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Recommendations of the Advisory Committee on Immunization Practices: Programmatic Strategies to Increase Vaccination Coverage by Age 2 Years -- Linkage of Vaccination and WIC Services

This statement by the Advisory Committee on Immunization Practices (ACIP), in collaboration with the U.S. Department of Agriculture's (USDA's) Food and Consumer Service (FCS), presents programmatic strategies to increase vaccination rates among preschool-aged children. This is the first statement to recommend assessment of vaccination status and referral for needed vaccinations of children receiving services from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Although vaccination coverage levels of first-grade school entrants are greater than 95%, during the 1989-1991 nationwide measles epidemic, coverage levels among urban children aged 2 years were commonly less than 50% (1). Based on studies conducted during the epidemic, 29%-63% of unvaccinated preschool-aged children with measles either were or had been enrolled in WIC.

WIC is a categorical federal grant program administered by the FCS through state health departments. The program provides supplemental foods, health-care referrals, and nutrition education to low-income pregnant, breastfeeding, or postpartum women; infants; and children aged less than 5 years. In 1995, approximately 1.8 million infants (44% of the U.S. birth cohort that year) and at least 5 million children aged less than 5 years participated in WIC monthly. In 1996, the total number of participants aged less than 5 years is expected to increase to approximately 6 million.

Assessment of vaccination status and referral for needed vaccinations linked with food-voucher issuance (more frequent visits for children not up-to-date and less frequent visits for those up-to-date) has been evaluated in New York City and Chicago and is being evaluated in Dallas. Among New York City WIC participants aged 12-59 months, 14% had not been vaccinated against measles; of these unvaccinated children, 79% who received assessment and referral linked with food-voucher issuance were vaccinated against measles within 6 months, compared with 86% who received assessment and escort to the vaccine-delivery site and 54% who received assessment and referral only (2). In Chicago, among groups receiving assessment and referral linked with voucher issuance, the prevalence of up-to-date status at age 2 years increased 36-40 percentage points; among the group receiving assessment and referral only, the prevalence increased only 4 percentage points (3).

CDC and USDA recommend that state and local vaccination and WIC programs collaborate to ensure that young children receive assessment and referral services (4). This recommendation requires that a documented vaccination record (parental recall alone is unreliable) of each WIC client be carefully reviewed as frequently as possible -- preferrably at each WIC visit. Providers are encouraged to provide vaccination records to parents to facilitate accurate assessment by WIC staff. Clients needing vaccinations should be referred to their usual source of comprehensive health care or be vaccinated on-site if feasible. Programs are encouraged to consider a variety of integrated service-delivery strategies, including the use of incentives for fully vaccinated young children, and outreach for and tracking of undervaccinated children. When possible, WIC and vaccination programs should use automated assessment modules and areawide vaccination data registries to increase the efficiency of assessment.

The ACIP recommends that WIC and vaccination programs assess regularly the vaccination coverage levels of WIC participants and develop new strategies and aggressive outreach procedures in those sites with coverage levels below 90%. In addition, vaccination programs and private providers are encouraged to refer eligible children to obtain WIC nutritional services. The linkage of WIC and vaccination services is expected to increase vaccination levels of high-risk preschoolers and to help sustain high coverage levels. CDC (in collaboration with WIC) is developing guidelines to implement this linkage, and in 1996, a portion of vaccination grant funds have been designated for the implementation.


  1. Hutchins SS, Gindler JS, Atkinson WL, et al. Preschool children at high risk for measles: opportunities to vaccinate. Am J Public Health 1993;83:862-7.

  2. Birkhead G, LeBaron CW, Parsons P, et al. The immunization of children enrolled in WIC: the impact of different strategies. JAMA 1995;274:312-6.

  3. Hutchins SS, Rosenthal J. Results from WIC demonstration projects. In: Proceedings of the 28th National Immunization Conference. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC;1995:1-4.

  4. Ad Hoc Working Group for the Development of Standards for Pediatric Immunization Practices. Standards for pediatric immunization practices. JAMA 1993;296:1817-22.

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