More than three years ago, Madalyn Wyatt, RN, and Nancy Gilfillan, RN, started taking a closer look at immunization practices for toddlers throughout the Sacramento, Calif., area-and they were surprised at what they found.

Wyatt and Gilfillan, employees of the Shots for Tots Regional Coalition, discovered that many of the employees in private physician offices had never learned the nuances of administering vaccinations. Infants and toddlers up to age 2 were receiving shots in the wrong sites, at the wrong time. Sometimes, improper needle lengths and gauges were used or the vaccines hadn't been mixed or stored properly.

The two RNs were concerned about children who could be growing up vulnerable to preventable diseases.

Now, the duo is on a mission to tackle this problem. Wyatt and Gilfillan have created a two-hour flash interactive course in immunization practices that they offer for free to offices interested in training their employees.

The need for a traveling vaccine course became clear soon after Wyatt and Gilfillan started working for Shots for Tots, an organization striving to reach a 90 percent immunization rate by 2003 for infants and toddlers in seven counties of the North Central Valley in California.

The nurses were hired by the organization in 1998 to assess immunization records in more than 130 private physician offices. They found that only about 64 percent of the infant and toddler patients were up-to-date on their immunizations. "There is no excuse for any child in the United States in 2001 not to be up-to-date on immunizations," Gilfillan said.

They gave feedback to each office on how to improve record-keeping procedures for immunizations. By the end of the project, the offices had improved their immunization rates by an average of 15 percent. But Wyatt and Gilfillan knew that the root of the problem entailed much more than poor record keeping.

"I think our growing concern was related to the misconceptions we were finding," Wyatt said. "One was that many doctors and patients think medical assistants are licensed, but there are no training standards for this group. Their training can vary from 10 hours to three to six months."

Immunization education isn't included in medical assistant training, either, Wyatt said. Another common misconception the nurses found was that immunizations are simple.

"They are extremely complex because there are so many of them; there are different brands and they need to be administered by different routes and at appropriate intervals," Wyatt said.

Toddlers need about 20 different vaccinations by the time they turn 2. Live vaccines for illnesses such as chickenpox (varicella) need to be stored at minus 15 degrees Fahrenheit, while the MMR shot (measles, mumps, rubella) must be stored in the dark.

Shots for varicella and MMR can be given with shorter needles that are five-eighths of an inch because the vaccine needs to penetrate only to subcutaneous tissue, while immunizations for illnesses such as hepatitis, meningitis and pertussis (whooping cough), tetanus and diphtheria require needles long enough to reach muscle tissue. But Wyatt and Gilfillan noticed that nurses and medical assistants sometimes were reluctant to use the longer needles.

"You don't want to hurt the little ones with a long needle," said Audrey Johnson, RN, a supervisor at Feather River Tribal Health in Yuba City, Calif. "But if it's not deep enough, it won't take."

Gilfillan and Wyatt presented their immunization course to the staff at Johnson's clinic in early November. Johnson said one of the most helpful lessons in the session was the reminder that proper vaccine procedures are essential for children. Sometimes, parents are hesitant to have nurses give a child several shots in one visit, but too often the parents never return to finish the job, Johnson said.

Wyatt and Gilfillan have funding through June to continue offering free presentations to offices. They've visited more than 35 offices since March, and their training session includes hands-on practice with giving injections to a mannequin. "It is extremely rewarding," Gilfillan said. "We've been very well received by offices, and it's information they really need."

Although Wyatt and Gilfillan would like to raise awareness about the need for more immunization training, they admit that their efforts are just the beginning.

"I feel we are just scratching the surface of a larger issue," Wyatt said. "If I save 100 children from getting a vaccine administered incorrectly, then my efforts were not in vain. If the end result after our training is that someone learns two new things, I've made a difference."