Don't Wait, Vaccinate! Tips & Resources for Communicating with Adult Patients about Vaccination

About the Webinar

This webinar explains the research on how adults make vaccination decisions, focuses on incorporating a strong recommendation for vaccination into routine practice, provides effective strategies to address common questions about adult vaccines, and identifies and locates immunization resources for patient education and implementation of practice standards.

Learning Objectives

Upon completion of the presentation, the participants will be able to:

• Understand and describe the research on how adults make vaccination decisions
• Incorporate a strong recommendation for vaccination into routine practice
• Utilize effective strategies to address common questions about adult vaccines
• Identify and locate immunization resources for patient education and implementation of practice standards

This webinar is supported by the Cooperative Agreement Number, 6 NH23IP000981-02-01, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

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Video Transcript

Moderator: Hello and welcome. Thank you for joining us today. I’m Gary from Blue Sky. Today’s Collaborative Webcast from the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention (CDC) is entitled “Don’t Wait, Vaccinate! Tips and Resources for Communicating with Adult Patients about Vaccination.” This webcast will focus on how to improve rates of adult immunization by delivering strong tailored recommendations to your patients and by utilizing the many resources available to assist with this task.

This webinar is supported by a cooperative agreement funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of ACOG and do not necessarily represent the official views of the CDC.

The faculty and Planning Committee wish to disclose the information displayed on this slide.

Before we move further into our presentation I would like to take a moment to acquaint you with a few features of this web-event technology. At any time you may adjust your audio using any computer-volume settings that you may have.

Now please let me introduce our program faculty for today’s webcast. Aparna Ramakrishnan is a Senior Health Communication Specialist Contractor supporting the Centers for Disease Control and Prevention National Center for Immunization and Respiratory Disease (NCIRD) in the Department of Communication Programs to improve immunization across the lifespan. She has worked with the CDC since 2007, coordinating program strategy, formative research, message and materials, development, evaluation, and technical assistance.

Please review the learning objectives for this presentation. And now ladies and gentlemen, without further ado please welcome Aparna Ramakrishnan.

Aparna Ramakrishnan: Thank you, Gary. I’m very pleased to be presenting today on behalf of the NCIRD Health Communication Science Office. Since 2009, ACOG and CDC have worked closely to address adult immunization and this webinar is one component of the larger ongoing collaboration we have. I’d like to bring my presentation with some brief background on the adult immunization context.

The burden of vaccine-preventable disease among adults in the US is high. For example, we see millions of influenza cases each year with an average of 226,000 hospitalizations and 3,000-49,000 deaths annually, mostly among adults. There are about 900,000 cases of pneumococcal pneumonia and as many as 400,000 hospitalizations each year. Invasive pneumococcal disease caused 3,700 deaths in 2013 nearly among all adults and there are about 1 million cases of zoster annually. About 1-out-of-3 will get shingles in their lifetime.

Vaccine effectiveness varies by vaccine type, the disease outcome and the age or health of the person vaccinated. Even in cases where vaccine effectiveness may be modest, the impact of vaccination overall is high given how common diseases are and the high number of cases that can be prevented. For example, zoster vaccine is 51-percent effective against shingles, 66-percent against postherpetic neuralgia (PHN) and almost 80-percent against most prolonged and extreme cases of PHN. PCV13, the pneumococcal conjugate vaccine, is 45-percent effective against vaccine type pneumococcal pneumonia and 75-percent effective against vaccine type invasive pneumococcal disease among adults aged 65 and older. Influenza vaccine effectiveness varies annually based on antigenic match and also age and health of person being vaccinated. About 60-70 percent in younger adults and about 30 percent in adults 65 and older against medically-attended influenza when there is a good match.

Each year the Recommended Immunization Schedule is voted on by the Advisory Committee on Immunization Practices, then approved by major medical associations, including ACOG. It includes recommendations by age group as well as by medical and other indications and is released annually by early February.

However, adults aren’t getting the vaccines recommended for them.

You can see that vaccination coverage is not optimal and hasn’t been increasing significantly over time for most vaccines. We are doing relatively better on influenza and pneumococcal vaccination of adults, 65 and older, as well as on tetanus boosters for adults 19 and above but there’s still room for improvement there as they are all below 70 percent. Less than a third of eligible adults have received other vaccines, even those at high risk for vaccine-preventable diseases and their complications.

This slide shows vaccination coverage among pregnant women from our internet-panel surveys from 2010 - 2011 to the last flu season. We see some slight increases here and there but vaccination coverage among pregnant women have been at about 50 percent since the 2012/2013 flu season.

Here you can see estimates of Tdap vaccine coverage among pregnant women. The estimates shown in green are women who are vaccinated during pregnancy, which is the current ACIP recommendation. The percent of women who received Tdap vaccination during pregnancy increased from 27 percent in 2013/’14 to 48.8 percent in 2015/’16. Hopefully this upward trend will continue.

So why are adult vaccination rates low? There are a number of challenges in adult vaccination that we don’t really see when it comes to childhood vaccination. Vaccines besides influenza are really not on the radar for most adults and there are competing priorities and missed opportunities for assessing adult vaccination needs. Adult patients often see more than one medical provider and some providers aren’t able to offer all vaccines recommended for adults. There are also challenges in vaccine record keeping, in these registries and, lastly, there are still some cost-coverage and payment issues for certain vaccines.

So, what can be done to improve vaccination rates? Evidence shows that providers strongly recommending and systematically offering vaccines can improve coverage and help reduce disparities. Using immunization information systems can also improve immunization practices.

Based on this evidence the National Vaccine Advisory Committee (NVAC) updated practice standards in 2013 to call on all providers, whether they provide immunization services or stock all vaccines to take steps to help insure that patients are getting the vaccines they need. This includes assessing immunization status of all patients in every clinical encounter, strongly recommending vaccines that patients need, administering needed vaccines or a referral to a provider who can immunize, and documenting vaccines received by patients including participating in immunization registries.

So now I’d like to talk a bit about implementing these practice standards.

Let’s start with assessment. This is the first critical step in ensuring patients get the vaccines they need. Assessing vaccination status at every clinical encounter decreases missed opportunities to vaccinate and this is important for a few reasons. Many adults don’t come in for annual check-ups and preventive services so we really have to catch them when we can. Some vaccines are indicated based on factors other than age and there may be lifestyle, occupation or other changes with patients that we have to stay on top of and, lastly, recommendations change over time so patients who were up-to-date may no longer be. Since most adults aren’t thinking about vaccination for themselves, routine assessment from providers is critical.

There are a number of strategies that are used to improve vaccine assessment. You can give your patient a vaccine questionnaire to complete at check-in. This can help identify vaccine patients may need such as upcoming travel, changes in medical conditions or occupation. “Implementing Standing Orders or Protocols”: This makes vaccine assessment and vaccination as routine as the way we measure weight and blood pressure and is incorporated into patient office visits. Next, use reminders to help your practice stay on top of needed vaccines that are due soon or that are overdue. These reminders can be generated by an EHR system or immunization registry or you can make a note of needed vaccines on a patient’s vaccination chart. Send your patients reminders about missed vaccines or vaccines that are due soon. This can help keep vaccines on your patient’s radar and encourage them to stay up-to-date and, lastly, review how your practice does in keeping your patients up-to-date on vaccines. This can be done by reviewing a sample of patients’ charts or analyzing electronic health-record data for your practice.

CDC has resources to help with assessment including a “Patient Check-In Vaccine Questionnaire” which can be adapted for your practice, a vaccine schedule app to stay on top of latest recommendations, and an online quiz that patients can take to generate a tailored list of recommended vaccines to discuss with you.

Next, I’d like to talk about the focus of today’s webinar, which is “Recommending and Educating Adult Patients about Vaccines.” Generally, adults believe vaccines are important and are likely to get them if recommended by their healthcare professional but most adults aren’t actively thinking about immunization for themselves, don’t know which vaccines they need throughout their lives, and really rely on their provider to let them know what vaccines are right for them.

Here’s an example of the impact of provider recommendation from data we collected as part of an internet-panel survey of pregnant women, following the 2012/2013 flu season. While the overall coverage estimate was about 50 percent, you can see that coverage was 70.5 percent among those who received a provider recommendation and offer of vaccination. When the vaccine was recommended but vaccination was not offered, the coverage was lower at 46.3 percent and without a recommendation or offer, coverage was substantially lower at 16.1 percent. This vaccination pattern was found in all demographic and other subgroups, even among women who had a negative attitude toward influenza vaccination, again, demonstrating the importance of the provider recommendation but this recommendation is not just impactful for pregnant women. Research shows that it’s a key factor in getting vaccinated for flu as well as for other vaccines.

In addition to reviewing existing research, CDC has conducted substantial formative research with adults and their healthcare providers on adult immunization through national surveys, focus groups, and interviews and what I’ll be presenting next is a summary of what we learned. So, as I mentioned before adults believe that vaccines are important, especially for certain groups of adults, like travelers, older adults and based on occupation. Those that consider themselves healthy were least likely to consider themselves susceptible to serious disease and therefore didn’t really think vaccines were as important to them so there is a range here about who they think they’re really important for but there’s a general belief in the importance of vaccinations. Adults also believe that vaccine-preventable disease can be serious and then sometimes deadly, however adults have low awareness and knowledge about vaccines they need beyond influenza. The most common vaccines adults were aware of or had gotten beyond influenza were tetanus and pneumococcal vaccine. Adults vary in their attitudes towards the vaccines that they have heard about. For example, adults have mixed attitudes about flu vaccines with some reporting that the vaccine really helped and others feeling that it didn’t work or may cause one to get the flu. Adults thinks that tetanus vaccine is important and necessary if you are cut and need to go to the hospital. Adults’ attitude towards pneumococcal vaccine is limited but many report that it could be important because it could be important because pneumonia is believed to be a common and serious disease.

Provider recommendation as I mentioned before is really the number one reported factor in influencing vaccination decision but adults unfortunately perceive receiving few recommendations for vaccines from their providers. Adults are motivated to get vaccines to protect their own health and many would get a vaccine in order to protect loved ones as well, however adults do have some concerns about the safety and side effects of vaccines as well as questions about vaccine effectiveness and cost. There are other challenges but they don’t come into play until an adult is trying to get vaccinated such as access and cost. The bottom line is that vaccination is really not on adults’ radar. Without a recommendation from a provider, most are really not thinking about it.

So when we told adults that they need certain vaccines, they had many questions that they wanted answered before making a decision. Key factors include perceived susceptibility, how likely am I to get the disease, risk of consequences, how serious could this disease be for me, efficacy, how well will the vaccine work, could I still get sick, side effects and cost. The bottom line here: they really want to know if the recommended vaccine is right for them and when we talked with providers about their communication with patients, they reported commonly discussing these same factors with their patients.

They also shared with us other factors that they’ve found to facilitate acceptance of vaccine recommendations. First and foremost is providing a tailored recommendation that makes it clear to patients why they need a vaccine and the potential consequences for them if they get the disease. Providers sharing that they themselves have been vaccinated also boosted patient confidence in getting vaccinated. In a long-standing relationship an ongoing conversation about vaccines with continued recommendations and reminders can help increase acceptance amongst those that may have questions or concerns. Providers we spoke to tried to time vaccine recommendations when patients are more likely to be receptive, including during annual physicals when patients are thinking about preventative care, around annual outbreaks when they’re aware of their susceptibility for disease and if they are pregnant or going to be around young children and are concerned about protecting them from disease. Lastly providers share that having patients who are aware and knowledgeable about the vaccines they need facilitate the recommendation process. So even though providing that strong, clear recommendation is a critical factor, sharing information and educating patients before they’re due for vaccines can also be helpful.

So, what does all this mean for you? If the patient is due for a vaccine it is critical to make a clear and strong recommendation that you advise getting the vaccine because it can help protect them against a disease that could be serious. For some patients, this may be sufficient information to accept the recommendation. Others may want to learn more about the vaccine and why it is right for them.

For those that need more than that recommendation you can share additional information to encourage vaccination by addressing those key factors I mentioned in “Decision Making.” Tell them why the recommended vaccine is right for them. Highlight positive experiences with vaccines, whether personal or in your practice to reinforce benefits and strengthen confidence in vaccination. Address patient questions and any concerns about vaccines, including side effects, safety, effectiveness in plain and understandable language. Remind patients that vaccines protect them and their loved ones from many common and serious diseases, and, lastly, explain the potential cost of getting vaccine-preventable diseases, including serious health effects time loss, such as missing work or family obligations and financial costs.

Even after sharing this additional information, some patients may not be ready to make a decision. There are a number of things you can do to continue to encourage them to get vaccinated. Emphasize the benefits of getting vaccinated during the current visit, which is especially important for adults who don’t come in often. Provide education materials or share trusted websites they can go to for more information. Document the conversation in the patient file and then continue the conversation at the next visit and send reminders about needed vaccines when appropriate or possible.

We also know it’s important to use a risk communication approach when educating about vaccines. This includes being proactive, consistent and using plain language for the information shared as clear, understandable, and credible. It also means acknowledging uncertainty and being transparent about side effects as well as showing empathy and respect when answering questions and concerns.

We know that many providers struggle with communicating thoughts on vaccination. Given the variability and unpredictability of flu it is especially important to use a risk communication approach. That means being transparent and sharing what we know, when we know it. This includes reminding people that every season is different including the circulating strains, severity, timing, vaccine effectiveness, et cetera so although we might have a less-than-ideal match one year that doesn’t mean we will see that again in the upcoming season and while we acknowledge that flu vaccination is not a perfect tool, it is the best way to protect against flu infection. What will be especially important to communicate is that anyone can get the flu and it can be serious even for those who perceive themselves to be healthy and to reinforce the benefits of flu vaccination. Flu vaccine can reduce flu illness, severity of illness, doctor’s visits, missed work and school due to flu as well as flu-related hospitalizations and deaths. It can also reduce the likelihood of passing on disease to others, protecting loved ones and those most vulnerable to illness.

Flu vaccination prevented an estimated 5 million flu-associated illnesses and 71,000 flu hospitalizations during the 2015/2016 season. This past season flu vaccination reduced overall risk for influenza, associated medical visits by 42 percent and in this coming season, one vaccine component was updated to match to match the viruses that we expect to be most common.

We know that many people have concerns or misinformation about flu vaccine safety. We also know that healthcare providers are the key to addressing these concerns of misinformation. So here are some things you can do: Explain that flu vaccines have a long and safe track record with millions of doses given every season. Emphasize that the vaccine cannot cause the flu but be clear that one may still get the flu due to personal factors like age and health status or virus-strain match for that year. Recognize that people may experience certain side effects after vaccination and explain that it is not necessarily flu illness, rather it is the body responding to the vaccine and that those side effects are much less unpleasant than getting sick with the flu itself. You can also put side effects of vaccination into context by explaining potential risks of influenza infection. As we get closer to flu season, CDC will have updated key points and new communication products that you can use. We’ll be sure to share them through ACOG or you can sign up for updates on the CDC flu website.

CDC has tip sheets on addressing common questions about other vaccines as well and the diseases that they prevent also based on our research and testing with consumers and providers. This includes sheets on zoster, pneumococcal, hepatitis, tetanus and pertussis vaccines. They’re all available on our website and you can download and use them as reference.

You can also view case presentations and brief video examples of how to answer patient questions in this Medscape module, developed in conjunction with the Immunization Action Coalition, American College of Physicians, and the American Association of Physicians Assistants.

A range of free resources for patient education are available in English and Spanish on the CDC website for download and most of the print materials can be ordered for free from our warehouse. The Adult Vaccine Quiz, which I’d mentioned earlier is a great tool to provide adults with tailored, actionable information and can be shared through your website or with your patients so they can have a little bit of information before they come to speak with you.

We have two General fact sheets that provide details on vaccine recommendations, vaccine-preventable diseases and reasons to get vaccinated. We also developed a shingle-specific fact sheet as there many questions about the disease and the vaccine.

Our more targeted efforts at CDC have focused on adults with chronic conditions that put them at higher risk for complications from certain vaccine-preventable diseases. So, you see here “Outreach and Educational Products for Adults with Asthma and COPD, Diabetes and Heart Disease.”

We also have web pages and other resources on adult immunization in Spanish that have been adapted and tailored for Spanish language audiences based on testing.

We also have a range of resources for patient education and referral for pregnant patients at this website here.

Okay next I’d like to cover briefly the remaining “Adult Vaccination Practice Standards.” There are a number of steps you can take to improve vaccine administration. Recommend and offer vaccines at the same visit. As I shared earlier research shows when patients receive a vaccine recommendation and are offered the vaccine at the same time, they are more likely to get vaccinated. For vaccines you don’t stock it is still critical to make the recommendation and then refer to another immunization provider. Train and educate your staff on vaccine administration. Building your staff’s skills and confidence in vaccine administration can help improve vaccine delivery and ensure patient safety. Properly store and handle vaccines. This is a critical step for safety and can also reduce wastage. Distribute vaccine information statements to patients. Help your patients make those informed decisions about vaccination by providing them with up-to-date information about benefits and potential risks for each vaccine they need, which is provided in the BIS. Ensure proper care for patients. Minimize potential risk to your patients by following safety protocols such as having your patient sit or lie down when you administer vaccines. Follow standard precautions to control infections. Minimize the risks of spreading disease when administering vaccines. Be aware of and prepared for potential adverse reactions. All vaccines have the potential to cause adverse reactions. Most are minor such as itching or soreness but severe reactions, while rare, can occur. Make sure you and your staff are prepared to handle those reactions. I mentioned standing orders when I spoke about assessment but they can also save time by authorizing nurses, pharmacists and other healthcare professionals where allowed by state law to administer vaccinations without examination or direct order from the attending provider.

Here are some resources you can access online to support vaccine administration, including the link to CDC’s new Vaccine Administration eLearning Portal. CDC offers self-paced online training with free CE or CME credit, webcasts and more as well as guidance on vaccine storage and handling, infection prevention and other issues. IAC has tools for healthcare staff and supervisors to assess immunization sills and develop a plan of action to improve performance if needed as well as charts for vaccine dosing and medical management of vaccine reaction.

It may not be possible to stock all or any vaccines in your practice but you can still ensure your patients are getting the vaccines they need by following up strong recommendations with a referral. There’s an expanding network of immunization providers, including pharmacies, health departments, travel clinics and others. You can use the HealthMap Vaccine Finder link on this slide to locate vaccination services in your area. Please remind patients to check with their insurance plans regarding which providers are covered for vaccine services.

Last but not least, “Documentation.” This is an important last step to ensure that patients get the vaccines they need and to prevent unnecessary vaccinations. Record vaccination in patients’ medical records; provide documentation of vaccines received to patients for their personal records and document vaccinations in immunization information systems. Even if you do not administer vaccines in your office please follow up with your patients to ensure they have received the recommended vaccines from another immunization provider.

Immunization Information Systems (IIS) are confidential, community-wide computerized database that record vaccines administered by participating healthcare professionals. Documenting vaccines into IIS can benefit your practice by consolidating vaccination records for all your patients, helping you assess your patient’s immunization status, making sure your patients have completed necessary vaccine series (for example all three doses of hepatitis C vaccine), reducing chances of unnecessary doses of vaccine or missed opportunities to provide vaccines, facilitating use as a reminder and recall notifications and making calculation of your office’s immunization coverage rates easier. For more information on how to access IIS contact your state coordinator. You can look at the link on this slide.

CDC has a series of fact sheets on each of the practice standards, including tips, resources, and tools for implementation, which I shared today in this presentation. You can download these tip sheets from our website at the link shown here.

ACOG as well has many resources aimed at assisting OBGYN’s and their staff in providing and improving immunization rates among their patients. ACOG offers tool kits focused on Tdap, HPV and influenza immunization as well as a comprehensive tool kit of immunization resources for OBGYN’s, each containing materials to help providers communicate with women about the importance of vaccination. ACOG also has many immunization-focused committee opinions that offer recommendations for OBGYN’s based on emerging clinical and scientific advances around the given topic. Additionally, ACOG has developed a series of webinars like this one to detail immunization recommendations and provide resources for incorporating immunizations into routine practice.

These immunization tool kits, committee opinions, archived webinars and more can be all found in one convenient location at ACOG’s Immunization for Women website. You can also utilize the Immunization for Women Website to locate up-to-date immunization recommendations, specific immunization information for pregnant and breastfeeding women, information on how to set up and expand an office-space immunization program and the latest immunization news and updates. Additionally, the site is set up with separate provider and patient sections with the patient section serving as an excellent resource to feature on your own practice or organization website.

Within the Immunization for Women website, you can also find information and resources to help you begin or manage a currently existing immunization program within your office setting. It includes information on coding of vaccinations to ensure you receive payments, strategies for managing the cost of your vaccine programs, and what is encompassed in proper storage and handling of vaccines.

So in conclusion there is a substantial burden of vaccine-preventable disease among adults. Vaccination rates among adults are very low, leaving many vulnerable to illness, hospitalization and death and all healthcare professionals, whether they provide immunization services or not, can take steps to help ensure adults get recommended vaccines. There are many tools and resources available to help providers implement adult-immunization practice standards and educate adult patients about the importance of vaccination.

Thank you very much for your attention and I hope the information was helpful. Please feel free to contact me or my colleagues listed here with questions or issues, accessing the resources in the presentation and I believe we have time for questions so I will hand it over to Gary.

Moderator: All right thank you, Aparna.

Aparna Ramakrishnan: Let’s start with this question: How can we educate our patients on the importance of vaccination when we honestly don’t have the time in an office visit to provide that kind of education, especially considering that is not the focus of the visit? That is a very practical and important question. Thank you. I think that there are a couple of things that can be done here. First you know trying to share information ahead of the office visit and provide reminders and a heads-up if a new vaccine is due for a patient, can really help answer in advance some of the questions patients may have and just have them prepared to make a decision about vaccination. There are also ways to integrate vaccine education into the workflow of your practice and maybe share that responsibility across-the-team so the burden of vaccine recommendation communication isn’t all on the clinician so you know for example providing that intake or mentioning that intake that a vaccine may be due, having standing orders so other office-team/practice-team members can talk to patients and administer vaccination and also making sure that patients have the VIS and all the information they need at the beginning of the visit so they can prepare questions and be ready to make a decision.

Is there a resource that clients or we can go to that show long-term potential complications or side effects from vaccines? Yes, there is certainly information on CDC’s website about side effects and including short and long-term for vaccines and I would be happy to share that information and link through ACOG following the presentation. I’m making a note of that right now.

Post webinar: CDC’s Safety Information About Specific Vaccines

Okay next question: What advice do you have for responding to a pregnant patient who does not want to receive Tdap and/or influenza vaccination? It’s a very good question. We do have a number of resources on CDC’s website specifically about how to answer common questions and educate pregnant patients about both Tdap and influenza immunization and, in fact, we are getting ready to release a tool kit specifically around maternal vaccination, which should be available shortly but I think you know just to give a brief response right now I think the important thing is to share the protection provided by vaccination both to the pregnant women and their babies. That is a critical motivator for pregnant women and understanding the antibody transfer that happens when they get vaccinated and the severity of disease for infants, you know, the potential impact that getting pertussis or influenza could have on the baby is very important for pregnant patients to understand. Also sharing information around safety, the information we have regarding safety of both vaccines for pregnant women, is really helpful. I would say those are the top three things but, again, I will also send a link to the maternal tool kit when it is available. All right, thank you for that question.

Post webinar: CDC’s Talking to Pregnant Patients about Vaccination

Next question: Where can we find the statistics that were quoted at the beginning of the presentation, including flu cases? The best place for this is the CDC has a section of their website called AdultVaxView and another one, similar, called FluVaxView and those both pages provide detailed information about coverage rates as well as other incidents and other statistics so I will add that to my list of links to share.

Okay, next question: Many adults do not have Hep A and Hep B vaccinations in their history, are these commonly recommended? Okay that’s a good question. Hep A and Hep B vaccination are recommended based on certain risk factors so it is not routinely recommended based on age but rather based on certain health conditions as well as other risk factors related to those diseases and I am happy to share the pages as well that detail those indications.

Post webinar: CDC’s Hepatitis B Vaccination Information and Hepatitis A Vaccination Information

Would the California Immunization Registry be considered an appropriate IIS? I believe so. Each state has their own immunization registry. I will admit I don’t know a lot about registries but there are folks on my team that are much more aware of specifics regarding the different state registries and if you email me I’d be happy to put you in touch with the right person to answer any questions you may have.

Post webinar: CDC’s Immunization Information Systems (IIS)

Moderator: Thank you very much to Aparna for this great presentation today and to our attendees for your time with us today. If you have any outstanding questions that are not answered today please contact ACOG’s Immunization Department at [email protected]. This concludes our program for today.

Again, we thank you for joining us and we'll see you next time.