**Chapter 11. WIC-Immunization Linkage**

**Overview**

Almost half the annual birth cohort in the United States participates in
the Women, Infants, and Children (WIC) Program, and these children are
at risk for being under-immunized. Certain activities in WIC that
promote immunizations (WIC-Immunization linkage programs) have been
shown to dramatically improve vaccination coverage rates among
WIC-enrolled children. Since 1994, the United States Department of
Agriculture (USDA) and the Centers for Disease Control and Prevention
(CDC) have collaborated to meet the Healthy People 2010 Objective of a
90% immunization completion rate in children 2 years of age and under.
The importance of this collaboration was highlighted in a December 2000
White House Executive Memorandum instructing WIC and CDC to partner in
order to improve the immunization status of WIC-enrolled children. The
memorandum guided WIC to assess each child's immunization status during
a WIC visit and to refer those children in need of immunizations to
their providers.

Assessment and referral forms the basis for all WIC Immunization linkage
programs, which consists of reviewing a child's immunization record to
determine if he/she is up to date (UTD) with immunizations. If the WIC
participant's immunizations are not UTD, the child is referred to an
immunization provider, preferably at his/her primary care setting.
Assessment and referral can be implemented alone, or with outreach and
tracking, parental or staff incentives, or with monthly benefit issuance
such as Monthly Voucher Pick-up (MVP). These and other innovative
strategies are described below. In an effort to decrease the burden on
WIC staff, WIC policy makes clear that assessment activities only at
certification/recertification visits are a viable option, although more
frequent assessments are encouraged. This policy also allows sites to
base assessment and referral on a single vaccine (DTaP) instead of on
multiple vaccines.

Since 1998, CDC has monitored the WIC Immunization linkage programs
through an annual survey of state Immunization and WIC programs. A
recent analysis of these data shows that immunization and WIC programs
are coordinating their activities to a larger extent, and that
immunization and WIC services are now more likely to be co-located.
Further promotion of this important intervention and addressing barriers
to implementation will be essential to reach some of our most vulnerable
children.

**References**

-   White House Executive Memorandum, December 11, 2000.

-   WIC Policy Memorandum #2001-7, August 30, 2001.

-   Recommendations regarding interventions to improve vaccination
    coverage in children, adolescents, and adults. Task Force on
    Community Preventive Services. Am J Prev Med 2000; 18(1
    Suppl):97-140.

-   2007 VFC Program Operations Guide:
    <http://www.cdc.gov/nip/home-partners.htm#progmgrs>

-   A Status Report from 1996-2004: Are More Effective Immunization
    Interventions Being Used in the Women, Infants, and Children (WIC)
    Program? George T, Shefer A, Rickert D, David F, Stevenson J,
    Fishbein D. Maternal and Child Health Journal. Published online 15
    March 2007.

-   2008-2012 Immunization Program Operations Manual (IPOM) Chapter 3,
    8, and 10

**Program Requirements**

None

**Activities to raise immunization coverage levels among children
enrolled in WIC:**

[Required activities]{.underline}

None

[Recommended activities]{.underline}

11a. Ensure buy-in from senior management including the WIC Director.

11b. Ensure adequate resources (fiscal, human, and technical) at the WIC
sites for WIC and/or immunization program staff to screen and refer
children to their immunization provider or to screen and immunize on
site.

11c. As part of the screening and referral process, promote and
facilitate the utilization of the Immunization Information System (IIS)
to access WIC-enrolled clients' immunization records and to conduct
direct data entry when vaccinations are administered on site. Ensure
that staff utilizes the IIS to verify that shots have been recorded and
enters missing data into the IIS when applicable. For example, in one
state, WIC staff utilizes the IIS to assess 4th DTaP vaccination status
and to refer as needed. The WIC data system is automatically linked with
the IIS and staff cannot proceed without reviewing the 4th DTaP. In
another state, the WIC-immunization linkage, including IIS utilization,
is included as review criteria for local health department
accreditation. In particular, criteria include whether or not the local
health department actively uses an IIS report to help track and
follow-up on children attending WIC clinics with incomplete immunization
records.

11d. Offer incentives to WIC staff for implementation of
immunization-promoting activities as well as WIC clients who are
up-to-date and/or whose up-to-date immunization records are entered into
the IIS. Examples of incentives for WIC clients include books,
toothbrushes, bibs, books, albums, bags, growth charts, magnets, and
toys. Examples of incentives for WIC staff include certificates of
appreciation, small gift cards, small stipends to highest up-to-date
rate clinics, and appreciation luncheons where tote bags, mugs, and
certificates are distributed.

11e. Consider implementation of the monthly benefit issuance (such as
MVP) protocol. The benefit issuance option is used to help provide
assisted referral and supportive follow-up for parents who need more
assistance in getting their children immunized. When a child is
identified as under-immunized, the parent is asked to call the child's
doctor and schedule an appointment for immunizations if the doctor
recommends it. A WIC appointment is scheduled for the following month,
and one month (rather than the usual two or three months) of WIC checks
is issued to the parent. When the parent returns the next month, the
child's immunization record is screened. In this way, children can be
followed more closely to ensure that they receive timely vaccinations.
This strategy can be implemented at all WIC visits, or given limited
resources or for ease of implementation, can be implemented only at
certain age milestones such as at or around the time when the child
turns 7 months and 15 months of age.

11f. Offer training on a regularly scheduled basis as needed to WIC
staff. Training may include information on immunization; how to
interpret the ACIP schedule and client records; VPDs; how to utilize the
IIS for screening, referral, and data entry; and open question and
answer sessions.

*Description of two successfully implemented WIC-Immunization linkage
programs:*

[Massachusetts]{.underline}:

In 1992, the Massachusetts WIC Program initiated collaboration with the
Massachusetts Immunization Program (MIP) as part of its commitment to
include immunization assessment and referral as part of the routine WIC
assessment and certification process. A complete immunization assessment
includes:

**Data collection and entry**: WIC staff reminds participants to bring
immunization documentation to each WIC appointment. These data are
entered into the WIC system whenever it is presented to staff.

Occasionally, staff is not able to conduct a complete assessment because
a parent/guardian fails to bring a current immunization record. Or they
may identify a child who is never up-to-date due to medical or religious
reasons. Although every effort is made to collect current immunization
data and to encourage parents to get their children immunized, the lack
of immunizations does not interfere with a participant's checks or check
pick-up schedule. The Massachusetts WIC program feels that the use of
'monthly voucher pickup' often unjustly punishes parents and other
caretakers whose children are under-immunized and their use is against
Massachusetts WIC policy. Local programs that experience difficulties in
obtaining participant immunization records are encouraged to contact the
Immunization Coordinator at the state office to discuss possible
strategies. Some of these strategies include:

-   Faxing a Release Form to the child's doctor in order to obtain the
    missing information.

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-   Reminding the parent/guardian to bring the immunization record to
    the next visit.

**Assessment and education**: All local WIC programs are required to
conduct immunization assessment and education at all certification,
recertification and follow-up appointments. The population of children
less than 24 months of age should be the primary focus of the program\'s
immunization initiative; however, it is expected that each child\'s
immunization status will be assessed until the child is fully immunized.
Assessment always includes a review of the shots that are due next or,
if applicable, overdue. Documentation of missing shots is provided to
the caretaker for each child.

**Referral**: When an immunization assessment determines that a child is
behind on or missing shots, caretakers are encouraged to:

-   Schedule an appointment with the child's own doctor to obtain the
    shots.

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-   Contact a local community health center if the child has no medical
    home and provide the caretaker with contact information.

-   Contact immunization program staff at the Massachusetts Department
    of Public Health Regional office. The staff can help direct the
    parent to places where they may be able to obtain immunizations for
    little or no cost to the participant.

The disparity between the up-to-date rates for two-year-old children in
the Massachusetts WIC Management Information System (MIS) database and
the National Immunization Survey for Massachusetts children indicates
that assessments are not performed consistently and/or are performed
with incomplete immunization data. Incomplete data result in less than
adequate assessments and referrals. Massachusetts WIC has developed and
implemented two incentive programs to address this disparity, one
focused on caregivers, the other on WIC staff.

In an effort to increase the accuracy of immunization assessments and
referrals performed for participants, an initiative referred to as
'Bring a Book-Get a Book' was implemented in October 2000. Storybooks
appropriate for preschool-aged children are given to caretakers as an
incentive to bring their children's shot records to WIC appointments.
Graphic materials, such as posters and handouts, are provided to local
WIC programs to promote the initiative.

Participants receive a book each time they bring new immunization data
to WIC at certification, recertification or follow-up appointments until
they complete the primary series of shots (4 DTaP, 3 Polio, 1 MMR, 3
Hib, 3 Hep B, 1 VZV, and 3 PCV7). The 'Bring a Book-Get a Book'
initiative has improved WIC's ability to keep its immunization database
current, enabling staff to make accurate immunization assessments in
conjunction with appropriate immunization education and referral.

A second incentive, referred to as immunization incentive funding,
provides additional funds to contracted local WIC agencies that are able
to show, through the use of the WIC MIS immunization database, 85
percent of children with 4-3-1-3 at 24 months or who have increased the
percent of children with 4-3-1-3 by 15 percentage points each year.

All local programs are offered annual technical assistance by the WIC
Immunization Coordinator, funded at .5 FTE by MIP, to help them in
achieving this goal. Strategies for improving rates included
implementing the use of an immunization release form which could be
faxed or mailed to the provider, assigning staff to oversee follow-up on
forms that were sent and ensuring data entry for new immunization data
obtained, making reminder phone calls to participants, prior to their
appointment, reminding them to bring their immunization record to WIC,
and reviewing files to ensure that all data provided by the participant
is entered into the WIC MIS.

The WIC Immunization Coordinator also conducts a bi-annual performance
evaluation at each local program to ensure that all performance
standards related to immunization are met. The coordinator also
organizes an annual immunization training, provides technical assistance
to newly hired local program nutrition staff, shares relevant
information regarding immunization with the local programs, develops and
distributes a quarterly newsletter for local program staff, and ensures
that state and locally produced immunization reports are correctly
utilized by local program as part of routine quality assurance
activities.

[California]{.underline}:

In California the Women, Infants, and Children (WIC) Supplemental
Nutrition program serves over 1.3 million participants each month. There
are 82 local WIC agencies that provide services at approximately 623
different sites statewide. Of the 82 agencies, 42 are part of local
public health departments and 40 are private non-profit agencies.
However, only nine of the public agencies and thirteen of the private
agencies have some or all of their sites housed at primary healthcare
clinics.

In 1991 the California Department of Health Services' Immunization
Branch initiated discussions and subsequently collaboration with the WIC
Branch on ways to improve immunization coverage among infants and
children enrolled in the WIC program. Initially a few local WIC agencies
worked with and received some funding from their local immunization
programs to screen immunization records and refer children to their
medical home for needed immunizations.

In 1998 a collaboration among the Immunization and WIC Branches and
California's largest local WIC agency, Public Health Foundation
Enterprises (PHFE) WIC program, and Los Angeles County Immunization
Program developed and implemented an automated immunization screening
module (ISIS-IZ) for WIC's automated service delivery system known as
ISIS. Use of the module is voluntary, and to date 31 local WIC agencies
have received varying levels of funding from their local immunization
programs or Immunization Branch collaborative grants to use the module
to screen immunization records and refer participants for immunizations.

As California's Statewide Immunization Information System (SIIS) becomes
more developed and used more widely, the redundancy of ISIS-IZ has
become apparent. The Immunization Branch now encourages local WIC
agencies to use their regional immunization information system (IIS) and
has provided funding through collaborative grants and local immunization
program funding to assist 38 WIC agencies to transition to using the
registry. It is likely that the ISIS-IZ module will be retired within
one to two years.

Currently there is no mandate in California for WIC agencies to conduct
immunization screening of all vaccines or to use the IIS. Therefore,
there are 35 local WIC agencies that have chosen the minimum
immunization screening option (manually counting doses of DTaP) mandated
by the U.S. Department of Agriculture effective March 2003. Nine WIC
agencies continue to use ISIS-IZ for the time being. The Immunization
Branch and the WIC program will continue to demonstrate the benefits of
using SIIS to these agencies to encourage their use of SIIS.

**Data collection and entry**: California WIC agencies are very diverse
and operate differently depending on their size, rural or urban
location, participant needs, and other factors, so the data collection
and data entry procedures at one agency are generally not the same at
other agencies. Currently, 47 agencies remind parents to bring a
documented immunization record to the enrollment appointment, infant
mid-certification appointment, and each recertification appointment;
twenty-four agencies ask for immunization records only at enrollment and
recertification appointments; and eleven agencies review immunization
records at every WIC appointment.

WIC agencies use a variety of methods to remind parents to bring
immunization records to the WIC appointment, including printed reminder
checklists, a reminder sticker on the parent's WIC folder, reminder
posters displayed at the WIC site, and autodialer appointment reminders.

Thirty-five WIC agencies manually count doses of DTaP vaccine received
and compare that to the number of doses the child should receive by a
specific age checkpoint. Eight of these agencies store this information
in a computer. Forty-seven agencies assess immunization records for all
vaccines; Thirty-eight of these use their regional IIS, and nine assess
the records manually. Additionally, eight agencies assess immunization
records for all vaccines at some of their sites and count doses of DTaP
at their remaining sites.

As in other states, the effectiveness of immunization assessment at WIC
depends upon the parent remembering to bring the child's immunization
record to the WIC appointment, upon the WIC staff person remembering to
assess the record, and finally upon the parent heeding WIC staff
recommendations to return to the child's medical home for needed
immunizations. The Immunization Branch offers colorful staff reminders
and parent reminders to help both staff and parents. Also, WIC staff
provides information on locations of free and low-cost immunization
clinics and, if needed, assists parents with making an appointment for
immunization services with the child's regular healthcare provider.

**Assessment and education**: All local WIC agencies, whether they count
doses of DTaP vaccine or use automated immunization assessment software
or an IIS, assess immunization records, at a minimum, of children birth
through 2 years of age. The education component includes a review of
immunizations that appear to be due or past due, a form that either
congratulates the parent for her child's up-to-date status or documents
the past due immunizations, and information on the recommended
immunization schedule for the child's age. Most WIC agencies offer an
immunization promotion class annually or more often as well.

**Referral**: As part of the education and supportive follow-up, 23
local WIC agencies have chosen to use the Monthly Voucher Pick-up (MVP)
strategy for under-immunization. The MVP option is used to help provide
assisted referral and supportive follow-up for parents who need more
assistance in getting their children immunized. When a child is
identified as under-immunized, the parent is asked to call the child's
doctor and schedule an appointment for immunizations if the doctor
recommends it. A WIC appointment is scheduled for the following month
and one month, rather than the usual two or three months, of WIC checks
is issued. When the parent returns the next month, the child's
immunization record is screened. If the child is still not up-to-date,
some agencies offer the parent an immunization promotion class, refer
the parent back to the provider, and follow-up again in one month. Often
if the child still has not received needed immunizations after two
months, the WIC staff person contacts the local immunization program to
follow-up with the family. However, local agencies report that children
are generally up-to-date after one month. Further, agencies that use the
MVP protocol report that there are many reasons that a participant is
issued one month of WIC checks; under-immunization is just one of them.
Parent interviews and staff focus groups conducted at five WIC agencies
using the MVP protocol indicated that this was not a strategy that
parents believed would prevent them from returning to WIC or that made
them think negatively about WIC.

**Strategies for improving immunization rates**: In addition to the MVP
Protocol, some local WIC agencies use other strategies to improve
immunization coverage levels. Sixteen agencies provide on-site
immunizations for children at some or all of their sites. Twelve
agencies escort parents and children to collocated or nearby
immunization clinics.

Sixteen agencies use various forms of parental incentives to encourage
parents to immunize their children. One agency gives third-trimester
pregnant women a luggage tag for the suitcase they take to the hospital.
The luggage tag is imprinted with a reminder to immunize their newborn
with the Hepatitis B birth dose. Five agencies offer monthly lotteries
for parents of children who are up-to-date. The prize is generally a
\$20-\$25 gift certificate. Five additional agencies offer gifts to
parents whose children are fully immunized at age two. The gifts include
a child's book, beach ball, snap-a-snack dish, lunch bag, First Aid Kit,
tote bag, photo album, Band-Aid holder, cups, or coupons for various
items. Smaller items offered by many other agencies include, magnetic
photo frames, stickers, buttons, magnets, Frisbees, and certificates of
achievement for parents whose children are fully immunized at age two
years.

Strategies used to inform and motivate staff include sharing 12- and
24-month up-to-date rates monthly with staff, providing charts and
graphs to show each site's progress in improving immunization rates, and
monthly strategy meetings. Some agencies provide incentive items to
staff such as immunization calendars, memo cubes, one hour per month of
paid leave for the staff person at each site who assesses the most
immunizations, or an employer-provided luncheon for the site that has
the most improved immunization rates.

**Support to local WIC agencies**: The immunization Branch regularly
provides technical assistance to local WIC agencies and to WIC Branch
staff through telephone, e-mail, and on-site immunization training. The
Immunization-WIC Coordinator works closely with Immunization Branch
Field Representatives, local Immunization Coordinators, and Immunization
Registry Managers to provide needed immunization assistance or training
to WIC agencies. Through an arrangement with the WIC Branch warehouse,
local agencies are able to order immunization materials---immunization
schedules, pamphlets, posters, and other materials---directly from the
warehouse along with their usual WIC materials orders. A biannual
immunization newsletter---WHIZ\* (**W**IC **H**elps **I**mmuni**Z**e)
Kids News---offers local agencies new immunization information, an
agency sharing corner, highlights of successful WIC immunization
projects, fun learning activities such as immunization crossword puzzles
or word scrambles, upcoming immunization conferences and events, and
other information.

Currently Immunization Branch staff is working with local WIC agencies
to assist them in transitioning to using their regional IIS.