AAP Cocooning Expert Meeting * March 23, 2012
“Cocooning” is a strategy to prevent serious pertussis infection by conducting targeted
vaccination to ensure that all of an infant’s close contacts and caregivers receive the tetanus,
diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Infants younger than 12 months have
the highest rates of pertussis infection and pertussis-related deaths. Babies under two months of
age are hardest hit: they are too young to be vaccinated and are more likely to become infected,
be hospitalized, and die of pertussis.
A recent Cocooning Expert Meeting addressed the concept of cocooning babies in a circle of
protection as both a family and community priority. The meeting was convened by the American
Academy of Pediatrics (AAP), with the support of sanofi pasteur. (For more information, see the
Proceedings Report.)
Key Issues in Cocooning
Throughout the Expert Meeting, participants presented on, and discussed, key issues affecting
community-wide cocooning efforts. Major discussion points are listed below, organized by
specific challenge area and/or population and potential solutions to address the barrier and/or
reach the target population.
LACK OF EVIDENCE ON COCOONING
BARRIER
POTENTIAL SOLUTIONS
There is a lack of evidence to support
 CDC support for studies to generate more data on
cocooning. There is a lack of safety data on
benefits and answer questions.
providing Tdap during pregnancy. There is a
 Research on different outcomes from immunization
need for research on outcomes from vaccinating
before conception, during pregnancy, postnatally.
at different times (pre-conception, prenatal,
 More research on what to do for repeat pregnancies
postpartum).
and on the impact of vaccinating the mother 1-2
years pre-conception.
ISSUES AFFECTING PROVIDERS
BARRIER
POTENTIAL SOLUTIONS
If providers do not recommend the vaccine to
 Provider educational campaign.
pregnant women and their families, patients are  Updated and clear ACIP guidelines.
less likely to seek the vaccine. Providers lack
 Communication among / between provider groups to
awareness of the need, and there is much
encourage engagement in immunization efforts.
confusion between the Td and Tdap vaccines.
 Position statements supporting Tdap and cocooning
Tdap recommendations have been a moving
from key groups (e.g., ACOG, U.S. Dept. of
target making it hard for providers to keep up
Education) to communicate the importance of
with them.
immunization and cocooning.
 Providers should not only offer the vaccine but also
promote access to services elsewhere.
 Assist providers in learning how to effectively use
state vaccine registries.
 Expand existing immunization registries to include
Tdap and minimize over-vaccinations.
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 Ensure that health care workers are vaccinated.
ISSUES AFFECTING PATIENTS / THE PUBLIC
BARRIER
POTENTIAL SOLUTIONS
Public lacks awareness of Tdap in general and
 Public education campaigns on pertussis
of their own vaccine history, specifically. Many
(particularly as an adult illness) and cocooning. Use
adults do not know if their last vaccine was Td
social media, PSA, texting, patient education, etc.
or Tdap. When vaccination recommendations
 Use of personal stories to raise awareness and
change, the public gets confused and concerned.
motivate vaccine uptake.
 Providers to promote cocooning to specific patients
and as a general concept.
 Address language barriers and need for translators to
reach non-English speaking populations.
 Use pharmacy databases for patient outreach and
education on immunization.
 Promote a standardized, universal Tdap vaccine
recommendation to simplify expectations.
 Mandates for Tdap immunization for students at
specific grades.
 Expand the use of vaccine registries.
 Educate policymakers and school staff to foster
support for vaccination and cocooning.
 Key groups to issue position statements (e.g.,
ACOG, US Department of Education) on the
importance of immunization and cocooning.
LACK OF ACCESS TO VACCINE
BARRIER
POTENTIAL SOLUTIONS
Providers may not offer the vaccine to the
 Work with pharmacies, retail-based clinics, and other
patients. Patients may have difficulty finding
providers to promote cocooning and refer patients to
Tdap providers. Providers may not be able to
vaccination services.
administer vaccines to caregivers who are not
 Provide ways for people to find a provider who has
their patients (e.g. pediatricians with parents;
the Tdap vaccine and can give it to them.
OBs with fathers).
 Track desired behaviors on immunization through an
NQF or CDC metric.
 Engage The Joint Commission (TJC) to include
quality measures for facilities and hospitals.
 Ensure Emergency Rooms carry Tdap (not Td).
 Offer to vaccinate individuals for cash.
FINANCIAL / REIMBURSEMENT ISSUES - PUBLIC
BARRIER
POTENTIAL SOLUTIONS
Td and Tdap vaccines are reimbursed under
 Simplify reimbursement of vaccines under CMS
different CMS programs (Part B vs. Part D).
regulations.
Some state Medicaid programs do not cover
 Encourage states to provide adult vaccines by
vaccines for adults. States that use Section 317
expanding funding for these services.
funding for cocooning may have to change
 Expand VFC to authorize coverage of adult vaccines.
strategy; after 2013, 317 funds cannot be used
for insured individuals. VFC is limited to those
19 and under and may not cover adult vaccines.
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FINANCIAL / REIMBURSEMENT ISSUES- PRIVATE
BARRIER
POTENTIAL SOLUTIONS
Global fees for delivery typically only include
 Cover vaccine and immunization charges (i.e., add
pre-natal care and delivery and do not cover
into the global delivery fee). (Updated and clear
vaccination (they certainly do not cover
ACIP guidelines will help, since private payers may
cocooning for the whole family).
follow ACIP recommendations in vaccine coverage.)
Immunizations and vaccines are usually
 Reimburse at levels equal to, or greater than, CMS’
covered under medical, not pharmacy, benefits,
Medicare rates.
presenting barriers to pharmacists being Tdap
 Recognize pharmacists as immunization providers
immunization providers.
by removing differential co-pays (secondary
providers).
LEGAL / REGULATORY ISSUES
BARRIER
POTENTIAL SOLUTIONS
Some providers need specific authority that
 Expanded definition of which providers can give the
would allow them to provide Tdap. Some
Tdap vaccine.
statewide registries are prohibited from sharing  Legislative / regulatory changes to enable
information with cities / communities, or
pharmacists to provide Tdap more broadly (i.e.,
restrict access to registries (e.g., for pharmacists
remove age restrictions for pharmacist
or schools).
administration of vaccine).
 Allow information-sharing between / among
registries.
 Ensure pharmacists have access to registries and
medical records on vaccinations.
 Mandates / requirements for vaccination of certain
populations (health care workers, students at specific
grades).
 Approve Tdap for more than a single use.
Breakout Group Discussion & Report Back
The participants divided into four groups to brainstorm and report back on the following
questions:
 Are there certain elements of successful programs that might serve as a model to
implement community-based cocooning? What are the top three models to pursue?
 Which stakeholder groups should be targeted, and what are the key messages that
need to be communicated?
 What educational pieces, internal supports, and/or other tools are necessary to
succeed?
 What policy changes are needed at the Federal, state, and local levels to ensure
successful adoption and implementation of community-wide cocooning strategies?
Are there certain elements of successful programs that might serve as a model to implement
community-based cocooning? What are the top three models to pursue?
 Using standing orders.
 Health care workers’ adopting vaccination themselves and promoting immunization.
 Providing employers with education about benefits: producing an ROI (return on
investment) case study on absenteeism, “presentism”, cost of employee sick leave, etc.
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
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Having a strong champion for a program.
Creating a stronger evidence base about what works, where, and what has the best
impact. Gather data in a formal way; it will take time but has to start at some point.
Vaccinating pregnant women with Tdap after 20 weeks of gestation: this has the most
bang for the buck. It also includes the strongest evidence of positive impact on infant
morbidity in the first 4-8 weeks after birth and on protecting the mother.
Vaccinating women post-partum is a second-best model; there is a clear audience and
provider group to get this started.
Stepping back from cocooning and emphasizing a universal pertussis vaccine
recommendation.
Which stakeholder groups should be targeted and what are the key messages that need to be
communicated?
 Stakeholders for promoting family cocooning goals:
 First: Ob-gyns, nurse midwifes, nurse practitioners: people who treat pregnant
women. This reaches the goal to immunize women prenatally.
 Second: Providers who treat women and babies post-partum.
 Third: Providers who treat women of childbearing age and children: pediatricians,
family physicians, etc.
 Fourth: Providers who treat women pre-conception (all women of childbearing age).
 Providers: get education and communication to patients in a fast and impactful way.
 Providers: clarify recommendations for when to give the shots, especially in terms of
pregnancy vs. right after birth, one time only vs. for every pregnancy, etc. Providers need
more information on what works best.
 Public health field.
 Emergency Room staff: the ER setting provides many opportunities for vaccination.
 Physician groups: particularly groups that focus on adult populations (including OBs and
ACOG); providers need help with billing and vaccine/cocooning implementation.
 Employers: engage them through business coalitions and national groups on health and
show the ROI for their leadership on this issue.
 Community members and the public.
 Consumers: provide information about risk factors and risks from pertussis.
 Fathers: Medicaid covers births and reaches the baby and mother, but fathers also need to
be reached; these men are often uninsured and may stay uninsured after the Accountable
Care Act (ACA) is fully implemented. It is critical to engage fathers to make cocooning
work.
 Involve “non-traditional” groups on messaging for the patients / public. Partner with
those who specialize in communication.
What educational pieces, internal supports, and/or other tools are necessary to succeed?
 Engage resources from which parents seek information (i.e., Every Child by Two, Baby
Center.com, etc.).
 Conduct marketing with baby-targeted products (i.e., Pampers box) and retailers (i.e.,
Babies R Us) to provide educational information to families.
 Create educational pieces that reach the public (not just providers).
 Create information and incentives for health care workers to get immunized.
 Give adult providers assistance on how to code and bill for this.
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
Issue stronger language from ACOG supporting cocooning, as it does with the flu
vaccine.
What policy changes are needed at the Federal, state, and local levels to ensure successful
adoption and implementation of community-wide cocooning strategies?
 Implement more flexibility in the use of Federal funds.
 Reduce barriers so vaccines can be made available at pharmacies, be covered by Medicaid
for adults, and be billed for by other providers.
 Address payment as a barrier: if reimbursement occurs through a bundled payment, then
vaccines have to be included in the payment bundle.
 ACOG needs to be front and center on this and to set the standard; it should issue a
statement that OBs can vaccinate anyone.
 Create quality measures and safety measures to help improve health care workers’
vaccination rates.
 Create statewide registries to eliminate duplicate doses and create alerts on needed doses.
 Work on the state level to create school entry requirements for teens: mandatory
requirements for school entry at grade 7 or 10 to increase immunization rates.
 Pass state laws to enable providers to vaccinate others (e.g., OBs can give vaccines or
treatment to men).
Take Home Points & Suggested Future Activities
While no clear recommendations on cocooning emerged from the meeting, there were specific
needs identified in order to advance Tdap vaccine uptake as well as cocooning as a general practice.
First and foremost, there is a clear need for additional evidence on cocooning outcomes. There are
good data (including safety data) on vaccinating pregnant women and thereby protecting infants
early on, at a time when there is a lot of mortality. More research is needed, however, on how much
coverage there needs to be to confer protection to the baby. People want definite evidence that the
vaccination process is working and is a cost-effective strategy — and this is currently lacking.
The forthcoming CDC 10-state study will be useful in assessing both vaccination outcomes and the
extent of protection. (This study will examine the effectiveness of maternal vaccination during
pregnancy vs. post-partum and of vaccinating family members.) Until more is known about
outcomes and benefits, a conclusive strategy cannot be selected among the various possibilities:
prenatal vaccination, cocooning, and universal Tdap vaccine recommendation.
Although there was no consensus on the best strategy, the meeting participants agreed that there is a
need for key stakeholders to engage in pertussis prevention efforts. These stakeholders include the
public; parents and other family members; policymakers; and a wide range of providers, including
those who treat pregnant women (i.e., ob-gyns, nurse midwifes, nurse practitioners); those who treat
babies (i.e., pediatricians); those who treat families (i.e., family physicians); and those who treat
members of the public (i.e., pharmacists).
While additional research is being conducted, these groups can work to promote vaccination in
general. Health care organizations groups like ACOG and the AAP can communicate with their
members about the importance of the Tdap vaccination. Providers can communicate with their
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patients about this issue, and health care facilities can ensure that their employees are vaccinated.
There is a need for some legislative / regulatory changes that could be addressed while data are
being gathered. If the ACA is fully implemented, vaccination services will be included in covered
prevention services and offered through the exchanges. But, if the ACA is struck down, there will
be a need for expanded Federal funding for promotion and facilitation of vaccination, particularly
for adults. Reducing barriers so vaccines can be provided by a range of health care providers
(including pharmacists) is an important action step. Creation of quality and safety measures can
encourage facilities and practices to be attentive to this issue.
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