In order to effectively achieve a 90% immunization level for our nation's children under the age of two, it is important to strengthen provider practices, educate parents and provide access to the under served, the uninsured, and the undocumented. Every child is important and will be served by these efforts. The following strategies should be operationalized.

Avoid Missed Opportunities to Immunize.

In every setting — office, clinic, school, home, emergency room — health care providers can assess each child's immunization status. If immunizations are needed, immunize immediately, and if not possible, assist the parent to make arrangements for the child to be immunized as soon as possible. Develop referral mechanisms in practice settings.

Educate Staff and Parents

Information as well as continuing education programs should be available for staff in all settings to acquaint them with the Standards for Pediatric Immunization Practice (Table 6).

• Immunization services are readily available.
• There are no barriers or unnecessary prerequisites to the receipt of vaccines.
• Immunization services are available free or for a minimal fee.
• Providers utilize all clinical encounters to screen for needed vaccines and when indicated, vaccinate.
• Providers educate parents and guardians about immunization in general terms.
• Providers question parents or guardians about contraindications and, before vaccinating a child, inform them in specific terms about the risks and benefits of the vaccinations their child is to receive.
• Providers follow only true contraindications.
• Providers administer simultaneously all vaccine doses for which a child is eligible at the time of each visit.
• Providers use accurate and complete recording procedures.
• Providers co-schedule immunization appointments in conjunction with appointments for other child health services.
• Providers report adverse events following vaccination promptly, accurately, and completely.
• Providers operate a tracking system.
• Providers adhere to appropriate procedures for vaccine management.
• Providers conduct semiannual audits to assess immunization coverage levels and to review immunization records in the patient populations they serve.
• Providers maintain up-to-date, easily retrievable medical protocols at all locations where vaccines are administered. Providers practice patient-oriented and community-based approaches.
• Vaccines are administered by properly trained persons.
• Providers receive ongoing education and training regarding current immunization recommendations.

Current vaccine administration guidelines are provided annually by the ACIP and are available in professional journals and directly on the CDC Internet site. As new vaccines become available, updates and inservice programs must be provided to all practitioners.

Parents also need education. They should be provided with the necessary information about reactions within 48 hours post inoculation that may require additional medical intervention. Although serious adverse events are rare, children who are seriously or fatally injured as a result of immunization can seek compensation through the National Vaccine Injury Compensation Program (Table 5). It is required that these be reported using the Vaccine Adverse Events Reporting System form available in all provider practices.

Identify Children in Need

Development of protocols for identification of children in need of immunization is imperative. Gill and Fisher (1997) found that three steps were useful in increasing immunization rates in a primary care setting: use of a tracking sheet recording the child's record, all dosages and contraindications, placing a stamp on each progress note for sick and well visits with nurses checking for immunizations on the progress note and alerting physicians. Reasons for non-administration of vaccine also were recorded.

Evaluate Existing Policies and Procedures

Office operation/environment can prove to be a barrier to infant immunization. Hughart et al. (1997) found that providing immunizations outside of regular well-child care visits would not necessarily decrease attendance at visits for well-child care. Office protocols should be developed to enable providers to automatically administer immunizations under standing orders (Gill and Fisher 1997).

Utilize a Tracking System

Computerized tracking systems can yield data to remind parents about appointments, to identify children with delayed immunizations, and to monitor and evaluate the practice efforts to reach the children in that particular practice. These programs will send postcards to parents as reminders. Alemi et al. (1996) found that the use of computer-generated telephone reminders to the parents' home was a very effective strategy to improve immunization rates.