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AFIX Policies and Procedures FAQs

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Q: Is it a CDC requirement to split the AFIX and VFC site visits?

A: No. Splitting the site visits is not a CDC requirement, but is strongly recommended. After the Office of Inspector General report was released in 2012, CDC’s response included the recommendation for awardees to review current policies and procedures. The purpose of the recommendation is to focus the attention of a VFC visit on VFC program requirements and an AFIX visit on AFIX program requirements. Based on thorough internal assessment, the awardee can choose whether or not to separate the visits as long as the awardee can ensure proper VFC oversight with particular attention on storage and handling practices. CDC does require that all site visit standards be fully met during a VFC or AFIX visit.


Q: Is it a CDC recommendation that awardees split the AFIX and VFC site visits?

A: Yes. CDC recommends splitting the AFIX and VFC site visits for the reasons stated above. The awardee can choose whether or not to separate the visits as they are in the best position to determine their specific program needs and resources. CDC does require that all site visit standards be fully met during a VFC or AFIX visit.


Q: Can we continue to conduct the VFC and AFIX site visits jointly?

A: Yes. An awardee can choose to conduct the site visits jointly or separately.

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Q: What changes are being made to the AFIX program and its standards (Policies and Procedures Guide)?

A: New developments

  • IIS-based assessments are becoming the new standard rather than chart-based assessments.
    • The IPOM Objective for the current project period not only requires awardees to conduct AFIX visits, but it also requires awardees to move towards the use of IIS as their data source for assessments.
  • AFIX site visit questionnaire.
    • A new questionnaire for AFIX visits will be required starting January, 2014 to provide baseline data on the current immunization strategies practiced in VFC provider offices. The baseline data will also be used to monitor improvements in immunization services.
  • AFIX checklists.
    • These checklists may be helpful for assessors preparing for AFIX visits. They are neither required nor standard, and programs may update them as they see fit
  • Beginning January 2014, the meaning of the “X” in AFIX will represent the follow-up process between awardees and providers. Additional information is available in the AFIX Policies and Procedures Guide.

Dropped or removed

  • The Hybrid Method.
    • This method is no longer an acceptable standard by CDC. The size of a practice (among other criteria) helps prioritize the visits but does not exclude any provider from AFIX. The data generated through the Hybrid Method does not provide a true assessment of coverage or a list of patients to remind/recall to bring up-to-date on immunizations.
    • CDC will work with awardees that utilize the hybrid method to assist with their transition away from this method.
  • AFIX Qualitative-only visits.
    • Beginning in January, 2014, every AFIX visit, regardless of the number of patients in the provider’s practice, will include both a quantitative component (coverage reports) and a qualitative component (site visit questionnaire).


  • The VFC Management Survey (for AFIX) will be replaced with the AFIX Annual Report. The separation was a decision made by the OIG Response Team to allow for a more detailed view and analysis of each program’s data.
    • Data may be reported via CoCASA and submitted in PAPA.
    • Data may be reported directly in PAPA using the AFIX online tool.
  • The Standards Guide and Core Elements will be replaced by the AFIX Policies and Procedures (P&P) Guide.
    • This guide is to function as CDC’s updated program standards.
    • This guide is to be referenced when updating and submitting your P&P Guides in 2014.
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Q: Is it a CDC requirement to visit 25% of providers for AFIX?

A: No. For CY 2013 and 2014, CDC recommends that awardees annually conduct AFIX visits to 25% of VFC-enrolled providers in their jurisdiction. More information will be shared about this for CY 2015 as it becomes available. It is important to note that Healthy People 2020’s objective for AFIX IID-17 targets 50% of public and private health providers to: “Increase the proportion of providers who have had vaccination coverage levels among children in their practice population measured within the past year.”

Continuing to visit 25% of VFC enrolled providers is an important step toward reaching the 50% goal outlined in Healthy People 2020.


Q: Is it a CDC requirement to conduct AFIX feedback in person?

A: No. CDC recommends that feedback be completed in person. The one-on-one feedback process with the provider office staff allows for a personal and positive environment to provide education and work collaboratively. The assessment standard for AFIX also recommends that an assessor observe any immunization practices or systems that could be addressed and improved upon during the feedback session. For example, when visiting the provider to discuss their immunization coverage rates, an assessor may notice that immunization schedules are not clearly displayed for patients/parents and may bring that to the provider staff’s attention.

However, if awardees find it unfeasible to reach a provider in person, then other tools may be used to conduct feedback, including webinars, telephone calls, mail, or email.


Q: Is it a requirement in the updated AFIX standards to give feedback to the provider one week following the assessment or the initial visit?

A: No. CDC recommends sharing feedback from the assessment as soon as possible after the provider visit, whether assessment reports are generated through pulling charts or IIS. CDC recommends that no longer than one week pass between assessment and feedback to ensure that the data generated presents an accurate picture of a provider’s coverage assessment. This recommendation is neither a change nor an update to AFIX standards.

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Q: Are the updated AFIX standards requiring that assessors pull 50-200 charts for the AFIX assessment?

A: It is a CDC recommendation that awardees pull 50-200 charts for the AFIX assessment. This standard has been in place since 2004. The AFIX Core Elements publication dated April 2004 and developed by an advisory group of awardees and CDC staff, states the following for pediatric and adolescent assessments: “If using the standard (chart audit) assessment method, it is recommended to review 50-200 charts” (page 8).

The level of accuracy when conducting a coverage assessment is an important consideration. The guidance provided for conducting AFIX activities was developed by considering both the accuracy of estimates from the assessment and the burden and feasibility of conducting the assessment. The basic recommendation to sample between 50 and 200 records was developed with the objective of obtaining estimates that would have an accuracy of at least +/- 7 percentage points. The accuracy of +/- 7 percentage points was chosen to minimize the sample size while simultaneously allowing you to accurately differentiate between low, medium and high performing clinics and to reliably determine if coverage for a clinic changed from one time point to another.

A sample size of 50 was selected for the lower range because it was determined to be feasible for implementation and would likely produce a sufficient number of cases to credibly illustrate provider practice problems such as missed opportunities.

In the future, more guidance will be issued by CDC regarding sampling plans and ensuring that a sampling plan will yield a representative sample with significant coverage estimates. CDC will also be reviewing the sampling methods utilized by awardees and providing support as needed.

As mentioned in multiple forums and conference calls, the future of AFIX is one in which we move to a more streamlined and efficient process. Our goal is to move away from the time-intensive process of pulling charts and toward utilization of IIS for AFIX coverage assessments.

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Q: Do the updated AFIX standards recommend including all immunization office staff in the feedback session?

A: Yes. CDC recommends that you invite all immunization office staff to attend the feedback session. The feedback session is, in part, an educational session that immunization staff, regardless of their role, will benefit from. As a result of feedback sessions, immunization staff should be knowledgeable about current ACIP recommendations, including minimum intervals and contraindications. For example, if the front desk and scheduling staff attend the feedback session, an assessor should ensure they are familiar with the schedule for immunization recommendations in order to schedule immunization appointments during appropriate times.

AFIX protocols have always encouraged as much staff participation in feedback as possible. This recommendation is neither a change nor an update to AFIX standards.


Q: Why was the age group 4-6 years separated for assessment?

A: CDC decided to revise this proposed standard so as not to duplicate efforts currently in place for the 4-6 age group assessments. The adolescent (13-18 years) vaccinations list will be kept in its current format to include: HepB, MMR, VAR, Tdap, MCV, and HPV. This content will be reflected in the Policies and Procedures Guide.

The reason for the separation we originally proposed is that Tdap, MCV, and HPV vaccines are the vaccines routinely recommended for teens at ages 11-12 years, while MMR, HepB, and VAR are equally important vaccines but the majority of teens should have received them as children. The addition of a 4-6 year-old childhood assessment group would have helped in collecting coverage data closer to the recommended age range for receiving recommended vaccines.

To date, AFIX adolescent (13-18 years) assessments have included HepB, MMR, VAR, Tdap, MCV, and HPV. To summarize your comments during the AFIX quarterly call on July 17th:

  • The assessment coverage for 4-6 age groups is already collected through school coverage assessments.
  • The assessment coverage including HepB, MMR, and VAR enables AFIX assessors to catch up on immunizations missed in childhood.
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Q: What are the updated AFIX standards regarding the tools for assessing flu coverage?

A: If you are using CoCASA to assess flu coverage, you will have the option of assessing patients as up-to-date for a full completed season only. However, if you select to assess an ongoing season, CoCASA will give you the option of generating a “quick count report” which provides the count of patients who have already received their flu vaccine. The “quick count” does not label patients as up-to-date or not up-to-date, it only counts them as having received or not received their flu vaccine.

The up-to-date report in CoCASA version 9.0 will be a new feature. This additional feature can help the provider view their performance in the prior flu season and get a better understanding of how to count patients as up-to-date on the flu vaccine.

On the other hand, if you are using IIS only and not generating the reports using CoCASA, the expectation is that you continue assessing flu coverage as you currently do until further guidance is provided in the IIS logic guidance expected to be released in 2014.

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Q: How will the logic guidance be prepared?

A: The logic guidance will support the movement toward the use of IIS as the primary source of data for provider coverage level assessment. It will follow a MIROW-like process with a select group of program representatives who will participate in intensive discussions while the broader community will have the opportunity to provide feedback during the process. CDC will continue to keep awardees informed as more information becomes available.


Q: How will the logic guidance impact awardees that already have IIS-based AFIX assessment reports?

A: Once the logic guidance is prepared, those circumstances will be handled individually between the program and CDC. There are variances that are natural and unavoidable across programs. However, once the logic guidance is developed, CDC will be in the best position to work with programs to determine if their existing practices that are different from the guidelines are acceptable variances, or if programs will need to modify reports and procedures.


Q: Will you provide a sample AFIX curriculum for training new AFIX reviewers and periodic training to existing reviewers?

A: We have developed an answer guide for the site visit questionnaire, but will not be able to address training or education needs for AFIX visits before the end of 2013. We will reach out to the AFIX coordinators early next year to discuss these needs.


Q: Will the AFIX Site Visit Questionnaire be a requirement beginning in 2014?

A: Yes. Awardees are required to use the AFIX questionnaire with every site visit. Answers to the questionnaire should be documented in the PAPA online tool or CoCASA version 9.0.


Q: Will you provide a QI plan template that we will be required to use, or are we allowed to use our own (if we already have one developed)?

A: We encourage you to use your own template. We may provide samples in the future but we will not require you to use a CDC-developed template. When you submit your P&P Guide next year (June 2014), please attach a copy of your template for the review process.

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