Immunize Georgia, Vol. 3 (Oct. 2005)

What's Inside

2 GRITS Provider Update 3 Vaccinating Healthcare

Workers Against Influenza

5 Coalition Activities Across

Georgia

Insert Parent Pages

Spot Light

Immunize 2005vol.3 Georgia's Little Guys
A PUBLICATION OF CHILDREN'S HEALTHCARE OF ATLANTA AND THE GEORGIA IMMUNIZATION PROGRAM

Katrina Project - GRITS Registry

Reminders vs. Call

Links to Gulf States' Registries

Backs - Timeliness

Hurricane Katrina taught us many lessons relative to

of Vaccines

emergency response. Additionally, important communication

Each year, the Centers

systems were put to the test.

for Disease Control and

Immunization Registries are critical to ensuring the transition of care when disasters occur. Louisiana Registry representatives made contact with Georgia before many of the rescue personnel arrived in New Orleans. As a result, GRITS (Georgia Registry of Immunization Transactions and Services) activated the Katrina Project assisting Katrina evacuees as they made their way to Georgia. Many of these families lost most of their critical

Prevention (CDC) publishes a state-specific report on vaccination coverage rates. Information is reported on the number of vaccinations

personal records, including immunization histories, which made registering for Georgia schools a challenge.

accumulated by age 19 to 35 months. These reports do

As this was the first time inter-state information sharing had been needed between GRITS and other state immunization registries, extensive collaboration was required to put processes in place. According to Tom Moss, GRITS Manager, immunization registry managers of the Gulf Coast states provided secure, remote access to the immunization registries in Louisiana (LINKS- Louisiana Immunization Network Kids Statewide) and Mississippi

not look at "whether the vaccinations were given at the appropriate ages. Children who are fully vaccinated at the time of the interview may

(MIR Mississippi Immunization Registry) by September 2 and later to the Alabama Immunization Registry

continued on page 4

(AIR). Announcements were made to all GRITS

partners via multiple outlets on how to request information and the process for managing immunizations for the evacuees.

The GRITS Help Desk began managing calls, which involved looking for the child's immunization information and entering it into GRITS under a separate category, designating the state registry from which the
continued on page 3

GRITS Champion

Dr. Marvyn Cohen Columbus Georgia

In June 2004, Dr. Marvyn Cohen's staff was trained in GRITS and they hit the ground running. As of November 1, 2005, Dr. Cohen's staff has manually entered 2,391 clients and 23,552 immunizations into GRITS. The staff was the first to use GRITS for printing the Form 3231 and is now using GRITS to manage their inventory.

According to Barbara Revera, LPN, managing the inventory with GRITS has simplified every aspect of their vaccine-tracking process. The staff enters the number of vaccines given and a GRITS report lists what vaccines should be in stock and what vaccines will be needed. The order is then automatically placed through GRITS, thereby eliminating paperwork and guesswork. Additionally, Revera states now that schools have access to GRITS, they receive fewer time-consuming calls from schools.
Dr. Cohen gives 99 percent of the credit to his staff for making it an excellent program in his office. He is amazed at how efficient GRITS has made the immunization process. Cohen especially feels GRITS is great for the mobility of today's families. He

Mary Paige, CMA and Barbara Revera, LPN
explains to his families that when they travel to other areas in Georgia, they should be able to access their child's immunization record on GRITS. Mary Paige, CMA, states "I just love the GRITS program. It is so great because we have patients that come in that don't have immunization records. We don't have to call around and it saves us a lot of time." Thank you to Dr. Cohen and his team for all you do.

Vaccine management and accountability needs have grown dramatically since the Vaccines for Children (VFC) program began in 1994. Many vaccine management and accountability processes are still conducted in ways established more than a decade ago. The National Immunization Program (NIP) is being increasingly challenged to improve business processes. New requirements, such as the national pediatric stockpile, have forced the NIP to reexamine its basic operating model for vaccine programs.
As a result, the Vaccine Management Business Improvement Project (VMBIP) was implemented. Information was gathered from across all parts of the vaccine supply chain. This data was used to examine many aspects of the VFC program, including funds management, vaccine distribution, provider ordering, inventory management, and the operation of the national pediatric stockpile.
The processes in place were found to be a patchwork of standalone computer applications and manual, paper-based systems operated at local, state, and federal levels.. The processes are

cumbersome, expensive, and do not enable rapid responses to changes in vaccine supply and demand at each level.
The Project led to the development of a new plan to consolidate vaccine distribution and warehousing nationally. Once the new process has been implemented in Georgia, vaccine will no longer be shipped from the warehouse in Atlanta. Vaccine inventory will be consolidated into a single stock at each national distributor location. Data reported by providers will be maintained in a central "data warehouse." Shipment amounts will be determined according to business rules set forth in the central system.
This new system will be able to show where a particular vaccine is in the supply chain and will offer savings on a national scale in shipping/courier costs. Vaccines will spend less time in transport, minimizing the potential for loss. Additionally, the program will improve responses to public health crises related to disease outbreaks, vaccine shortages and disruption of the vaccine supply. Implementation of centralized distribution will be rolled out in three phases and completed by the end of 2006. Additional information on the new process will be communicated to VFC providers as it becomes available.

2

IGLG / 2005 / VOL. 3

Vaccine Management Business Improvement

Vaccinating Healthcare Workers Against Influenza

Data from the National Health Interview Survey (NHIS) show only 36 percent of healthcare workers are immunized against influenza each year. Healthcare workers who have been infected with influenza often continue to work and/or have less than ideal handwashing and infection control practices, which can be a significant factor in the spread of influenza in healthcare settings. Preserving sick leave was listed as one reason for continuing to work.
According to the Centers for Disease Control and Prevention (CDC), the best way to reduce transmission is for healthcare workers to be vaccinated against the flu. One study reported those who received influenza vaccine had 25 percent fewer episodes of respiratory illness, 43 percent fewer days of sick leave from work due to respiratory illness and 44 percent fewer physician office visits.
Factors in deciding to receive the influenza vaccine Personal protection Previous influenza infection Free vaccine Protecting patients Avoid missing work

Action Steps for Increasing Healthcare Worker Vaccination Rates Select a leader and get a commitment from top management. Create a policy and mission statement. Remove cost barriers "Vaccination is an infection control and
patient safety measure that is the ultimate fiscal responsibility of the institution." Communicate message via e-mail, newsletter, posters, and with "I got my flu shot" stickers. Provide convenient access to influenza vaccine with grand rounds, medical records areas and department meetings. Track and report on influenza vaccination rates. Applaud successes with a pizza party or provide incentives.
For the latest news and resources on the 2005-2006 Flu Season, go to www.cdc.gov/flu/. Visit the Flu Gallery under "Patient and Provider Education Materials" to download posters that can be displayed in employee areas.
For the 2005-2006 Influenza Vaccine Information Statements, go to www.cdc.gov/nip/publications/VIS/default.htm#flu.
The information in this article was adapted from "Improving Influenza Vaccination Rates in Healthcare Workers Strategies to Increase Protection for Workers and Patients." www.nfid.org/publications.

Katrina Project GRITS continued from page 1
child came. GRITS can transmit the information back to the home state registry system when needed. If a doctor's office calls the Help Desk and is not a GRITS user, GRITS staff provide the immunization information that has been entered into the registry, and encourage the provider to join GRITS.
As of September 27, 2005, the number of immunizations added to GRITS totaled 9,846 for 1,115 LINKS clients, 2,038 for 189 MIR clients, and 50 for 8 AIR clients. The Georgia Department of Education (DOE) is in the process of working with the Georgia Immunization Program to identify children who have been displaced due to Hurricane Katrina.
Georgia Immunization Program Consultants (IPC) staffed some of the Super Center shelters where evacuees were brought to obtain a variety of services, including information about immunizations. They saw firsthand the importance of providers participating in a registry.
"Parents affected by Hurricane Katrina appreciate the immunization registries," stated Leonard Lang. "There were parents who stated the registry made the process of enrolling their children in school or daycare easy." Angie Webster said she was saddened that

"immunizations were not entered into the state registries and [parents] could not get access from their providers because their offices were destroyed. If Georgia had a true Kurt Palan working with Deshaun Smith and her son disaster and our children had to be dispersed, we could at least take comfort in knowing the immunizations could be located in a central database."
GRITS is prepared in the case of a disaster through the Georgia Disaster Recovery Plan. GRITS has agreements with other states whereby the data, which is backed up each night, would be sent to them and restored on existing hardware. GRITS partners would then be able to access the system without modification to their existing setup.
For more information about GRITS or if you have questions about the Katrina Project, please call the GRITS Team at 888-223-8644.
IGLG / 2005 / VOL. 3 3

continued Spot Light from page 1

have received some vaccinations too early for the vaccines to be effective, or they may have been under vaccinated during much of their first two years."
In 2002, a national-level study found that while "73 percent of children received all vaccinations in the standard 4:3:1:3:3* series by age 19 to 35 months, only 13 percent of children received all of these vaccinations at the recommended ages." 1
In 2005, one study, "Timeliness of Childhood Immunizations: A StateSpecific Analysis" analyzed data from the 2000-2002 National Immunization Surveys to determine timeliness of vaccine administration at the state level. State-specific information allows state immunization programs to evaluate timeliness of vaccinations for children in their state and to compare their rates to other states. 1
Results The study found wide variation between states, with 2 percent to 26
percent of children receiving all vaccinations at the recommended ages. In Georgia, 15 percent of children received all vaccinations at the recommended ages. Compared to Georgia, one state (Massachusetts) had a statistically significantly higher rate of children receiving all vaccinations at the recommended ages while 25 states reported statistically significantly lower rates. Vaccination rates in the other 24 states were not statistically different from Georgia. Antigen-specific series that required fewer doses had higher percentages of children vaccinated at the recommended ages. For example, a single dose of MMR ranged from 64 percent in Montana to 84 percent in Hawaii (74 percent in Georgia). Whereas, for the three to four Hib doses, there was a range of 11 percent in Mississippi to 45 percent in Massachusetts (23 percent in Georgia).
Why is the timeliness of vaccines important? "Inappropriately timed vaccinations may be less effective. The safety
and efficacy of early and late vaccination has been evaluated for some vaccines but not all and may vary by dose." 1 Timely vaccinations protect children as early as possible and prevent disease outbreaks. This is especially important for diseases that are continuously circulating such as pertussis and for diseases with a potential for large outbreaks, such as measles. Delayed or inappropriately timed vaccinations have administrative, programmatic and cost implications. Doses given too early to be considered valid must be repeated.

After the first birthday, some children may not be seen again until they are between two and four years of age and sometimes not until they are six years of age. This can lead to children not completing the series of shots at the times they are recommended.
A recent review of 43 patient-reminder studies found that patients who were reminded were 70 percent more likely to have been immunized. Person to person telephone reminders had the greatest effect on immunization rates. Reminders seemed to also have an effect with other preventive care needs, providing opportunities for healthcare providers to intervene with other needs.2
The American Academy of Pediatrics (AAP) endorses reminder/ recall systems and recommends the following3: Chart Reminders can be placed in prominent positions in the
charts of high-risk patients, indicating they will need a vaccine at their next visit. Standing Orders are easy to implement and work when a large number of people need vaccination. Phone contacts ensure the message is understood and allow for appointments to be scheduled. Mail reminders may need to be bilingual. Be sure to send a reminder to complete the recommended vaccine series between 12 and 18 months. Expanding clinic hours includes increasing hours; making them more convenient; or using "drop-in" clinics or "express lane" vaccination services. This approach helps increase access to care for lower income and other disadvantaged people. Computerized records or registry systems can program software to determine the dates certain preventive procedures are due or past due and then print computer-generated reminder messages. They can also print a list of patients with medical conditions that put them at high risk for certain conditions or for whom a vaccine is recommended. The Georgia Registry of Immunization Transactions and Services (GRITS) enables providers to determine which clients will be due for immunizations within a specified time period and generate reminder messages to be sent to those individuals. If your organization uses GRITS but needs assistance with using this function, please call the GRITS Help desk at 888-223-8644.
* Four doses of DTaP (Diphtheria, Tetanus, Pertussis), three doses of OPV/IPV (Polio - oral or injected), one dose of MMR (Measles, Mumps, Rubella), three doses of Hib (Haemophilus influenzae type b) and three doses of Hep B (Hepatitis B).

Reminder/recall systems assist with the timeliness of vaccines Reminder systems focus on contacting clients to remind them of upcoming vaccinations or already scheduled immunization appointments. Recall systems involve contacting patients after they have fallen behind on immunizations or missed appointments. The preventive approach with reminder systems can be an effective way to improve the timeliness of vaccination coverage.

(1) "Timeliness of Childhood Immunizations: A State-Specific Analysis" American Journal of Public Health. August 2005 v 95,n 8.
(2) "Patient Reminders Boost Immunization Rates" Center for the Advancement of Health. July 19, 2005. http://www.cfah.org
(3) The AAP Childhood Immunization Support Program adapted this information from The Task on Community Preventive Services. This article can be found at www.cispimmunize@aap.org.

IGLG / 2005 / VOL. 3 4

Coalition Activities across Georgia

This year marks the 12th year the Everybody Counts Immunization Coalition (ECIC) has impacted the community of Chatham County. Over the years, ECIC has utilized creative strategies to promote and celebrate immunizations from school initiatives to across the lifespan immunization calendars to birthday parties for immunized two year olds.
Many partners in Chatham County also have contributed to the success of ECIC, especially the energetic and positive influence of Marianne Pappas, Coastal Health District Immunization Coordinator. These experiences have enabled Pappas to support other communities in Georgia as they establish local immunization coalitions. In 2005, Pappas consulted with several communities who have begun establishing local immunization coalitions. She has worked with them on the steps involved in building coalition partnerships, setting short/long term goals, and composing mission statements, by-laws and a marketing plan.
Two groups began their initiatives in May. The Liberty County Immunization Brigade is being led by nurse Amanda Blanchard and Eric Tollison with sanofi pasteur. The Coastal Georgia Immunization Coalition in Glynn County is being led by Sharon G. Smith, Glynn County Nurse Manager, and June Paul, Director of School Nurses for Glynn County Board of Education.
Through the efforts of Monica Trigg, Immunization Program Consultant with the Georgia Immunization Program; Melba McNorrill, District Immunization Coordinator; and Jeff Ligon,

with sanofi pasteur, immunization coalition initiatives will begin with Richmond County in 2006 and ultimately reach outward to other areas in this health district.
In September, representatives from Health District Seven attended the first immunization coalition meeting in their area. Libby Massiah, IPC presented a summary of the demographics in District Seven and Muscogee County. Coalition efforts will begin with Muscogee County. Approximately 20 people attended with representation from the Georgia Chapter of the American Academy of Pediatrics, the Health Department, United Way and family and private practices.
The goal for these coalitions is to increase awareness in the community about vaccine-preventable diseases and immunizations. Each community works to identify partners with an interest in increasing immunizations and protecting their citizens. These groups then pinpoint strategies for educating providers and citizens.
If you are interested in starting an immunization coalition, please call 404-657-3158 and ask for the IPC assigned to your area. For information about any of the above mentioned coalitions, please contact the persons listed below: Amanda Blanchard 912-876-2173 Libby Massiah 404-657-3158 Marianne Pappas 912-644-5204 Sharon Smith 912-264-3961 Monica Trigg 404-657-3158

Mike Chaney to Retire

Mike Chaney, Manager for the Georgia Immunization Program for the past 21 years, will retire February 1, 2006. Chaney began his career with the Georgia Department of Human Resources 32 years ago at the Chatham County Health Department. He also worked in the Clayton and Cobb County Health Departments and as a Senior Epidemiologist with the Immunization Program before becoming Manager.
Chaney's successes include getting the VFC program in Georgia started and running efficiently and helping to develop standard immunization practices such as AFIX and CASA. He was instrumental in developing and very successfully implementing the Georgia Registry of Immunization Transactions and Services (GRITS). But most importantly, it has been Chaney's incredible leadership and communication skills that have created solid partnerships and programs to protect Georgia's children. One of these solid partnerships has been with the Georgia Chapter of the American Academy of Pediatrics (GAAAP). The

Chaney (middle) received award from Rick Ward, Executive Director, GAAAP
(right). Also pictured is Dr. Martin Greenberg (left), who received a
Lifetime Achievement Award
Chapter recently recognized Chaney with an award at their October 2005 meeting.
As Dean Mason, President and CEO of the Albert B. Sabin Vaccine Institute puts it, "there are tens of thousands of adults, adolescents, children and infants in the great state of Georgia who, albeit unknowingly, have Mike Chaney and his fine staff to thank for implementing sound public health policies which protect them to this day against vaccine preventable diseases." The many people who have worked with Mike Chaney will surely miss him. IGLG wishes Mike all the best in his upcoming endeavors.

5

IGLG / 2005 / VOL. 3

Upcoming Events

Adolescent Vaccine Brochure Now Available In 2005, IGLG produced a new vaccine brochure entitled, "Take 5 for Teens." This brochure features the five key vaccinations for adolescents and young adults Hepatitis B; Measles, Mumps and Rubella (MMR); Diphtheria, Pertussis and Tetanus; Varicella (Chickenpox); and Meningococcal Disease. The brochure is designed for all levels of healthcare staff to use when educating parents and adolescents about these critically important vaccines. If you are interested in having this free brochure for your patients, please email Angie Matthiessen at angie.matthiessen@choa.org. Be sure to provide the following information: Contact Name, Agency, Address, Phone Number and Quantity being requested.
12th Annual IGLG Conference Update IGLG is looking forward to holding the IGLG Conference on Thursday, January 5, 2006. We appreciate your patience as we rescheduled the conference, and we are grateful that so many people will be able to attend on the new date. The response to the conference this year has been incredible and record-breaking with 380 attendees registered. Due to the large number of registered attendees, we are unable to take additional registrations at this time.
All of the speakers are available, allowing us to keep the agenda the same. Twenty exhibitors will be attending from communities and agencies in Georgia to provide you with resource information and networking opportunities. Additionally, Walt Orenstein will present the five Walt Orenstein Champions for Immunization Awards. IGLG wishes all of you a wonderful holiday season and we look forward to seeing you in the New Year at the conference!!
2005 Children's Healthcare of Atlanta/CHDA913351 jt10.05 DPH05/102HW

Immunize Georgia's Little Guys
Published by Children's Healthcare of Atlanta 1655 Tullie Circle NE, Atlanta, Georgia 30329-2321
Children's Healthcare of Atlanta 404-250-kids, www.choa.org
Immunize Georgia's Little Guys Angie Matthiessen, M.S.W. 404-785-7225, fax 941-505-8267 angie.matthiessen@choa.org
Georgia Immunization Program 404-657-3158, fax 404-657-1463 http://health.state.ga.us/programs/immunization/
Vaccines For Children Program 404-657-5013, fax 404-657-5736 800-848-3868, fax 800-372-3627
American Academy of Family Physicians Georgia Chapter 404-321-7445, www.gafp.org
American Academy of Pediatrics Georgia Chapter 404-876-7535, www.gaaap.org
CDC-INFO Contact Center 800-232-4636, www.cdc.gov/nip
CDC Spanish-Language Hotline 800-232-4636, www.cdc.gov/spanish/

Children's Healthcare of Atlanta Community Health Development and Advocacy 1655 Tullie Circle Atlanta, Georgia 30329-2321

Please route to:
Physician(s) Nurse Practitioner(s) Registered Nurse(s) Nurse Tech(s) Office Manager

Parent Pages / IGLG / 2005 / VOL. 3
ParentPages
SHOTSMARTS FROM IMMUNIZE GEORGIA'S LITTLE GUYS

Children and the Flu
According to the Centers for Disease Control and Prevention (CDC), five to 20 percent of Americans get the flu each year; more than 200,000 are admitted to the hospital; 36,000 die from the flu each year.

How does influenza affect the lives of children and their families? The flu strikes in winter months when children are spending time
in close quarters, which can help the virus spread. Children can spread the virus to the family and elderly. The flu in children can lead to serious complications and even
death in severe cases. Children miss school and parents miss work to take care of them
at home or in the hospital.
Which children are more at risk to get seriously ill from influenza? Children who have a hard time fighting infection, such as those
with cancer, chronic lung disease, asthma, sickle cell, diabetes, heart or kidney disease. Children less than two years of age are more likely to be admitted to the hospital. Even healthy children can get the flu and have a serious illness, which is what happened to many of the children who died during the 2003-2004 influenza season. Most of the 152 flu-related deaths nation wide were in children less than five years of age and 40 percent were previously healthy children.
How do I know it is really the flu? The flu is not a mild sickness, such as the typical cough and cold. Symptoms can include high fever, shaking chills, headache, runny
nose, congestion, dry cough as well as muscle and joint pain. Nausea, vomiting and diarrhea are more common in children. Doctors can now identify the flu more quickly. Medicines can shorten the time your child is sick by one or two
days and make them less contagious to others. It is important to see a doctor quickly because these medicines
must be started within the first two days of illness.

Prevention is the key to avoiding influenza for you and your family. Wash hands with soap and water. Cover a cough with a tissue and throw the tissue away. Remind children not to touch their eyes, nose or mouth. Stay home when sick. Getting vaccinated against the flu each year is the best way to
prevent the flu. Children 6 months of age or older with chronic conditions,
including asthma, should receive the flu vaccine. Healthy children 6 to 23 months of age need to receive the
flu vaccine. Children less than nine years of age who have not previously
received the flu vaccine should receive two doses, one month apart. There are two types of influenza vaccine. Be sure to ask your doctor which one is best for your family. If you are a parent, brother, sister, grandparent or babysitter/ caregiver of an infant younger than 23 months of age, you will want to get the flu shot.
Information for this article was taken from www.cdc.gov/flu/. For the latest information on the flu and how to protect your family, please visit this site.

2005 Children's Healthcare of Atlanta/CHDA913351 jt10.05 DPH05/102HW Parent Pages are intended to be copied and distributed to parents. www.choa.org 404-250-kids www.health.state.ga.us/programs/immunization/

Parent Pages / IGLG / 2005 / Vol.3

The Importance of Getting Your Child's Shots on Time

Sometimes, you may feel as if your child has to get a lot of shots (vaccines) to protect against diseases that do not exist anymore.
Thanks to vaccines, many of these diseases no longer occur in the United States. Because of high vaccination levels in the United States, the only measles cases that have occurred since 2001 have been due to people bringing the disease into the country.1 In June 2005, 34 people in Indiana (mostly children whose parents had chosen not to vaccinate them) got measles from an unvaccinated teenager. The teenager had just returned from Romania where there were many cases of measles. Throughout the world, measles causes 30 to 40 million cases and 530,000 deaths annually.1
Other diseases still exist in the United States. Pertussis (whooping cough) is on the rise and can be deadly for infants. The key to preventing this disease and others is to be sure your child receives all of his vaccines at the recommended age.
Often, doctor visits after the first birthday can be forgotten and children are not seen until they are two years of age or older. This can lead to children not completing the series of shots at the times they are recommended which is critical to offering the best protection against diseases.

Why is it necessary to have a series of shots to protect against one disease?2 Some vaccines require more than one dose
to provide the best protection against the disease. Protection from some vaccines may fall over time.
"Booster" doses are needed to increase protection.
Why is it important to receive vaccines (shots) on time?2 The time between each dose is very important. If shots are
not given on time, your child may not be fully protected. Getting shots on time prevents disease outbreaks -
important for diseases that we see more frequently such as pertussis and for diseases like measles.
Action Steps Make a goal to have your child up to date on his vaccines
by his first birthday. Take your child to the doctor to receive the recommended
vaccines at age 15 to 18 months. Your child will need several shots, including the fourth dose of DTaP, the booster doses of Hib to protect against Haemophilus influenzae type b and PCV to protect against pneumococcal disease.* If your child's doctor reminds you of a needed vaccine for your child, be sure to followup in a timely manner. Because teenagers, adults and the elderly can unknowingly pass some diseases to an unprotected infant, it is important for you and your family to be immunized according to the recommended schedule. To find out which vaccines you might need, ask your doctor or take the quiz at www2.cdc.gov/nip/adultImmSched/. The Recommended Childhood and Adolescent Immunization Schedule changes every year. To see which vaccines your child (under age 6) may need, go to www2a.cdc.gov/nip/scheduler_le/default.asp.

* DTaP stands for Diphtheria, Tetanus and Pertussis. PCV stands for Pneumococcal Polysaccharide Vaccination.
1 "Import Associated Measles Outbreak--Indiana, May-June 2005." Morbidity and Mortality Weekly Report (MMWR). October 28, 2005 / 54/42; 1073-1075.
2 "General Recommendations on Immunizations." Morbidity and Mortality Weekly Report (MMWR). February 8, 2002 / 51 (RR02); 1-36

2005 Children's Healthcare of Atlanta/CHDA913351 jt10.05 DPH05/102HW Parent Pages are intended to be copied and distributed to parents. www.choa.org 404-250-kids www.health.state.ga.us/programs/immunization/