Improve Childhood Immunization Research Articles

Trends in the types and quality of childhood immunisations research output from Africa 1970–2010: mapping the evidence base

BackgroundOver the past four decades, extraordinary progress has been made in establishing and improving childhood immunization programmes around Africa. In order to ensure effective and sustainable positive growth of these childhood immunisations programmes, the development, adaptation and implementation of all interventions (programme activities, new vaccines, new strategies and policies) should be informed by the best available local evidence.MethodsAn assessment of the peer-reviewed literature on childhood immunization research published in English from 1970 to 2010 was conducted in PubMed and Africa-Wide databases. All study types were eligible for inclusion. A standard form was used to extract information from all studies identified as relevant and entered into a Microsoft Access database for analysis.ResultsOur initial search yielded 5436 articles from the two databases, from which 848 full text articles were identified as relevant. Among studies classified as clinical research (417), 40% were clinical trials, 24% were burden of disease/epidemiology and 36% were other clinical studies. Among studies classified as operational research (431), 77% related to programme management, 18% were policy related and 5% were related to vaccine financing. Studies were conducted in 48 African countries with six countries (South Africa, The Gambia, Nigeria, Senegal, Guinea-Bissau and Kenya) accounting for 56% of the total research output. Studies were published in 152 different journals with impact factors ranging from 0.192 to 53.29; with a median impact factor of 3.572.ConclusionA similar proportion of clinical versus operational research output was found. However, an uneven distribution across Africa was observed with only six countries accounting for over half of the research output. The research conducted was of moderate to high quality, with 62% being published in journals with 2010 impact factors greater than two. Urgent attention should be given to the development of research capacity in low performing countries around Africa, with increased focus on the process of turning immunisations programme research evidence into policy and practice, as well as increased focus on issues relating to vaccine financing and sustainability in Africa.

Improving immunization rates of underserved children: a historical study of 10 health departments.

Despite high immunization rates, hundreds of thousands of poor and underserved children continue to lack their necessary immunizations and are at risk of acquiring a vaccine-preventable disease. Local Health Departments (LHDs) and public health clinicians figure prominently in efforts to address this problem. This exploratory research compared ten (10) North Carolina LHDs with respect to immunization delivery factors. The study sample was identified based on urban designation as well as county demographic and socio-economic indicators that identified predicted "pockets" of underimmunization. Survey instruments were used to identify specific LHD immunization delivery factors. It was found that hours of operation, appointment policies, use and type of tracking systems, and wait times influence a health department's ability to immunize underserved children. This exploratory research is of particular importance, because it suggests that the implementation of specific policy interventions may reduce the morbidity and mortality related to vaccine-preventable diseases in poor and underserved children. This research also highlights the significance of the nurses' role in the policy making process in this important area of community health assurance. To improve childhood immunization rates, policy-makers should encourage adequate and appropriate funding for LHDs to adopt service delivery factors that are associated with higher-performing local health departments. LHDs should study the population they serve to further refine service delivery factors to meet the population's needs.

India's Universal Immunisation Programme to prevent children from preventable disease: retention and dropout approach

BackgroundThe Universal Immunisation Programme was integrated with the Reproductive and Child Health Programme to improve childhood immunisation in India. However, there is a lack of empirical research on understanding about childhood immunisation by the standard schedule of WHO. This study aimed to estimate the level of retention and dropouts from one vaccination to the next among Indian children aged 12–23 months. MethodsWe use data from the nationwide District Level Household and Facility Survey (DLHS-3), which was carried out in all 596 districts and covered 64 702 children aged 12–23 months in India during 2007–08. We used the Kaplan–Meier method to assess the retention rate of childhood immunisation. FindingsOnly 52·5% (33 959 of 64 702) of children aged 12–23 months have received the full course of vaccination. Children of the poorest and illiterate mothers have the lowest rate of full immunisation. 86·1% (55 688 of 64 702) of children would have been fully vaccinated if each child had been administered all three doses of diphtheria, pertussis, and tetanus (DPT) and polio vaccines and measles vaccine. The retention rate of childhood immunisation was in maximum decline between the second round of DPT and polio (70%, 95% CI 69–71) and the third round (56%, 55–57). On the other hand, if all children are brought under the health-system network by way of registering all births for BCG, the existing dropout rate at different stages of vaccination will yield 60·8% (33 869 of 55 688) of children being fully immunised. InterpretationThe findings of this assessment reveal that immunisation coverage varies from one vaccine to another and declines over the schedule prescribed by the WHO. BCG, third-round DPT, and third-round polio vaccination coverage may play a critical role in full immunisation, as the dropout rates were higher for these vaccinations. Specially designed interventions are needed to meet Millennium Development Goals regarding the under-5 mortality rate, infant mortality rate, and proportion of 1-year-old children immunised against measles. FundingDY was supported by the Government of India/National Eligibility Test Doctoral Fellowship award from the University Grants Commission and Ministry of Health and Family Welfare, Government of India. The funders had no role in study design, data collection, analysis, or preparation of the abstract.

Cochrane Review: Interventions for improving coverage of child immunization in low‐ and middle‐income countries

AbstractBackgroundImmunization coverage remains low, particularly in low‐ and middle‐income countries (LMIC), despite its proven effectiveness in reducing the burden of childhood infectious diseases. A Cochrane review has shown that patient reminder recall is effective in improving coverage of immunization but technologies to support this strategy are lacking in LMIC.ObjectivesTo evaluate the effectiveness of intervention strategies to boost and sustain high childhood immunization coverage in LMIC.Search methodsWe searched the following databases for primary studies: Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 1, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 8 July 2010); MEDLINE, Ovid (1948 to March Week 3 2011) (searched 30 March 2011); EMBASE, Ovid (1980 to 2010 Week 26) (searched 8 July 2010); CINAHL, EBSCO (1981 to present ) (searched 8 July 2010); LILACS, VHL (1982 to present) (searched 8 July 2010); Sociological Abstracts, CSA Illumnia (1952 to current) (searched 8 July 2010). Reference lists of all papers and relevant reviews were identified and searched for additional studies.Selection criteriaIncluded studies were randomized controlled trials (RCTs), non‐randomized controlled trials (NRCTs), and interrupted‐time‐series (ITS) studies. Study participants were children aged 0 to 4 years, caregivers, and health providers. Interventions included patient and community‐oriented interventions, provider‐oriented interventions, health system interventions, multi‐faceted (any combination of the above categories of interventions), and any other single or multifaceted intervention intended to improve childhood immunisation coverage The primary outcome was the proportion of the target population fully immunized with recommended vaccines by age.Data collection and analysisTwo authors independently screened full articles of selected studies, extracted data, and assessed study quality.Main resultsSix studies were included in the review; four were at high risk of bias. There was low quality evidence that: facility based health education may improve the uptake of combined vaccine against diphtheria, pertussis, and tetanus (DPT3) coverage (risk ratio (RR) 1.18; 95% CI 1.05 to 1.33); and also that a combination of facility based health education and redesigned immunization cards may improve DPT3 coverage (RR 1.36; 95% CI 1.22 to 1.51). There was also moderate quality evidence that: evidence‐based discussions probably improve DPT3 coverage (RR 2.17; 95% CI 1.80 to 2.61), and that information campaigns probably increase uptake of at least a dose of a vaccine (RR 1.43; 95% CI 1.01 to 2.02).Authors' conclusionsHome visits and health education may improve immunization coverage but the quality of evidence is low.Plain Language SummaryInterventions that will increase and sustain the uptake of vaccines in low‐ and middle‐income countries.Millions of children in low‐ and middle‐income countries still die from diseases that could have been prevented with vaccines. In order to reach these children, a variety of interventions have been developed and, in some cases, their effect has been evaluated. The studies in this review took place in both rural and urban areas in several countries, including Pakistan and Ghana. The interventions included organising village meetings where immunisation was discussed and promoted; giving information to mothers during their visits to clinics; and distributing specially designed immunisation cards to remind mothers of their children's immunisation appointments. The families receiving these interventions were compared to families who only received the usual health services.The review showed that village meetings probably lead to an increase in the number of children who get vaccinated. The quality of this evidence is moderate. Giving information to mothers during visits to the clinic, or giving them specially designed immunisation cards may increase the number of children who get vaccinated, but the quality of this evidence is low.

Primary care strategies to improve childhood immunisation uptake in developed countries: systematic review

ObjectivesTo conduct a systematic review of strategies to optimize immunisation uptake within preschool children in developed countries.DesignSystematic review.SettingDeveloped countriesParticipantsPreschool children who were due, or overdue, one or more of their routine primary immunisations.Main outcome measuresIncrease in the proportion of the target population up to date with standard recommended universal vaccinations.ResultsForty-six studies were included for analysis, published between 1980 and 2009. Twenty-six studies were randomized controlled trials, 11 were before and after trials, and nine were controlled intervention trials. Parental reminders showed a statistically significant increase in immunisation rates in 34% of included intervention arms. These effects were reported with both generic and specific reminders and with all methods of reminders and recall. Strategies aimed at immunisation providers were also shown to improve immunisation rates with a median change in immunisation rates of 7% when reminders were used, 8% when educational programmes were used and 19% when feedback programmes were used.ConclusionGeneral practitioners are uniquely positioned to influence parental decisions on childhood immunisation. A variety of strategies studied in primary care settings have been shown to improve immunisation rates, including parental and healthcare provider reminders.

Randomized controlled trial to improve childhood immunization adherence in rural Pakistan: redesigned immunization card and maternal education

A substantial dropout from the first dose of diphtheria-tetanus-pertussis (DTP1) to the 3rd dose of DTP (DTP3) immunization has been recorded in Pakistan. We conducted a randomized controlled trial to assess the effects of providing a substantially redesigned immunization card, centre-based education, or both interventions together on DTP3 completion at six rural expanded programme on immunization (EPI) centres in Pakistan. Mother-child pairs were enrolled at DTP1 and randomized to four study groups: redesigned card, centre-based education, combined intervention and standard care. Each child was followed up for 90 days to record the dates of DTP2 and DTP3 visits. The study outcome was DTP3 completion by the end of follow-up period in each study group. We enrolled 378 mother-child pairs in redesigned card group, 376 in centre-based education group, 374 in combined intervention group and 378 in standard care group. By the end of follow-up, 39% of children in standard care group completed DTP3. Compared to this, a significantly higher proportion of children completed DTP3 in redesigned card group (66%) (crude risk ratio [RR] = 1.7; 95% CI = 1.5, 2.0), centre-based education group (61%) (RR = 1.5; 95% CI = 1.3, 1.8) and combined intervention group (67%) (RR = 1.7; 95% CI = 1.4, 2.0). Improved immunization card alone, education to mothers alone, or both together were all effective in increasing follow-up immunization visits. The study underscores the potential of study interventions' public health impact and necessitates their evaluation for complete EPI schedule at a large scale in the EPI system.

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.

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.

The Australian Childhood Immunisation Register—A model for universal immunisation registers?

The Australian Childhood Immunisation Register (ACIR) was established in 1996 as an opt-out register built on the platform of Medicare, the universal national health insurance scheme. Introduction of financial incentives for providers and parents, linked to the ACIR, followed from 1998. Over the subsequent decade, national levels for receipt of all vaccines by 12, 24 and 72 months of age have risen to 91%, 93%, and 88%, respectively. Conscientious objection to immunisation can be registered, with retention of eligibility for incentives. The ACIR has been important in implementation of a range of measures to improve childhood immunisation coverage in Australia. Linkage of a universal childhood immunisation register to national health insurance schemes has potential applicability in a variety of settings internationally.

Development of Vaccine Risk Communication Messages Using Risk Comparisons and Mathematical Modeling

It is important to systematically assess the vaccine information needs of parents in order to maintain or improve childhood immunization coverage. Our objectives were to obtain suggestions for the optimal presentation of vaccine-related information and to determine if an educational intervention affected mothers' vaccine safety attitudes. Focus groups were used to develop messages that then were tested through a randomized, pre- and post-test mail survey of non-Hispanic White mothers who reported vaccine safety concerns (n = 927). Focus groups were analyzed using text analysis software. Increases in attitude scores between the pre- and post-test surveys were calculated, and logistic regression was used to compare intervention groups with a control group. Of survey participants who recalled the test messages, 50% (85/171) who received a “consequences of reduced coverage” message reported an improved opinion of vaccines. A greater proportion of participants receiving one or more intervention messages reported an improved attitude score from pre-to post-test compared with the control group for four of the five variables measured; however, differences were small and none were statistically significant. A mixed method approach was used to develop and test vaccine messages. The message describing potential consequences of reduced vaccination coverage had the greatest impact on improving concerned mothers' opinions of childhood vaccines.

Utilizing Peer Academic Detailing to Improve Childhood Immunization Coverage Levels

Interventions that utilize academic detailing to improve childhood immunization have been implemented across the country. This study evaluates the effectiveness of an academic detailing intervention to increase childhood immunization rates in pediatric and family medicine practices in a major metropolitan area. Educational teams of one physician, nurse, and office manager delivered 83 peer education sessions at practices in the intervention group. Postintervention immunization rates for children 12-23 months of age increased 1% in the intervention group and decreased 3% in the control group. Postintervention coverage levels for children 12-23 months of age did not differ between the intervention and control groups. Results indicated this office-based intervention was not sufficient to effect measurable changes in immunization coverage levels after 1 year of participation. Future interventions need to provide initial feedback regarding practice immunization coverage levels prior to the educational interventions and include multiple encounters.

Improvement in Provider Immunization Knowledge and Behaviors Following a Peer Education Intervention

Provider education programs that use academic detailing to improve childhood immunization have been implemented in several states. The purpose of this study was to evaluate the impact of these types of programs to improve immunization-related behaviors in private provider offices. The intervention included peer-based academic detailing in which teams of 1 physician, 1 nurse, and 1 office manager visited pediatric and family practices to deliver an educational presentation and develop practice-specific action plans. Comparison of pre-post intervention surveys showed that providers' willingness to give the maximum number of immunizations due at 1 visit (P < .001) increased. More providers reported routinely screening immunization records at sickness or injury visits (P < .05) and using minimum intervals (P < .001) postintervention. Mean change in baseline and postintervention overall scores was significant for pediatric practices (0.40, P < .05), small practices (0.64, P < .01), Vaccines for Children (VFC) practices (0.74, P < .05), and non-VFC provider practices (0.67, P < .01) but not for family or large practices.

Private provider participation in statewide immunization registries

BackgroundPopulation-based registries have been promoted as an effective method to improve childhood immunization rates, yet rates of registry participation in the private sector are low. We sought to describe, through a national overview, the perspectives of childhood immunization providers in private practice regarding factors associated with participation or non-participation in immunization registries.MethodsTwo mailed surveys, one for 264 private practices identified as registry non-participants and the other for 971 identified as registry participants, from 15 of the 31 states with population-based statewide immunization registries. Frequency distributions were calculated separately for non-participants and participants regarding the physician-reported factors that influenced decisions related to registry participation. Pearson chi-square tests of independence were used to assess associations among categorical variables.ResultsOverall response rate was 62% (N = 756). Among non-participants, easy access to records of vaccines provided at other sites (N = 101, 68%) and printable immunization records (N = 82, 55%) were most often cited as "very important" potential benefits of a registry, while the most commonly cited barriers to participation were too much cost/staff time (N = 36, 38%) and that the practice has its own system for recording and monitoring immunizations (N = 35, 37%). Among registry participants, most reported using the registry to input data on vaccines administered (N = 326, 87%) and to review immunization records of individual patients (N = 302, 81%). A minority reported using it to assess their practice's immunization coverage (N = 110, 29%) or generate reminder/recall notices (N = 54, 14%). Few participants reported experiencing "significant" problems with the registry; the most often cited was cost/staff time to use the registry (N = 71, 20%).ConclusionMost registry participants report active participation with few problems. The problems they report are generally consistent with the barriers anticipated by non-participants, but did not impede participation. Recruitment efforts should focus on demonstrating the benefits of the registry to providers. In addition, many participants are not utilizing the full range of registry features; further study is needed to determine how best to increase use of these features.

Diphtheria in Thailand in the 1990s.

Diphtheria remains endemic in developing countries, but there are limited published data on the subject. Thailand's diphtheria surveillance data are relatively complete and may give a fuller picture of the situation in similar countries. After routine immunization began in 1977, the incidence of reported diphtheria decreased by >98% to <0.1 case per 100,000 persons annually in the 1990s. Despite infant immunization coverage of >90%, diphtheria cases were reported throughout the 1990s, primarily among children <15 years old. Outbreaks were linked to both persistent endemic circulation and to importation of toxigenic Corynebacterium diphtheriae; suboptimal immunization coverage in minority and disadvantaged groups contributed. A serologic survey found 25% of adults 20-39 years old and 14% of adolescents 10-19 years old lacked immunity to diphtheria; these data indicate an accumulation of susceptible adolescents and adults. Diphtheria remains a threat in Thailand; improvements in diphtheria control will depend on improving childhood immunization coverage in Thailand and the surrounding region.

Health care incentives in immunisation

BackgroundAustralia has Introduced a nationwide immunisation incentive scheme. This yet to be evaluated two-year program offers financial rewards to providers and parents to encourage childhood immunisations. ObjectivesTo review the use of incentives in immunisation uptake, identify issues in developing an incentive program for childhood immunisation and examine the findings within the context of the Australian scheme. MethodsMedline was searched under ‘immunization and financial incentive’ and ‘immunization and incentive’ in English 1966 to 1998. ResultsThe search identified six and 93 articles respectively, of which six examined the role of material incentives influencing coverage of immunisation. References and reviews identified a further three studies. Among these nine studies (two British, six American, one Nicaraguan), two reported the same intervention. Of the eight incentives examined, four referred to non-financial incentives such as food vouchers and four to monetary incentives for parents (1) or providers (3). Groups receiving the incentives were up to three times more likely to be immunised and had overall immunisation rates up to 17% higher than comparison groups. ConclusionsEffective incentives require collaboration of key players, using a program appropriate to the characteristics of the population. Although varying in cost-effectiveness, both monetary and nonmonetary incentives can improve childhood immunisation uptake. Evaluation of current programs including the Australian ones will assist future allocation of resources.

Evidence on Office-Based Interventions to Improve Childhood Immunization Delivery

Evidence on Office-Based Interventions to Improve Childhood Immunization Delivery

Initiatives to improve childhood immunisation uptake: a randomised controlled trial

Levels of childhood immunisation are high in the United Kingdom but are proving difficult to maintain. Several initiatives to improve uptake have been described, including sending written information to parents,1...

CINCH: an urban coalition for empowerment and action. Consortium for the Immunization of Norfolk's Children.

CINCH (Consortium for the Immunization of Norfolk's Children) is an urban coalition that was developed in 1993 to improve childhood immunization rates in Norfolk, Virginia. CINCH involves diverse citizens and institutions in effective community-based assessment, planning, and action. A needs assessment from 1993 found that only 49% of Norfolk 2-year-olds were adequately immunized. Using this data, CINCH developed a plan focused on education and communication, support for at-risk families, increased access to immunizations, and improved immunization delivery. After federal funding ended in 1995, members voted to expand the scope of the coalition to address additional child health needs and to broaden the membership. CINCH is a model for a sustainable city-citizen learning environment that intervenes to "help families help themselves to better health." The coalition is presented as an organization that focuses on community empowerment and development. The stages of coalition development and implications for coalition implementation in other sites are discussed.