How CHOC pediatricians helped raise immunization rates in Orange, Los Angeles counties

Further championing the importance of vaccines in protecting children’s health and well-being, a quality improvement project recently completed by CHOC pediatricians successfully increased childhood immunization rates in Orange and Los Angeles counties. The project produced a number of QI strategies that could be replicated by pediatric providers across the country who are likewise seeking to improve immunization rates among their patients.

The project, funded by an American Academy of Pediatrics grant, focused on children ages 19 months to 35 months and their adherence to the Combo-10 portion of the AAP immunization schedule. The immunization panel known as Combo-10 includes DTaP, IPV, MMR, HiB, HepB, VZV, PCV, HepA, RV and Influenza vaccinations. The AAP’s immunization schedules outlines recommended ages for routine immunization administration.

Nationwide, the compliance rate for Combo-10 is between 40-50%. This means as many as half of U.S. children are not considered up to date on vaccinations, leaving them vulnerable to contracting these 10 illnesses the Combo-10 panel protects against.

“We sought to make sure that children ages 19-35 months were up-to-date with all immunizations they should have received by their age,” says Dr. Dan Kowabunpat, a CHOC pediatrician and project co-leader.

Dr. Dan Kowabunpat, a CHOC pediatrician and project co-leader.

Participating in the project were 15 practices across CHOC’s Primary Care Network including 87 providers who collectively care for approximately 60,000 patients. Each practice sought to raise immunization rates 5% over baseline figures – a goal they would not only meet but succeed, with immunization rates raising 5.8% overall.

Also participating in the project were UCLA, Vanderbilt Children’s Hospital, Penn State Children’s Hospital, the Children’s Hospital at Oklahoma University Medical Center and Gundersen Health System.

Although a recent California law eliminating the possibility of a personal belief exemption for immunizations raised kindergarten vaccination rates, rates for younger children had remained low.

“Southern California’s vaccination rates skew low. CHOC’s Primary Care Network tends to have higher than average vaccination rates for our area with between 60% and 70% of our children fully immunized, but we recognized there was still work to be done to protect children,” says Dr. Eric Ball, a CHOC pediatrician and study co-leader.

The reason behind lower-than-desired immunization rates, per Dr. Ball, is not necessarily because parents don’t want to immunize.

“The fault lies with missed opportunity,” Dr. Ball says. “If a patient is sick during a visit, or if their well check was scheduled before they’re due for a vaccine, over time these missed opportunities build up and then we have kids who are not fully immunized.”

The quality improvement project, completed earlier this year, included both clinical education for staff, as well as strategies that could be replicated and implemented by other practices with similar goals.

Dr. Eric Ball, a CHOC pediatrician and study co-leader.

Clinician education

  • Physician learning sessions — Led by pediatric infectious disease experts from CHOC, these sessions provided vital education on both quality improvement efforts, as well as strategies for discussing the importance of vaccines with parents.
  • Front-office staff learning sessions — While essential to practice operations, many of these clerical team members do not have formal medical training. As the first faces patients and parents see before their doctor, these staff members would routinely fields questions such as, “Am I getting shots today? Do I need this vaccine? What does this vaccine do?” With more comprehensive training, staff members were better able to speak to these topics, and curious patients and parents were more informed.

Monthly strategies

For the first three months of the project, participating practices implemented strategies aimed at boosting immunization rates outlined by project leaders. For subsequent months, each practice identified strategies based on their specific patient population and office dynamics. Proven strategies include:

  • Checking eligibility at all visits — Providers began checking immunization eligibility at every non-sick visit, rather than just well-checks. For instance, if a patient visits their pediatrician for a sports physical, their doctor checks for vaccine eligibility and administers any necessary vaccines. Before this project, checking vaccine eligibility was only done at well checks, but 75% of appointments are not checkups.
  • Implementing a recall system In collaboration with CHOC’s information services department, each practice developed a recall program to identify patients who were not up to date on vaccinations. The practice would then send calls/texts/postcards to remind patients to come in for immunizations.
  • Promoting staff vaccinations Practices took this project as an opportunity to provide education that staff were receiving vaccinations, too. For example, each CHOC staff member’s employee badge features a color-coded sticker updated annually indicating they receive an influenza vaccine that year. New signs in some offices read, “If you see this sticker on my badge, it means I got my flu shot, just like you.”
  • Waiting room activities One practice created a flu quiz for patients to complete in the waiting room, as a way to start a conversation with kids about vaccines.
  • Nurse appointments Walk-in flu shot offerings were implemented with nurses. Historically, patients had to make an appointment with their pediatrician.
  • One-on-one QI sessions Quality improvement advisers from CHOC’s population health team held on-on-one sessions with providers to pour over their practice’s immunization rates and how it compared to other practices and discuss strategies for boosting immunization rates.
  • Comfort measures — Comfort measures for immunization delivery, including distraction devices, sucrose solution for babies and mindfulness techniques for older children.
  • Collaboration CHOC physicians leaders collaborated with colleagues at participating sites around the country to share findings and best practices.

Flu season roundup: Resources to share with families

With the 2019-2020 flu season already here, it’s important to have some go-to prevention resources on hand for patients and families.

These articles cover prevention, signs and symptoms, and important information about the influenza vaccine.


6 ways to keep your kids safe from the flu
Essential steps families should take to avoid and protect from the virus


14 myths and misconceptions about the flu vaccine
This US News & World Report article explores common myths about the important vaccine

Facts & Tips

How to tell if your child has a cold or the flu
Help parents distinguish between the two despite similar symptoms

Stomach flu vs. influenza
Teach families to spot the key differences between gastroenteritis and influenza

What every parent should know about emergency departments during flu season
Tips for families and patients who face a trip to the ED during a busy flu season

Immunization Roundup: Resources to share with families

August is National Immunization Awareness Month, an annual observance highlighting the importance of vaccinations in people of all ages.

The immunization schedule outlined by Centers for Disease Control & Prevention (CDC) and supported by the American Academy of Pediatrics (AAP) has been shown to be the most effective and safest way to protect children from potentially fatal diseases.

Nevertheless, many families lack knowledge about vaccines, especially due to the rise of misinformation on the internet.

The following is a collection of useful immunization resources—both for providers and for the families they serve—intended to encourage families to vaccinate and to quell worries brought on by vaccine myths.

General immunization references

Providers can direct families to these resources about the safety of and necessity for immunization in general.

Vaccines at a glance
This page that lays out the importance of vaccines, defines herd immunity and debunks common myths in a simple, reader-friendly way.

American Academy of Pediatrics 2019 Immunization Schedule
The CDC and AAP agreed-upon recommendations for immunizations for ages 18 and under, this resource clearly outlines timing of vaccines based by age, appropriate intervals for vaccine catch-up and special situations.

If you choose not to vaccinate your child, understand the risks and responsibilities
If parents decline recommended vaccines for their child, it is important to inform them that the decision creates major risks not only to their own child, but to every unvaccinated person they meet. This handout clearly defines the responsibilities that comes with this choice.

Condition-specific vaccine information to give to families

Diseases and vaccines that prevent them-for parents of infants and young children
This list breaks down vaccines by the conditions they prevent, including English and Spanish versions.

What vaccines does my teen need?        
Vaccines aren’t just important for babies. Teens need to be vaccinated too! Parents should be aware of vaccines that will benefit their adolescents.

The HPV vaccine: a pediatrician’s perspective
With all the talk of infant vaccinations, it’s easy to forget that some immunizations occur later in adolescence. This Kids Health blog outlines the important vaccines for teens, including meningococcus (MCV), human papillomavirus (HPV), tetanus, diphtheria and pertussis (Tdap) and others.

What parents should know about measles
Once labeled dormant in the US, measles are on the rise worldwide—most recently marked by a historically high number of cases in 2019. This Kids Health blog gives a thorough look at measles and the accompanying vaccine.

Vaccine talking points and tips for providers

American Academy of Pediatrics tips for talking to vaccine-hesitant parents
A resource for providers outlining best ways to approach parents who are hesitant to vaccinate—includes mythbusting, suggested approaches and strategies and a breakdown of types of parental attitudes toward immunizing.

Talking with parents about vaccines for infants
A guide to speaking with parents about vaccines, including common parental concerns and questions, communication strategies and suggested responses.

Presentation: 10 ways to create a culture of immunization within a pediatric practice
This CDC slide deck outlines ways hospitals can integrate accepted vaccine practices and incorporate all staff in the adoption of immunization culture.

Nasal Flu Vaccine Not Recommended This Season – What Patients and Families Should Know

An advisory committee of the Centers for Disease Control and Prevention (CDC) recently recommended that the nasal spray influenza vaccine not be used this upcoming flu season. In this Q&A, Dr. Jasjit Singh, medical director of infection prevention and control at CHOC, offers an explanation for your patients and their families.

Q: What does this mean for influenza vaccine recommendations for the upcoming flu season?

A: All individuals over the age of 6 months are recommended to get the influenza vaccine, and that will continue to be the case.  However, for this season at least, the nasal flu vaccine is not an option. Therefore, parents will need to plan for their children to get the flu shot this upcoming season.

Jasjit Singh, M.D.
Jasjit Singh, M.D.

Q: How does the standard flu shot differ from the nasal spray version in terms of composition and effectiveness?

A: Both the flu shot and the nasal spray contain the anticipated predominant circulating strains of influenza every year, but the nasal spray strains are made of weakened live virus while the flu shot is made of inactivated viral components. The CDC reviewed data from this past season that suggested that the nasal spray did not perform as well as it had in the past.

Q: Besides ensuring their children get a flu shot, what else can parents do to help prevent the flu?

A: In addition to ensuring their child is vaccinated against the flu every year, there are many things parents and other caregivers can do to help prevent the flu. Use proper hand-washing techniques, use respiratory etiquette, and stay home from work or school if you are sick with the flu, to prevent spreading it to others.

Q: What do you anticipate will be parents’ reactions to this recommendation? Is there anything else you’d like them to know? Is there anything else you’d like to share with parents about the importance of vaccinations?

A:  Vaccinations are one of the most effective public health measures that have been developed and they save thousands of lives each year. Influenza vaccinations are important because young children can get quite sick from the flu, and some even require hospitalization. Every year there are pediatric deaths in the U.S. due to influenza, about half of which occur in normal healthy children. Children can pass influenza on to the elderly or other fragile members of our community. It’s important for adults to get the flu shot too, particularly those who are caring for young children. Even though the nasal spray is not an option for vaccinating this particular season, it is still important to have your child vaccinated for this year.