Ponerse al día con las vacunas infantiles

(En inglés)

Getting Up-to-date with Childhood Immunizations

Steve Shuman: On today's webinar, we have Dr. Jill Sells, Kimberly Clear-Sandor, and Dr. Mariana Glusman, who will officially introduce themselves. Next slide, Barbara.

Jill Sells: Thank you, Steve, and welcome, everyone. We are just delighted to have you here with us today. I'm Jill Sells. I'm a pediatrician and I serve as the medical advisor to the National Center on Health, Behavioral Health, and Safety, which is bringing you this webinar today. I'm also a Clinical Professor of Pediatrics at the University of Washington School of Medicine, and a long-term advocate for early childhood and just delighted to be part of this today. Kim.

Kim Clear-Sandor: Good afternoon, everybody. My name is Kim Clear-Sandor, and I am a nurse and family nurse practitioner who is currently a senior training and technical assistant associate with the National Center on Health, Behavioral Health, and Safety, and have been working in the early childhood space for many, many years supporting programs and staff to do the wonderful things that you do promoting children's health in the context of your child care or Head Start program. It's so great to be with you today to talk about all the important work you do in bringing children up-to-date with immunizations. Mariana.

Dr. Mariana Glusman: Hello. Good afternoon. I am Mariana Glusman. I am a pediatrician in Chicago. I've been a practicing pediatrician for the past 27 years and I love my job. I'm thrilled to be here to talk about the importance of vaccinations. This is such an important thing that we do to keep everybody safe.

Jill: Thank you. Next slide. Today's presentation will have three parts. First, I'm going to do an overview of immunizations in early childhood. Then I'll hand it over to Kim, who will talk about how programs can support childhood immunizations. I'll come back on and have a nice conversation with Dr. Glusman, who can help answer a lot of common questions that we know you all have about immunizations from her perspective as a pediatrician.

First just want to remind you and put this in the context that we are lucky to be part of a program in Head Start that has always incorporated health and supporting child health, including well-child care and immunizations from the start. Part of your role is around supporting families around access to and using health insurance and making sure they have a primary health care provider, that they're able to get those well-child visits and other preventive care. And, of course, childhood immunizations are a part of all of that. Next.

I want to start by grounding this in the Head Start program performance standard, specifically number 1302.42. This requires programs to obtain a determination from a healthcare professional as to whether or not a child is up-to-date on immunization recommendations issued by the Centers for Disease Control and to assist families with bringing their child up-to-date as quickly as possible.

On this performance standard that you'll see on the screen, we highlighted these two areas because we know we've gotten a lot of questions from all across the country over the years to help clarify this. Just wanted to show you where it points to, the CDC's recommendations and the role of staff to really support parents in this process. In a moment, we're going to start to go through the CDC recommendations.

First, just briefly the benefits of childhood immunizations at a high level. Vaccines work to strengthen children's immune systems to fight off many important diseases. And timely vaccination helps protect children from becoming ill when they are exposed to serious diseases. It's always better to prevent an illness than to treat it. When children are up-to-date on their immunizations, they are more able to be healthy and attending school and doing all the things that we want children to do. Their families around them are more likely to stay healthy as well as the communities. This is such an important thing to do. Next.

This is the high-level view of the immunization schedule. This is to 2023 version, and this is updated every year by the CDC. It's titled Recommended Vaccinations for Infants and Children Birth through Six Years. If you go to the link that we're showing on the bottom of the slide, you will see this, what they call easy to read version. This chart appears in the web version. We're going to briefly talk about this and then do a deeper dive.

This schedule is approved by a committee called the Advisory Committee on Immunization Practices. Then it is approved and recommended by the Centers for Disease Control, the American Academy of Pediatrics, and the American Academy of Family Physicians. We have this system that means all these different organizations come together and unite behind one national recommended schedule. That's what we're going to be talking about today. I know you can't read the details on this but we're showing the whole view just you can, at a glance, see the variety of vaccinations that you can see in one view. Next, please.

It does come in a printable version. When it's helpful for you as staff or for families to print it out on an 8 and 1/2 by 11 piece of paper to show all of these, you can do that and just wanted to show you the link to that as well. Both of these do come in Spanish, the online version as well as the printable version. Next.

I also want to point out if you scroll down further on the page where you find that vaccination schedule, there's a chart called diseases and the vaccines that prevent them. Sometimes parents or staff have more questions about what all these things are that we're vaccinating against. And this is a handy chart that gives a high-level detail of that.

You'll see across the top the first column is the disease. Some vaccines are targeting just one disease. Some vaccines have multiple diseases within them. Hepatitis B is just one, but when you look at DPT it has several things in it. On the left it'll be the disease, then the next column is what vaccine works against that disease.

Then the third column tells you how the disease is spread. Sometimes we know but sometimes we don't always remember whether this is one that's transmitted through blood or body fluids or through respiratory secretions or through GI-related things. You can find that in this chart.

The next column then is common disease symptoms. The following the final one is disease complications. This is just really a reminder that these are all serious diseases that can have serious complications, including death. This is just wanted to make sure you knew this was there if you're looking for more information about the diseases. Next.

It's important to remember and share with families that all the recommended vaccines that are on this schedule have been studied and shown to be both safe and effective in young children. There's a long process through which they go before they ever make it on this schedule, and that's just important to remember that and be able to share that with families. Next.

We're going to just do a little bit deeper dive looking at this. This is the same schedule but just zoomed in a little bit so we can look at it more closely. It looks a little bit different than the one that was up there last year. It's really read like a book from left to right and top to bottom. The order of vaccines that is on here is based on the order in which they're given. Hepatitis B is the only one on this schedule right now that is given at birth, that's why that one appears first.

The second one is rotavirus, which is one of the vaccines that is given starting at age two months, but it only the last dose is in that six-month time frame. That's why it's listed second because it's not given later than that. One other thing to note as you look at this schedule is there are occasional little stars or asterisks. Rotavirus is an example of that. And it means you need to look at a footnote and see what it's telling you.

In this case, rotavirus is a vaccine that isn't given to older children, and the latest time you would give a dose is in a child who's eight months old, and a footnote would tell you that. What that means is if you were looking at a child who was three years old and they'd never gotten rotavirus, they're actually up-to-date on that vaccination because it's no longer needed once they've gotten to that age. Next slide, please.

This is just circling the top to indicate that across the top are the ages of children. This particular chart is for birth through age six. Each of those black circles or dark blue circles is a child's age. Next slide. Then down the left, that's where the names of the vaccines are. Again, hepatitis B is listed first because it's the first one given. You just can read down the left there to see the names of the vaccines, the abbreviation that's frequently used, and then it's written out beneath that as well. Next slide.

The center of this is where all the detail is. This is telling us about the number of doses and their timing. Even though you might not be able to see all the detail, I think at a glance, you can see how many bars there are on each line. That's the number of doses. For the first line of hepatitis B, there's three that you can see. The next line has three. The third line has five, et cetera. At a glance, you can see over time in this age group how many doses are needed for optimal protection against those diseases.

The second part is the timing. Again, as we've talked about, the hepatitis B one is given at birth. But if we look down, say, at DTaP, the third one there, the first one is at two months and there's a small bar in that range. But if you look over to the right, some of the bars are longer. In the example of — maybe we'll do hepatitis B because it's a little easier to see, on that first line.

The third red bar stretches from six months through 18 months. That means that third dose can be given any time in that range and still be considered up-to-date. While it's fine to give it on the early end of that range, if you see a child who's 15 months old and they haven't had their third hepatitis B, they're not behind. They're eligible to get that. If they're in to see their provider, it would be fine to get that next dose, but they're not behind.

I know sometimes that's a little bit confusing. Those bars show the earliest dose on their left side, the earliest timing, sorry, on the left edge and the latest timing on the right edge to be considered on time. Looking at this, it's clear that there's a lot of different vaccines. They all are a little bit different potentially in their schedule and their dosing. That's because each one of these diseases is a bit different and each one of these vaccines is a bit different.

The whole process is trying to make sure that we give kids optimal protection for each of these diseases. We want to give the least amount of doses that will work. We want to make sure that the doses are given in such a way that the body builds that immune response that's strong to help protect a child, and to help protect a child as early as possible, and to make sure that they're protected during the time that they're most at risk. That's why it appears somewhat complicated because for each one, that turns out sometimes to be a little bit different. Next.

That brings us to the point, though, that it's never too late to start catching up on immunizations. While we would love everyone to get the doses as we just saw them on the schedule and as early as possible, if something is missed or a little bit late, it's OK. We can still work on catching kids up. That's, again, what the performance standard is all about. Where are children compared to where we'd like to be? How can we work with them and the families to get them up-to-date? 

Reviewing immunization records is really this great opportunity to connect with families and understand why a child is behind. There's many reasons that this might be the case. We know sometimes families are moving. They might have difficulty with insurance or finding a provider or transportation, all kinds of things that could be a challenge and might be why this child is behind. It often doesn't mean that the family's unwilling to vaccinate. Even if you do have a family who has made a decision that they don't want a particular vaccine or they're not sure, they can always change their mind.

It's important to just open the conversation, not make assumptions, and really meet families where they are, then provide information about what the recommended vaccinations are using this schedule and then encourage them to have those regular checkups and visits with the child's health provider for checkups and for immunizations as needed. Then do what you can to make it as easy as possible for them to be able to do that.

Steve: Jill, I'm going to stop you here. There are a number of people that because the schedules that you were showing as examples, they didn't see vaccines they're familiar with. If we could go back, I think it's slide number 8 that has the whole schedule.

Jill: Would like me to read them all? 

Steve: Just people can see that hep A is there. MMR is there.

Jill: You bet.

Steve: I think we went past, Barbara. There you go. I think.

Jill: You bet. You know, I just got an alert on my phone that was loud even though It's muted. if that happens to folks, I'm sorry. It's a day of a national emergency message going out. Here is the chart. It's hepatitis B, rotavirus, diphtheria, pertussis, and tetanus, or DTaP, Hib, pneumococcal vaccine, polio, COVID-19, flu, MMR, varicella, and hepatitis A.

Steve: Thank you, Jill. Barbara 

Jill: You bet. Thanks.

Steve: Yeah.

Jill: Barbara, go ahead and go back to the catch-up section. There we go. Next slide, please. again, this is just an excerpt of the schedule. I'm sorry if it's confusing to only show part of it, but just wanted to make it more visible. You can see the first few lines. When we're talking about catch-up, sometimes people just haven't got there yet but they're only a few days past their birthday. We're not talking about needing to get these vaccines right on the day that you turn two months old.

If there's a child who's really starting late or is more than one month behind, there is a special schedule to help figure out how to help them catch up. That's especially an issue when you're really small because, as you saw, there's a lot of vaccines in those early months. If you miss one or two well-child visits in those when you're just an infant, you can quickly get behind on the doses. There's a special chart to help make it clear exactly how to catch folks up. And sometimes the interval between the vaccines and a catch-up schedule might be a little bit different than someone who was on time from the start.

This is just to let you know that this exists. The health providers are responsible for looking at what the child has already received and creating a catch-up schedule for them as needed. It's not your responsibility to figure out all of these details, but it is helpful to know that this exists. You're certainly welcome to look at it and try to understand what a particular child might need, and to help the family understand that as they're partnering with you and with their child's health provider in order to catch up.

This is set up similarly where the vaccines are in that first column and then the columns across talk about what the minimum age is, like the first time you could get a particular vaccine, and then what the minimal interval is between doses, meaning if you need to get multiple doses, how long do you need to wait between them to make sure it works effectively? Just wanted to make sure you were aware that this chart exists. Next, please.

There's been a lot of charts to look at so just wanted to show you a pretty slide as a breaking point in between. This is falling in some areas of our country, and we're heading in that direction. It's a reminder that as exciting as back-to-school time can be and as pretty as fall might be, it also heralds the start often of respiratory season, which is not quite so much fun. We'll shift gears a little bit to talk about that. Next. It's important to know that influenza, COVID-19, and RSV are all now common respiratory viruses, and they can make young children quite ill.

While they are also more frequent in fall and winter and they can cause a lot of illness among young children, sometimes it's mild, but it can cause severe illnesses, including hospitalizations, especially for the youngest children. This, unfortunately, is true even in children who have no preexisting health conditions. Overall, these can have serious impact on children, on adults, on programs, and communities, particularly if these viruses are hitting more than one at the same time. Next, please.

In recognition of this, the CDC and others are starting to talk about all of these together so that we can understand and think about them together. There's a new website that the link is on the bottom here at the CDC, which is talking about all three of these respiratory viruses. I just noted, it's common to get sick from any of these, especially in the fall and winter. There are actions that we can all take to help protect ourselves and others. Just a reminder, again, that infants and young children are at higher risk for serious illness, hospitalization, and death than our older children. Next.

The latest then on COVID-19 as you have probably heard, there is a brand new updated for fall vaccine that has just come out really in recent weeks and is starting to become more available. It's on the CDC's recommended schedule for children six months and older and for everyone up through adults. If you are six months to four years old, they do need more than one dose of a COVID-19 vaccine.

If you are five years and older, it's official that you only need one, regardless of whether you've been vaccinated in the past. It's much simpler now for five and older. The little ones, though, to get that antibody response that we need to see, they do need more than one dose. How many they need depends on whether they've already gotten some and which manufacturer they have gotten a vaccine from if they've already received part of those vaccines.

But everyone, regardless of what they've gotten before, needs that one dose of the updated version. There's only updated versions available now. If you go anyone goes in, gets a COVID-19 vaccine, it will be the updated version. That's great news because the newer vaccines more closely match the latest variants.

COVID, like the flu, is changing all the time. The newer vaccines are made to more closely match what we're seeing now, which means they will build a better antibody response now than if we gave the old vaccine for what's happening right now. They'll also build a better antibody response than we might have if we had been sick with COVID, say, last year. The antibodies last year are different than the ones that we need now. This is, again, the official recommendation for all, is to get that updated vaccine. Next slide.

In terms of influenza, it's a long-standing recommendation also that everyone, six months and older, gets a flu vaccine in the fall. The youngest children need two doses the first time and there's a few other circumstances where people might need two doses the first time. Once you've been getting it regularly, it's just one dose each fall. October is actually an ideal time for annual flu vaccines and for COVID because it's the new vaccine that's out as well. Right now is a great time for everyone to be seeing where they can get the vaccine from their regular healthcare provider or otherwise. Next.

The third virus that we were talking about that's happening in the fall, and you may have heard more about in recent years, is RSV. We're really excited that there is a new injection of an RSV antibody for infants and toddlers. This is new this year and is just in the process of becoming available. It's officially recommended by the CDC and the AAP just in recent weeks. It doesn't appear on the picture schedule that I showed you yet, but if you look at a footnote on the website, they are showing that it's a new recommendation. I expect that it will eventually show up in the picture as well.

This is just relevant if you are serving families with very young children because this is only for infants who are younger than eight months and who are born or going into their first RSV season, little ones right now. There are some children who are a little bit older, 8 to 19 months, if they have underlying health conditions, it may be indicated for them as well. But just wanted you to be aware that this is out there if you are working with families that have infants and toddlers.

Those are the children most at risk for being hospitalized and severely ill, even those who don't have any underlying conditions. We’re hopeful this will make a big difference for infants during RSV season. Next. It's important to know that COVID-19 and flu vaccines can be given at the same time as each other and as any other of the vaccines. Next. OK. I'll turn it over to Kim.

Kim: Thank you, Jill, and thank you, for going over the CDC recommended immunization schedule. There's good content and information in there is much to think about as programs collect this information and do their determination of up-to-date status for children's vaccines. As you've talked about in the very beginning, Head Start really prioritizes children's health and it's reflected in those Head Start program performance standards by requiring this determination of up-to-date status on their immunizations as recommended by the Center for Disease Control and Prevention schedule.

Head Start always elevates the work with families and collaborating with families and doing that important work together. As programs look at the schedule and do these determinations, it's really that ongoing commitment to promoting children's health and working with families that gets elevated. Next slide. Programs may do all this in their own way to meet the standards, but they often create policies and procedures to guide how they're going to collect information and determine their up-to-date status.

Programs often create a process to collect information, to review them, and then how you're going to document the immunizations that children have received. It's also up to programs to make a determination on how they're going to track children that are behind, maybe they're unimmunized or under-immunized, maybe they're on that catch-up schedule. But programs need to keep track of that information as well.

Programs might also [inaudible] good practice to have a policy about how to identify children who are under-immunized or unimmunized against certain diseases because if there is an outbreak of vaccine-preventable disease, the program is going to need to identify children who have not received the vaccine that prevents that disease because the health department may advise them to exclude children. Ensuring that your policy and your practices not only allows you to document and follow who's up-to-date, but also be able to track those who need follow-up. Next slide.

As you can imagine, when Jill went back and showed the slide that showed all of the vaccines across all zero to five years old there, there's a lot of different vaccines happening at a lot of different ages. Your record-keeping and tracking system is really critical to being able to, not only make the initial determination of up-to-date status, but to do the very important work of helping children get up-to-date and then maintaining that up-to-date status so that you can continue to track and complete those important immunizations.

When your program, whatever you're using to track, it's important that your program reflects the most up-to-date schedule. you can see that we showed you the 2023 CDC recommended immunization schedule. That's the one that the Head Start program performance standards point to. You want to make sure that those immunizations are reflected in your data tracking system. If you haven't double-checked that, it's a really good practice to do that at the beginning of the year.

It's also really important to think about who's entering the data. Are we all trained so that the data that we're entering is good, complete, and reliable? You want to review how you're receiving the schedules, how the information is getting inputted that when you're going in to follow-up and track children that you have good, reliable, and complete data. Next slide, please.

Jill talked a lot about the Head Start program performance standards pointing to the CDC recommended vaccination schedule. That is what the Head Start program performance standards point to. But it's also important to know that programs meet and some follow state licensing and federal child care development fund requirements for immunizations and they might include different immunizations.

The CDC schedule is usually stricter than the state schedule. That is what you follow but there may be state licensing immunization requirements as well. They also might have different requirements in states, such as exclusion around certain time frame or certain time frames for a child to get up-to-date. It's really important you understand what is required in your state as well as you are creating your systems in your program. This also may include waivers and exemptions. Some states, territories, or tribes allow waivers and exemptions for immunizations. Some of them have specific forms.

Other states may not have forms. But again, it's important to know what's going on in your state, territory, or tribe so that you can follow what you need to be documenting. Next slide, please. I just wanted to highlight a couple helpful tips. Sometimes I saw in the chat some comments about sometimes it's hard to get documentation, sometimes families might have lived in different places. They don't have easy access to records. We just want to share a little helpful tip that there are State Immunization Information Registry.

We have the link on the slide. It'll also be on the handout you have. Some states allow Head Start programs access to the registry. It is great to check this out. This might be a little pearl that you can take away from today that helps you to get some immunization records for some of the children in your program. Another useful tool is the CDC vaccine-preventable disease, but it's in multiple languages. You have children that are coming from different countries and maybe handing you immunization records that reflect maybe perhaps languages you're not familiar with and perhaps countries immunization schedules that you're not familiar with. This link will help you begin to sort that out.

Also, it is quite common that if in your state or your county, there are a large number of people from a different country that the local health department or the state department may also have great resources to help you figure it out so that you're not alone. Some of the schedules are different, the names are different, definitely a little bit different, and it does take a little bit of time to understand some of those schedules.

I didn't post it on the slide, but I just want to remind everybody that healthcare providers offices and your program have different confidentiality policies. Healthcare provider offices may have different HIPAA privacy protection laws. Knowing these things, so working with your local health your local healthcare providers to find out if you need to sign a release of information form or whatever they require in order to share things with you, those are great things that can really help to smooth the getting of the records that you need so that you can make your up-to-date determination status. Next slide, please.

As we mentioned in the beginning, collaborating with families is so important in Head Start. It's all about the children and families. It's no different when we're talking about immunizations. We know that taking the time to develop relationships and have honest, open, safe spaces to have good communication goes a long way in helping families make decisions about receiving services. We talked a lot about documenting the actual vaccines that are up-to-date, but it's also important to document all the collaboration that's going on with families.

As you work with families around immunizations and health things, you want to make sure that whoever it is that's in your program that's working with families has the information that they need to be successful in having these important conversations. I always like to say, listen for teachable moments. Sometimes if a child's been sick and they're going for a follow-up visit, that might be a great time to bring up catching up on some important immunizations that are needed. Sometimes looking for those open doors creates a nice way to have some of these conversations.

When those that are working with families might learn that a family is experiencing homelessness. And it's really important that programs understand the McKinney-Vento Act, which actually requires programs to enroll children experiencing homelessness immediately and work with the families to obtain immunizations and other medical records and arrange those necessary immunizations and to not exclude the child. Working with the family, documenting these things, and being aware of these rules is really supportive of all children. Next slide.

As we're working with families or you're working with the staff to or you're working with your staff to prepare to work with families, I'm going to just talk about a couple of different tips that we have and then show you some different resources. One approach to preparing families for immunization is talking about what families can do before a visit, during a visit, or after a visit. We pop some of those things up on the slide. In the interest of the time, I'm not going to review them, but that link that's on the slide does go into some really nice, simple tips that will go a long way to support a family in knowing what to expect and knowing how they can best support their child when they go for immunizations.

The next slide talks about some of the challenges that families may encounter. As Jill said, there's a lot of reasons a child may be behind on their immunizations and it's not up to anyone to make assumptions what those are. But as you work with families, it's so important to listen to some of those challenges, whether it's getting a day off of work or the timing of an appointment, or just finding the right healthcare provider who speaks the family's language and understands their culture. Sometimes it's just getting some transportation to get there. Navigating those challenges, being aware of those challenges goes a long way in supporting children getting up-to-date. Next slide.

We also mentioned that sometimes families are struggling to make a decision for their children. They might have concerns about the safety or side effects or just want to learn more about what it is. Preparing staff for having these conversations will really support some positive relationships. It's really important that whoever's working with families keep in mind that you may have your own thoughts and feelings and questions about the vaccines that you bring into the conversation, but keep the conversation focused on the family's needs.

The focus is not to change anyone's minds. It's to talk to them about what their needs are and how you can help collaborate together to do the health services that they feel comfortable with. Family engagement requires mutual respect for the roles and strengths of all the family members. It's important to provide a safe space with accurate information and deliver it in a non-judgmental, comfortable way. That's taking the time to understand their concerns, use those relationship-based techniques. I know you're all so good at it. But really making sure people are ready to have this information is critical.

I'm going to highlight a couple of resources. If you can just move to the next slide and then the next one. I'll share with you, again, these are things that are on your handout, but I just want to give you a peek at them to entice you to go check them out a little bit further. This is a CDC page that actually has some really nice content that talks about why the recommended immunization schedule, the timing of it is so important. It's written in very plain language, really supportive of health literacy needs of families. It has great little pictures.

The next slide shows a great video. There's actually a whole video library. Sometimes using multimodal pieces of information, pulling it up on your phone or an iPad, is a way to, again, support family literacy. The next slide brings you to a whole treasure trove of resources on vaccines during the many different ages. They have an assessment tool where you can go in and put in the child's age. These are really great interactive things that you can do together with the family and then look up the information together with a family. I hope that would be a helpful tool for some of you.

The next slide just shows that is also available in Spanish. Then the next slide is another handout. There's different flyers and posters that are available, and they even touch on why vaccination is important during pregnancy. In English and Spanish. Last, but not least, is another little app that I think is really neat. The CDC links to this, but it's actually from the Children's Hospital of Philadelphia. It's an app that goes on your phone. You can pop in a child's age and it can bring you up to the vaccines that are required for the age. But more importantly, it tells you about the illnesses. It tells you about the side effects and some other information that may support positive conversations with family.

Remember, in your programs you're going for that documentation of up-to-date status on the CDC recommended schedule and then you're working with families to get them up-to-date, and you are documenting that all along the way so that you can continue to support the child's positive health. With that, I'm going to turn it back over to Jill.

Jill: Thank you much, Kim. A lot of great information. Go ahead and take down the slides and we'll have Dr. Glusman come on here with me as well. I just want to say that we know that this is a ton of information and we just encourage you to just take in what you can and then to download the handouts for more information and all the links. A lot of the questions that people have will be answered when you go to those links. We also have our information line that is available to you at all times. Try to join us now and listen to this conversation.

Dr. Glusman, thank you, for joining us.

Mariana: Thank you for having me.

Jill: I'm going to jump right in. We got a lot of questions from the Head Start community and we're going to ask you some of the common ones that we hope you can help us with. First is, can you tell us how you talk with families who are concerned about vaccines, maybe they're unsure about what they want to do or say they don't want to immunize their child? 

Mariana: Yeah. I mean, I think that Kim brought up some really, really wonderful points, and it is starting with where the family is. I don't think you can convince anybody. It's not about convincing people. It's really about answering what their concerns are, eliciting what their concerns are. Some people have some legitimate concerns. Perhaps they're concerned about side effects. Perhaps they saw a scary something on TikTok or something. And of course, parents want the best for their kids.

I think that just asking them, what's the issue? What are you concerned about? Where are you getting the information? Then debunking whatever myths or misinformation they might have heard, is a good place to start.

Jill: Great. Thank you.

Mariana: Just let me just add one more thing. Sometimes I have these conversations over and over and over again. A lot of it is about building trust. Somebody may not decide to vaccinate the first time I bring up the option or the opportunity, but oftentimes as we get to know each other, as they get to trust me as their provider, as somebody that truly cares about their child and their child's health and their child's future, eventually a lot of people do end up coming around, even if they were very hesitant at the beginning.

Jill: Yeah, I think that's a really good point. Most of us can't make important decisions really fast, especially if there's a lot of information, just like it's happening to those of you who are listening to us now. You can't take it all in and decide what to do that fast. Remembering that, that it takes patience and it takes repetition and it takes relationships. That's important for staff in our programs as well as with the health providers. Next one is, why do young children need so many different vaccines and so many doses? 

Mariana: Well, first of all, many different vaccines because there are many different diseases that we need to protect kids against. But one of the ways that I've started thinking about vaccines, and I think this analogy is going to work very well in this audience, is I kind of like to think about vaccines as teachers. What they're doing is they're teaching our immune system by helping it recognize what a disease might be and get ready in case our immune system encounters whatever virus or bacteria it is.

What if you think about how many times does it take you to hear something when you finally begin to really understand it and retain it and process it, well, it takes multiple times. Well, it's the same with our immune system. It doesn't just learn it the first time. It needs to be reminded and re-taught. That's what the vaccines are doing and that's what each of the boosters is doing, is it is re-educating our immune system so that it is ready when the time comes, and it needs to be activated and fight against those infections.

Jill: I think that's a really good analogy and one that parents could understand. Maybe if you talked about, gosh, you're watching your child learn to talk or learn to walk and they don't just jump up and do it. They have to try and learn and try again. Our immune system's pretty smart but it does need that multiple exposures. Is it OK to delay starting or spreading out the doses so that children don't get so many at one visit? 

Mariana: Yeah that's a question I get a lot. I think the root of it is that people are worried that if they give a lot of vaccines at the same time, it's, for some reason, going to be bad. You said it yourself, Jill, is these vaccines have been studied extensively and they've been studied being given all together. We know that it is safe to give them all together.

I encourage families to stick to the recommended schedule because otherwise you begin to fall behind and that any time you fall behind, that's an opportunity for your child to or for a bacteria to if there's an outbreak, your child could get sick and could get severely ill. Now sometimes parents are very worried and they're not ready for that. I do work with families to try and figure out how to best get all the vaccines in a way that families feel comfortable because really my goal is to get the child immunized. If I need to be flexible, I think that's an important thing to be able to do.

Jill: You try to encourage them to follow the schedule as much as possible. If they just won't, on some part of it, you'll work with them on that while encouraging them to move the others forward.

Mariana: I mean, sometimes that's part of building trust, is that I hear you. I hear I see that you're really worried. I'm not worried but let's see. What can we do? What are you comfortable with today? Then we can take it from there.

Jill: I can see how that really builds trust because they know you really heard them.

Mariana: Exactly.

Jill: Which is important for us to do even if it's hard when we really want to help that child be as healthy as possible.

Mariana: It's true. It's true. Sometimes that's I just want to say, you know, I vaccinated my own kid. I would never do anything to your child that I didn't do for mine. As a pediatrician knowing that this is important, it can be difficult to feel like my like I'm not being trusted. It's important to not take it personally and to know that there's so many different reasons why people may have misgivings. Really working with them and understanding why they're having those concerns can help me best respond to them.

Jill: Great. Thank you. How do you work with families who are behind on vaccines to help them catch up? 

Mariana: I mean, the biggest thing is making it easy. You said that, and Kim said also, there are many reasons why kids are not vaccinated. Perhaps they've moved. Perhaps they lost their vaccine record, and they don't know what vaccines they've gotten. Perhaps there's transportation issues. The biggest thing that we do is we take every opportunity to vaccinate. If a child comes in for a cold, I take the opportunity to vaccinate. If they come in for a follow-up on whatever it is that the concerns are, take the opportunity to vaccinate.

We also offer nurse visits that if they can't come in to see me, they can still come in to see one of our nurses and it's much easier to make those appointments. We'll offer flu clinics that as many people can get in as possible on a particular day and get vaccinated against the flu, for example. We'll be doing that for COVID as well. Really making it convenient. We know parents are really busy. There's a lot of they have a lot of commitments, a lot of things that are pulling them in a lot of different directions. We want to make it vaccines accessible and easy to get as much as we can.

Jill: It sounds like it might be really helpful for our programs to, as best they can, understand what the local providers or the local clinics are doing so they kind of know how to help families connect.

Mariana: Absolutely.

Jill: I know one of the questions families will often say is, OK, I know I have vaccines to catch up on but I want to wait till the next checkup. Is it important to really encourage them to come in for those catch-up vaccines in between visits if that's when the schedule their updated schedule says that they should? Do you have any thoughts about that? 

Mariana: Yeah. I mean, I think that, again, the more up-to-date a child is, the safer they are. Maybe they can't come in to see me in between checkups but they can come in to see our nurse. Trying to figure out other ways to get those vaccines in and encourage families to do that is really important. Sometimes there's nothing you can do and then you have to just catch them up at the next checkup. Ideally, you want kids to be as up-to-date as possible.

Jill: We've talked a fair amount about fall respiratory season and what's happening right now. Can you share any thoughts about how you talk with families about the flu vaccine and the COVID-19 vaccine for their children?

Mariana: Yeah. I think that one of the issues that we get into with COVID, and flu is a lot of people think about them as separate from the rest of the vaccines, but they're just the same as all the other vaccines. They are studied. They're effective. They're safe. I talk to families about the flu and the COVID vaccine in the same way that I talk to families about all of the other vaccines. They are the teachers for our immune system, like I mentioned before. They are again, safety, allaying people's fears.

Sometimes people worry about the side effects. Is it going to make my child sick? I hear that all the time. “Oh, my child I got the vaccine, and it gave me the flu.” Well, we know that that's not the case. Sometimes, yes, vaccines can have some side effects: make you tired, have a fever. It's not the same as the flu. Also, it protects you. And sometimes you can have the flu at the same time as you got a vaccine. Really sort of addressing the questions that parents might have. But again, the most important thing is the flu vaccine and the COVID vaccine are just like all the other vaccines and they're just as important.

Jill: Hopefully now that when COVID first came out, it was a new thing, and it wasn't given out in the normal way. It wasn't given out in doctor's offices in the same way as the other vaccines just because of the whole process. One of the great things is what you're saying, like we're moving this back. It's on the regular schedule. It's in the regular office. It's part of the regular discussion. Just that's what we're trying to move towards, that transition of talking about them in that way as well.

Mariana: Parents sometimes there's this kind of feeling that, well, maybe COVID is new. It hasn't been studied as well. The fact is that even the COVID vaccine and the methods of the COVID vaccine were studied even before COVID ever arrived on the scene. The way that they did the studies, they just stacked them up on top of each other. They didn't cut corners. These vaccines are just as studied as the other vaccines. It's just that they were able to do it in a faster way. They are safe and they are effective, and that's important for parents to know as well.

Jill: Do you have any suggestions for Head Start staff as they work with families around immunizations?

Mariana: I think that the biggest thing is, again, asking them what are their concerns? What are the barriers? They having do they not have a provider? Do they not have transportation? What are the issues that are facing them? Not making assumptions that it's because they don't want to get their child vaccinated. Encouraging families to talk to their providers and ask them if they have any questions, and to make sure that if they are going online to get information, that they're going to reputable sources, like the CDC.

Kim showed those beautiful websites. It's resources that are available. The American Academy of Pediatrics also has a great website and a lot of up-to-date information about the recommendations. Just making sure that people are going to places that are going to give them the most accurate and truthful information about vaccines.

Jill: We hear often from families that it's hard for them to connect with healthcare providers. And the staff and programs will frequently say that too. It's like, I'm trying. I'm trying, but they just it's hard. Do you have any suggestions for, again, for staff to build those relationships or communicate in ways that will be helpful with the healthcare community? 

Mariana: Yeah. I think that probably I will say the theme of this webinar is relationships. I think that's probably the theme to everything, that's what I feel, like relationships are so important. If you can, build relationships with the pediatricians or family practitioners, nurse practitioners that work in your area. The people that tend to see the most of the children that you work with reach out to them. We all have the same goal for children, and that is to be safe and to be healthy and to thrive and flourish. I think that most pediatricians are thrilled to talk to teachers.

Obviously, we need to make sure that all HIPAA and all that parents give their permission for us to talk about a specific child and give information about that and concerns. But in general, I think it's also good to make broader relationships. Sometimes you can even have a pediatrician come talk to the parents. If you're nearby a residency, a training program that trains pediatricians, for example, sometimes the trainees will be happy to go and give talks. Really as you start to develop these relationships, you might find that there's other creative ways to work together to make sure that kids are immunized and up-to-date.

Jill: Thank you. I think that's a really great way to end this part of the webinar. We are so thankful for your perspective and for your work working with families on the front lines and appreciate you joining us here today.

Mariana: Thank you. Thank you to all of the work that everybody on this call does. Head Start is so important. Like I said, it's not just about health. It's about thriving. The work that everybody on Head Start does is an incredible thing for the families that you all serve. Thank you for the work that you all do.

Jill: Thank you. With that, I'll turn it back to Steve.

Steve: Thank you, Jill, and thank you, Mariana, and thank you, Kim. We tried to answer as many questions as we possibly could. They were coming in fast and furious. If we didn't answer your question, I'm going to tell you in just one moment how you can. You can write to us. But first, let me make a plea for you to complete our evaluation. We have a URL and a QR code on the slide. There'll also be an evaluation, the same evaluation pop up when the Zoom platform closes. There's also a link on your handout. After submitting the evaluation, you'll see a new URL that will allow you to access, download, save, and print your certificate. Next slide, please.

Thank you. You can subscribe to our monthly resource list. Next slide. You can follow us next slide. Thank you. You can follow us on social — there you go. Follow us on social media. You can send you can post questions in MyPeers. We have a very active health, safety, and wellness and child care health consultation pages if that's of interest to you. The last slide has where you can send questions. Next slide, please. You can send any questions to health@ecetta.info. We are always open. We are always answering any questions, immunization or otherwise. We welcome hearing from you.

With that, again, thank you to our presenters. Thank you to Barbara and Kim, our interpreters, Nancy and Marco, everyone backstage that were answering that was busily answering questions and responding to everything that needed to happen to make this webinar a success. Again, please fill out the evaluation. We want to hear from you. If you have questions, reach out to us if we didn't answer them already. Thank you very much for taking such good care of children and families in our Head Start programs. You can close the slides.