Immunizations are a cornerstone of childhood wellness in the United States. In the United States, childhood immunization programs have led to dramatic declines in the rates of vaccine-preventable diseases such as measles, polio and haemophilus influenzae serotype b, with significant reductions in morbidity and mortality. Routine childhood immunizations with DTaP, Td, Hib, Polio, MMR, Hep B, and varicella vaccines in just one birth cohort in the U.S. prevents about 14 million cases of disease and saves about 33,000 lives. It also reduces direct health care costs by about $9.9 billion and saves about $33.4 billion in indirect costs.
For the most recent National Immunization Survey (NIS), 2018-2020, the CDC assessed vaccination coverage by age 24 months among children born in 2017 and 2018. The coverage nationally was highest for ≥3 doses of poliovirus vaccine (92.7%); ≥3 doses of
hepatitis B vaccine (HepB) (91.9%); ≥1 dose of measles, mumps, and rubella vaccine (MMR) (91.6%); and ≥1 dose of varicella vaccine (VAR) (90.9%). Coverage was lowest for ≥2 doses of influenza vaccine (60.6%). Disparities in coverage were noted for race/ethnicity, poverty status, and health insurance status. Coverage with most vaccines was lower among children who were not privately insured, with the largest disparities among uninsured children. It should be noted that those reported estimates reflect vaccination opportunities that mostly occurred prior to disruptions from the COVID-19 pandemic.
About the Improving Childhood Immunization Project (ICHIP) - Phase 3
From June 2020 through December 2021, the American Academy of Pediatrics (AAP) partnered with two AAP state chapters engaged with primary care practice teams to improve vaccine coverage rates for children between ages 19-35 months old. The HEDIS (Healthcare Effectiveness Data and Information Set) immunization measure set (Combo 3) of the combined 7-vaccine series (four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV), was analyzed monthly, along with the rates of each of those individual vaccine series and rates of missed opportunities to vaccinate, to monitor improvement.
The collaborative was comprised of 14 practices representing urban, rural, and suburban areas across two states. Practice teams participated in a series of online learning sessions during which they learned about immunization related clinical content and quality Improvement (QI) methods and tools. Learning sessions were followed by “action periods” during which practices implemented what they learned and tested ways to improve immunization care. Throughout the project, the AAP National Team and the AAP chapter leaders provided direct QI coaching support, clinical expertise, access to a data collection system, and a variety of educational resources.
This project followed the vaccine schedule recommendations for children through 2 years of age, according to the Advisory Committee of Immunization Practices (ACIP) and expanded successful interventions tested during previous immunizations projects, along with best practice guidance for infant and child wellness from the AAP Bright Futures and the CDC. Suggested interventions included implementing reminder/recall systems for well visits, vaccinating at acute visits, use of standing orders and nurse-only visits, integrating State Immunization Information System (IIS) use into daily workflow, and reviewing vaccination status at all visits. Resources for each intervention are included in this childhood-focused change package under the appropriate key driver(s).
At the conclusion of a Childhood Immunization Improvement Project (Phase 1) in 2019, six immunization chapter leadership teams submitted feedback on the interventions tested and employed by their participating teams that led to improvement in coverage rates. This feedback across the learning network culminated in a list of “Top Ten” Interventions. This same list of tested improvement strategies was again identified as top interventions by the participants of the ICHIP (Phase 3) Collaborative.
Phase I Top Ten Interventions
- Requiring vaccination records at initial appointment
- Reviewing vaccination status at all visits
- Vaccinating at acute visits
- Integrating immunization registry into daily workflow
- Utilizing non-confrontational communication with parents
- Implementing a reminder/recall system
- Ensuring accurate patient lists
- Implementing standing orders for routine and 'shot only' visits
- Clinician and staff training on vaccine office systems and communication strategies
- Using data and rapid cycle testing to continuously improve