Presentation on theme: "Tactics for Increasing Immunization Coverage Among Adults."— Presentation transcript:
Tactics for Increasing Immunization Coverage Among Adults
Educational Learning Objectives At the conclusion of this presentation, the participant should be able to: Acknowledge the indications and recommendations for current vaccines and vaccine schedules across adult populations Address immunization barriers frequently encountered during patient/caregiver communications regarding safety, efficacy, and possible misinformation Implement strategies for improving immunization rates within one’s clinical practice, taking into account current immunization schedules and guidelines
Vaccines For Adults Based on Medical and Other Indications 2011 CDC. MMWR Morb Mortal Wkly Rep. 2011;60(4).
Recent Updates to the Adult Immunization Schedule Influenza Pneumococcal Tdap CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(34): ACIP. Accessed Nov 2010.
HR: High Risk Adult Immunization Coverage National Health Interview Survey yrs, HR ≥ 65 yrs CDC. Accessed Nov yrs, HR yrs, HR N = 1,067Sample size→N = 1,046N = 2,444N = 8,070N = 5,275
HR: High Risk Adult Immunization Coverage National Health Interview Survey yrs ≥ 65 yrs ≥ 60 yrs CDC. Accessed Nov yrs yrs yrs yrs, HR Sample size→ N = 14,3786,5405,132N = 13,127N = 1,05212,454N = 7,335N = 1,785
These new parents (age 30) both received Td vaccine 3 years ago prior to their marriage. Should they be vaccinated with Tdap in order to protect their young son from pertussis?
Both parents should receive a single dose of Tdap promptly to protect their son from pertussis.
Tdap for Adults CDC. MMWR Morb Mortal Wkly Rep. 2009;58(14): ACIP. Accessed Nov to 64 years: single dose of Tdap in place of Td (if no previous Tdap received) Especially important for adults around young infants –Parents, grandparents, nannies ≥ 65 years (no previous Tdap) who have close contact with infants < 12 months* Tdap can be administered regardless of interval since last Td *Off-label ACIP recommendation; Medicare Part D coverage
Self-reported Tetanus and Pertussis Coverage Adults, National Health Interview Survey CDC. MMWR Morb Mortal Wkly Rep. 2010;59(40): Tetanus Preceding 10 years Adults ≥ 18 yrs Tdap 2008 Adults 18–64 yrs
25-year-olds Sexually active since age 13 Multiple partners Not previously vaccinated for HPV Not previously sexually active Now in a monogamous relationship Not previously vaccinated for HPV Should either of these women receive the HPV vaccine? Human Papillomavirus
Available HPV Vaccines Quadrivalent Merck - Gardasil ® Bivalent GSK - Cervarix ® Licensed in the US Virus-like Particle TypesHPV 6, 11, 16, 18HPV 16, 18 Protection against HPV 16/18 related CIN2+ ≥ 98%≥ 93% Protection against HPV 6/11 related genital lesions ~99%--- Hypersensitivity-related contraindication YeastLatex Licensed age range9–26 yrs10–25 yrs ACIP Recommendations Routine 11–12 yrs, catch-up 13–26 yrs Routine 11–12 yrs, catch-up 13–26 yrs Schedule 0, 2, 6 months0, 1, 6 months Markowitz L. ACIP Meeting Oct Accessed Nov CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ
HPV – ACIP Recommendations Quadrivalent HPV (HPV4) and Bivalent HPV (HPV2) Routine vaccination of females age 11 to 12 years –Catch-up yrs (HPV4); yrs (HPV2) ACIP: no preference for either vaccine HPV4 or HPV2 vaccination for prevention of HPV 16/18- related cervical cancers, pre-cancers, and dysplastic lesions Vaccination with HPV4 for additional prevention against genital warts, pre-invasive and invasive lesions of the vagina and vulva ACIP Schedules. Accessed Nov FDA. Accessed Nov 2010.
HPV Vaccination and Pregnancy HPV vaccines are not recommended for use in pregnant women Delay initiation of vaccination until after completion of pregnancy If a woman is found to be pregnant after initiating the vaccination series, delay remaining doses until after the pregnancy Two vaccine in pregnancy registries: –Quadrivalent HPV vaccine/pregnancy: –Bivalent HPV vaccine/pregnancy: CDC. MMWR Morb Mortal Wkly Rep. 2010;59:
HPV Quadrivalent Vaccine in Males FDA approved quadrivalent HPV vaccine for boys and men ages 9 through 26 ACIP: Permissive HPV vaccine for males CDC. MMWR Morb Mortal Wkly Rep. 2010;59:
Quadrivalent HPV Vaccine for Women 27 to 45 years Under FDA Review ACIP Considerations As women age from their mid 20s, reduced prevalence and incidence of HPV Disease outcomes (genital warts, CIN 2/3) peak among women in their mid to late 20s Questions on natural history of incident infections in adult women Greatest benefit from vaccinating females in early adolescence Clinical trial data (women 24–45 years) –Efficacy against HPV 6/11/16/18-related persistent infection, CIN, external genital lesions –Well tolerated Dunne E. hpv.pdf. Accessed Nov Haupt R. hpv.pdf. Accessed Nov CIN: cervical intraepithelial neoplasia
This 65-year-old recently recovered from a case of shingles. Is he a candidate for the zoster vaccine? If so, how long should he wait before receiving the vaccine?
Varicella-Zoster Vaccine Shingles Prevention Study Randomized, placebo-controlled, double-blind vaccine trial –Study population 38,546 volunteers at 22 sites; adults 60+ years 95% of volunteers completed study –Follow-up: median duration 3.12 years Vaccine recipients: Overall incidence of herpes zoster reduced by 51% Incidence of postherpetic neuralgia reduced by 67% Injection site reactions were more frequent in the vaccine group Oxman MN, et al. N Engl J Med. 2005;352:
Varicella-Zoster Vaccine Shingles Prevention Study Oxman MN, et al. N Engl J Med. 2005;352: Postherpetic NeuralgiaHerpes Zoster
Zoster (Shingles) Vaccine Single-dose vaccine licensed for persons 60+ years of age Shingles Postherpetic neuralgia CDC. MMWR Recomm Rep. 2008;57(RR5):1-30. CDC. Accessed Nov 2010.
Zoster Vaccine Contraindications and Precautions Contraindications –Previous severe allergic reaction to a vaccine component –Immunocompromised persons HIV, AIDS, leukemia, lymphoma, or other malignant neoplasms Persons on immunosuppressive therapy, including high-dose corticosteroids Persons receiving immune mediators/modulators –Pregnancy or planned pregnancy within 4 weeks Precautions –Moderate or severe acute illness CDC. MMWR Recomm Rep. 2008;57(RR5):1-30.
A previous case of shingles is not a contraindication for the zoster vaccine. The data are not definitive regarding how long to wait following a case of shingles to vaccinate with the zoster vaccine. Some professionals suggest 5 years.
Zoster Vaccine Cost Issues Routine vaccination not previously covered by Medicare part B –Eligible for reimbursement by Medicare part D Patient assistance programs With health care reform –Private sector health plans ‘1 st Dollar Coverage’ –Medicare personalized prevention plan Affordable care act. Accessed Nov AAFP. Accessed Nov 2010.
VariableEstimated Annual Impact Cases24.7 million Outpatient visits31.4 million Hospitalizations334,185 Hospitalized days3.1 million Days of productivity lost due to illness44.0 million Deaths41,008 Life years lost610,656 Medical costs$10.4 billion Lost earnings due to illness and loss of life$16.3 billion Total economic burden$87.1 billion Seasonal Influenza Has a Huge Annual Impact in the United States Molinari NA, et al. Vaccine. 2007;25: Based on 2003 US population demographics
Influenza Vaccination Coverage Levels CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. Accessed Nov *Data from the Behavioral Risk Factor Surveillance System and National 2009 H1N1 Flu Survey
Annual Influenza Vaccine Is Recommended for All people* age 6 months and older! High risk groups include: Adults > 50 yrs Young children Pregnant women People with chronic comorbidities CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. * Without contraindications
2010–2011 Influenza Season Trivalent Influenza Vaccines –A/California/7/2009(H1N1)-like virus –A/Perth/16/2009(H3N2)-like virus –B/Brisbane/60/2008-like virus Current information from the CDC and FDA –http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref –http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ ucm htm CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. Accessed Nov FDA. Accessed Nov 2010.
Seasonal Influenza Vaccines FactorLAIVTIV Route of administrationIntranasal sprayIntramuscular injection Type of vaccineLive virusKilled virus Number of included virus strains3 (2 influenza A, 1 influenza B) 3 (2 influenza A, 1 influenza B) Vaccine virus strains updatedAnnually Frequency of administrationAnnually* Approved age2–49 yrs≥ 6 mos OK for persons with medical risk factors for influenza-related complications † NoYes CDC. MMWR Morb Mortal Wkly Rep. 2010;59(RR8):1-62. TIV: trivalent inactivated influenza vaccine; LAIV: live, attenuated influenza vaccine † Includes medical conditions such as chronic pulmonary, cardiovascular, renal, hepatic, neurologic, hematologic or metabolic disorders; those who are immunosuppressed; those who are or will be pregnant during influenza season; residents of nursing homes and chronic-care facilities *Children ≥ 6 mos–8 yrs without prior influenza vaccination or who only received 1 dose of seasonal influenza vaccine should receive 2 doses
2010–2011 Influenza Season VaccineTrade NameAge Group Route of Administration TIVFluzone; sanofi ≥ 6 months Intramuscular TIVFluvirin; Novartis ≥ 4 years Intramuscular TIVFluarix; GSK ≥ 3 years Intramuscular TIVFluLaval; GSK ≥ 18 years Intramuscular TIVAfluria; CSL ≥ 6 months Intramuscular TIVFluzone High-Dose;* sanofi ≥ 65 years Intramuscular LAIVFluMist; MedImmune 2–49 yearsIntranasal TIV: trivalent inactivated influenza vaccine; LAIV: live attenuated influenza vaccine *Each 0.5 mL dose contains 60 μg each of the 3 influenza strains CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(31):
Nosocomial Influenza Is Well Documented Nosocomial outbreaks documented on –Solid organ transplant units –Oncology units –Neonatal ICU –Pediatric units –Long term care facilities –General medical wards Results: morbidity for patients & staff, increased costs for institution & impaired capacity to provide care Vectors for transmission include staff, visitors, patients Stott DJ, et al. Occup Med (Lond). 2002;52: Encourage hygiene etiquette amongst staff and patients
Considerations for Those Morbidly Obese High-risk Group for Influenza For Intramuscular (IM) Injections gauge needle CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. Immunization Action Coalition. Accessed Nov GroupWeightNeedle Length Adults< 130 lbs (< 60 kg)5/8” Adults lbs (60-70 kg)1” Women lbs (70-90 kg)1-1½” Men lbs ( kg)1-1½” Women> 200 lbs (> 90 kg)1½”1½” Men> 260 lbs (> 118 kg)1½”1½”
This woman is 6 months pregnant and would like to get an influenza vaccine. Should she get the trivalent inactivated vaccine, the live attenuated influenza vaccine, or neither?
Influenza vaccination is recommended for all pregnant women, due to the increased risk for influenza-related complications. She should receive the trivalent inactivated influenza vaccine. Live attenuated influenza vaccine is contraindicated during pregnancy.
Maternal Influenza Immunization and Protection of Infants Eick A, et al. Arch Pediatr Adolesc Med Oct 5. [Epub ahead of print] Nonrandomized, prospective, observational cohort study Navajo and White Mountain Apache Indian Reservations N = 1160 mother infant pairs; birth–6 months Infants Born to Vaccinated Mothers vs Unvaccinated Mothers 41% ↓ in risk of laboratory confirmed influenza virus infection RR: 0.59; 95% CI, 0.37– % ↓ in risk of influenza-like illness hospitalization RR: 0.61; 95% CI, 0.45–0.84 Higher hemagglutinin inhibition antibody titers at birth and 2–3 months
Cumulative Cases of Laboratory-Confirmed Influenza in Infants of Moms Who Received Influenza Vaccine Compared with Controls; Bangladesh Zaman K, et al. N Engl J Med. 2008;359: N = 340 mothers randomized to either inactivated influenza vaccine or 23-valent pneumococcal polysaccharide vaccine
Influenza Vaccination Coverage Levels Among Pregnant Women CDC. MMWR Morb Mortal Wkly Rep. 2010;59(47): NHIS: National Health Interview Survey PRAMS: Pregnancy Risk Assessment Monitoring System; 10 States NHIS PRAMS Sample size→N = 113N = 177N = 6,225N = 5,112
Influenza in the Elderly Serious complications from influenza –Secondary infections –Exacerbations of chronic diseases –Increased hospitalization and death Influenza vaccination –Reduced hospitalizations and death CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.
High-Dose Inactivated Influenza Vaccine for Adults ≥ 65 Years, Influenza Season Rationale Higher antigen content –Standard dose TIV 45 μg total virus hemagglutinin antigen per dose –High-dose TIV 180 μg total virus hemagglutinin antigen per dose –Higher immune response; clinical ramifications unknown ACIP: no preference for any specific inactivated trivalent influenza vaccine for use in adults ≥ 65 years CDC. MMWR Wkly Rep. 2010;59(16):
Risk Factors for Invasive Pneumococcal Disease Extremes of age Comorbidities Certain ethnic groups Immune deficiencies Lynch J, Zhanel G. Semin Respir Crit Care Med. 2009;30(2):
S. Pneumoniae ABCs Data < ≥ 65 Cases Per 100,000 Population Deaths per 100,000 Population Age (years) Cases Deaths CDC ABC Surveillance report. Accessed Nov 2010.
Invasive Pneumococcal Disease Among Adults ≥ 65 Years, 1998/99–2007 Pilishvili T, et al. J Infect Dis. 2010;201: Cases/100,000 population Year PCV7 introduced Serotype group PCV7 type Non-PCV7 type 19A *92% reduction in PCV7 serotypes, 2007 vs baseline *
Pneumococcal Polysaccharide Vaccine (PPSV23) for Adults Vaccine contains 23 polysaccharide serotypes from S. pneumoniae Single dose recommended for: –All ≥ 65 years –Asthmatics and smokers age 19 to 64 years –19 to 64 years: chronic cardiovascular disease, chronic lung disease, diabetes, alcoholism, chronic liver disease, CSF leaks, asplenia, cochlear implants –Immunocompromised persons CDC. MMWR Morb Mortal Wkly Rep. 2010;59(34):
Revaccination with PPSV23 19 to 64 years: one-time revaccination after 5 years –Chronic renal failure or nephrotic syndrome –Functional or anatomic asplenia –Persons with immunocompromising conditions ≥ 65 years: one-time revaccination if vaccinated ≥ 5 yrs previously and < 65 years at time of primary vaccination ACIP. Accessed Nov 2010.
Pneumococcal Polysaccharide Vaccine Coverage –Adults ≥ 65 Years, 1997–March 2010 CDC/NCHS. Accessed Nov 2010.
Effectiveness of Pneumococcal Polysaccharide Vaccine in Older Adults: The VSD Cohort Study 3-year cohort study of 47,365 members of Group Health Coop (Seattle) PPV was associated with lower rates of bacteremia: –HR 0.56 (95% CI 0.33 to 0.93) PPV was not associated with lower rates of pneumonia –HR 1.07 (95% CI 0.99 to 1.14) HR = hazard ratio. Jackson LA, et al. N Engl J Med. 2003;348:
Effectiveness of PPSV23 in Adults 2008 Meta-analysis 22 studies; 15 randomized controlled trials (RCTs), N = 48,656 patients; 7 non-RCTs, N = 62,294 patients Results from RCTs –Invasive pneumococcal disease (IPD) Strong evidence of protection (74%); OR 0.26 (95% CI 0.15–0.46); P < No statistical heterogeneity –All-cause pneumonia Inconclusive efficacy (29%); OR 0.71 (95% CI 0.52–0.97); P = Substantial statistical heterogeneity –All-cause mortality No evidence of protection; OR 0.87 (95% CI 0.69–1.10); P = 0.25 –Adults with chronic illness Evidence is less clear Results from non-RCTs –IPD Evidence of protection (52%); OR 0.48 (95% CI 0.37–0.61); P < Moberley S, et al. Cochrane Database Syst Rev. 2008;(1):CD
PPSV23 and Prevention of Pneumonia in Elderly Patients Cohort studies suggest protection against IPD Some cohort studies suggest protection against pneumonia, while others do not No randomized trials have demonstrated efficacy against pneumonia in the elderly
Investigation of Pneumococcal Conjugate Vaccine for Adults Hak E, et al. Netherlands J Med. 2008;66(9): NCT Accessed November Randomized, placebo-controlled clinical trial 13-valent pneumococcal conjugate vaccine – Serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F conjugated to CRM ,000 adults ≥ 65 years – No prior vaccination with pneumococcal vaccine Primary/Secondary endpoints: –Cases of 1 st episode vaccine-serotype specific pneumococcal community-acquired pneumonia –Cases of vaccine-serotype invasive pneumococcal disease, safety
Hepatitis A Vaccine International Travel For healthy persons 40 years of age or younger –2 doses 6 months apart prior to departure –The first dose of Hepatitis A vaccine should be administered as soon as travel is considered –1 dose of single-antigen vaccine administered at any time before departure Consider both HAV and Ig for –Persons age > 40 with chronic illness traveling in less than 2 weeks and only receiving one dose of HAV –Persons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or sooner CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):
Hepatitis A: Families of International Adoptees Hep A vaccination –All previously unvaccinated persons who anticipate close personal contact with an international adoptee from countries of high or intermediate endemicity during the first 60 days following arrival in the US 1 st dose of Hep A vaccine –As soon as adoption is planned –Ideally at least two weeks prior to the arrival of the adoptee CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
Hepatitis A Postexposure Prophylaxis For healthy persons 12 months through 40 years of age who have not previously received HepA vaccine Immunoglobulin and/or single-antigen hepatitis A vaccine Efficacy of Ig or HepA when administered > 2 weeks postexposure is unknown CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41): CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
FACT: Hepatitis B virus infects over 40,000 Americans annually CDC. Accessed March 2010.
Hepatitis B Vaccine Adult Schedule *Approved Twinrix schedule **A 4-dose schedule of Engerix-B is licensed for all age groups CDC. MMWR Recomm Rep. 2006;55(RR16): dose schedules for adults age ≥ 20 years –0, 1, and 6 months* –0, 1, and 4 months –0, 2, and 4 months –0, 1, 2, and 12 months** 2-dose schedule for adolescents age 11 to 15 years – 0 and 4-6 mos using adult 10 ug formulation, Recombivax-HB Behavioral, occupational, and medical indications; persons seeking protection from Hep B infection
MMR Evidence of Immunity for Health Care Personnel: Mumps, Measles, & Rubella Born in 1957 or later –Laboratory confirmation of disease or immunity Or –Appropriate vaccination 2 doses of MMR, 4 weeks apart Born before 1957 –Recommend 2 doses of MMR, 4 weeks apart to those unvaccinated without laboratory confirmation of disease or immunity Stronger recommendation if there is an outbreak ACIP. Accessed Nov 2010.
Identify and Address Barriers Patient Issues for Vaccination Awareness –Disease –Vaccine –Personal risk Provider recommendation Misconceptions/fears –About vaccine –About health care system Access and ability to pay
Main Reason for Not Being Vaccinated: NIS, Adult 2007 Adapted from Euler GL. Accessed Nov N = 2,181Sample size→N = 539N = 843N = 221
Cost Is Important, But…. Perceived cost as a significant barrier to patients being vaccinated Johnson DR, et al. Am J Med. 2008;121:S28-S35. Percent
Improving Vaccination Rates – Provider Issues Know the facts Recommend vaccinations to your patients Get organized and use systems approaches –Ensure offering and administration of vaccine Automatic processes that empower nurses are effective Address convenience, efficiency, durability Evaluate and provide feedback Consider new paradigms –New venues –Extend vaccination season Practice what we preach (get vaccinated!) Nichol KL. Cleve Clin J Med. 2006;73:
Shots Immunization App - Free For iPhone/iPod, iPad, Android, Blackberry, and PC Select vaccine name for information on High risk indications Adverse reactions Contraindications Catch-up Administration Risk communication Epidemiology Available at iTunes Store Content includes Childhood, Adolescent, and Adult Immunization Schedules for the US
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Provider Recommendation Can Overcome Negative Attitudes Among Patients Vaccination Rates Among High Risk Patients With Negative Attitudes Nichol KL, et al. J Gen Intern Med. 1996;11:
Standing Orders Are Among the Most Effective Strategies Nonphysicians offer and administer vaccinations Established with physician approved policies and protocols Locations: –Clinics and hospitals CDC. Accessed Nov McKibbin LJ, et al. MMWR Recomm Rep. 2000;49 (RR1):15-26.
Success of Standing Orders as Part of a Multifaceted Program Education Standing Orders Nichol KL. Am J Med. 1998;105: Influenza Vaccination Rates for Elderly Patients in General Medicine Clinics
Patient and Provider Reminders Vaccinations Due or Past Due Patient/parent – Telephone, letter/postcard Provider –Computerized record reminders –Chart reminders Jacobson V, Szilagyi P. Cochrane Database Syst Rev. 2005;(3):CD
Tailored Interventions for Inner-City Health Centers to Improve Vaccination Rates Nowalk M, et al. J Am Geriatr Soc. 2008;56: InfluenzaPneumococcal (≥ 65) ** **P < vs Tailored Interventions Standing orders Provider and patient education Walk-in influenza clinics Electronic prompts Patient reminders
Provider Assessment and Performance Feedback Retrospectively assess the delivery of vaccine(s) Incorporates principles of continuous improvement AFIX –Assessment –Feedback –Incentives –eXchange Comprehensive Clinic Assessment Software Application (CoCASA) Immunization Information System (IIS) CDC. Accessed Nov The Community Guide. Accessed Nov 2010.
Expanding Access Consider new paradigms –New venues, walk-in clinics –Extended hours for vaccinations –Extend vaccination season Nichol KL. Cleve Clin J Med. 2006;73:
Where Flu Shots Are Received (Often Not the Doctor’s Office) Singleton J, et al. Am J Infect Control. 2005;33:
Vaccinations in Nontraditional Settings Potential advantages –Cost –Access/convenience –Increased public awareness and demand –New providers and new strategies –For flu, pneumo, ??? other vaccines CDC. MMWR Recomm Rep. 2000;49 (RR1):1-13.
Targeting Hospitalized Patients Makes Sense Hospitalization is a marker for increased risk Hospitalized patients may be less likely to be immunized –Providers often miss opportunities to immunize Organized programs work in the inpatient setting
The Community Guide. Accessed Nov Briss PA, et al. Am J Prev Med. 2000;18(suppl 1): Evidence-based Methods for Improving Immunization Rates Reducing client out-of-pocket costs Client reminder and recall systems Vaccination requirements for college attendance Provider reminder systems when used alone Standing orders when used alone Provider assessment and feedback
Summary Critical patient issues for increasing adult vaccination rates –Knowledge / awareness –Provider recommendations Critical provider issues for increasing adult vaccination rates –Stay current with the immunization schedule, recommendations –Identify and address barriers –Educate patients –Recommend vaccines to patients –Implement organizational and systems strategies –Ensure health care workers are vaccinated –Consider new paradigms
Resources for Providers Immunization Schedules ACIP recommendations & provisional recommendations The Immunization Action Coalition: vaccine information for the public and health professionals The Guide to Community Preventive Services. Vaccine recommendations Assessment, Feedback, Incentives, and Exchange (AFIX) National Foundation for Infectious Diseases Centers for Medicare & Medicaid Services
Resources for Patients and Parents Guide to evaluating information on the web CDC Vaccine Information Statements (VISs) Vaccine Safety National Network for Immunization Information (NNII) Allied Vaccine Group Immunization Action Coalition (IAC) Vaccine Education Center at CHOP TCH Center for Vaccine Awareness and Research