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By: Joseph St. Geme, MD

  • Chair, Department of Pediatrics, Professor of Pediatrics and Microbiology, Perelman School of Medicine at the University of Pennsylvania
  • Physician-in-Chief, Leonard and Madlyn Abramson Endowed Chair in Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania


Please be aware there are three common 9 treatment issues specific to prisons buy discount reminyl 4 mg line, claim-related issues that are not considered claim payment disputes medical treatment 80ddb cheap reminyl 4 mg with amex. You will not be penalized for filing a claim payment dispute symptoms to pregnancy purchase reminyl with visa, and no action is required by the member symptoms tonsillitis buy cheap reminyl on-line. The reconsideration represents your initial request for an investigation into the outcome of the claim. Claim payment appeal: this is the second step in the provider payment dispute process. If you disagree with the outcome of the reconsideration, you may request an additional review as a claim payment appeal. A claim payment dispute may be submitted for multiple reason(s), including: Contractual payment issues. Please note, we cannot process a reconsideration without a finalized claim on file. When submitting reconsiderations, please include as much information as you can to help us understand why you think the claim was not paid as you would expect. If a reconsideration requires clinical expertise, the appropriate clinical Amerigroup professionals will review it. Amerigroup will make every effort to resolve the claims payment reconsideration within 30 calendar days of receipt. We will mail you a written extension letter before the expiration of the initial 30 calendar day. Support for the action, including applicable statutes, regulations, policies, claims, codes or provider manual references. Claim payment appeals received more than 30 calendar days after the claims reconsideration determination letter will be considered untimely and upheld unless good cause can be established. When submitting a claim payment appeal, please include as much information as you can to help us understand why you think the reconsideration determination was in error. If a claim payment appeal requires clinical expertise, it will be reviewed by appropriate clinical Amerigroup professionals. Amerigroup will make every effort to resolve the claim payment appeal within 30 calendar days of receipt. If additional information is required to make a determination, the determination date may be extended by 30 additional calendar days. We will mail you a written extension letter before the expiration of the initial 30 calendar days. Online (for reconsiderations and claim payment appeals): Use the secure Provider Availity Payment Appeal Tool at. Through Availity, you can upload supporting documentation and will receive immediate acknowledgement of your submission. Written (for reconsiderations and claim payment appeals): Mail all required documentation (see below for more details), including the Claim Payment Appeal Form or the Reconsideration Form, to: Payment Dispute Unit Amerigroup Washington, Inc. Submit written claim payment appeals on the form Claim Payment Appeal Form, located at providers. Lactose is the principal sugar (or carbohydrate) naturally found in milk and dairy. Lactose is composed of glucose and galactose, two simpler sugars used as energy directly by our body. Although glucose could be found in several types of foods, lactose is the only source of galactose. Galactose has various biological functions and serves in neural and immunological processes. Galactose is a component of several macromolecules (cerebrosides, gangliosides and mucoproteins), which are important constituents of nerve cells membrane. According to more recent studies, lactose may play a role in the absorption of calcium and other minerals such as copper and zinc, especially during infancy. Moreover, if it is not digested in the small intestine, lactose may be used by the intestinal microbiota (the microorganism population that lives in the digestive tract) as a nutrient (prebiotic). Lactose and other milk sugars also promote the growth of bifidobacteria in the gut and may play a life-long role in countering the aging-associated decline of some immune functions. Effects of dietary lactose and lactase preparation on the intestinal absorption of calcium and magnesium in normal infants. Intestinal fermentation of lactose and prebiotic lactose derivatives, including human milk oligosaccharides. Lactose maldigestion is the difficulty to digest lactose, a type of sugar naturally found in milk and dairy food. It is due to the normal reduction of the activity of lactase, the enzyme that transforms lactose into glucose and galactose, both simpler sugars used by our body for energy and various functions. Lactose intolerance is the inability to digest lactose that results in intestinal discomfort such as bloating, diarrhea, and gas. However, these symptoms are not specific to lactose intolerance and can be associated with psychological factors, such as stress and emotional trauma, or intestinal dysfunctions occurring, for example, during infection or malnutrition. It is important to remind that lactose intolerance is not a disease but a condition. In both cases (lactose maldigestion and intolerance), only a fraction of lactose is digested. For some individuals, the bacterial fermentation of non-digested lactose in the colon results in one or many symptoms such as bloating, diarrhea, and flatulence. Thus, lactose intolerance is lactose maldigestion that results into one or many of these symptoms. Moreover lactose intolerance concerns very few people, whereas lactose maldigestion concerns 70-75% of the world population. This includes the tests you could find on the Internet, as these tests are not scientifically validated. The diagnosis of lactose intolerance is solely performed under strict medical control with an ad hoc hydrogen breath test. This test includes an oral challenge with a standard dose of lactose (usually 20 to 50g) followed by the detection, in the exhaled air, of hydrogen produced by the intestinal flora and by the occurrence of one or several/many of the following symptoms: bloating, diarrhea, and flatulence. Often, lactose intolerance is self-diagnosed by individuals who experience intestinal discomfort after the consumption of dairy products. When they undergo the correct medical diagnosis, only 50% of individuals with self-diagnosed lactose intolerance see their condition confirmed. Nevertheless, the diagnosis of lactose intolerance should not rule out any other underlying digestive pathology. The relationship between lactose tolerance test results and symptoms of lactose intolerance. For lactose intolerants and maldigesters, avoidance of milk and dairy products could have health consequences. All medical organizations recommend that lactose maldigesters and intolerants should not avoid dairy foods in order to prevent nutrients shortcomings. The consumption of yogurt, which contains live bacteria that help digesting the lactose it contains, and of cheeses that contain low or no lactose is possible and even encouraged (cheddar, provolone, mozzarella, etc. Lactose-free food or avoidance of dairy food is only needed for the rare infants with congenital lactase deficiency. Total lactase deficiency is rare (less than 50 patients in the world, mainly in Finland). Lactase supplemented food are also not necessary for lactose maldigesters and lactose intolerants. Self-perceived lactose intolerance results in lower intakes of calcium and dairy foods and is associated with hypertension and diabetes in adults. Yogurt is a type of predigested food that contains sugars, proteins and fats, broken into simple forms. Lactose maldigesters and lactose intolerants can consume yogurt because the lactose in yogurt is digested more efficiently than any other dairy sources. Yogurt is a form of fermented milk that contains live bacteria, Lactobacillus delbrueckii subsp.


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  • Mievis Verellen Dumoulin syndrome
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Set Client defaults (Controls > Defaults > Practice and Workstation > select Client from the menu on the left) holistic medicine generic reminyl 4 mg free shipping. Set Patient defaults if you also plan to medications 2355 discount reminyl 8mg mastercard set up patients now (Controls > Defaults > Practice and Workstation > select Patient from the menu on the left) georges marvellous medicine cheap reminyl 4 mg on-line. Do one of the following: · · · On the Patient Clipboard medications hyponatremia reminyl 8 mg on-line, right-click in the Client area (top-left area) and select New. To access the Client Information window for a new client: On the Lists menu, select Client and then click New on the Client List window. Then in Alerts defaults (Controls > Defaults > Practice and Workstation > Alerts), select Classification in the Client alerts list. If the Show trainer and barn option is selected in Patient defaults (Controls > Defaults > Practice and Workstation > Patient), the Type field is displayed. If you want to add another name to this client record, click the Secondary Names button and enter the name information. Secondary names are useful if the pet belongs to two or more people with different last names. This allows you to search for the client (and patient) record under more than one name. Select the Print check box next to the secondary name to include the name on invoices and statements. If the client does not want to provide the email address, select the Email declined check box. This turns off the highlight and turns off missing email alerts if you have them set up. If you want this client to receive reminders via email, select the E-mail reminders check box. In the Phones area, right-click to select from a menu of options for adding, updating or deleting a phone number. See "Setting Up and Updating Client Phone Numbers" in the next section for information on entering client phone information. Tip: Use the scroll bar on the right side of the Phones area to view additional phone numbers. In the Patients area, right-click to select from a menu of options for adding, updating or deleting a patient for this client. See "Chapter 4: Entering Patient Information" beginning on page 53 for information on entering patient information. The Client reports group includes many reports that allow you to view client information. Tip: To access client phone numbers and any associated notes from the Patient Clipboard, click the Phones 1. To add or update a client phone number: Open the Client Information window and click the Information tab. In the Phones area, right-click and select New (or double-click) to open the Phone Information dialog box. Click Print to print a record of the client with the duplicate phone number or click Close to close the alert. To cancel and close the Phone Information dialog box without saving the phone number, click Cancel and click No when prompted to save changes. In the Location drop-down list, select the location associated with this phone number, such as home, work, cellular, etc. In the Notes text box, type any notes associated with this phone number, such as times available. If the client has more than one phone number and you want this phone number to be the primary number, select the Primary Phone Number check box. The primary phone number prints on reports and displays in windows that display only one phone number. When you use prompts and notes, you can: · · Create a prompt to be used as an alert. Tip: To access client prompt answers and notes from the Patient Clipboard, click the Prompts and Notes 1. To answer client prompts or add a note to Client Information: Open the Client Information window and click the Prompts/Notes tab. In the Prompts/answers area, the client prompts that were set up in User Defined Prompts (in Controls > User Defined Prompts) are displayed. For a list of clients and their answers to prompts, print a Client Prompts Report. You can identify which advertising media creates the most new clients so you get the most from your advertising budget. Tip: Set up advertising media as clients, and then link the media referral source to the client to track the effectiveness of your advertising. For example, set up clients with the last names Newspaper, Street Sign and Yellow Pages and mark those clients inactive so they will not display in the Client List. Before You Begin · · · Set up the discounts you want to use in your practice (Controls > Discounts). Set up a default credit code in Client defaults (Controls > Defaults > Practice and Workstation > select Client from the menu on the left). In the Monthly charges area, if monthly charges should be applied (when applicable) for this client, select the Finance charge and/or Billing charge check boxes. Select any Discounts to apply to this client (highlighted/shaded discounts are selected). The discounts will apply to invoice items that are also set up with this discount. Note: When using a Multi-Location/Single Database configuration, every client must have a home practice assigned. At the time when the Multi-Location/Single Database option is activated, the primary practice is automatically designated as the home practice for all clients. However, the clients can later be assigned to different practices using the Assign Clients to Practice tool. To see how accounts receivable information has been set up for clients, print a Client A/R Information Report. Merging Clients and Patients If you have clients with different last names who together are responsible for a patient, you may have set up two different accounts for the clients. A message appears to remind you that merging should be performed during times of low system use. Under Merge Type, specify the type of record to merge-Client or Patient (click the icon to change the record type). If there were any errors, click Print to view a description of the error on the Merge Clients/Patients Report. Setting Up New Client Accounts (for New Cornerstone Practices only) Use the following set of instructions only if you are setting up a new Cornerstone system and your existing client accounts have not been converted to Cornerstone accounts. In most cases, client account balances are automatically converted as part of the initial conversion process and do not need to be manually entered into Cornerstone. Before You Begin Enter an adjustment comment in Account defaults (Controls > Defaults > Practice and Workstation > select Account from the menu on the left). For example, an initial adjustment comment might be "Client set up in system 00/00/00. Do one of the following: · On the Patient Clipboard, select the client and in the Client information area, click the Account Information · · tab. Note: At the bottom of the Adjusted column: · · Total due reflects what the client now owes your practice. You can print this report for any time period processed-End of Day, End of Month or End of Year. Client Information Reports Cornerstone includes several reports related to client information. In the Reports list, click the plus sign to the left of Client to expand the list of client reports.

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Microbial testing may be necessary when available or outsourced Identification Assay Uniformity of dosage unit Disintegration Dissolution Related substances/ Impurities Endotoxin Sterility Foreign particulate matter Viscosity pH Visual inspection (Level 1) Simple visual inspection may identify important characteristics related to symptoms rotator cuff injury 8 mg reminyl with mastercard product quality (registration status medicine runny nose buy reminyl mastercard, expiry symptoms 9f diabetes trusted reminyl 4 mg, product packaging medicine guide buy reminyl 8mg line, etc. Testing at this level can be primarily performed in the field at the point of sampling and can be used to identify falsified, substandard, unregistered, or incorrectly labeled medicines. For example, if a box of aspirin is discolored and moldy, immediate action is warranted rather than additional field screening or compendial testing. Failed samples can, in some cases, be omitted from further testing, which reduces the costs associated with post-marketing surveillance. Before assessing other aspects of quality, inspectors should confirm that the product is registered with the appropriate and relevant regulatory authority and has not expired. When unregistered or expired products are detected, inspectors should discuss the findings with the regulatory Implementing Risk-Based Post-Marketing Surveillance Programs 17 authority to determine appropriate next steps. Depending on the objective of the study, further assessment of the quality of the product may be warranted. Visual inspection can also include an assessment of the product label, packaging, and presentation. Inspectors may review the batch number, scientific name, company logo, number of units per container, dosage form, strength, manufacturer address, presence of a package insert, integrity of packaging, color, texture, presence of particulates, and other characteristics. Ensuring that inspectors have access to a current medicines registry or other visual inspection tools is critical to effectively supporting the detection of quality issues at Level 1. Products that fail some aspect of visual inspection should be discussed with the regulatory authority to determine appropriate action. In some cases, the regulatory authority may choose to seek clarification with the manufacturer, proceed with other aspects of quality testing, or take other decisions based on the results presented at Level 1. Field-based screening (Level 2) Level 2 involves analytical testing of product quality using field-based screening technologies. Field-based screening technologies can identify potential product quality issues that may not be apparent at Level 1 and can further reduce the number of samples that require compendial testing (Level 3). This level of test is qualitative to semi-quantitative and, depending on the capability of the screening technology utilized, provides information on the identity of the active ingredient, possible degradation, and/or impurities. Depending on the objective of the sampling and testing protocol, a product that passes identification and other applicable field-based screening provides sufficient information and eliminate the need for additional testing. Alternatively, based on which screening tools are used and the tests performed, the regulatory authority may choose to send a portion of the passed samples for compendial testing (Level 3) to confirm the results. Samples that fail field-based screening tests may be retested at the compendial level to confirm results. If a product passes identification, additional tests should be prioritized in the following order: content, disintegration, and impurities. Implementing Risk-Based Post-Marketing Surveillance Programs 19 Compendial testing (Level 3) Compendial testing provides the most extensive information on product quality, but it is also the most complex, expensive, and time-consuming type of testing. Using a riskbased approach in the development of the study protocol, collection of samples, and testing of samples through the Three-Level Approach can reduce the number of samples that need to be tested using compendial methods, and can therefore reduce the costs associated with conducting sampling and testing activities. Compendial testing should be carried out on suspected samples that fail field-based screening tests and, depending on the protocol, on a portion of samples to confirm the results from Level 2. Figure 3 proposes a scheme for prioritizing compendial testing based on the type of product being tested, the risk associated with samples, the costs associated with particular tests, and the technical complexity. Note that if a product fails a test at Level 2 (for example, the sample does not pass disintegration), the same test should be performed at Level 3 using compendial methods before initiating tests for other quality attributes. If the result from Level 2 is confirmed at Level 3, then no further testing is needed. If, on the other hand, conducting the same test using compendial methods does not confirm the result from Level 2 testing, it is recommended that the analyst proceed with the suggested prioritization of compendial tests as outlined in Figure 3. The approach described in Figure 3 is not intended as a list of compendial test requirements, and does not include every testing scenario that one may encounter. Rather, the flow diagram is meant to illustrate the prioritization of analytical tests to guide the sequence for testing the majority of medicines samples, as applicable. The suggested prioritization takes into consideration the resources, time, materials, and number of samples required to perform each test. Depending on the dosage form, formulation, or other considerations, appropriate adjustments to this sequence may be necessary. For example, if the product being tested is an injectable, disintegration and dissolution tests are not applicable and should be skipped. Additionally, for products procured by the Global Fund or similar organizations with sound quality assurance measures in place. For instance, if samples from a Global Fundprocured lot were collected from the port-of-entry, then performing an assay of the sample may be sufficient. Similarly, if the same lot of product is sampled further downstream in the distribution chain. Finally, some products may require additional tests that are not listed in Figure 3. Figure 3 should be used together with the applicable pharmacopeial requirements for the product. Suggested prioritization for compendial testing (Level 3) § Start Did product fail any test at Level 2? For injectable products, basic tests such as pH and fill volume should be confirmed before starting Level 3 testing. The number of samples is determined based on the objectives and information about the area. Selection of area to sample Information required Administrative and health structure, updated demographic information, disease prevalence, medicines supply chain, pharmaceutical sector information (number of outlets for each sector). Selection of medicines Most-used medicines, most-sold medicines, higherrisk medicines (stability, storage). Selection of collection sites Complete data on supply systems for targeted medicines. Complete and up-todate information about the pharmaceutical sector in the area (number of outlets, levels of distribution, type of outlets, type of available sectors for supplies, geographical and administrative structure. Selection of sampling method Sampling methods depend on the type of medicine, its supply system, and the objectives of sampling and testing activity. Data and knowledge of the pharmaceutical sector, the supply chain systems, and the known practices and behaviors of consumers and dispensers are required. Central medical store, wholesalers should provide information about supply systems (often different among public, private, and informal). Data on the capacity of the laboratories where the tests will be performed should also be considered. Key stakeholders involved in a sampling and testing activity are outlined in Table 4. However, stability testing would be an important measure of quality for samples collected further downstream in the supply chain. In these instances, following the sampling and testing guidelines provided earlier in this section and using the Three-Level Approach could help reduce the number of samples tested at Level 3, reduce the overall cost of the exercise, while also ensuring appropriate quality testing is conducted. Implementing Risk-Based Post-Marketing Surveillance Programs 25 26 Risk-Based Post-Marketing Quality Surveillance 04 Risk-Based Post-Marketing Surveillance Tool Sampling of medicines during post-marketing surveillance studies are often not conducted systematically and may have limited usefulness due to a poorly designed study protocol, leading to ungeneralizable or non-statistically significant conclusions. Figure 4 depicts the conceptual framework for the surveillance tool and shows the three dimensions of risk considered-medicines, geographic area, and supply chain-that are assessed to help countries identify the most susceptible medicines, determine the number of samples required, and prioritize sampling at the most vulnerable locations. The tool is designed to perform stratified randomized sampling of facilities based on their risk profile. If needed, the tool can also accommodate less rigorous sampling methods such as convenience sampling. To effectively use this tool, countries should map medicines outlets within the public and private sectors. It is recognized that a sizable amount of poor-quality medicines are found in the informal sector, sometimes in hard-to-reach areas. It is therefore important to carefully select sentinel sites and/or use purposeful sampling methods based on the risk posed to the population. Sentinel sites can also provide a means to monitor the impact of interventions aimed at reducing poor medicines quality. Framework for risk-based post-market surveillance tool 28 Risk-Based Post-Marketing Quality Surveillance Table 5. Output List of medicines to sample based on rank order of their individual risk scores.

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Among adults medicine search reminyl 4 mg fast delivery, as well treatment 8th feb cheap reminyl 8 mg line, Minnesota-specific data indicate narrowing of the disparities among some racial and ethnic groups in flu shot coverage among Medicare recipients treatment 6 month old cough cheap reminyl 8mg. Between 2001 and 2007 treatment norovirus 4 mg reminyl visa, the gap between the White and African American rates shrank by roughly five percentage points, while the gap between Whites and Asians was reduced by roughly eight points. However, it is not clear whether these changes are significant because the data used had its limitations, which are discussed later in this report. The lack of data specific to Populations of Color about the burdens of chronic disease, or scores on certain indicators of health, such as immunization, are common challenges in trying to eliminate many types of health disparities. This report begins with a brief discussion on the importance of maintaining high immunization rates, followed by a discussion of different ways to measure immunization rates, and factors affecting immunization rates. The report will also examine available sources of data on overall immunization rates among Minnesota children and adults, as well as evaluate potential sources of data on immunization disparities among Populations of Color. Finally, the report will describe steps that can be taken to continue our progress towards eliminating disparities in immunization rates in Minnesota. It has been one of the critical weapons in the battle to control and eliminate infectious diseases. In the United States, immunization rates are at an all-time high, and vaccinepreventable diseases (with few exceptions) are at all-time lows. At the beginning of the 20th century, infectious diseases were widely prevalent in the United States and took an enormous emotional, social, and economic toll on the population. However, since the mid-1900s, with the development of vaccines such as diphtheria, pertussis, tetanus, measles, rubella, mumps, polio, and meningitis - to name a few - there has been a dramatic decline in many infectious diseases in the United States (Table 3) and Minnesota (Attachment A). Table 3 selected vaccine-Preventable diseases, united states Disease Diphtheria Smallpox Hib (<5 yrs old) Measles Mumps Pertussis Polio Rubella Tetanus Cases per year (Average Before Vaccines) 175,885 48,164 20,000 503,282 152,209 147,271 16,316 48,164 1,314 Cases in 2007 0 0 2,541 43* 800 10,454 0 12 28 Decrease in Cases Per Year 100% 100% 87% 99. Impact of Vaccines Universally Recommended for Children ­ United States, 19001998. Herd Immunity ­ the Key to Immunization Success Herd immunity is achieved when the vast majority of the population is immune to a disease; the infectious agent cannot readily spread in a highly immune community. Those who are susceptible to the disease will be protected by the immune people around them. With herd immunity, vaccinated people help those who do not or cannot receive a vaccine by reducing the likelihood that they will come in contact with an infected individual. These people are susceptible to disease; their only hope of protection is for the people around them to be immune ­ meaning they will not pass disease to the unvaccinated. Therefore, it is important that immunization Minnesota Department of Health 9 rates remain high among all groups of people in a society. High immunization rates can result in disease rates of less than 1 percent or even disease eradication and prevent the spread of disease among entire populations. Cost Effectiveness Preventing disease through immunization has proven to be one of the most cost-effective preventive health measures. Vaccine-preventable diseases not only harm and sometimes kill their victims, but also have high financial and societal costs. For example, resurgence in measles in the United States in the early 1990s resulted in more than 55,467 measles cases, 132 measlesrelated deaths, and 11,251 hospitalizations, resulting in more than 44,100 hospital days, with an estimated $150 million in direct medical costs. Table 4 summarizes the expected cases of disease, deaths, and costs of a number of vaccine-preventable diseases with and without a vaccination program. For example, if there was not a vaccine for diphtheria, it is projected that there would be 247,214 cases and 24,721 deaths annually in the U. Table 4 Health and economic outcomes for selected vaccine-Preventable diseases With and Without a vaccination Program* Without Vaccination Program Disease Cases, No. Direct Costs $ (Million) Total Costs $ (Million) Prevented of Saved by Vaccination Program Cases, No. Because immunizing is an ongoing process and certain populations, such as Populations of Color, may need additional support to achieve adequate vaccination coverage, immunization rates must be regularly evaluated. Data on immunization coverage can help to identify groups at risk of vaccine-preventable diseases, target interventions to increase coverage, and evaluate the effectiveness of programs designed to increase vaccination coverage levels. There are a number of methodologies used to measure immunization rates and a variety of variables can be evaluated. In addition, there are multiple vaccines that prevent over seventeen life threatening diseases for both children and adults. There are four additional vaccines recommended exclusively for adults ­ pneumococcal vaccine, tetanus booster, zoster vaccine and influenza vaccine. I n order to sustain the benefits of vaccination, high immunization rates must be attained for each birth cohort of 4 million children in the United States (about Immunization Data There are several different ways to collect and evaluate immunization data by varying the data elements collected, such as age, vaccine doses, geographic area, and race/ethnicity. Even though these factors are discussed separately, researchers most often measure immunization rates by combining multiple factors. Children receive their first vaccination shortly after birth and individuals continue to need vaccinations into old age. Measuring immunization rates, whether in adults or children, requires determining age goal points, for example, the ages when a child should have received certain vaccines in order to optimize disease protection and enhance herd immunity. For the purposes of measuring immunization rates, it is not uncommon to divide childhood into three different age groups: 24 - 35 month old, 5 - 6 year olds (kindergarten), and 11-12 year olds (seventh grade). However, rates are most commonly assessed in the 24 - 35 month age range, by which timethechildshouldhavereceivedtheir"primaryseries"ofvaccines. Childhood immunization rates are also sometimes measured at 3 months of age, which reflects how many infants actually saw a health care provider to initiate immunization. Vaccine Doses Another factor to measure to determine immunization rates is to look at the number of doses of each vaccine or antigen received at a given point in time. Typically, an antigen is defined as a foreign substance in the body (such as a bacterium, virus, or protein) that can cause disease and whose presence triggers an immune response (the formation of antibodies). When measuring immunization rates, researchers might look at the number or percentage of people who have received antigens in a specific vaccine group. One challenge is that as new vaccines are added to the immunization schedule, we must add them to our immunization coverage measurements as well. Geographic Area/Zip Code Looking at immunization rates by geographic location can be a useful way to measure disparities among groups. For example, a 1992 study in Minnesota found that coverage rates frequently varied significantly by neighborhood (zip code). These areas also had a higher proportion of Populations of Color than zip codes with higher immunization rates. Race/Ethnicity Finally, there are different ways to compare immunization rates by race/ethnicity. Finally, one of the newer methods is to do a comparison among three or more racial/ethnic groups using summary statistics such as the"indexofdisparity. Looking at racial/ethnic disparities can be useful to determine where interventions should be targeted; however, limited data are available and they can be confounded by other factors, such as income. This report will address six of them: school immunization laws, insurance status and access to medical care, vaccine financing, clinic-based factors, parental concerns/patient knowledge and beliefs, and social and environmental characteristics. Moreover, these laws provide a safety net for those children who have not accessed preventive services, including immunizations. Finally, these laws help assure that children are immunized by the time they enter school, regardless of where they live, their socioeconomic status, or their race/ethnicity. A number of studies have shown that school immunization laws increase4 vaccination rates and reduce rates of vaccine-preventable disease. School immunization laws can also reduce immunization disparities among racial and ethnic lines and socioeconomic status. One recent study found that there was a dramatic decrease in disparities of hepatitis B vaccination coverage among White, Black, and Hispanic students after a hepatitis B vaccine school-entry requirement was enacted. This requirement effectively increased hepatitis B vaccination coverage levels regardless of race/ethnicity. For example, a 2005 study found that children who were continuously uninsured since birth, children who were currently uninsured but previously insured, and children who were currently insured but had experienced a break in insurance coverage had significantly lower vaccination rates than did children who were continuously insured. A recent report on disparities in health care in Minnesota by Minnesota Community Measurement found that income and insurance status affect the quality of health care, including immunizations. The report found that Minnesotans enrolled in state health plans had lower immunization rates than those with private insurance. The study found that children with public full-year health care coverage were significantly more likely to be up to date with their immunizations than children with either private full-year or intermittent private health care coverage. The researchers believe that this may reflect federal and state efforts to provide free vaccines and other safety net programs to eligible children. Related to uninsurance is underinsurance, defined for immunization purposes as patients who have health insurance but also have high deductibles or copays for immunizations or plans that do not cover immunizations at all.

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