsin chapter also used many components of North Carolinas successful adolescent immunization program "Roll Up Your Sleeves."
Members also worked with lobbyists from SmithKline Beecham Pharmaceuticals to gain access to key legislative committee members and the governors office to promote the necessary administrative rule changes. Private-sector representatives also provided testimony supporting the proposed rule revisions during required public hearings held around the state.
Assurance was sought from the state immunization division that adequate vaccine supplies would be available to cover VFC vaccine used in both the private and public health setting.
Immunization school-entry requirements in Wisconsin alter existing administrative rules. The process includes approval by state legislative committees and public hearings, but full legislative action is not required.
The adolescent health maintenance visit and its immunization component were then publicized to all pediatricians and family practitioners through various newsletters over a two-year span, emphasizing the need to include the full hepatitis B vaccine series for kindergarten and seventh grade entry. Catch-up vaccination through age 19 was also promoted.
The chapter stressed to physicians that new school entry immunization rules were coming and that implementation was scheduled for fall 1997. Pilot school-based programs began in several large and small county sites to identify glitches and to prove the concept to the medical community.
Three statewide pediatrician surveys were conducted on current and projected adolescent immunization practices. These surveys identified and addressed areas of physician concern in subsequent newsletters. Feedback from the survey results were used to inform all Wisconsin physicians about their peers.
The two-year plan proved successful, and in May, Wisconsin legislators approved an administrative rule which now requires all children in day care, kindergartners and seventh graders be immunized against hepatitis B before entering school or day care this fall, Saari said.
"This process began in October 1995 and was completed in May 1997 after many hurdles were cleared," Saari said.
James Watt, MD, MPH, of the California Department of Health Services immunization branch said California developed a new strategy for promoting adolescent immunization based on the idea of an adolescent preventive service visit at 11-12 years of age. The four-point strategy includes:
A key element of Californias strategy is promoting adolescent immunization through managed care organizations, Watt said.
- market the concept of adolescent immunization to pre-teens and their parents;
- encourage immunization providers to more actively immunize adolescents;
- promote changes in the health care delivery systems, and;
- enhance the public health system with regard to adolescent immunizations.
This program involves the school system and an entertaining, face-paced video called Immunization Days, which was created with middle-school students in mind. A curriculum for parents was also designed.
This program just began and even preliminary data are not yet available.
Betsy Wentzel, ARNP, is having success with high-risk access strategies through Planned Parenthood of Greater Iowa (PPGI). The 16-clinic agency began a hepatitis B vaccination program in July 1996 aimed at patients from 11 to 18. The goal is to vaccinate as many people in that age group as possible and to ensure compliance.
The programs strategy of educating patients who are already in a preventative state-of-mind has been effective. The program is currently at a 70% compliance rate. As of April 30, PPGI clinicians have given at least one hepatitis B vaccine dose to 784 people. Program strategies include:
Funding and vaccine supplies are provided through the CDCs Vaccines for Children program and the Iowa Department of Public Health.
- Contracted with the state health department to provide hepatitis B education and vaccine to about 6,000 adolescents who visited the clinics in 1995;
- persuaded CDC to provide vaccine to PPGI at no cost;
- educated clinicians and counselors about the vaccination program; and
- received a small federal grant to ensure the agency could cover cost of education and recall.
Wanda Miller, RN, SNP, MA, is coordinating school-based clinic strategies within the St. Paul public school system. The Wellness program for St. Paul public schools accessed children through student placement centers and received reimbursement by billing various private managed care organizations. The immunization status of children is assessed at two points of entry: the preschool Early Childhood Screening appointments and at the Student Placement Center during school registration. This plan also helped set-up clinics in every city high school.
A small grant provided by the National Association of Pediatric Nurse Associates and Practitioners and Merck allowed three nurses to work with sixth graders in areas with lower vaccination rates. The nurses goals included:
In the first year, the district immunized 1,862 students; through March 30 of the 1996-1997 school year, the district immunized 1,848 students.
- implementing curriculum development;
- providing classroom presentations; and
- generating each students immunization records through the schools computerized immunization registry.
Angela Salazar, immunization coordinator of Group Health Cooperative of Puget Sound in Seattle, tackled managed care strategies by developing a tracking system using the existing exception report format.
The tracking system alerts providers and parents when measles-mumps-rubella and hepatitis B vaccines are needed. Group Health also works with several local and middle schools to assist in immunizing sixth through eighth graders who do not meet school-entry requirements. Key points include:
Group Health Cooperative is a non-profit managed health care system which delivers care in 33 primary care medical centers and has contracts with over 2,400 outside physicians.
- role clarification and accountability;
- data entry quality improvements;
- training clinic staff, and;
- ongoing feedback to providers.
Access to the online system has been positive, Salazar said. Feedback regarding specific measurement windows has had mixed reviews because of the additional work required. Improvement measurements for 1997 are not yet available.
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