Recommendations of the Advisory Committee on Immunization Practices: Programmatic Strategies to Increase Vaccination Coverage
by Age 2 Years -- Linkage of Vaccination and WIC Services
This statement by the Advisory Committee on Immunization
Practices
(ACIP), in collaboration with the U.S. Department of Agriculture's
(USDA's)
Food and Consumer Service (FCS), presents programmatic strategies
to
increase vaccination rates among preschool-aged children. This is
the first
statement to recommend assessment of vaccination status and
referral for
needed vaccinations of children receiving services from the Special
Supplemental Nutrition Program for Women, Infants, and Children
(WIC).
Although vaccination coverage levels of first-grade school
entrants
are greater than 95%, during the 1989-1991 nationwide measles
epidemic,
coverage levels among urban children aged 2 years were commonly
less than
50% (1). Based on studies conducted during the epidemic, 29%-63% of
unvaccinated preschool-aged children with measles either were or
had been
enrolled in WIC.
WIC is a categorical federal grant program administered by the
FCS
through state health departments. The program provides supplemental
foods,
health-care referrals, and nutrition education to low-income
pregnant,
breastfeeding, or postpartum women; infants; and children aged less
than 5
years. In 1995, approximately 1.8 million infants (44% of the U.S.
birth
cohort that year) and at least 5 million children aged less than 5
years
participated in WIC monthly. In 1996, the total number of
participants aged
less than 5 years is expected to increase to approximately 6
million.
Assessment of vaccination status and referral for needed
vaccinations
linked with food-voucher issuance (more frequent visits for
children not
up-to-date and less frequent visits for those up-to-date) has been
evaluated in New York City and Chicago and is being evaluated in
Dallas.
Among New York City WIC participants aged 12-59 months, 14% had not
been
vaccinated against measles; of these unvaccinated children, 79% who
received assessment and referral linked with food-voucher issuance
were
vaccinated against measles within 6 months, compared with 86% who
received
assessment and escort to the vaccine-delivery site and 54% who
received
assessment and referral only (2). In Chicago, among groups
receiving
assessment and referral linked with voucher issuance, the
prevalence of
up-to-date status at age 2 years increased 36-40 percentage points;
among
the group receiving assessment and referral only, the prevalence
increased
only 4 percentage points (3).
CDC and USDA recommend that state and local vaccination and
WIC
programs collaborate to ensure that young children receive
assessment and
referral services (4). This recommendation requires that a
documented
vaccination record (parental recall alone is unreliable) of each
WIC client
be carefully reviewed as frequently as possible -- preferrably at
each WIC
visit. Providers are encouraged to provide vaccination records to
parents
to facilitate accurate assessment by WIC staff. Clients needing
vaccinations should be referred to their usual source of
comprehensive
health care or be vaccinated on-site if feasible. Programs are
encouraged
to consider a variety of integrated service-delivery strategies,
including
the use of incentives for fully vaccinated young children, and
outreach for
and tracking of undervaccinated children. When possible, WIC and
vaccination programs should use automated assessment modules and
areawide
vaccination data registries to increase the efficiency of
assessment.
The ACIP recommends that WIC and vaccination programs assess
regularly
the vaccination coverage levels of WIC participants and develop new
strategies and aggressive outreach procedures in those sites with
coverage
levels below 90%. In addition, vaccination programs and private
providers
are encouraged to refer eligible children to obtain WIC nutritional
services. The linkage of WIC and vaccination services is expected
to
increase vaccination levels of high-risk preschoolers and to help
sustain
high coverage levels. CDC (in collaboration with WIC) is developing
guidelines to implement this linkage, and in 1996, a portion of
vaccination
grant funds have been designated for the implementation.
References
Hutchins SS, Gindler JS, Atkinson WL, et al. Preschool children
at high
risk for measles: opportunities to vaccinate. Am J Public Health
1993;83:862-7.
Birkhead G, LeBaron CW, Parsons P, et al. The immunization of
children
enrolled in WIC: the impact of different strategies. JAMA
1995;274:312-6.
Hutchins SS, Rosenthal J. Results from WIC demonstration
projects. In:
Proceedings of the 28th National Immunization Conference.
Atlanta,
Georgia: US Department of Health and Human Services, Public
Health
Service, CDC;1995:1-4.
Ad Hoc Working Group for the Development of Standards for
Pediatric
Immunization Practices. Standards for pediatric immunization
practices.
JAMA 1993;296:1817-22.
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