Immunization Screening and Referral in WIC

I. PURPOSE

The purpose of this policy memorandum is to assure that children served by WIC are screened for immunization status and, if needed, referred for immunizations. WIC state and local agencies must ensure that WIC infants and children are screened and referred for immunizations using a documented immunization history.

It is not the intent of this policy memorandum to outline procedures to replace more comprehensive immunization screening, assessment and referral activities now in place in WIC and/or paid for and conducted by other services and programs. Instead, these procedures specify the minimum requirements for immunization screening and referral in WIC, as directed by the Executive Memorandum of Dec. 11, 2000.

II. BACKGROUND

WIC’s mission is to be a full partner in ensuring healthy and well-nourished women, infants, and children. Low-income children are less likely to be immunized than their counterparts, placing them at high risk for potentially serious diseases, such as diphtheria, pertussis, poliomyelitis, measles, mumps, and rubella. According to the Centers for Disease Control and Prevention (CDC), children who are not fully immunized are at increased risk for other preventable conditions, such as anemia and lead toxicity.

Educating WIC participants and their families about the importance of immunizations and providing referrals to immunization services has been a part of WIC’s efforts for over 20 years. WIC staff have approached immunization promotion activities with energy and creativity and have made a positive difference in immunization rates in many states. WIC is acknowledged as an important ally in reaching the immunization coverage objectives for the nation. CDC’s National Immunization Survey (NIS) data indicates that children participating in WIC have significantly lower immunization coverage rates than their more affluent, non-WIC counterparts.

However, low-income children in WIC are better immunized than low-income children who do not participate in WIC.

In December 2000, an Executive Memorandum was issued directing the Secretaries of Agriculture and Health and Human Services to continue to focus efforts to increase immunization levels among children participating in the WIC program. The Executive Memorandum specified that the immunization status of children applying for WIC services be evaluated using a documented immunization history. It also directed that immunization screening and referral procedures should never be used as a condition of eligibility for WIC services or nutritional assistance.

III. WIC’s Role in Immunization Screening and Referral

The immunization program in each state is the lead agency in immunization planning and screening, and is responsible for design of immunization services, etc. As an adjunct to health services, the WIC program’s role in immunization screening and referral is to support existing funded immunization activities. WIC involvement in immunization screening and referral activities should enhance rather than substitute for on-going immunization program initiatives.

WIC state and local agencies must develop plans to coordinate with providers of immunization screenings so that children participating in WIC are screened and referred for immunizations using a documented immunization history. The purchase of vaccines and delivery of immunizations remain unallowable costs to WIC.

IV. Minimum Immunization Screening and Referral Protocol in WIC

The following minimum screening protocol was developed by CDC and the American Academy of Pediatrics specifically for use in WIC programs where children are not screened and referred for immunizations by more comprehensive means. The purpose of the minimum screening and referral protocol is to identify children under age two who may be at risk for under-immunization. It is not meant to fully assess a child’s immunization status, but allows WIC to effectively fulfill its role as an adjunct to health care by ensuring that children who are at risk for under-immunization are referred for appropriate care.

This is the minimum requirement; however, some WIC programs conduct more comprehensive immunization screening and referral. For example, some have access to software that automatically reviews all vaccinations and identifies which ones are needed. WIC programs with the capacity to perform more comprehensive screening should continue to do so.

Minimum Screening and Referral Protocol

1. 1. When scheduling WIC certification appointments for children under the age of two, advise parents and caretakers of infant and child WIC applicants that immunization records are requested as part of the WIC certification and health screening process. Explain to the parent/caretaker the importance that WIC places on making sure that children are up to date on immunizations, but assure applicants that immunization records are not required to obtain WIC benefits.
2. At initial certification and all subsequent certification visits for children under the age of two, screen the infant/child’s immunization status using a documented record. A documented record is a record (computerized or paper) in which actual vaccination dates are recorded. This includes a parent’s hand-held immunization record (from the provider), an immunization registry, an automated data system, or a client chart (paper copy).
3. At a minimum, screen the infant/child’s immunization status by counting the number of doses of DTaP (diphtheria and tetanus toxoids and acellular pertussis) vaccine they have received in relation to their age, according to the following table:
   
   By 3 months of age, the infant/child should have at least 1 dose of DTaP.
   By 5 months of age, the infant/child should have at least 2 doses of DTaP.
   By 7 months of age, the infant/child should have at least 3 doses of DTaP.
   By 19 months of age, the infant/child should have at least 4 doses of DTaP.
    
4. If the infant/child is under-immunized: (1) provide information on the recommended immunization schedule appropriate to the current age of the infant/child, and (2) provide referral for immunization services, ideally to the child’s usual source of medical care.
5. If a documented immunization record is not provided by the parent/caretaker: (1) provide information on the recommended immunization schedule appropriate to the current age of the infant/child, (2) provide referral for immunization services, ideally to the child’s usual source of medical care, and (3) encourage the parent/caretaker to bring the immunization record to the next certification visit.

V. Coordination

CDC will ensure that the immunization programs in each state coordinate with WIC state and local agencies to assure that children participating in WIC are screened by and referred to dedicated immunization programs and immunization providers when available. immunization program managers should:

• cooperatively plan and fund, where needed, immunization screening and referral in WIC
• train WIC staff • provide information on provider networks to whom WIC participants can be referred
• conduct provider education and outreach
• conduct participant outreach/tracking
• provide information on state and local immunization coverage rates for WIC children
• provide recommended immunization schedules

We encourage state and local WIC programs to coordinate with their immunization counterparts to ensure that a screening and referral system is in place for WIC participants, as outlined above. This coordination can be facilitated through a formal agreement that outlines the responsibilities of the state immunization program and the WIC program. CDC is providing state immunization program managers with a copy of this policy memorandum and will also issue guidance to immunization programs on working with WIC (see attached CDC “Dear Colleague” letter).

VI. Training

CDC will take the lead role in developing materials and training to assist WIC staff in implementing the screening and referral activities outlined above. Training will be coordinated with the Food and Nutrition Service (FNS), the National Association of WIC Directors, the Association of Immunization Managers, and the Association of state and Territorial Health Officials. Each WIC local agency with staff qualified to conduct immunization screening may provide training, as needed, to WIC staff who make referrals. FNS recognizes that the training component is under development and that sufficient time must be allowed for WIC staff to be trained to conduct these activities.

VII. Implementation

WIC programs in state or local areas where National Immunization Survey data show that immunization coverage rates in WIC children by 24 months of age are 90 percent or greater are not required to comply with the minimum screening and referral protocol. WIC programs can coordinate with immunization programs to determine pockets of need within a state through additional data sources if desired.

Implementation of this policy memorandum is expected to be in place by Oct. 1, 2002. This date allows sufficient time for training, modification of certification in-take procedures, and coordination with immunization programs.

In the state plan for fiscal year (FY) 2003 (section on certification and eligibility), each state agency must outline how it is meeting the requirements of this policy memorandum. The state agency must document one or more of the following: 1) WIC local programs are screening children under the age of two using a documented immunization history, either using the minimum screening protocol or by more comprehensive means; or 2) another program or entity is screening and referring WIC children using a documented immunization history; or 3) implementation of the minimum screening protocol is not necessary because immunization coverage rates in WIC children by 24 months of age are 90 percent or greater; or 4) it has been unable to formalize a coordination agreement with the state immunization program, and provide explanation of extenuating circumstances.

PATRICIA N. DANIELS
Director
Supplemental Food Programs Division