Up-to-date Rates Research Articles

County-Level Factors Associated With HPV Vaccine Coverage Among 11-Year-Olds to 12-Year-Olds Living in Florida in 2019

BackgroundIn the United States, human papillomavirus (HPV) vaccine initiation and up-to-date (UTD) status are associated with multiple factors at the individual level such as racial/cultural (e.g., race, immigration status), socioeconomic status (e.g., living below poverty level, education), and healthcare access (e.g., insurance status/type). HPV vaccination rates differ dramatically by US geographic areas and within states. To tailor interventions to local areas, it is important to understand county-level characteristics associated with HPV vaccination rates. MethodsUsing linear regression, we assessed the association between county-level HPV vaccination initiation and UTD rates for 11-year-olds to 12-year-olds in Florida (collected from the Florida SHOTS immunization registry) and county-level variables. Factors found significant in bivariate analysis and with a variance influence factors <4 were included in multivariable models. ResultsIn 2019, county-level HPV vaccine coverage among Florida 11-year-olds to 12-year-olds ranged from 31% to 92% initiation and 3%–36% UTD. Counties with the lowest HPV vaccine coverage were concentrated in Florida's North-Central and Panhandle regions. In multivariable models, counties with primarily rural populations had lower vaccination initiation and UTD coverage. Above and beyond the association with rurality, UTD coverage was associated with family physicians per 100,000 residents and uninsured or Medicaid-enrolled populations. DiscussionWhile Florida county-level HPV vaccine initiation rates among 11-year-olds to 12-year-olds varied by county in 2019, UTD rates remained universally low despite recommendations. Tailoring interventions toward healthcare access in rural communities may increase HPV vaccine coverage.

Improving Care for Patients with Chronic Hepatitis B via Establishment of a Disease Registry.

ABSTRACT.In the United States, there is poor clinician adherence to the American Association for the Study of Liver Disease and other guidelines for chronic hepatitis B virus (CHB) management. This prospective cohort study evaluated whether a CHB registry improves CHB management. We included patients with CHB aged ≥ 18 years and who had a clinical encounter during September 1, 2016–August 31, 2019. We divided patients into three groups based on care received before September 1, 2019: 1) CIH: primary care clinician at HealthPartners Center for International Health, 2) GI: not CIH and seen by gastroenterology within previous 18 months, and 3) primary care (PC): not CIH and not seen by gastroenterology within previous 18 months. We created and implemented a CHB registry at CIH that allowed staff to identify and perform outreach to patients overdue for CHB management. Patients with laboratory testing (i.e., alanine transaminase and hepatitis B virus DNA) and hepatocellular carcinoma screening in the previous 12 months were considered up to date (UTD). We compared UTD rates between groups at baseline (September 1, 2019) and pilot CHB registry end (February 28, 2020). We evaluated 4,872 patients, 52% of whom were female: 213 CIH, 656 GI, and 4,003 PC. At baseline, GI patients were most UTD (69%) followed by CIH (51%) and PC (11%). At pilot end the percent of UTD patients at CIH increased by 11%, GI decreased by 10%, and PC was unchanged. CHB registry use standardized care and increased the percent of CHB patients with recent laboratory testing and HCC screening.

Effects of California Assembly Bill 2109 in Low Vaccination Rate Counties: Are We Looking at the Right Variables?

California Assembly Bill 2109 (AB2109) was passed in 2012 and restricted the obtainment of personal belief exemptions (PBEs) for vaccination requirements for school-aged children. This study examined changes in up-to-date (UTD) vaccination rates, PBEs, and conditionally accepted students (CASs) at 3 time points. The study also examined the association of PBEs and CASs on county and school immunization rates. This study utilized 6 academic years of immunization data from all kindergartens in California from 2010-2011 to 2015-2016. The years were selected to include data 2 years prior to the introduction of the bill, 2 years prior to implementation, and 2 years after the new legislation went into effect in 2014. Data were analyzed for changes in variables over time at the state, county, and school levels. A Pearson correlation was performed to assess the association between CAS, PBE, and not-UTD rates in low- and high-UTD counties. Counties with the highest percentage of unimmunized students have significantly higher mean CAS rates than PBE rates (P < .01 for all years). CASs were found to be more highly correlated with students not-UTD with immunizations than PBEs in all years studied (P < .01 for all years) and with far greater effect size in low-UTD counties (<90% UTD rate). There was a small rise in PBEs and a small reduction in UTD rates after AB2109 was signed but a fall in PBE and CAS rates and a rise in UTD rates postimplementation. Many California counties have high levels of CASs at the time of kindergarten entry. The extent to which schools require CASs to complete required vaccinations is not known, which could contribute to the pool of undervaccinated students in California. Public health officials should be vigilant to ensure that schools follow up and enforce the completion of vaccines for conditionally admitted students. This study has policy implications due to the fact that it has been revealed that there is a large undervaccinated population remaining relatively unaccounted for in California despite recent efforts.

Using Spatial Analysis to Inform Community Immunization Strategies.

Introduction:Recent pertussis outbreaks in the United States suggest our response to local disease outbreaks (eg, vaccine-preventable Bordetella pertussis) may benefit from understanding and applying spatial analytical methods that use data from immunization information systems at a subcounty level.Methods:A 2012 study on Denver, CO, residents less than 19 years of age confirmed pertussis cases and immunization information system records were geocoded and aggregated to the census tract (CT) level. An algorithm assessed whether individuals were up-to-date (UTD) for pertussis vaccines. Pearson, Spearman, and Kendall correlations assessed relations between disease incidence and pertussis vaccine coverage. Using spatial analysis software, disease incidence and UTD rates were spatially weighted, and smoothed. Global and local autocorrelations based on univariate Moran’s I spatial autocorrelation statistics evaluated whether a CT’s rate belong to a cluster based on incidence or UTD measures.Results:Overall disease incidence rate was 116.8/100 000. Assessment of pertussis vaccination coverage was available for 90% of the population. Among 134 672 Denver residents less than 19 years old, 103 496 (77%) were UTD for pertussis vaccines. Raw correlation coefficients showed weak relationships between incidence and immunization rates due to the presence of outliers. With geospatial and clustering analysis, estimates and correlation coefficients were improved with statistically significant Moran’s I values for global and local autocorrelations rejecting the null hypothesis that incidence or UTD rates were randomly distributed. With evidence indicating the presence of clusters, smoothed and weighted disease incidence and UTD rates in 144 CTs identified 21 CTs (15%) for potential public health intervention.Conclusions:Correlation of raw disease incidence and vaccine UTD rates in subcounty regions showed limited association, providing limited information for decision making. By assessing for clusters using spatial analysis methods, we identified CTs with higher incidence and lower immunization coverage for targeted public health interventions.

Centralized Reminder/Recall to Increase Immunization Rates in Young Children: How Much Bang for the Buck?

ObjectiveWe compared the effectiveness and cost-effectiveness of: 1) centralized reminder/recall (C-R/R) using the Colorado Immunization Information System (CIIS) versus practice-based reminder/recall (PB-R/R) approaches to increase immunization rates; 2) different levels of C-R/R intensity; and 3) C-R/R with versus without the name of the child's provider. MethodsWe conducted 3 sequential cluster-randomized trials involving children aged 19 to 25 months in 15 Colorado counties in March 2013 (trial 1), October 2013 (trial 2), and May 2014 (trial 3). In C-R/R counties, the intensity of the intervention decreased sequentially in trials 1 through 3, from 3 to 1 recall messages. In PB-R/R counties, practices were offered training using CIIS and financial support. The percentage of children with up-to-date (UTD) vaccinations was compared 6 months after recall. A mixed-effects model assessed the association between C-R/R versus PB-R/R and UTD rates. ResultsC-R/R was more effective in trials 1 to 3 (relative risk = 1.11; 95% confidence interval 1.01–1.20; P = .009). Effectiveness did not decrease with decreasing intervention intensity (P = .59). Costs decreased with decreasing intensity in the C-R/R arm, from $18.72 per child brought UTD in trial 1 to $10.11 in trial 3. Costs were higher and more variable in the PB-R/R arm, ranging from $20.63 to $237.81 per child brought UTD. C-R/R was significantly more effective if the child's practice name was included (P < .0001). ConclusionsC-R/R was more effective and cost-effective than PB-R/R for increasing UTD rates in young children and was most effective if messages included the child's provider name. Three reminders were not more effective than one, which may be explained by the increasing accuracy of contact information in CIIS over the course of the trials.

Influence of Office Systems on Pediatric Vaccination Rates.

This study seeks to better understand the impact of practice-level factors on up-to-date (UTD) rates in children. We compared practice-level vaccination rates for 54 practices to survey data regarding office practices for staffing, vaccine delivery, reminder-recall, and quality improvement. Vaccination rates at 24 and 35 months were analyzed using t tests, analysis of variance, and linear regression. Private practices and those using standing orders had higher UTD rates at 24 months ( P = .01; P = .03), but not at 35 months. Having a pediatrician in the office was associated with higher UTD rates at both 24 and 35 months ( P < .01). Participating in a network and taking walk-in patients were associated with lower UTD rates ( P = .03; P = .03). As the percentage of publicly insured patients decreases, the UTD rate rises at 24 and 35 months ( r = -0.43, P = .001; r = -0.037, P = .007). Reported use of reminder recall-systems, night/evening hours, and taking walk-in patients were not associated with increased UTD rates.

Evaluation of a community immunization outreach program--Philadelphia, Pennsylvania.

Every year the Philadelphia Department of Public Health selects roughly 5000 10-month olds not up-to-date (UTD) for their 6-month vaccinations for a community-based outreach program. To evaluate the outreach program's effectiveness from 2008 to 2012. Outreach children from 2008 to 2012 were compared with children not selected for outreach on UTD rates and median UTD age in a retrospective cohort study. Philadelphia, Pennsylvania : 10- to 15-month olds from targeted Philadelphia ZIP codes. Outreach workers investigated immunization status, educated families on the importance of timely immunizations, and assisted patients in securing health care services to bring children UTD on their 6-month vaccinations. Outcomes included UTD status for recommended vaccinations due by 6, 15, and 18 months and median age at which 15- and 18-month vaccinations were completed for outreach versus nonoutreach children. Outreach children had significantly higher UTD rates for 6-month vaccinations than nonoutreach children. Outreach children also had significantly higher UTD rates for 15- and 18-month vaccinations, and therefore the effect of outreach is lasting. From 2008 to 2012, median UTD ages for 15- and 18-month vaccinations were significantly lower for outreach than for nonoutreach children. Outreach was effective in increasing immunization UTD rates and is a useful tool for improving childhood immunization rates in urban settings.

Incomplete Early Childhood Immunization Series and Missing Fourth DTaP Immunizations; Missed Opportunities or Missed Visits?

The successful completion of early childhood immunizations is a proxy for overall quality of early care. Immunization statuses are usually assessed by up-to-date (UTD) rates covering combined series of different immunizations. However, series UTD rates often only bear on which single immunization is missing, rather than the success of all immunizations. In the US, most series UTD rates are limited by missing fourth DTaP-containing immunizations (diphtheria/tetanus/pertussis) due at 15 to 18 months of age. Missing 4th DTaP immunizations are associated either with a lack of visits at 15 to 18 months of age, or to visits without immunizations. Typical immunization data however cannot distinguish between these two reasons. This study compared immunization records from the Oregon ALERT IIS with medical encounter records for two-year olds in the Oregon Health Plan. Among those with 3 valid DTaPs by 9 months of age, 31.6% failed to receive a timely 4th DTaP; of those without a 4th DTaP, 42.1% did not have any provider visits from 15 through 18 months of age, while 57.9% had at least one provider visit. Those with a 4th DTaP averaged 2.45 encounters, while those with encounters but without 4th DTaPs averaged 2.23 encounters.

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.

Immunization milestones: a more comprehensive picture of age-appropriate vaccination.

A challenge facing immunization registries is developing measures of childhood immunization coverage that contain more information for setting policy than present vaccine series up-to-date (UTD) rates. This study combined milestone analysis with provider encounter data to determine when children either do not receive indicated immunizations during medical encounters or fail to visit providers. Milestone analysis measures immunization status at key times between birth and age 2, when recommended immunizations first become late. The immunization status of a large population of children in the Oregon ALERT immunization registry and in the Oregon Health Plan was tracked across milestone ages. Findings indicate that the majority of children went back and forth with regard to having complete age-appropriate immunizations over time. We also found that immunization UTD rates when used alone are biased towards relating non-UTD status to a lack of visits to providers, instead of to provider visits on which recommended immunizations are not given.

Immunization status and risk factors of migrant children in densely populated areas of Beijing, China

Objective To properly evaluate the immunization status and determine risk factors of migrant children in 23 densely populated towns and townships in Beijing. Methods A household cluster sampling survey was implemented and standard face-to-face interviews were conducted with 1820 migrant children aged 12–35 months. Demographic characteristics of the child and primary caregiver, the child's migrant characteristics, the primary caregiver's knowledge and attitude toward immunization, information about immunization services provided by the local clinic, and the child's immunization history were obtained. Weighted up-to-date (UTD) and age-appropriate immunization rates for the following four vaccines were assessed: three doses of diphtheria, tetanus and pertussis combined vaccine (DTP); three doses of oral poliomyelitis vaccine (OPV); three doses of hepatitis B vaccine (HepB); and one dose of Measles-containing vaccine (MCV). Weighted UTD and age-appropriate immunization rates for the overall series of these four vaccines (the 3:3:3:1 immunization series) were also estimated. Risk factors for not being UTD, being invalid and being delayed for the 3:3:3:1 immunization series were explored using both single-level and multi-level multinomial logistic regression models. Results For each antigen, the weighted UTD immunization rate was above 83%, but the age-appropriate immunization coverages for HepB, OPV, DPT, and MCV were only 45.6%, 49.6%, 50.8% and 54.7%, respectively. The 1st dose was most likely to be invalid or delayed within HepB, OPV and DPT series. For the 3:3:3:1 immunization series, the weighted UTD and age-appropriate immunization rates were 78.1% and 20.5%, respectively. Immunization status of migrant children tended to be homogenous within a village and therefore, multi-level model was more appropriate for assessing risk factors. Besides demographic characteristics, several other factors were significantly associated with age-appropriate immunization coverage. These factors included: the child's migrant characteristics; the primary caregiver's awareness of the importance of vaccination, and outreach services provided by immunization clinics including notification services and supplementary immunization activities (SIAs). The frequency and duration of clinical immunization sessions significantly influenced the UTD immunization rate but not the age-appropriate immunization rate. The degree of the primary caregiver's satisfaction with clinic services and convenience to vaccination clinic had no impact on the child's immunization status. Conclusion Alarmingly low age-appropriate immunization coverage of migrant children in densely populated areas demanded immediate intervention. Community context was an important factor to a migrant child's vaccination status and should be considered when taking measures. Strategies to strengthen outreach immunization service need to be developed to effectively improve the age-appropriate immunization coverage of migrant children.

Reminder Cards and Immunization Rates Among Latinos and the Rural Poor in Northeast Colorado

Immunization rates are static in the United States. Risk factors for not being up to date (UTD) include ethnicity and lower socioeconomic status. Reminder cards increase immunization rates in urban settings. Their effect in poor, Latino, and rural children is unknown. Language-appropriate reminder cards were sent to active patients not UTD listing the vaccines missing; the card served as the physician order for the vaccine. Missed opportunities were addressed through discussion with staff and posters in patient care rooms. UTD rates before and after intervention were measured. Dual-purpose reminder/order cards increased the rate of UTD from 61.3% to 73.4%; children living near the clinic, patients who speak only Spanish, and Latinos overall showed preferential effectiveness. Children eligible to participate in the Vaccines for Children program had similar increases in UTD rates but had lower baseline and final UTD rates than did children not eligible for the Vaccines for Children program. The rate of missed opportunities did not change. The number of children to whom reminder cards needed to be sent for them to become fully immunized is 8 (number needed to treat). In poor, rural, and Latino populations, language-appropriate reminder/order cards increase immunization rates.

Quality Improvement in Immunization Delivery Following an Unsuccessful Immunization Recall

Within a clinic serving disadvantaged children, 1) to evaluate a multifaceted quality improvement (QI) project to improve immunization (IZ) up-to-date (UTD) rates and 2) to assess the efficacy of IZ reminder/recall performed following QI. A year-long QI project followed by a trial of reminder/recall. QI interventions were targeted at previously identified barriers to IZ and were designed specifically to improve the efficacy of reminder/recall. QI interventions were designed to 1) increase the use of medical record releases to document IZs received elsewhere; 2) improve the accuracy of parental contact information; and 3) reduce missed opportunities by utilizing chart prompts, provider education, and provider reminders. Following QI, we conducted a randomized trial of reminder/recall. UTD rates for 7-11 month olds increased from 21% before the QI project to 52% after (P <.0001); rates for 12-18 month olds increased from 16% before QI to 44% after (P <.0001); 19-25 month olds 18% before to 33% after (P <.001). After QI, an average of 61 records per month were updated with IZs received elsewhere. However, the accuracy of parental contact information worsened (29% unreachable before QI vs 44% after, P <.001) and missed opportunities did not improve (8% before vs 6% after, P = not significant [NS]). A subsequent trial of reminder/recall did not increase UTD rates, with 17% of recalled children brought UTD vs 16% of controls (P = NS). Clinic-based QI increased documented UTD rates in a disadvantaged patient population. However, IZ reminder/recall did not further increase UTD rates above the rates achieved by the QI process.

Immunization recall: Effectiveness and barriers to success in an urban teaching clinic

Objective: To examine effectiveness of immunization recall in an urban pediatric teaching clinic and to identify barriers to recall effectiveness. Design: Randomized, controlled trial. Children aged 5 to 17 months who were not up to date (UTD) with recommended immunizations were identified and assigned to intervention (n = 294) or control groups (n = 309). The intervention consisted of a mailed postcard and up to 4 telephone calls. Two months after intervention, UTD status, visit, and probable missed opportunity rates were assessed. Results: Of the intervention group, 30% could not be reached. In 12-month-old children in the intervention group compared with those in the control group, there was a trend toward higher UTD rates (51% vs 39%, P =.07) and a higher proportion of UTD children receiving immunizations as opposed to getting more complete documentation (25% vs 10%, P =.005). Similar differences between intervention and control children were not seen in the 7-month and 19-month age categories. More children in the intervention group had a health maintenance visit (17% vs 11%, P =.03). Of children in the intervention group who were seen when not UTD, 17 of 24 (71%) of those seen for an illness visit and 5 of 24 (21%) of those seen for health maintenance probably had missed opportunities to be immunized. Conclusions: Recall efforts were partially successful but were undermined by inability to reach the clinic population, poor documentation of immunizations, and missed opportunities. (J Pediatr 2001;139:630–5)

How Much Does a Regional Immunization Registry Increase Documented Immunization Rates at Primary Care Sites in Rural Colorado?

To determine increases in immunization up-to-date (UTD) rates at a rural pediatric practice with the sequential addition of records from other sites in a 2-county region. UTD rates for children aged 3 months to 35 months (n = 876) were determined for the index practice and then recalculated after sequential addition of records from 1) the other private practice in the region, 2) 7 public primary care sites, and 3) 2 public health clinics in the region. Adding records from all sites increased documented UTD rates in the index practice from 49% to 64% at 3 months (N = 33, P = 0.025), 50% to 68% at 5 months (N = 38, P = 0.008), 28% to 45% at 7 months (N = 113, P <.01), 29% to 54% at 12 months (N = 200, P <.001), 11% to 35% at 19 months (N = 124, P <.001), and 10% to 33% at 24 months (N = 368, P <.001). Regional registries will be valuable tools for immunization delivery if there is an ongoing commitment to effective collection of current and historical immunization data.