Memorandum on Improving Immunization Rates for Children at Risk

Memorandum for the Secretary of Agriculture, the Secretary of Health and Human Services

Subject: Improving Immunization Rates for Children at Risk

In 1992, less than 55 percent of children under the age of 3 nationwide had received the full course of vaccinations. This dangerously low level of childhood immunizations led me to launch, on April 12, 1993, the Childhood Immunization Initiative, which helped make vaccines affordable for families, eliminated barriers preventing children from being immunized by their primary care provider, and improved immunization outreach. As a result, childhood immunization rates have reached all-time highs, with 90 percent or more of America's toddlers receiving the most critical vaccines by age 2. Vaccination levels are nearly the same for preschool children of all racial and ethnic groups, narrowing a gap estimated to be as wide as 26 percentage points a generation ago.

Despite these impressive gains, immunization levels in many parts of the country are still too low. According to the Centers for Disease Control and Prevention, low-income children are less likely to be immunized than their counterparts. In fact, immunization rates in certain inner-city areas are as low as 65 percent, placing them at high risk for potentially deadly diseases such as diphtheria, pertussis, poliomyelitis, measles, mumps, and rubella. These diseases are associated with birth defects, paralysis, brain damage, hearing loss, and liver cancer. In addition, children who are not fully immunized are proven to be at increased risk for other preventable conditions, such as anemia and lead toxicity. Clearly, more needs to be done.

Today, I am directing you to focus your efforts to increase immunization levels among children at risk in a place where we clearly can find them: the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This program, which serves 45 percent of infants nationwide and more than 5 million children under the age of 5, is the single largest point of access to health services for low-income preschool children who are at the highest risk for low vaccination coverage. State data indicates that in 41 States, the immunization rates for children enrolled in WIC are lower than the rates for other children in their age group— in some cases, by as much as 20 percent.

Therefore, I hereby direct you to take the following actions, in a manner consistent with the mission of your agencies:

(a) Include a standardized procedure as part of the WIC certification process to evaluate the immunization status of every child applying for WIC services using a documented immunization history. Children who are determined to be behind schedule on their immunizations or who do not have their immunization records should be referred to a local health care provider as appropriate;

(b) Develop user-friendly immunization materials designed to ensure that information on appropriate immunization schedules is easily accessible and understandable for WIC staff conducting nutritional risk assessments. WIC staff should be trained to use these materials by State and local public health authorities;

(c) Develop a national strategic plan, within 60 days, to improve the immunization rates of children at risk. In developing the plan, the Departments of Agriculture and Health and Human Services should: consult with representatives from the Office of Management and Budget to ensure consideration for the FY 2002 budget; include input from provider, health care consumer, and nutrition communities, and develop a blueprint for action to:

1. expand the availability of automated systems or computer software to provide WIC clinics with information on childhood immunization schedules, with the eventual goal of providing this service in every WIC clinic nationwide, to provide more accurate and cost-effective immunization assessment, referral, and follow-up, in a manner that addresses cost-sharing concerns by both agencies;

2. disseminate a range of best practices for increasing immunization rates for low-income children to WIC State and local agencies, as well as immunization programs nationwide, including developing efficient and effective ways to educate WIC staff about the importance of immunization, appropriate immunization schedules, and the information necessary to make a meaningful referral;

3. foster partnerships (through written guides and/or technical assistance) between WIC offices and health care providers/advocates who can assist with immunization referrals and conduct appropriate follow-up with families;

4. include information on the importance of immunizations and appropriate immunization schedules in standard WIC efforts to educate families about breastfeeding, anemia, lead poisoning, and other health-related topics; and

5. evaluate whether other Federal programs serving children should require a standard question on immunizations as part of their enrollment process, and if deemed appropriate, develop a plan for implementing that requirement.

The actions I am directing you to take today, and any further actions developed as a result of interagency collaboration or public-private partnerships, should not create barriers to WIC participation. Immunization outreach and assessment procedures should never be used as a condition of eligibility for WIC services or nutritional assistance. Rather, activities to improve immunization rates for children participating in WIC should be complementary, aggressive, and consistent with my Administration's overall initiative to increase immunization rates for children nationwide.

WILLIAM J. CLINTON