Delivery Of Childhood Immunizations Research Articles

Cost of COVID-19 vaccine delivery in nine States in Nigeria via the U.S. Government Initiative for Global Vaccine Access

BackgroundIn 2022, the U.S. Centers for Disease Control and Prevention collaborated with implementing partners, African Field Epidemiology Network and Sydani Group, to support COVID-19 vaccination efforts in Nigeria. To characterize the costs of COVID-19 vaccination, this study evaluated financial costs per dose for activities implemented to support the intensification campaign for COVID-19 vaccination.MethodsThis retrospective evaluation collected secondary data from existing expenditure and programmatic records on resource utilization to roll out COVID-19 vaccination during 2022. The study included incremental financial costs of the activities implemented to support an intensification campaign for COVID-19 vaccination across nine states and six administrative levels in Nigeria from the perspective of the external donor (U.S. Government). Costs for vaccines and injection supplies, transport of vaccines, and any economic costs, including government in-kind contributions, were not included. All costs were converted from Nigerian Naira to 2022 U.S. Dollars (US$).ResultsThe estimated financial delivery cost of the COVID-19 vaccination intensification campaign was US$0.84 per dose (total expenditure of US$6.29 million to administer 7,461,971 doses). Most of the financial resources were used for fieldwork activities (86%), followed by monitoring and supervision activities (8%), coordination activities (5%), and training-related activities (1%). Labor (58%) and travel (37%) were the resource inputs that accounted for the majority of the cost, while shares of other resource inputs were marginal (1% for each). Most labor costs (79%) were spent on payments for mass vaccination campaign teams, including pay-for-performance incentives. By administrative level, the largest share of costs (46%) was for pay-for-performance incentives at the community, health facility, or campus levels combined, followed by local government area level (24%), community level only (15%), state level (9%), national level (3%), campus level only (1%), and health facility level only (< 1%).ConclusionsFindings from the evaluation can help to inform resources needed for vaccination activities to respond to future outbreaks and pandemics in resource-limited settings, particularly to reach new target populations not regularly included in routine childhood immunization delivery.

National vaccine coverage trends and funding in Latin America and the Caribbean

BackgroundFrom 2006 to 2011 nearly 174,000 deaths were prevented in Latin America and the Caribbean through vaccination of children under five, which is widely attributed to the Expanded Program on Immunization (EPI). Despite near global adoption of EPI recommendations, vaccination coverage shows substantial variation across world regions. Causes for low immunizations within regions are multifaceted and include vaccination program costs. To date, publications regarding vaccine coverage across Latin America and the Caribbean are not readily available. This study aimed to: (1) compare vaccine coverage trends across nations within the region; and (2) assess whether national immunization program expenditures are correlated with vaccine coverage. MethodsCoverage for nine vaccines were collected by nation using publicly available data from WHO. National immunization program expenditures for each country were collected from the World Bank Index. The proportion of countries achieving 90% coverage in the years 2013 and 2017 for each vaccine were compared. Pearson correlation coefficients were calculated to measure the relationship between financing variables and DTP3 coverage for 2017. ResultsIn 2017, fewer Latin American and Caribbean nations were able to achieve 90% vaccine coverage for five vaccines compared to 2013. Mostly weak to moderate positive relationships were found between national immunization program expenditures and DTP3 coverage for 2017. Excluding Haiti, a weak negative relationship was found between total government expenditure on vaccines per infant and DTP3 coverage for 2017. Countries across Latin America and the Caribbean were largely self-reliant in funding vaccine expenditures. ConclusionsFewer countries across Latin America and the Caribbean are currently achieving optimum national vaccine coverage and weak to moderate relationships between routine immunization and vaccine expenditures and coverage were observed. Additional factors contributing to national vaccine coverage should be concomitantly examined to implement strategies which optimize delivery of childhood immunizations.

A method for measuring the effect of certified electronic health record technology on childhood immunization status scores among Medicaid managed care network providers.

To provide a methodology for estimating the effect of U.S.-based Certified Electronic Health Records Technology (CEHRT) implemented by primary care physicians (PCPs) on a Healthcare Effectiveness Data and Information Set (HEDIS) measure for childhood immunization delivery. This study integrates multiple health care administrative data sources from 2010 through 2014, analyzed through an interrupted time series design and a hierarchical Bayesian model. We compared managed care physicians using CEHRT to propensity-score matched comparisons from network physicians who did not adopt CEHRT. Inclusion criteria for physicians using CEHRT included attesting to the Childhood Immunization Status clinical quality measure in addition to meeting "Meaningful Use" (MU) during calendar year 2013. We used a first-presence patient attribution approach to develop provider-specific immunization scores. We evaluated 147 providers using CEHRT, with 147 propensity-score matched providers selected from a pool of 1253 PCPs practicing in Maryland. The estimate for change in odds of increasing immunization rates due to CEHRT was 1.2 (95% credible set, 0.88-1.73). We created a method for estimating immunization quality scores using Bayesian modeling. Our approach required linking separate administrative data sets, constructing a propensity-score matched cohort, and using first-presence, claims-based childhood visit information for patient attribution. In the absence of integrated data sets and precise and accurate patient attribution, this is a reusable method for researchers and health system administrators to estimate the impact of health information technology on individual, provider-level, process-based, though outcomes-focused, quality measures. This research has provided evidence for using Bayesian analysis of propensity-score matched provider populations to estimate the impact of CEHRT on outcomes-based quality measures such as childhood immunization delivery.

HIV Donor Funding Has Both Boosted And Curbed The Delivery Of Different Non-HIV Health Services In Sub-Saharan Africa

Donor funding for HIV programs has increased rapidly over the past decade, raising questions about whether other health services in recipient-country health systems are being crowded out or strengthened. This article--an investigation of the impacts of increased HIV donor funding on non-HIV health services in sub-Saharan Africa during 2003-10--provides evidence of both effects. HIV aid in some countries has crowded out the delivery of childhood immunizations, especially in countries with the lowest density of health care providers. At the same time, HIV aid may have positively affected some maternal health services, such as prenatal blood testing. These mixed results suggest that donors should be more attentive to domestic resource constraints, such as limited numbers of health workers; should integrate more fully with existing health systems; and should address these constraints up front to limit possible negative effects on the delivery of other health services.

To Give or Not to Give: Approaches to Early Childhood Immunization Delivery in Oregon Rural Primary Care Practices

Little is known about rural clinicians' perspectives regarding early childhood immunization delivery, their adherence to recommended best immunization practices, or the specific barriers they confront. To examine immunization practices, beliefs, and barriers among rural primary care clinicians for children in Oregon and compare those who deliver all recommended immunizations in their practices with those who do not. A mailed questionnaire was sent to all physicians, nurse practitioners, and physician assistants practicing primary care in rural communities throughout Oregon. While 39% of rural clinicians reported delivering all childhood immunizations in their clinic, 43% of clinicians reported that they refer patients elsewhere for some vaccinations, and 18% provided no immunizations in the clinic whatsoever. Leading reasons for referral include inadequate reimbursement, parental request, and storage and stocking difficulties. Nearly a third of respondents reported that they had some level of concern about the safety of immunizations, and 14% reported that concerns about safety were a specific reason for referring. Clinicians who delivered only some of the recommended immunizations were less likely than nonreferring clinicians to have adopted evidence-based best immunization practices. This study of rural clinicians in Oregon demonstrates the prevalence of barriers to primary care based immunization delivery in rural regions. While some barriers may be difficult to overcome, others may be amenable to educational outreach and support. Thus, efforts to improve population immunization rates should focus on promoting immunization "best practices" and enhancing the capacity of practices to provide immunizations and ensuring that any alternative means of delivering immunizations are effective.

Qualitative Analysis of Immunization Programs With Most Improved Childhood Vaccination Coverage From 2001 to 2004

State and urban immunization programs are responsible for the implementation of comprehensive programs to vaccinate populations within their geographic area. Given the variability in immunization coverage rates between geographic areas, the purpose of this two-phase study was to first identify the state and urban areas that achieved the highest increases in coverage, and then those with the highest sustained coverage, between two designated periods, and to interview key program staff members and their community counterparts to capture their perspectives on what factors may have contributed to increasing and sustaining high rates. In this article, we describe phase 1, in which we visited the seven sites that achieved the largest increases in coverage from 2001 to 2004. Results describe outcomes from the 71 semistructured key informant interviews with internal staff and external partners at the site's immunization programs. Interview transcripts were analyzed qualitatively, using a general inductive approach. Common challenges encountered among the seven sites included increasing reluctance among parents and overcoming barriers to accessing care. Common strategies to address these and other challenges included collecting and using data on immunization coverage, developing communication and education efforts, and continuously reaching out and collaborating with immunization partners. Lessons learned from these programs may help inform others who are working to improve childhood immunization delivery and coverage in their own programs.

A Qualitative Analysis of Immunization Programs With Sustained High Coverage, 2000–2005

Despite record-high immunization coverage nationally, there is considerable variation across state and local immunization programs, which are responsible for the implementation of vaccine recommendations in their jurisdictions. The objectives of this study were to describe activities of state and local immunization programs that sustained high coverage levels across several years and to identify common themes and practical examples for sustaining childhood vaccination coverage rates that could be applied elsewhere. We conducted 95 semi-structured key informant interviews with internal staff members and external partners at the 10 immunization programs with the highest sustained childhood immunization coverage from 2000 to 2005, as measured by the National Immunization Survey. Interview transcripts were analyzed qualitatively using a general inductive approach. Common themes across the 10 programs included maintaining a strong program infrastructure, using available data to drive planning and decision making, a commitment to building and sustaining relationships, and a focus on education and communication. Given the challenges of an increasingly complex immunization system, the lessons learned from these programs may help inform others who are working to improve childhood immunization delivery and coverage in their own programs.

Vaccine safety perceptions and experience with adverse events following immunization in Uzbekistan

The success of vaccination programmes depends on the continued acceptance of vaccines by parents yet rumours misperceptions and fears about vaccines exist and can lead parents to delay or refuse vaccination. Few quantitative studies have addressed the prevalence of vaccine-related concerns among parents in countries in economic transition. The objective of this survey study was to describe the vaccine safety concerns among parents/ guardians in Uzbekistan. This study was divided into two stages. The first stage used formative research including qualitative key informant interviews and focus groups to obtain detailed information about the childhood immunization delivery system and concerns about immunization safety in Uzbekistan; these results have been described elsewhere. Cognitive interviews and the findings from the formative research were used to develop and pilot-test survey instruments for the second stage of the study which is described below. (excerpt)

Interchangeability of vaccines.

The delivery of childhood immunizations can be complex, often requiring numerous injections over months or years to complete the recommended schedule. The ability to interchange similar vaccines from different manufacturers during a vaccination series is important because the product administered previously may be unknown or no longer available. The current vaccine literature was reviewed to identify available data and determine the consensus on the interchangeability of current vaccines. In the instance of diphtheria-tetanus toxoids-acellular pertussis (DTPa) vaccine, no serologic markers of protective efficacy against Bordetella pertussis exist; therefore it is difficult to evaluate interchangeability of available products. Consequently the ACIP, AAP and AAFP have recommended that the same DTPa product be used for the first three doses of the immunization series. However, if the previously administered product is unknown or not readily available, any licensed DTPa product may be used. More recent data suggest that at least some of the DTPa products have similar immunogenicity and appear to be interchangeable. For other families of vaccines, such as those designed to prevent infection with hepatitis B virus, poliovirus and Haemophilus influenzae type b, there is good evidence attesting to sustained immunogenicity when products from different manufacturers are used to complete a series. The use of approved combination vaccine products whenever possible is advocated by the ACIP, AAP and AAFP because such products decrease the number of injections needed to complete the recommended immunizations and may reduce health care costs, improve program performance and aid in documentation of administered vaccines.

Safety of combination vaccines: perception versus reality.

Combination vaccines contain multiple antigens to protect against several diseases simultaneously and have simplified the delivery of childhood immunizations. Children are healthier today because of the use of combination vaccines, and the United States is benefiting from record low numbers of vaccine-preventable diseases. Despite obvious benefits, concerns and misconceptions exist regarding the safety and efficacy of combination vaccines. A review of the pediatric literature to dispel the common misperceptions and potential barriers to combining vaccines. Assurance that combination vaccines approved by the United States Food and Drug Administration undergo extensive testing will help to alleviate concerns regarding safety and efficacy of combination vaccines. Food and Drug Administration standards are rigorous and require that combination vaccines be as safe and effective as each component of the vaccine administered separately. Combination vaccines have been available for >50 years, and lessons learned during this time are continuously applied to the development and use of new products. Children will benefit from new combination vaccines because fewer injections will be required to protect against vaccine-preventable diseases, allowing for the introduction of new vaccines into the immunization schedule and prevention of additional diseases.

Evidence on Office-Based Interventions to Improve Childhood Immunization Delivery

Evidence on Office-Based Interventions to Improve Childhood Immunization Delivery

Medicaid Managed Care and Childhood Immunization Delivery

Childhood immunization rates can be used as a barometer of the quality of care delivered to children. Medicaid managed care has the potential to improve childhood immunization delivery by implementing population-based medicine in primary care. Studies of immunization rates under Medicaid managed care have found mixed results; in some settings immunization rates were higher for children covered by Medicaid managed care than for children covered by fee-for-service Medicaid, but in other settings immunization rates were similar for children in the two types of Medicaid programs. In most studies, overall rates were well below national guidelines for all populations enrolled in Medicaid.

Public-sector immunization coverage in 11 states: the status of rural areas.

This report uses county-level immunization data generated by state public health agencies to explore the rural-urban variation in the delivery of childhood immunizations in the public sector. Public health department-documented immunization coverage rates for 1995 were obtained from 882 counties in 11 states east of the Mississippi River. To assess the possible association between public health department immunization coverage rates and county rurality, descriptive statistics were calculated. A multiple regression model then was estimated. In all states except West Virginia, nonmetropolitan counties averaged higher completion rates than metropolitan counties. Consistent with the descriptive statistics, in the regression analysis nonmetropolitan counties had average immunization rates 2.47 percentage points higher than metropolitan counties, even when controlling for county socioeconomic characteristics. For the 11 states in the analysis, rural children immunized in the public sector had higher completion rates compared with urban children. These data reflect the dependence of rural families on the public health system and the potential for successful health care delivery through public clinics. As new health care systems are brought into rural areas, the success of this existing avenue for care must not be overlooked.

Parental perceptions of barriers to childhood immunization: results of focus groups conducted in an urban population.

The current US immunization rates for 2 year olds are approximately half of the goal set for the year 2000. Research studies have focused primarily on the perception of health care providers in the identification of barriers and benefits to childhood immunization. While health care providers are an important part of the immunization delivery process, the perceptions of parents are also important. In this study, qualitative methods were used to explore perceived parental barriers to childhood immunization delivery. Twelve focus groups comprising White, African-American, Hispanic, urban and non-urban people were conducted at a variety of sites, including clinics, churches, schools and work sites. The results indicated that time off from work, access to well-child care and difficulty understanding the complexity of the immunization schedule were seen as barriers to adhering to an immunization schedule. Participants emphasized problems in taking time off from work to get immunizations, sometimes without pay, and expressed fears that doing so would jeopardize promotions and raises. While some of the parental perceptions were similar to those identified in studies of health care providers in the literature, many were not. This study emphasizes the importance of gathering information from parents as well as from health care providers.

Risk factors for delayed immunization among children in an HMO.

Improving the timely delivery of childhood immunizations has become a national imperative. This study aimed to identify nonfinancial predictors of delayed immunization among patients with good financial access to preventive care. This prospective cohort study used telephone interviews and a computerized immunization tracking system to evaluate 13-month-old children (n = 530) in a regional group-model health maintenance organization. More than one third of parents interviewed did not know when the next immunization was due. Thirteen percent were late for the measles-mumps-rubella immunization, recommended at 15 months of age, by 90 days or more. Independent predictors of delayed immunization included having a larger number of children (odds ratio [OR] = 1.4, P < .01), not having a regular doctor (OR = 2.9, P < .05), not knowing when the shot was due (OR = 2.0, P < .01), and not worrying about the risks of shots (OR = 1.4, P < .05). Financial access alone does not guarantee timely childhood immunization. In managed care settings, which may cover increasing numbers of children under health care reform, interventions are needed to better inform parents of when immunizations are due.