Childhood Immunization Rates Research Articles

Ethnic Disparities in Routine Immunization Coverage

Karachi is the only mega city in the world with persistent poliovirus transmission. We determined routine childhood immunization rates in Karachi and identified predictors of vaccine completion. A population-based cross-sectional survey was conducted in Karachi between August and September 2008. Data on demographics, socioeconomic, and DTP3 vaccination status in children 12 to 23 months old were collected. Logistic regression was used to identify predictors of vaccination completion. Overall, 1401 participants were approached; 1391 consented to participate. Of these, 1038 (75%) were completely vaccinated. Punjabi families had the highest DTP3 coverage (82%), followed by Urdu-speaking families (79%). Pashtun (67%) and Bengali (48%) families had the lowest vaccine coverage. Children of mothers with ≥ 12 years of schooling (OR = 25.4; 95% CI = 5.7-113.1) were most likely to be vaccinated. A quarter of study participants were unvaccinated. Targeted strategies for boosting DTP3 rates in communities with low immunization coverage are essential for polio eradication in Karachi.

Population-based versus practice-based recall for childhood immunizations: a randomized controlled comparative effectiveness trial.

We compared the effectiveness and cost-effectiveness of population-based recall (Pop-recall) versus practice-based recall (PCP-recall) at increasing immunizations among preschool children. This cluster-randomized trial involved children aged 19 to 35 months needing immunizations in 8 rural and 6 urban Colorado counties. In Pop-recall counties, recall was conducted centrally using the Colorado Immunization Information System (CIIS). In PCP-recall counties, practices were invited to attend webinar training using CIIS and offered financial support for mailings. The percentage of up-to-date (UTD) and vaccine documentation were compared 6 months after recall. A mixed-effects model assessed the association between intervention and whether a child became UTD. Ten of 195 practices (5%) implemented recall in PCP-recall counties. Among children needing immunizations, 18.7% became UTD in Pop-recall versus 12.8% in PCP-recall counties (P < .001); 31.8% had documented receipt of 1 or more vaccines in Pop-recall versus 22.6% in PCP-recall counties (P < .001). Relative risk estimates from multivariable modeling were 1.23 (95% confidence interval [CI] = 1.10, 1.37) for becoming UTD and 1.26 (95% CI = 1.15, 1.38) for receipt of any vaccine. Costs for Pop-recall versus PCP-recall were $215 versus $1981 per practice and $17 versus $62 per child brought UTD. Population-based recall conducted centrally was more effective and cost-effective at increasing immunization rates in preschool children.

Childhood immunization rates in rural Intibucá, Honduras: an analysis of a local database tool and community health center records for assessing and improving vaccine coverage

BackgroundVaccines are highly effective at preventing infectious diseases in children, and prevention is especially important in resource-limited countries where treatment is difficult to access. In Honduras, the World Health Organization (WHO) reports very high immunization rates in children. To determine whether or not these estimates accurately depict the immunization coverage in non-urban regions of the country, we compared the WHO data to immunization rates obtained from a local database tool and community health center records in rural Intibucá, Honduras.MethodsWe used data from two sources to comprehensively evaluate immunization rates in the area: 1) census data from a local database and 2) immunization data collected at health centers. We compared these rates using logistic regression, and we compared them to publicly available WHO-reported estimates using confidence interval inclusion.ResultsWe found that mean immunization rates for each vaccine were high (range 84.4 to 98.8 percent), but rates recorded at the health centers were significantly higher than those reported from the census data (p≤0.001). Combining the results from both databases, the mean rates of four out of five vaccines were less than WHO-reported rates (p <0.05). Overall immunization rates were significantly different between townships (p=0.03). The rates by individual vaccine were similar across townships (p >0.05), except for diphtheria/tetanus/pertussis vaccine (p=0.02) and oral polio vaccine (p <0.01).ConclusionsImmunization rates in Honduras were high across data sources, though most of the rates recorded in rural Honduras were less than WHO-reported rates. Despite geographical difficulties and barriers to access, the local database and Honduran community health workers have developed a thorough system for ensuring that children receive their immunizations on time. The successful integration of community health workers and a database within the Honduran decentralized health system may serve as a model for other immunization programs in resource-limited countries where health care is less accessible.

NPs Should Dispel Misinformation About Immunizations

The widespread immunization of children in the 20th century for the prevention of common childhood illnesses is acclaimed as one of the greatest public health success stories. No longer do parents watch as child after child succumbs to the ravages of these diseases. One of the major reasons behind the decrease in childhood morbidity and mortality from these infectious diseases is the requirement for immunization as part of state-based school-entry requirements. While there is a great deal of success, there is also evidence of failure in achieving adequate child immunization rates. The best example is the recent epidemic of pertussis (whooping cough) in California. Pertussis is an endemic disease in the United States, with frequent outbreaks and periodic epidemics every 3 to 5 years. In 2010, 27,550 cases of pertussis were reported to the Centers for Disease Control and Prevention, and many more cases go unreported. As part of that number, 9,143 cases of pertussis (including 10 infant deaths) were reported throughout California. This is the highest number of cases reported in 63 years. Michigan and Ohio also have reported very high pertussis numbers over the past few years1Centers for Disease Control and Prevention Pertussis (whooping cough) outbreaks.http://www.cdc.gov/pertussis/outbreaks.html/Google Scholar Approximately 40% of reported pertussis cases are among children younger than 5 years old. In recent years, an increasing proportion of cases have been reported among adolescents and adults, and the number of outbreaks reported among school-age children and adolescents has been increasing. Infected adolescents and adults may introduce pertussis into households where susceptible preschool-age children and more vulnerable elders could be exposed.2Centers for Disease Control and Prevention Guidelines for the Control of Pertussis Outbreaks.http://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htmGoogle Scholar An article3Choi BK The immunization status of home-schooled children in America.J Pediatr Health Care. 2010; 24: 42-47Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar that examined the immunization status of American home-schooled children suggested that there are several reasons why children continue to be at risk for these preventable diseases: •Many current parents underappreciate the risks and severity of disease.•Some children go without immunizations until required when they enter school.•Clinicians may miss opportunities to immunize children because the child is ill.•Parental concern over possible vaccine adverse effects and safety and efficacy is fueled by anti-vaccine groups.•Parents claim exemptions from immunization for children because of religious or philosophical beliefs, freedom and individualism, misinformation about risk, and overperception of immunization risk. In fact, ○25% of parents in a survey believed falsely that their child's immune system could become weakened as a result of too many immunizations.○Parents choose to withhold particular vaccines or lengthen intervals between doses.○Parents distrust the health care system.•As many as 2 million American children are schooled at home. Although mandatory immunizations are required for entry into public schools, state-based school-entry vaccination laws generally do not apply to home-schooled children. Little is known about the vaccination status of this population. There is a lot of false and misleading information that scares parents. Nurse practitioners (NPs) must be leaders in studying the scientific literature so they are accurately informed about the risks and benefits of immunizations. NPs should actively seek to correct misinformation because failure to immunize those who require it increases the risk for all of us. ErratumThe Journal for Nurse PractitionersVol. 8Issue 5PreviewThe article, “NPs Should Dispel Misinformation About Immunizations,” in the April 2012 issue had incorrect terminology reported in the second paragraph. The sentence should read, “The best example is the recent epidemic of pertussis (whooping cough) in California.” JNP regrets this error. Full-Text PDF

Editorial Commentary: Accounting for Pertussis

The resurgence of measles and pertussis in the United States [1, 2] is a reminder of the importance of maximum immunization coverage, even in a developed country with relatively high rates of childhood immunization. The exact parameters of herd immunity may not be established for some vaccine-preventable diseases, but maximal effective use of available vaccines providespopulation-level immunity toprevent or reduce transmission. Evidencebased strategies published by the Advisory Committee on Immunization Practices (ACIP) for improved control of pertussis promote effective use [3, 4]. Observation of vaccine effectiveness in routine clinical use provides insight that may not be available from clinical efficacy trials and may be used to inform recommendations. The article by Witt et al [5] in this issue of Clinical Infectious Diseases presents a retrospective study of acellular pertussis vaccine effectiveness made possible by the unique circumstances of a community-wide outbreak of Bordetella pertussis infection affecting a large population under the care of an integrated healthcare system.This allowedestimation of vaccine effectiveness by age group. The relative duration of protection achieved with diphtheria toxoid–tetanus toxoid–acellular pertussis (DTaP) vaccines (introduced in theUnited States in the 1990s) remains a question [6], one made more relevant by the possibilities arising from the availability of pertussis antigen containing vaccines (tetanus toxoid– reduced diphtheria toxoid–acellular pertussis vaccine for adolescents and adults [Tdap]) that allow for booster dosing of individuals >7 years of age. The authors were able to demonstrate less than expected effectiveness of DTaP in 8to 12year-olds, while also demonstrating substantial overall effectiveness of pertussis vaccines. On the basis of their observations, they suggest evaluation of earlier and more frequent doses of pertussis containing vaccine (Tdap) in outbreak settings, and even on a routine basis. More studies of strategic use of Tdap as a booster dose vaccine would be worthwhile, especially after the broad experience with the vaccine and its safety profile. The ACIP already recommends Tdap use in undervaccinated children as young as 7 years of age [3]. A question might be raised as to the use of polymerase chain reaction (PCR) as the exclusive diagnostic test for pertussis in the Witt et al study, especially as the minimal cough duration in the practice guidance was only 1 week. PCR is a widely used, sensitive test that is faster and easier to perform than culture and can identify evidence of B. pertussis infection in situations where culture results are negative. However, high sensitivity and low specificity, with pseudo-outbreaks described due to false positives and environmental contamination with B. pertussis genome [7, 8], suggest that PCR only be used with care and for patients with cough duration of≥2 weeks and a clinical picture consistent with pertussis. However, the observations by Witt et al [5] occurred in the presence of a widespread, welldocumented stateand community-wide outbreak of pertussis (high prevalence of diseaseimprovingpositivepredictivevalue), and testing was done in a central laboratory, using a closed system test platform, and simultaneous testing for Bordetella parapertussis. Furthermore, rates of testing were high across the spectrum of ages, but rates of positive PCR results are very different by age, so false-positive test results do not seem to be a factor contributing to the results unless there was a systematic bias in selection for testing by age. Pertussis remains a threat to infants, in whom protection awaits the initial doses of the DTaP vaccine series. Public health recommendations for the use of Tdap vaccines have been a work in progress since licensure in the United States, and approaches have been designed to protect older children, adolescents, and adults, in large part to protect infants they may expose to pertussis (as symptomatic and asymptomatic cases to the extent that overall reduction in incidence may reduce asymptomatic carriage). Initially, Tdap Received 27 February 2011; accepted 1 March 2012; electronically published 15 March 2012. Correspondence: Altred De Maria Jr, Bureau of Infectious Disease, Massachusetts Department of Public Health, William A. Hinton State Laboratory Institute, 305 South St, Jamaica Plain, MA 02130 (Alfred.DeMaria@state.ma.us). Clinical Infectious Diseases 2012;54(12):1736–8 © The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@ oup.com. DOI: 10.1093/cid/cis313

Using Reminder/Recall Systems to Improve Influenza Immunization Rates in Children With Asthma

IntroductionAsthma is a major public health concern in the U.S. pediatric population. Children with asthma tend to fare worse when they acquire respiratory illnesses such as influenza, requiring more episodic office visits and hospitalizations than do healthy children with the same illnesses. Despite the American Academy of Pediatrics recommendation that children with chronic diseases be immunized for seasonal influenza annually, influenza immunization rates in this population peaks at < 30%. The purpose of this literature review was to examine the effectiveness of reminder/recall systems in improving influenza immunization rates among children with asthma. MethodThis literature review was conducted using PubMed, CINAHL, EMBASE, and Cochrane. Of the 178 articles found, 12 met criteria for inclusion. Articles were included if they addressed influenza vaccination in asthmatic children and “high-risk” children and considered asthmatics in the definition of “high risk.” Additionally, inclusion criteria required discussion of at least one mode of reminder method or recall method that was used to influence the rate of influenza vaccination in children with asthma. For the purposes of this review, “reminders” is defined as any action performed by health provider or representative of the health provider that was aimed at informing and/or reiterating to patients the importance of influenza vaccination for asthmatic children and/or the potential for increased morbidity with acquisition of the flu and/or availability of the vaccine. “Recall” methods included all efforts made by the health provider or his/her representative to encourage patients to return to clinics for vaccination during the influenza season. Articles were excluded if they focused on improving influenza vaccination rates in healthy children and if they used reminder/recall systems to influence vaccination against diseases other than influenza. No systematic review was found on this particular topic. ResultsProviders have used reminder and recall systems that alert patients of the need for vaccination and encourage compliance with this recommendation. Implemented techniques included verbal and mailed reminders, electronically generated alerts, and year-round scheduling of flu vaccination appointments. DiscussionImprovements have been seen in influenza immunization rates with the implementation of reminder/recall systems; however, most have been modest. Enhancements in patient education and access to vaccination are other areas of needed improvement.

Improving the Quality of Immunization Delivery to an At-Risk Population: A Comprehensive Approach

Immunization quality improvement (QI) interventions are rarely tested as multicomponent interventions within the context of a theoretical framework proven to improve outcomes. Our goal was to study a comprehensive QI program to increase immunization rates for underserved children that relied on recommendations from the Centers for Disease Control and Prevention's Task Force on Community Preventive Services and the framework of the Chronic Care Model. QI activities occurred from September 2007 to May 2008 at 6 health centers serving a low-income, minority population in Washington, DC. Interventions included family reminders, education, expanding immunization access, reminders and feedback for providers, and coordination of activities with community stakeholders. We determined project effectiveness in improving the 4:3:1:3:3:1:3 vaccination series (4 diphtheria-tetanus-pertussis vaccines, 3 poliovirus vaccines, 1 measles-mumps-rubella vaccine, 3 Haemophilus influenzae type b vaccines, 3 hepatitis B vaccines, 1 varicella vaccine, and three 7-valent pneumococcal conjugate vaccines) compliance. We found a 16% increase in immunization rates overall and a 14% increase in on-time immunization by 24 months of age. Improvement was achieved at all 6 health centers and maintained beyond 18 months. We were able to implement a comprehensive immunization QI program that was sustainable over time.

Napa Immunization Study: Immunization Rates for Children with Publicly Funded Insurance Compared with those with Private Health Insurance in a Suburban Medical Office.

Healthy People 2020 set a goal to increase the proportion of children who receive the recommended doses of Diphtheria Tetanus and Pertussis, polio, measles mumps and rubella, Haemophilus influenzae type b, hepatitis B, varicella and pneumococcal conjugate vaccines to 80% from the 2009 baseline rate of 69%. The purpose of this study is to compare the recommended immunization rates for low-income children insured through publicly funded health insurance (PFI) to the rates for children with private health insurance (PHI) in a suburban medical office. The immunization rates and health access measures of 109 children ages 24 to 48 months who had PFI were compared with 300 children of the same age with PHI in the same medical practice. Overall immunization rates for the study population were very high and exceeded the Healthy People 2020 goals for full immunization. Children with PFI had lower rates of immunization and fluoride prescriptions; however the differences were only significant in the cohort of children age two years. By three years of age, the immunization rates and the fluoride prescription rates were similar. There were no significant differences in health outcomes for Spanish-speaking compared with English-speaking children. Barriers to successful immunization practices and strategies to overcome those barriers are discussed. The successful immunization practices and secondary outcomes in this study are a reflection of the integrated care model in this practice that facilitates comprehensive, coordinated, and accessible care for patients and allows physicians and support staff to practice culturally sensitive and compassionate care-the definition of a medical home.

NIH-DC Initiative to Reduce Infant Mortality in Minority Populations in Washington, DC: History and Lessons Learned

In the years leading up to implementation of the NIH-DC Initiative, the infant mortality rate among blacks was at least twice as high as among whites. National data (Table 1) demonstrate that while infant mortality rates were decreasing for both white and black infants, the discrepancy between the rates increased. Table 2 provides the infant mortality rate among white and black infants In Washington, DC, as well as the rate ratio. During this period, the rate for blacks in Washington, DC was higher than observed nationally for blacks and the discrepancy in rates between whites and blacks was also higher [1–3]. Similar disparities existed between the rates for blacks and whites for other birth outcomes related to infant mortality, such as low birth weight [4] (Tables 3, 4) and preterm delivery. Data on low and very low birth weight showed a similar pattern: the actual rates and the discrepancy in rates comparing whites and blacks were higher in Washington, DC than nationally. In response to this problem, the United States Senate and House [5] urged the National Institutes of Health to close the health gap between minority and majority Americans by addressing issues such as infant mortality and health behaviors in adolescent and young adult minorities. To address these issues in Washington, DC, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and what is now the National Institute on Minority Health and Health Disparities (formerly the NIH Office of Research on Minority Health) established the NIH-DC Initiative to Reduce Infant Mortality. This was a collaborative research network between the NICHD, a data coordinating center, and various primary collaborating sites in the District of Columbia. There are multiple known risk factors for poor perinatal outcome, including perceived racial discrimination, young maternal age, low level of maternal education, poverty, inadequate housing, lack of social support, being unmarried, late or no prenatal care, unintended childbearing, adverse health behaviors during pregnancy like smoking, drinking and drug abuse. Additionally there are a number of medical risk factors, including preeclampsia, premature rupture of the membranes, urinary tract and vaginal infections. To address these health discrepancies, the overarching goals of the NIH-DC Initiative were to develop projects with the objectives of understanding the determinants of risk factors for the high rates of infant mortality, understanding risk factors for low birth weight among minorities in DC, and developing interventions that help reduce those risk factors. Phase I began in 1992 and included diverse projects that: evaluated an educational program for new mothers who had inadequate or no prenatal care; studied the characteristics of neonatal intensive care units within Washington DC; addressed immunization rates for DC children; evaluated a program to prevent adolescent pregnancy; described the barriers, motivators and facilitators of prenatal care utilization; surveyed childhood injuries; and assessed alcohol consumption during pregnancy. These studies produced many relevant results. Three key results: First, that mothers randomized to an intervention for women with M. Kiely (&) M. Davis Division of Epidemiology, Statistics and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development/NIH/DHHS, 6100 Executive Blvd, Rockville, MD 20852-7510, USA e-mail: kielym@nih.gov

Improving Immunization Rates at 18 Months of Age: Implications for Individual Practices

We sought to model the effect that a targeted immunization visit at 18 months of age could have on immunization rates of preschool-aged children in a sample of pediatric practices. We conducted retrospective chart reviews in six practices of all active patients aged 18-30 months. Up-to-date (UTD) status was defined as receipt of four diphtheria-tetanus-acellular pertussis, three polio, one measles-mumps-rubella, three hepatitis B, and one varicella vaccines. Haemophilus influenza tybe b vaccine was not included due to a shortage in vaccine supply during the time of the study. Practice vaccination rates were determined at 17 months, 18 months, and the age at assessment. Of those not UTD at 17 months, the percentage of children who could be brought UTD with one visit was calculated for each practice. This calculated rate was compared with the measured rate at 18 months of age and at the age of assessment. At each practice, we reviewed 183-616 charts (median = 382). Observed UTD immunization rates at 17 months ranged from 26% to 64% (median = 38%) and increased 3 to 27 percentage points (median = 6) from age 17 months to 18 months and 9 to 39 percentage points (median = 17) from age 17 months to the age at assessment. A simulated vaccination visit at 18 months of age could improve the UTD rates from 27 to 61 percentage points (median = 44). Practice-based interventions aimed at encouraging an 18-month well-child visit that emphasizes delivery of vaccines have the potential to substantially increase timely vaccination rates among individual practices.

Achieving high immunisation rates amongst children in the Australian Capital Territory: a collaborative effort

In September 2008 the ACT achieved the highest childhood coverage rates in Australia with rates of 93.5% (12-15-month age cohort), 94.9% (24-27-month age cohort) and 90.58% (60-63-month age cohort). To analyse the key contributing factors and policy initiatives that have likely to have led to high childhood immunisation rates in the ACT. Data used in this report were sourced from the Australian Childhood Immunisation Register (ACIR) held at Medicare Australia, General Practice Immunisation Incentives (GPII) 'calculation' data held at ACT Division of General Practice and internal immunisation databases held at Health Protection Service. Although the reasons for the high coverage rates seen in children are multi factorial (including national and consumer factors), key reasons locally in the ACT include: (a) the implementation of an ACT-wide immunisation strategy; (b) proactive follow up of children overdue for immunisation; (c) more sustainable provision of immunisation services across both public and private health providers; and (d) a centralised vaccine delivery service and 'cold chain' monitoring system. Although nationwide immunisation policy has been successful in increasing childhood coverage rates across all Australian jurisdictions, it is important to also acknowledge local factors that have likely to have contributed to the successful implementation of the Immunise Australia Program at the coal face.

Interactions between Bordetella pertussis and the complement inhibitor factor H

Bordetella pertussis causes whooping cough in humans, a highly contagious disease of the upper respiratory tract. An increase in cases of whooping cough in adolescents and adults in many countries has been reported, despite high immunization rates in children. To efficiently colonize the host the bacteria have to resist complement, the first defence line of innate immunity. B. pertussis has previously been shown to bind the classical pathway inhibitors C4b-binding protein and C1-inhibitor being thereby able to escape the classical pathway of complement. In this study recent clinical isolates of B. pertussis and B. parapertussis were found to survive alternative pathway attack in fresh non-immune serum better than the reference B. pertussis strain, Tohama I. By using adsorption assays, flow cytometry and a radioligand binding assay we observed that both B. pertussis and B. parapertussis bound the alternative pathway inhibitor factor H (FH) from normal human serum. The surface attached FH maintained its complement regulatory activity and promoted factor I-mediated cleavage of C3b. The main binding region was located to the C-terminal part of FH, into short consensus repeat domains 19–20. In contrast, the avian pathogen B. avium did not bind FH and was sensitive to the alternative pathway of human complement. In conclusion, the human pathogens B. pertussis and B. parapertussis are able to evade the alternative complement pathway by surface acquisition of the host complement regulator FH.

Improving timely childhood immunizations through pay for performance in Medicaid-managed care.

To evaluate the impact of a "piece-rate" pay-for-performance (P4P) program aimed at rewarding up-to-date immunization delivery to 2-year-olds according to the recommended series. Plan-level data from New York State's Quality Assurance Reporting Requirement and claims data from Hudson Health Plan for 2003-2007. In 2003 Hudson Health Plan, a not-for-profit Medicaid-focused managed care plan, introduced a U.S.$200 bonus payment for each fully immunized 2-year-old and provided administrative supports for identifying children who may need immunization. This represented a potential bonus of 15-25 percent above base reimbursement for eligible 2-year-olds. Case-comparison and interrupted times series. Immunization rates within Hudson Health Plan rose at a significantly, albeit modestly, higher rate than the robust secular trend noted among comparison health plans. Supplementary analyses suggest that there was no significant change in preexisting disparities during the study period, and that children with chronic conditions have significantly greater odds of being fully immunized during the entire study period. This study suggests that a piece-rate P4P program with appropriate administrative supports can be effective at improving childhood immunization rates.

Utilizing an Electronic Health Record System to Improve Vaccination Coverage in Children

Electronic Health Records (EHR) are widely believed to improve quality of care and effectiveness of service delivery. Use of EHR to improve childhood immunization rates has not been fully explored in an ambulatory setting. To describe a pediatric practice's use of Electronic Health Records (EHR) in improving childhood immunization. A multi-faceted EHR-based quality improvement initiative used electronic templates with pre-loaded immunization records, automatic diagnosis coding, and EHR alerts of missing or delayed vaccinations. An electronic patient tracking system was created to identify patients with missing vaccines. Barcode scanning technology was introduced to aid speed and accuracy of documentation of administered vaccines. Electronic reporting to a local health department immunization registry facilitated ordering of vaccines. Immunization completion rates captured in monthly patient reports showed a rise in the percentage of children receiving the recommended series of vaccination (65% to 76%) (p<0.000). Barcode technology reduced the time of immunization documentation (86 seconds to 26 seconds) (p<0.000). Use of barcode scanning showed increased accuracy of documentation of vaccine lot numbers (from 95% to 100%) (p<0.000). EHR-based quality improvement interventions were successfully implemented at a community health center. EHR systems have versatility in their ability to track patients in need of vaccines, identify patients who are delayed, facilitate ordering and coding of multiple vaccines and promote interdisciplinary communication among personnel involved in the vaccination process. EHR systems can be used to improve childhood vaccination rates.

The Use of an Immunization Information System to Establish Baseline Childhood Immunization Rates and Measure Contract Objectives

Measuring progress toward national immunization objectives at the local level, although difficult, is becoming more feasible owing to statewide immunization information systems. This article describes how a state immunization program expanded the scope of immunization service contracts with local health departments (LHDs) to address the immunization rates among children living within their jurisdictions using the Wisconsin Immunization Registry (WIR) to measure achievement of population-based objectives. By contract year (CY) 2008, 99 percent of Wisconsin LHDs selected population-based contract objectives. In late 2008, the Wisconsin Immunization Program assessed all children at 24 months of age for completeness of the 4:3:1:3:3:1 (diphtheria, tetanus, pertussis/poliovirus/measles-containing vaccine/Haemophilus influenzae type b/hepatitis B/varicella) series by county for each of four CYs, using the WIR. From CY 2005 to CY 2008, LHDs in 61 (86%) of the 71 counties demonstrated increased series completeness rates for the series, and the overall statewide series completeness increased from 58 percent to 64 percent. However, the increases we observed cannot be attributed solely to LHDs' acceptance of population-based objectives because controlling for other factors known to influence immunization coverage levels was outside the scope of this case study. We found the WIR to be a powerful tool that can measure immunization coverage among local populations independent of the immunization provider, assess improvement toward contract objectives, and target resources toward pockets of need.

Impact of Electronic Health Record-Based Alerts on Influenza Vaccination for Children With Asthma

The goal was to assess the impact of influenza vaccine clinical alerts on missed opportunities for vaccination and on overall influenza immunization rates for children and adolescents with asthma. A prospective, cluster-randomized trial of 20 primary care sites was conducted between October 1, 2006, and March 31, 2007. At intervention sites, electronic health record-based clinical alerts for influenza vaccine appeared at all office visits for children between 5 and 19 years of age with asthma who were due for vaccine. The proportion of captured immunization opportunities at visits and overall rates of complete vaccination for patients at intervention and control sites were compared with those for the previous year, after standardization for relevant covariates. The study had >80% power to detect an 8% difference in the change in rates between the study and baseline years at intervention versus control practices. A total of 23 418 visits and 11 919 children were included in the study year and 21 422 visits and 10 667 children in the previous year. The majority of children were male, 5 to 9 years of age, and privately insured. With standardization for selected covariates, captured vaccination opportunities increased from 14.4% to 18.6% at intervention sites and from 12.7% to 16.3% at control sites, a 0.3% greater improvement. Standardized influenza vaccination rates improved 3.4% more at intervention sites than at control sites. The 4 practices with the greatest increases in rates (>or=11%) were all in the intervention group. Vaccine receipt was more common among children who had been vaccinated previously, with increasing numbers of visits, with care early in the season, and at preventive versus acute care visits. Clinical alerts were associated with only modest improvements in influenza vaccination rates.

Disappearance of Vaccine-Type Invasive Pneumococcal Disease and Emergence of Serotype 19A in a Minority Population with a High Prevalence of Human Immunodeficiency Virus and Low Childhood Immunization Rates

We analyzed the epidemiology of invasive pneumococcal disease (IPD) following introduction of pneumococcal conjugated vaccine in an urban population with a 2% human immunodeficiency virus (HIV) prevalence and history of low childhood immunization rates. We observed near-elimination of vaccine-type IPD. Substantial disease remains due to non-vaccine-type pneumococci, highlighting the need to increase pneumococcal immunization among HIV-infected adults.

Effect of a novel birth intervention and reminder-recall on on-time immunization compliance in high-risk children

Objectives: Profound racial/ethnic immunization rate disparities exist among young children in Chicago. We created BIRTH PIP, a program combining immunization education at birth with ongoing reminder-recall, to achieve greater than 90% on-time adherence with AAP/ACIP immunization recommendations among inner-city children aged 0-35 months. The study also examines the cost of this effort.Study Design: Outreach workers met with post-partum mothers who were English speaking, Chicago residents and receiving Medicaid, to provide immunization education and determine a contact strategy. Parents were reminded of each well-child appointment. Those missing appointments were re-contacted and rescheduled. Home visits were made when there was no contact by phone and mail. Enrollees and immunizations were tracked until all recommended immunizations were received. On-time immunization rates were compared with city-wide immunization data. Costs were calculated by assessing outreach worker effort and other programmatic costs.Results: A total of 400 neonates were enrolled. At all examined time points, on-time immunization rates exceeded city-wide data. Of those completing the program, 92% of children had 100% compliance with prescribed immunizations by 24 months. No child required follow-up past 29 months. Retention was an important problem, primarily due to pre-set eligibility requirements. Mean cost per child to complete recommended immunizations was $288. Compliant families were less expensive to maintain.Conclusions: BIRTH PIP is effective in improving immunization rates in underserved children. Economies of scale will decrease the per child cost. Preventing even a few cases of vaccine-preventable illness would likely render this initiative cost-effective.

Zoster Vaccination: A New Opportunity for Adult Immunization

Zostavax (Merck Frosst Canada, Inc) was granted approval for use in Canada in the summer of 2008. However, due to initial production limitations, this vaccine has only become available in September 2009 for the prevention of herpes zoster (shingles) infection in Canadian adults. Zostavax is a live, injectable, attenuated herpes zoster vaccine based on the Oka/Merck strain that is similar to varicella vaccine with the exception that it contains an approximately 14-fold higher dose. The underlying rationale for the vaccine is to boost the normal waning of cell-mediated immunity to varicella zoster virus that occurs with aging to reduce the risk of zoster and associated complications (1). Although a rare cause of death, zoster is an important cause of human disease and suffering among Canadian adults. A number of studies have identified an overall incidence of zoster in adults of approximately four cases per 1000 population per year and a lifetime risk of 20% to 30% (2–4). While zoster may occur at any age, there is a significant increased risk for zoster with advancing age beginning at 50 to 60 years, with a steep rise in incidence thereafter. Acute zoster may occasionally be severe, as with infections involving the eye or central nervous system, or those complicated by secondary bacterial infection. Reported rates of hospital admission in older adults may be as high as 10% (3). However, the most common complication of zoster is postherpetic neuralgia (PHN). PHN is characterized by prolonged (often defined as greater than 90 days) and debilitating neurogenic pain that persists from or follows acute zoster. This complication occurs in approximately one-fifth of adults overall but in one-third or more of octogenarians (5). PHN frequently has a major adverse impact on quality of life and treatments are of limited effectiveness (6–10). Paradoxically, models have projected that the incidence of zoster could rise over time as a result of childhood vaccination against varicella (due to the lack of boosting of immunity in adults through exposure to children with chickenpox) (11), although empirical data to date have failed to document such an effect (12). One large phase III randomized clinical trial, The Shingles Prevention Study, evaluated the efficacy of zoster vaccination (13). In this trial, nearly 40,000 healthy adults aged 60 years or older with a prior history of chickenpox (or residence in the continental United States for greater than 30 years), were randomized to a single subcutaneous injection of either zoster vaccine or placebo (13). Subjects were followed for a mean of 3.1 years and assessed for the primary end point of herpes zoster burden of illness as determined using a previously validated scale for measurement of health-related quality of life (7). Herpes zoster burden of illness scores were significantly reduced in the zoster vaccine group as compared with placebo (2.21 versus 5.68; P<0.001), and both duration and severity of zoster were reduced in vaccine recipients. Overall vaccine efficacy was 51% for confirmed zoster and 67% for PHN; burden of illness scores were also reduced by 61% in vaccinees. Although mild injection site reactions were more common in vaccine recipients, the vaccine was safe and generally well-tolerated. All Canadian adults are currently recommended to have immunity (either by previous natural infection or by vaccination) to tetanus, diphtheria, measles, mumps, rubella, pertussis and varicella (14,15). While rates of immunity in Canadian adults are suboptimal, rates of these diseases are generally low and may reflect, at least in part, high rates of childhood immunization with a degree of resultant herd immunity. In addition to these routine vaccines, some vaccines are recommended in a subset of adults. Influenza vaccination is widely recommended for adults but a particular focus is in those with conditions associated with increased risk for complications (16). Pneumococcal polysaccharide vaccine is recommended for adults older than 65 years of age and those with health conditions associated with an increased risk of severe pneumococcal disease (17). There are also a number of travel-recommended vaccines, and more recently the use of human papilloma virus vaccine has been recommended for certain adults (18).

The Impact of Changing Medicaid Enrollments on New Mexico's Immunization Program

BackgroundImmunizations are an important component to pediatric primary care. New Mexico is a relatively poor and rural state which has sometimes struggled to achieve and maintain its childhood immunization rates. We evaluated New Mexico's immunization rates between 1996 and 2006. Specifically, we examined the increase in immunization rates between 2002 and 2004, and how this increase may have been associated with Medicaid enrollment levels, as opposed to changes in government policies concerning immunization practices.Methods and FindingsThis study examines trends in childhood immunization coverage rates relative to Medicaid enrollment among those receiving Temporary Assistance for Needy Families (TANF) in New Mexico. Information on health policy changes and immunization coverage was obtained from state governmental sources and the National Immunization Survey. We found statistically significant correlations varying from 0.86 to 0.93 between immunization rates and Medicaid enrollment.ConclusionsNew Mexico's improvement and subsequent deterioration in immunization rates corresponded with changing Medicaid coverage, rather than the state's efforts to change immunization practices. Maintaining high Medicaid enrollment levels may be important for achieving high childhood immunization levels.