The Importance of Supervising Toothbrush Usage for Young Children at Risk of Lead Toxicity.

Lead exposure in childhood causes lasting deleterious health effects through multi-system organ toxicity, including in brain, skeletal system, and oral cavity. We report a case that illustrates the imperative for providers to give specific anticipatory guidance on supervising toothbrush usage for young children. A healthy 18-month-old male presented for routine well-child care and had an unremarkable physical exam and developmental assessment. Two days after his routine visit, his blood lead test result was more than 180 mcg/dL (acceptable level is less than five mcg/dL). Upon review of his home environment, the mode of exposure was determined to be the child rubbing his toothbrush against the window well and putting the toothbrush in his mouth, thus causing exposure to lead dust. Health care and dental providers who advocate for toothbrushing have a responsibility to provide specific guidance on toothbrush usage for toddlers with hand-to-mouth behavior.

Cost effectiveness of school-located influenza vaccination programs for elementary and secondary school children.

BACKGROUND: Studies have noted variations in the cost-effectiveness of school-located influenza vaccination (SLIV), but little is known about how SLIV's cost-effectiveness may vary by targeted age group (e.g., elementary or secondary school students), or vaccine consent process (paper-based or web-based). Further, SLIV's cost-effectiveness may be impacted by its spillover effect on practice-based vaccination; prior studies have not addressed this issue. METHODS: We performed a cost-effectiveness analysis on two SLIV programs in upstate New York in 2015-2016: (a) elementary school SLIV using a stepped wedge design with schools as clusters (24 suburban and 18 urban schools) and (b) secondary school SLIV using a cluster randomized trial (16 suburban and 4 urban schools). The cost-per-additionally-vaccinated child (i.e., incremental cost-effectiveness ratio (ICER)) was estimated by dividing the incremental SLIV intervention cost by the incremental effectiveness (i.e., the additional number of vaccinated students in intervention schools compared to control schools). We performed deterministic analyses, one-way sensitivity analyses, and probabilistic analyses. RESULTS: The overall effectiveness measure (proportion of children vaccinated) was 5.7 and 5.5 percentage points higher, respectively, in intervention elementary (52.8%) and secondary schools (48.2%) than grade-matched control schools. SLIV programs vaccinated a small proportion of children in intervention elementary (5.2%) and secondary schools (2.5%). In elementary and secondary schools, the ICER excluding vaccine purchase was $85.71 and $86.51 per-additionally-vaccinated-child, respectively. When additionally accounting for observed spillover impact on practice-based vaccination, the ICER decreased to $80.53 in elementary schools -- decreasing substantially in secondary schools. (to $53.40). These estimates were higher than the published practice-based vaccination cost (median = $25.50, mean = $45.48). Also, these estimates were higher than our 2009-2011 urban SLIV program mean costs ($65) due to additional costs for use of a new web-based consent system ($12.97 per-additionally-vaccinated-child) and higher project coordination costs in 2015-2016. One-way sensitivity analyses showed that ICER estimates were most sensitive to the SLIV effectiveness. CONCLUSIONS: SLIV raises vaccination rates and may increase practice-based vaccination in primary care practices. While these SLIV programs are effective, to be as cost-effective as practice-based vaccination our SLIV programs would need to vaccinate more students and/or lower the costs for consent systems and project coordination. TRIAL REGISTRATION: ClinicalTrials.gov NCT02227186 (August 25, 2014), updated NCT03137667 (May 2, 2017).

Provider Communication, Prompts, and Feedback to Improve HPV Vaccination Rates in Resident Clinics.

BACKGROUND AND OBJECTIVES: Human papillomavirus (HPV) vaccination rates lag behind vaccination rates for other adolescent vaccines; a bundled intervention may improve HPV vaccination rates. Our objective is to evaluate the impact of quality improvement (QI) training plus a bundled practice-based intervention (provider prompts plus communication skills training plus performance feedback) on improving HPV vaccinations in pediatric resident continuity clinics. METHODS: Staff and providers in 8 resident clinics participated in a 12-month QI study. The intervention included training to strengthen provider communication about the HPV vaccine. Clinics also implemented provider prompts, received monthly performance feedback, and participated in learning collaborative calls. The primary outcome measure was eligible visits with vaccination divided by vaccine-eligible visits (captured HPV vaccination opportunities). Practices performed chart audits that were fed into monthly performance feedback on captured HPV vaccination opportunities. We used conditional logistic regression (conditioning on practice) to assess captured vaccination opportunities, with the time period of the study (before and after the QI intervention) as the independent variable. RESULTS: Overall, captured opportunities for HPV vaccination increased by 16.4 percentage points, from 46.9% to 63.3%. Special cause was demonstrated by centerline shift, with 8 consecutive points above the preintervention mean. On adjusted analyses, patients were more likely to receive a vaccine during, versus before, the intervention (odds ratio: 1.87; 95% confidence interval: 1.54-2.28). Captured HPV vaccination rates improved at both well-child and other visits (by 11.7 and 13.0 percentage points, respectively). CONCLUSIONS: A bundled intervention of provider prompts and training in communication skills plus performance feedback increased captured opportunities for HPV vaccination.

A Learning Collaborative Model to Improve Human Papillomavirus Vaccination Rates in Primary Care.

OBJECTIVE: Human papillomavirus (HPV) vaccination rates remain low, in part because of missed opportunities (MOs) for vaccination. We used a learning collaborative quality improvement (QI) model to assess the effect of a multicomponent intervention on reducing MOs. METHODS: Study design: pre-post using a QI intervention in 33 community practices and 14 pediatric continuity clinics over 9 months to reduce MOs for HPV vaccination at all visit types. MEASURES: outcome measures comprised baseline and postproject measures of 1) MOs (primary outcome), and 2) HPV vaccine initiation and completion. Process measures comprised monthly chart audits of MOs for HPV vaccination for performance feedback, monthly Plan-Do-Study-Act surveys and pre-post surveys about office systems. INTERVENTION: providers were trained at the start of the project on offering a strong recommendation for HPV vaccination. Practices implemented provider prompts and/or standing orders and/or reminder/recall if desired, and were provided monthly feedback on MOs to assess their progress. ANALYSES: chi-square tests were used to assess changes in office practices, and logistic regression used to assess changes in MOs according to visit type and overall, as well as HPV vaccine initiation and completion. RESULTS: MOs overall decreased (from 73% to 53% in community practices and 62% to 55% in continuity clinics; P < .01, and P = .03, respectively). HPV vaccine initiation increased for both genders in community practices (from 66% to 74% for female, 57% to 65% for male; P < .01), and for male patients in continuity clinics (from 68% to 75%; P = .05). Series completion increased overall in community practices (39% to 43%; P = .04) and for male patients in continuity clinics (from 36% to 44%; P = .03). CONCLUSIONS: Office systems changes using a QI model and multicomponent interventions decreased rates of MO for HPV vaccination and increased initiation and completion rates among some gender subgroups. A learning collaborative model provides an effective forum for practices to improve HPV vaccine delivery.

Cost effectiveness analysis of Year 2 of an elementary school-located influenza vaccination program-Results from a randomized controlled trial.

BACKGROUND: School-located vaccination against influenza (SLV-I) has the potential to improve current suboptimal influenza immunization coverage for U.S. school-aged children. However, little is known about SLV-I's cost-effectiveness. The objective of this study is to establish the cost-effectiveness of SLV-I based on a two-year community-based randomized controlled trial (Year 1: 2009-2010 vaccination season, an unusual H1N1 pandemic influenza season, and Year 2: 2010-2011, a more typical influenza season). METHODS: We performed a cost-effectiveness analysis on a two-year randomized controlled trial of a Western New York SLV-I program. SLV-I clinics were offered in 21 intervention elementary schools (Year 1 n = 9,027; Year 2 n = 9,145 children) with standard-of-care (no SLV-I) in control schools (Year 1 n = 4,534 (10 schools); Year 2 n = 4,796 children (11 schools)). We estimated the cost-per-vaccinated child, by dividing the incremental cost of the intervention by the incremental effectiveness (i.e., the number of additionally vaccinated students in intervention schools compared to control schools). RESULTS: In Years 1 and 2, respectively, the effectiveness measure (proportion of children vaccinated) was 11.2 and 12.0 percentage points higher in intervention (40.7 % and 40.4 %) than control schools. In year 2, the cost-per-vaccinated child excluding vaccine purchase ($59.88 in 2010 US $) consisted of three component costs: (A) the school costs ($8.25); (B) the project coordination costs ($32.33); and (C) the vendor costs excluding vaccine purchase ($16.68), summed through Monte Carlo simulation. Compared to Year 1, the two component costs (A) and (C) decreased, while the component cost (B) increased in Year 2. The cost-per-vaccinated child, excluding vaccine purchase, was $59.73 (Year 1) and $59.88 (Year 2, statistically indistinguishable from Year 1), higher than the published cost of providing influenza vaccination in medical practices ($39.54). However, taking indirect costs (e.g., averted parental costs to visit medical practices) into account, vaccination was less costly in SLV-I ($23.96 in Year 1, $24.07 in Year 2) than in medical practices. CONCLUSIONS: Our two-year trial's findings reinforced the evidence to support SLV-I as a potentially favorable system to increase childhood influenza vaccination rates in a cost-efficient way. Increased efficiencies in SLV-I are needed for a sustainable and scalable SLV-I program.

Seasonal influenza vaccination at school: a randomized controlled trial.

BACKGROUND: Influenza vaccination coverage for U.S. school-aged children is below the 80% national goal. Primary care practices may not have the capacity to vaccinate all children during influenza vaccination season. No real-world models of school-located seasonal influenza (SLV-I) programs have been tested. PURPOSE: Determine the feasibility, sustainability, and impact of an SLV-I program providing influenza vaccination to elementary school children during the school day. DESIGN: In this pragmatic randomized controlled trial of SLV-I during two vaccination seasons, schools were randomly assigned to SLV-I versus standard of care. Seasonal influenza vaccine receipt, as recorded in the state immunization information system (IIS), was measured. SETTING/PARTICIPANTS: Intervention and control schools were located in a single western New York county. Participation (intervention or control) included the sole urban school district and suburban districts (five in Year 1, four in Year 2). INTERVENTION: After gathering parental consent and insurance information, live attenuated and inactivated seasonal influenza vaccines were offered in elementary schools during the school day. MAIN OUTCOME MEASURES: Data on receipt of ≥1 seasonal influenza vaccination in Year 1 (2009-2010) and Year 2 (2010-2011) were collected on all student grades K through 5 at intervention and control schools from the IIS in the Spring of 2010 and 2011, respectively. Additionally, coverage achieved through SLV-I was compared to coverage of children vaccinated elsewhere. Preliminary data analysis for Year 1 occurred in Spring 2010; final quantitative analysis for both years was completed in late Fall 2012. RESULTS: Results are shown for 2009-2010 and 2010-2011, respectively: Children enrolled in suburban SLV-I versus control schools had vaccination coverage of 47% vs 36%, and 52% vs 36% (p<0.0001 both years). In urban areas, coverage was 36% vs 26%, and 31% vs 25% (p<0.001 both years). On multilevel logistic analysis with three nested levels (student, school, school district) during both vaccination seasons, children were more likely to be vaccinated in SLV-I versus control schools; ORs were 1.6 (95% CI=1.4, 1.9; p<0.001) and 1.5 (95% CI=1.3, 1.8; p<0.001). CONCLUSIONS: Delivering influenza vaccine during school is a promising approach to improving pediatric influenza vaccination coverage. TRIAL REGISTRY: ClinicalTrials.govNCT01224301.

Increasing adolescent immunization rates in primary care: strategies physicians use and would consider implementing.

Strategies to increase adolescent immunization rates have been suggested, but little is documented about which strategies clinicians actually use or would consider. In spring 2010, we surveyed primary care physicians from 2 practice-based research networks (PBRNs): Greater Rochester PBRN (GR-PBRN) and national pediatric COntinuity Research NETwork (CORNET). Network clinicians received mailed or online surveys (response rate 76%, n=148). The GR-PBRN patient population (51% suburban, 33% rural, and 16% urban) differed from that served by CORNET (85% urban). For nonseasonal vaccines recommended for adolescents, many GR-PBRN and CORNET practices reported using nurse prompts to providers at preventive visits (61% and 52%, respectively), physician education (53% and 53%), and scheduled vaccine-only visits (91% and 82%). Strategies not used that clinicians frequently indicated they would consider included patient reminder/recall and prompts to providers via nurses or electronic health records. As preventive visits and immunization recommendations grow more complex, using technology to support immunization delivery to adolescents might be effective.

Cost effectiveness analysis of elementary school-located vaccination against influenza--results from a randomized controlled trial.

School-located vaccination against influenza (SLV-I) has been suggested to help meet the need for annual vaccination of large numbers of school-aged children with seasonal influenza vaccine. However, little is known about the cost and cost-effectiveness of SLV-I. We conducted a cost-analysis and a cost-effectiveness analysis based on a randomized controlled trial (RCT) of an SLV-I program implemented in Monroe County, New York during the 2009-2010 vaccination season. We hypothesized that SLV-I is more cost effective, or less-costly, compared to a conventional, office-located influenza vaccination delivery. First and second SLV-I clinics were offered in 21 intervention elementary schools (n=9027 children) with standard of care (no SLV-I) in 11 control schools (n=4534 children). The direct costs, to purchase and administer vaccines, were estimated from our RCT. The effectiveness measure, receipt of ≥1 dose of influenza vaccine, was 13.2 percentage points higher in SLV-I schools than control schools. The school costs ($9.16/dose in 2009 dollars) plus project costs ($23.00/dose) plus vendor costs excluding vaccine purchase ($19.89/dose) was higher in direct costs ($52.05/dose) than the previously reported mean/median cost [$38.23/$21.44 per dose] for providing influenza vaccination in pediatric practices. However SLV-I averted parent costs to visit medical practices ($35.08 per vaccine). Combining direct and averted costs through Monte Carlo Simulation, SLV-I costs were $19.26/dose in net costs, which is below practice-based influenza vaccination costs. The incremental cost-effectiveness ratio (ICER) was estimated to be $92.50 or $38.59 (also including averted parent costs). When additionally accounting for the costs averted by disease prevention (i.e., both reduced disease transmission to household members and reduced loss of productivity from caring for a sick child), the SLV-I model appears to be cost-saving to society, compared to "no vaccination". Our findings support the expanded implementation of SLV-I, but also the need to focus on efficient delivery to reduce direct costs.

Parent and adolescent perspectives about adolescent vaccine delivery: practical considerations for vaccine communication.

We surveyed parents of adolescents (n=430) and their adolescents ages 15-17 years (n=208) in 9 primary-care settings in Monroe County, NY to assess perceptions about adolescent vaccine delivery. Parents and adolescents most wanted to discuss vaccine side effects and the diseases prevented with the adolescents' provider. Those who perceived vaccines as very safe were more accepting of adolescent vaccines. Most participants agreed with vaccinating the teen during a mild illness and with providing multiple vaccines concomitantly. Participants most preferred medical, as opposed to other settings, for receipt of adolescent vaccines. For parents and adolescents who are wary of vaccination, strategies are needed to enhance communication about risks and benefits of vaccinations.

Patient-provider communication and human papillomavirus vaccine acceptance.

The authors performed telephone interviews of parents of adolescents (n = 430) and their older adolescents (n = 208) in Monroe County, New York to measure parent and adolescent acceptance of human papillomavirus (HPV) vaccine, its association with ratings of provider communication, and vaccine-related topics discussed with the adolescent's provider. More than half of adolescent girls had already received an HPV vaccination, with fewer than one quarter refusing. Parent and teen ratings of provider communication was high, and not related to HPV vaccine refusal. Parents were more likely to refuse if they were Hispanic (odds ratio [OR] = 5.88, P = .05) or did not consider vaccines "very safe" (OR = 2.76, P = .04). Most parents of boys (85%) believed males should be given HPV vaccine if recommended. Few parents and teens recalled discussing that vaccination does not preclude future Pap smear testing. Providers should address cultural and vaccine safety concerns in discussions about HPV vaccine.

Cost of universal influenza vaccination of children in pediatric practices.

OBJECTIVES: The goals were to estimate nationally representative pediatric practices' costs of providing influenza vaccination during the 2006-2007 season and to simulate the costs pediatric practices might incur when implementing universal influenza vaccination for US children aged 6 months to 18 years. METHODS: We surveyed a stratified, random sample of New York State pediatric practices (N = 91) to obtain information from physicians and office managers about all practice resources associated with provision of influenza vaccination. We estimated vaccination costs for 2 practice sizes (small and large) and 3 geographic areas (urban, suburban, and rural). We adjusted these data to obtain national estimates of the total practice cost (in 2006 dollars) for providing 1 influenza vaccination to children aged 6 months to 18 years. RESULTS: Among all respondents, the median total cost per vaccination was $28.62 (interquartile range: $18.67-45.28). The median component costs were as follows: clinical personnel labor costs, $2.01; nonclinical personnel labor costs, $7.96; all other (overhead) costs, $10.43. Vaccine purchase costs averaged $8.22. Smaller practices and urban practices had higher costs than larger or suburban practices. With the assumption of vaccine administration reimbursement for all Vaccines for Children (VFC)-eligible children at the current Medicaid median of $8.40, the financial loss across all US pediatric practices through delivery of VFC vaccines would be $98 million if one third of children received influenza vaccine. CONCLUSION: The total cost for pediatric practices to provide influenza vaccination is high, varies according to practice characteristics, and exceeds the average VFC reimbursement.

How effectively can health care settings beyond the traditional medical home provide vaccines to adolescents?

OBJECTIVES: Our goal was to evaluate the capacity of various health care settings to supplement the activities of the traditional medical home by delivering vaccines to adolescents. METHODS: A group of experts in the fields of adolescent-immunization delivery and the provision of preventive care in various health care settings summarized the available literature, considered setting-specific factors, and assessed the ability of various health care settings beyond the traditional medical home to conform to the immunization quality standards set by the National Vaccine Advisory Committee, report vaccination information for the quantitative assessment of vaccine-coverage rates, be likely to offer vaccines to adolescents, and be viewed by adolescents as acceptable sites for receiving vaccinations. RESULTS: Seven candidate settings were evaluated: pharmacies, obstetrics-gynecology practices, sexually transmitted disease clinics, hospital emergency departments, family planning clinics, teen clinics, and local public health department immunization clinics. The panel concluded that all could safely provide vaccinations to adolescents but that vaccination efforts at some of the settings could potentially have a markedly greater impact on overall adolescent-immunization rates than could those at other settings. In addition, for adolescent-vaccination services to be practical, candidate settings need to have a clear interest in providing them. Conditional on that, several issues need to be addressed: (1) funding; (2) orienting facilities to provide preventive care services; (3) enhancing access to immunization registries; and (4) clarifying issues related to immunization consent. CONCLUSIONS: With supporting health policy, health education, and communication, health care settings beyond the traditional medical home have the potential to effectively augment the vaccination efforts of more traditional settings to deliver vaccines to adolescents. These health care settings may be particularly well suited to reach adolescents who lack access to traditional sources of preventive medical care or receive fragmented medical care.

The feasibility of universal influenza vaccination for infants and toddlers.

BACKGROUND: Physicians' opinions on the feasibility of routine influenza vaccination of infants and toddlers are unknown. OBJECTIVE: To assess the opinions of primary care providers regarding (1) the feasibility of an expanded influenza vaccination recommendation, (2) potential barriers, and (3) current and projected use of immunization reminder systems for influenza vaccination. METHODS: In February 2001, we mailed a 20-item, self-administered survey to a national random sample of pediatricians and family physicians (FPs). The survey primarily focused on a scenario of routine influenza vaccination for children aged 12 through 35 months using either injected or intranasal spray vaccine. RESULTS: Four hundred fifty-eight eligible physicians completed the survey (eligible response rate: pediatricians, 72%; FPs, 52%). Regarding the scenario mentioned above, most physicians agreed that implementation would be feasible (pediatricians, 80%; FPs, 69%); would significantly decrease illness visits during influenza season (pediatricians, 67%; FPs, 57%); and was justified by influenza's severity and complications (pediatricians, 61%; FPs, 41%). When considering a scenario that extended down to 6 months of age and only allowed use of injectable vaccine for infants, fewer physicians (pediatricians, 50%; FPs, 40%) considered implementation feasible. The issues most frequently cited as important potential barriers for practices were costs (77%), vaccine safety issues (52%), and the inability to identify eligible children (46%). CONCLUSION: To make widespread implementation feasible, the following are needed: minimizing costs for families and physician practices, educational campaigns on key issues, and primary care system changes (eg, tracking of eligible children, reminder and/or recall systems, and immunization clinics).

Streptococcus pneumoniae-related illnesses in young children: secular trends and regional variation.

BACKGROUND: Children <2 years old have been targeted for routine pneumococcal conjugate vaccine. Laboratory-confirmed illnesses represent a minority of all medical care utilization for pneumococcal disease. OBJECTIVES: To evaluate trends in medical care utilization for Streptococcus pneumoniae-related illnesses before introduction of pneumococcal conjugate vaccine (1995 to 1999) and to evaluate regional variation in utilization. METHOD: Retrospective cohort analysis with the use of computerized billing data of children <2 years old enrolled in Tennessee (Medicaid program) and the Rochester, NY area (commercial and Medicaid managed care plans). Secular trends (1995 to 1999) analysis included 316 519 person-years in Tennessee Medicaid. Regional variation (1998 to 1999) analysis included 130 525 person-years in Tennessee and 26 140 and 3184 person-years in commercial and Medicaid plans, respectively, in the Rochester, NY area. RESULTS: From 1995 to 1999 in Tennessee, the net increase in medical care visits was 12% for pneumococcal and nonspecific pneumonia and invasive disease, 11% for otitis media and 11% for other acute respiratory conditions. Analysis of trends indicated that a significant vaccine effect could be detected if utilization rates declined by 32, 9 and 21%, respectively. In the Tennessee Medicaid population, rates of pneumococcal and nonspecific pneumonia and invasive disease were 60% higher than in either the New York Medicaid or the commercial populations. Children with commercial insurance had the highest medical care utilization for otitis media. CONCLUSIONS: Geographic variation and large population differences in medical care utilization among children < 2 years old in three study populations suggest that the benefits of vaccination may vary by region and by population. In the Tennessee Medicaid population, temporal trends and year-to-year variability of pneumococcal-related outcomes were observed from 1995 to 1999. In this population a 10% decline in otitis media visits after the introduction of pneumococcal conjugate vaccine could be detected by trend analysis.

Physician perspectives regarding pneumococcal conjugate vaccine.

OBJECTIVES: Pneumococcal conjugate vaccine (PCV) was first licensed for routine administration to young children in February 2000. The objective of this study was to assess physician perspectives about the use of PCV, to ascertain which children were being given the vaccine soon after licensure, and to determine how the addition of PCV to the schedule of recommended childhood vaccines may affect the timing of other vaccinations. METHODS: A 30-item survey containing questions about the use of PCV was sent to all pediatricians and family physicians who provide primary care to young children in Monroe County (Rochester, NY) and Davidson County (Nashville, TN) in October 2000. As many as 3 subsequent mailings were sent to nonresponders. Descriptive and chi(2) statistical analyses and logistic regression were used to evaluate the responses. RESULTS: Response rates were 82% in Rochester and 78% in Nashville. Eighty-two percent of responding physicians, including 92% of pediatricians and 55% of family physicians, indicated that they were giving PCV to their patients at the time of the survey. Sixty percent noted that an initial lack of insurance reimbursement for the cost of the vaccine caused them to delay introducing PCV. Fifty-one percent delayed initially offering the vaccine to any of their patients because the Vaccines for Children (VFC) program did not begin to offer PCV until several months later. The vast majority routinely vaccinated healthy children who are younger than 2 years as well as older children who had defined chronic medical conditions that put them at high risk of invasive pneumococcal disease. Fewer than 15% were recalling patients for PCV, with most recall efforts focused on patients who had chronic medical conditions. When discussing PCV with parents, 78% of physicians primarily emphasized the vaccine's potential to decrease the risk of sepsis and/or meningitis, whereas smaller percentages primarily emphasized the vaccine's potential to decrease the risk of pneumonia or ear infections. Approximately 20% of physicians who gave PCV delayed other vaccinations (primarily varicella vaccine, hepatitis B vaccine, or polio vaccine) because of concern about administering 4 or more vaccines simultaneously. Similarly, 40% of physicians indicated that they considered PCV to be more important than varicella vaccine or hepatitis B vaccine, whereas 26% percent considered PCV to be more important than polio vaccine. CONCLUSIONS: PCV has been widely accepted by physicians in both Rochester and Nashville. However, many physicians delayed introducing the vaccine for reasons that were ultimately related to financial considerations. For privately insured patients, delays were related to when coverage for PCV was added to benefit packages. For patients who receive publicly purchased vaccine via the VFC program, delays were related to availability of the vaccine through the VFC program. In addition, after the introduction of PCV, some physicians began delaying the administration of other vaccines because of the need to give multiple vaccinations simultaneously. Although lack of insurance or VFC coverage and concerns about multiple simultaneous injections may somewhat delay the initial use of newly recommended vaccines, physicians rapidly begin to provide new vaccines that they believe to be beneficial once those vaccines are incorporated into existing payment mechanisms.