“When the pandemic started, we saw parents not coming in for their infant checkups as regularly as they should because they were afraid to bring their baby out given the risk of contracting COVID-19, which is completely understandable,” Dr. Thomas said.

NPs and PAs Play Key Roles in Vaccine Uptake

Nurse practitioners (NPs) and physician assistants (PAs) play key roles in efforts to increase childhood immunization rates as they can build on their trusted relationship with parents to increase vaccine schedule adherence, Dr. Scott said. “Providers must acknowledge that underlying their roles is the fact that marginalized members of the community are disparately impacted by the aftermath of COVID-19 and, therefore, the urgency with which local health providers must act is critical.”

“Nurses are among the most trusted professionals and encouragement from long-standing community providers means a lot to parents,” Dr. Scott added. Personalized stories are viewed as encouraging by parents and personalized phone calls are very effective, she said. Text reminders have been shown to be moderately effective.

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Dr. Scott also suggests offering catch-up vaccines at all visits, including for acute and chronic care, not just well-visits. Vaccine review should be conducted at the beginning of every visit, she said. For vaccine-hesitant parents, first determine if the parents are opposed to all vaccines or a specific vaccine; this information will determine the counseling approach. The goal is to dispel myths and promote credible information. Providers need to “empathize, listen, and care,” she said.

Other evidence-based strategies suggested by Dr. Scott include use of electronic health records to set up provider reminders and patient email/text appointment reminders. “There is also burgeoning research on the effectiveness of public service announcements targeting specific communities and credible social media postings on the need for childhood immunizations,” she said.

“Follow-up immunization recommendations made during telemedicine visits can be completed during established follow-up visits, or additional ‘immunization only’ visits with medical assistants or nurses can be offered,” said Pamela Rockwell, DO, the American Academy of Family Physicians’ liaison to the Advisory Committee on Immunization Practices and associate professor in the Department of Family Medicine at the University of Michigan Medical School in Ann Arbor.4 “Offering drive-through immunization clinics is another effective strategy,” Dr. Rockwell noted.

AANP President Offers Tips and Strategies for Increasing Immunization Uptake

Dr. Thomas has a 3-step strategy to boost immunization uptake. First, babies and children are scheduled for their next appointment at each checkup to avoid delays. Second, her practice uses lists provided by insurance companies to detect patients with lapses in immunizations. Dr. Thomas personally calls parents on the phone to explain that she received a letter from the insurance company notifying the practice that their child is behind on their immunization schedule.

She says a personal phone call carries more weight than an automated text or email and allows for a conversation if the parent has any questions or expresses hesitancy. “I think people appreciate that personal outreach,” she said. The call typically offers parents a nudge in the right direction to get their child scheduled for their next immunization, she said. 

The third strategy Dr. Thomas implements is the CASE (Corroborate, About me, Science, Explain/Advise) approach for talking to vaccine-hesitant parents (Table).5 Dr. Thomas applies the CASE approach during office visits and when calling parents to inform them that their child has missed a vaccine.

Table. Tips on Using the CASE Approach to Overcome Vaccine Hesitancy5

CorroborateAcknowledge and validate parents’ concerns
● Find points on which the clinician and parent can agree
● Example: “Tell me what your concerns are”; “I hear your concerns and understand what you are saying”
About meExplain how you became an expert on the issue
Explain what experts and medical associations advise
Explain the choices you made to vaccinate your own children, if applicable
Example: “Let me tell you about me and my research on vaccines”
ScienceShare the science on vaccines in a straightforward way
Include points that are central to countering the specific concerns of the parents
Explain the benefits and risks of the vaccine
Explain the risks of vaccine-preventable diseases
Explain/AdviseDiscuss why you feel strongly about the need to vaccinate
Explain why vaccination is best for the patient

This communication method is “very effective, acknowledges and respects the parent and the parent’s role as the decision-maker for their child, and explains the science behind the rationale for childhood immunizations,” Dr. Thomas said. During these conversations, she advocates for the health of the child.

“A lot of times people just need more information,” Dr. Thomas said. “They read things on the internet, or they talk to friends who heard something on Facebook. The CASE approach is a quick and easy way to share accurate information with parents.”

In her practice, well-visit numbers have increased in recent months and comprise approximately half of all in-office visits, which she said is reassuring. She emphasized the importance of in-person well visits not only for vaccinations, but also to assess children’s growth and development.

“We are starting to see the light at the end of the tunnel,” she said, but added that this improvement may not be found in other areas of the country.

Childhood Immunization Resources for Parents

To arm parents with accurate scientific information on immunizations, Dr. Scott refers parents to the following resources:

Parents may also benefit from understanding the CDC’s catch-up immunization schedule. Dr. Thomas also provides parents with the CDC’s Vaccine Information Statements (VISs).


1. Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration – United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(19):591-593. doi:10.15585/mmwr.mm6919e2

2. WHO and UNICEF warn of a decline in vaccinations during COVID-19. News Release. World Health Organization. July 15, 2020. Accessed April 20, 2021. https://www.who.int/news/item/15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations-during-covid-19

3. Kulkarni AA, Desai RP, Alcalá HE, Balkrishnan R. Persistent disparities in immunization rates for the seven-vaccine series among infants 19-35 months in the United States. Health Equity. 2021;5(1):135-139. doi:10.1089/heq.2020.0127

4. CDC updates immunization schedules for 2021. News release. American Academy of Family Physicians. February 24, 2021. Accessed April 20, 2021. https://www.aafp.org/news/health-of-the-public/20210224immschedules.html

5. Jacobson RM, Van Etta L, Bahta L. The C.A.S.E. approach: guidance for talking to vaccine-hesitant parents. Minn Med. 2013;96(4):49-50.