Immunization coverage levels among 19- to 35-month-old children in 4 diverse, medically underserved areas of the United States

Compulsory Vaccination Coverage in 12 Sub-Saharan African Countries Two Years Following the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic is a global threat, challenging health services' provision and utilization. This study aimed to assess compulsory vaccination coverage in 12 Sub-Saharan African countries two years following the COVID-19 pandemic using the Health Belief Model. A cross-sectional survey was conducted from November 1 to December 15, 2022. Multivariate logistic regression was conducted to identify the determinants of vaccination coverage. Among the 5032 respondents, 73.1% reported that their children received compulsory vaccination. The lowest coverage was observed in Ghana (36.5%), while the highest was in Burkina Faso and Congo (92.0%). Factors associated with non-vaccination included older mothers (adjusted odds ratio (AOR) = 1.04, 95%CI: 1.03-1.05), lower mothers' education, older children (AOR = 0.76, 95%CI: 0.60-0.96), children with chronic illnesses (AOR = 0.55, 95%CI: 0.45-0.66), and difficult accessibility to healthcare facilities (AOR = 11.27, 95%CI: 9.48-13.44). Low perceived risk, in which non-vaccinated children were believed to be at no higher risk for infectious diseases and the disease severity would not worsen among non-vaccinated children, increased the likelihood of non-vaccination (AOR = 2.29, 95%CI: 1.75-2.99 and AOR = 2.12, 95%CI: 1.64-2.73, respectively). Perceiving vaccines as unnecessary, and needless for breastfed babies increased the probability of non-vaccination (AOR = 1.38, 95%CI: 1.10-1.73 and AOR = 1.69, 95%CI: 1.31-2.19, respectively). Higher odds of non-vaccination were found when the provision of vaccine information did not motivate parents to vaccinate their children (AOR = 4.29, 95%CI: 3.15-5.85). Conversely, believing that vaccines were safe for children decreased the odds of non-vaccination (AOR = 0.72, 95%CI: 0.58-0.88). Parental perceptions and concerns should be considered in interventions aiming to increase compulsory vaccine acceptance and coverage.

Barriers to and facilitators of early childhood immunization in rural areas of the United States: a systematic review of the literature

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Early childhood vaccination coverage is low in rural areas of the United States.

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Reminder-recall & positive family-provider relationships facilitate vaccine uptake.

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Parental hesitancy is a barrier to early childhood vaccination in the rural U.S.

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Vaccine referrals & distance to providers are also rural-specific barriers.

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To increase vaccine coverage, interventions across rural populations are needed.

Early childhood vaccination rates are lower in rural areas of the U.S. compared with suburban and urban areas. Our aim was to identify barriers to and facilitators of early childhood immunization in rural U.S. communities. We completed a systematic review of original research conducted in the U.S. between January 1, 2000-July 25, 2021. We searched PubMed, Cumulative Index for Nursing and Allied Health Literature, and Web of Science. We included studies that examined barriers to and facilitators of routine immunizations in children <36 months old in rural areas. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we reported studies’ methodologies and targeted populations, definitions of rurality, and common themes across studies that reflected barriers to or facilitators of vaccination. Ultimately, 17 papers met inclusion criteria for review. The majority of studies (10/17) were conducted within one U.S. state, and the same number (10/17) were conducted prior to 2005. Facilitators of vaccine uptake in rural communities identified across studies included reminder/recall systems and parents’ relationships with providers. Parental hesitancy, negative clinic experiences, referrals outside of primary care settings, and distance to providers were identified as barriers to vaccination in rural settings. This review revealed a limited scope of evidence on barriers to and facilitators of early childhood immunization in rural communities. More investigations of the causes of low vaccine coverage and the effectiveness of interventions for increasing vaccine uptake are urgently needed in rural pediatric populations to address persistent rural–urban immunization disparities.

The impact of parents' health behaviours on their preferences regarding vaccinations in Bialystok, Poland

BACKGROUND

Currently, as the number of vaccinated children in Poland and throughout Europe is decreasing. Many factors impact on the rate vaccination and parents' health behaviours may affect the frequency of vaccinations. The aim of the study was to assess the association of parents' health behaviors with children's vaccinations.

METHODS

A cross-sectional survey was conducted from July 2015 to June 2016 to assess to assess the association of parents' health behaviors with children's vaccinations in Białystok city, Poland. We used the the Inventory of Health Behaviours and an original questionnaire including demographic data and questions about vaccination. Three hundred parents were recruited from the Pro Medica Family Medica Center in Bialystok, Poland.

RESULTS

Only 3.7% of respondents did not vaccinate their children. The level of health behaviours was average in 42.3% of the respondents, low in 33%, and high in 24.7%. Significant differences in health behaviours, mainly the level of normal eating habits (p = 0.038) and positive mental attitude (p = 0.022), were found in relation to views on the toxicity of vaccines. Participants who reported that vaccines can cause autism engaged in a higher level of prophylactic behaviours. Respondents who vaccinated their children with combined vaccines had a significantly higher level of health practices.

CONCLUSIONS

Parents preferred health behaviours did not effect on children vaccination. Parents who believed in the toxicity of vaccines were more concerned about proper nutrition, had a positive mental attitude, and engaged in a higher level of preventive behaviours and health practices. Parents who did not vaccinate their children had lower levels of normal eating habits. Parents who vaccinated their children with combined vaccines had a higher level of health behaviours, especially in terms of health practices.

Timeliness and completeness of routine childhood vaccinations in young children residing in a district with recurrent vaccine-preventable disease outbreaks, Jerusalem, Israel

BackgroundChildhood vaccination schedules recommend vaccine doses at predefined ages.AimWe evaluated vaccination completeness and timeliness in Jerusalem, a district with recurrent vaccine-preventable disease outbreaks.MethodsVaccination coverage was monitored by the up-to-date method (vaccination completeness at age 2 years). Timeliness of vaccination was assessed in children (n = 3,098, born in 2009, followed to age 48 months, re-evaluated at age 7 years) by the age-appropriate method (vaccine dose timeliness according to recommended schedule). Vaccines included: hepatitis B (HBV: birth, 1 month and 6 months); diphtheria, tetanus, acellular pertussis, polio, Haemophilus influenzae b (DTaP-IPV-Hib: 2, 4, 6 and 12 months); pneumococcal conjugate (PCV: 2, 4 and 12 months); measles-mumps-rubella/measles-mumps-rubella-varicella (MMR/MMRV: 12 months) and hepatitis A (HAV: 18 and 24 months).ResultsOverall vaccination coverage (2014 cohort evaluated at age 2 years) was 95% and 86% for MMR/MMRV and DTaP-IPV-Hib4, respectively. Most children (94%, 91%, 79%, 95%, 92% and 82%) were up-to-date for HBV3, DTaP-IPV-Hib4, PCV3, MMR/MMRV1, HAV1 and HAV2 vaccines at 48 months, but only 32%, 28%, 38%, 58%, 49% and 20% were vaccinated timely (age-appropriate). At age 7 years, the median increase in vaccination coverage was 2.4%. Vaccination delay was associated with: high birth order, ethnicity (higher among Jews vs Arabs), birth in winter, delayed acceptance of first dose of DTaP-IPV-Hib and multiple-dose vaccines (vs MMR/MMRV). Jewish ultra-Orthodox communities had low vaccination coverage.ConclusionsConsiderable vaccination delay should be addressed within the vaccine hesitancy spectrum. Delays may induce susceptibility to vaccine-preventable disease outbreaks; tailored programmes to improve timeliness are required.

Countering vaccine hesitancy through immunization information systems, a narrative review

Immunization is one of the most important public health interventions to contrast infectious disease; however, many people nowadays refuse vaccination. Vaccine hesitancy (VH) is due to several factors that influence the complex decision-making process. Information technology tools might play an important role in vaccination programs. In particular, immunization information systems (IISs) have the potential to improve performance of vaccination programs and to increase vaccine uptake. This review aimed to present IIS functionalities in order to counter VH. In detail, we analyzed the automatic reminder/recall system, the interoperability of the system, the decision support system, the web page interface and the possibility to record adverse events following immunization. IIS could concretely represent a valid instrument to increase vaccine confidence, especially trust in both health-care workers and decision makers. There are not enough trials aimed to evaluate the efficacy of IIS to counter VH. Further researches might focalize on this aspect.

Rural-urban comparison of routine immunization utilization and its determinants in communities in Anambra States, Nigeria

Objectives:

The study determined the levels of geographic differences in the utilization of routine immunization between households in an urban and a rural community. It also identified and compared the determinants of utilization of routine immunization in the two geographic areas.

Method:

The study was undertaken in two randomly selected communities (one rural and one urban) in Anambra State, Nigeria. Interviewer-administered questionnaires were used to collect information on utilization of immunization services from households. Data were analyzed using descriptive and multiple logistic regression analyses.

Result:

Households in the urban community had a higher level of utilization of routine immunization (95.5%) than those in the rural community (75.3%) and the difference was statistically significant (p < 0.05). It was also found that more rural dwellers (83.3%) received immunization services from public health facilities compared to the urban dwellers (42%; p < 0.05). Health facilities were nearer to households in the urban community than the rural community (p < 0.05). Mean cost of service per visit was higher in the urban community (p < 0.05), but the difference in the mean cost of transportation per visit was not significant (p = 0.125). Regression analysis shows that place of residence was highly significant for utilization of routine immunization services (p < 0.05).

Conclusion:

Urban–rural differences exist in utilization of routine immunization services. Health facilities are more proximal to consumers in the urban community than the rural community, with higher travel costs among rural dwellers. Ensuring that there is a functional primary healthcare center in every ward and provision of routine immunization services in market places on local market days can help to increase utilization and reduce rural–urban differences in utilization of immunization services.

The Effect of Vaccine Literacy on Parental Trust and Intention to Vaccinate after a Major Vaccine Scandal

Health literacy, and more specifically vaccine literacy, might be an important factor in reducing the negative effects of exposure to misleading reports on vaccination. This study explores the association between vaccine literacy and vaccination-related outcomes after misleading reports on a scandal concerning locally produced childhood vaccines had emerged in 2016 in China. Data for this study came from a cross-sectional survey, which was conducted in April 2016 in Hangzhou, China. Data were collected in kindergartens and community health centers among parents of children up to 6 years of age. Data were analyzed for 1864 participants. Binary logistic regression models showed that, after controlling for socio-demographics and children's age, parents who had better vaccine literacy (<0.05) were more likely to trust and choose domestically produced vaccines, which account for about 95% of the total vaccinations in China. This study provides evidence on a still largely understudied relationship between vaccine literacy and vaccination-related outcomes. Findings might suggest that higher literacy levels could reduce some of the negative effects of being exposed to misleading information on vaccination, eventually leading to less vaccination hesitancy.

Does birth under-registration reduce childhood immunization? Evidence from the Dominican Republic

The consequences of lacking birth certificates remain largely unexplored in the economic literature. We intend to fill this knowledge gap studying the effect of lacking birth certificates on immunization of children in the Dominican Republic. This is an interesting country because a significant number of children of Haitian descent face the consequences of lacking proper documentation. We use the distance to the civil registry office and the mother's document of identification as instrumental variables of the child's birth certificate. After controlling for distance to immunization services and other determinants, this paper finds that children between 0 and 59 months of age that do not have birth certificates are behind by nearly one vaccine (out of a total of nine) compared to those that have birth certificates.

Interventions to increase pediatric vaccine uptake: An overview of recent findings

Although much is known about factors contributing to variation in pediatric immunization uptake, there is a need for synthesis of effective vaccine promotion strategies. With growing public health concern on how to best sustain high pediatric immunization rates, and improve where the rates are suboptimal, this review offers evidence gathered from several studies on the achievement of these goals. We identified and analyzed reported findings on childhood (primarily ≤ 7 years) immunization outcomes from tested intervention strategies that focused on parents, guardians, and caregivers, as well as providers, clinics/practices, and communities. The findings suggest that targeted and tailored interventions offer substantial possibilities, especially in a combined manner. We describe promising intervention models that have been operationalized with success and provide evidence for scalability across contexts. Moreover, they are sensitive to parents' and providers' needs, are feasibly integrated in daily clinical practice, and account for broader community concerns and issues.

Determinants of under-immunization and cumulative time spent under-immunized in a Quebec cohort

BACKGROUND

Under-immunization refers to a state of sub-optimal protection against vaccine preventable diseases. Vaccine coverage for age may not capture intentional or non-intentional spacing of vaccines in the recommended provincial immunization guidelines. We aimed to identify factors associated with coverage and under-immunization and to determine the number of days during which children were under-immunized during their first 24months of life.

METHODS

Secondary analysis of children ≤3years recruited through active surveillance for gastroenteritis from three Quebec pediatric emergency departments from 2012 to 2014. Vaccination status for children at least 24months of age was determined using provincial immunization guidelines. Cumulative days under-immunized were calculated for DTaP-VPI-Hib, PCV, MMR, and Men-C-C. Factors associated with up-to-date (UTD) status at 24months of life and for under-immunization ≥6months were analyzed using logistic regression.

RESULTS

Of 246 eligible children, 180 (73%) were UTD by 24months of life. The mean cumulative days under-immunized for MMR was 107days, for PCV 209days, for Men-C-C 145days, and for DTaP-VPI-Hib 227days. Overall, 149 children (60%) experienced delay for at least 1 vaccine. Factors associated with both an UTD status at 24months and concurrently associated with being under-immunization ≥6months, included timely initiation of immunization (OR=5.85; 95% CI: 2.80-12.22) and (OR=0.13; 95% CI: 0.07-0.24), failure to co-administer 18-month vaccines (OR=0.15; 95% CI: 0.10-0.21) and (OR=3.29; 95% CI: 2.47-4.39), and having a household with ≥3 children under 18years ((OR=0.50; 0.28-0.86) and (OR=2.99; 1.45-6.22), respectively.

CONCLUSION

Paired with an unexpected low level of coverage at 24months of life, the majority of our cohort also experienced a state of under-immunization for a least one vaccine. Estimates of coverage do not capture intentional or non-intentional gaps in protection from vaccine preventable illnesses. Timely preventive care should be prioritized.

Age-appropriate versus up-to-date coverage of routine childhood vaccinations among young children in Israel

BACKGROUND AND AIMS

Routine childhood vaccinations schedules recommend that children receive the vaccine doses at specific ages. Vaccination coverage data are conventionally reported by the up-to-date method. We aimed to assess vaccination timeliness by the age-appropriate method and compare with the up-to-date vaccination coverage.

METHODS

Assessment of age-appropriate and up-to-date vaccination coverage among children born in Israel in 2009 and followed to age 48 months (national representative sample, n = 3892). The vaccinations included: Hepatitis B vaccine (HBV), Diphtheria-Tetanus-acellular Pertussis-Polio-Haemophilus-influenzae-b (DTaP-IPV-Hib), Pneumococcal conjugate vaccine (PCV), Measles-mumps-rubella-varicella vaccine (MMR/MMRV) and Hepatitis A vaccine (HAV). The categories defined: age-appropriate (at the recommended age and up to 1 month), delayed less than 6 months, delayed 6 months and above and unvaccinated (48 months).

RESULTS

The age-specific vaccinations assessment showed considerable delay in receipt of routine vaccination. While most (96%, 95%, 91%, 96%, 94% and 86%) children were vaccinated up-to-date for HBV3, DTaP-IPV-Hib4, PCV3, MMR/MMRV1, HAV1and HAV2 vaccine doses; only 26%, 29%, 47%, 64%, 55% and 12% were vaccinated age-appropriate. Vaccination delay was more common in vaccines with multiple doses. Vaccination delay was associated with high child's birth order, low socio-economic rank, ethnicity (delay more common in Jews vs. Arabs), season of birth (winter) and delayed receipt of DTaP-IPV-Hib vaccine 1st dose.

CONCLUSIONS

This study assessed age-appropriate childhood vaccination coverage in a national cohort of children. While the overall vaccination coverage stands in line with the WHO goals, vaccination timeliness and equity are inadequate and targeted public health intervention programs aimed at vaccination timeliness are necessary.

Determination of factors affecting the vaccination status of children aged 12-35 months in Lao People's Democratic Republic

Vaccines are one of the most important achievements in public health, and a major contributor to this success is the Expanded Programme on Immunization. The utilisation of vaccination services and completion of the recommended schedule are determined by numerous factors. In Lao People’s Democratic Republic (Lao PDR), the overall immunisation coverage has been improving. However, notwithstanding the improvement in immunisation coverage and the supplementary immunisation activities, there have been measles, diphtheria, and polio outbreaks in the country. The recent multicounty study of household health surveys revealed that the within-country economic-related inequality in the delivery of a vaccine was still high in Lao PDR.

Our previous work evaluated the factors associated with vaccination status among the children aged 5–9 years old, which was older age group for this type of study. This study evaluated factors that affect vaccination status among children aged between 12 and 35 months. It is a nationwide population-based cross-sectional study that used data obtained through multistage cluster sampling. We found that the proportion of infants who were fully immunised was lower than the national target and that “maternal ethnicity” (odds ratio (OR) 0.34, 95% confidence interval [CI]: 0.20–0.60), “paternal education” (OR 1.87, 95% CI: 1.12–3.10), and “source of information about vaccination date by medical staff” (OR 1.65, 95% CI: 1.01–2.71) were significantly associated with the children’s vaccination status. Numerous factors are associated with the completion of the recommended vaccine schedule, and some factors are location-specific. Identification of these factors should lead to actions for facilitating the optimal use of vaccination services by all the children in Lao PDR.

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.

Developing the Evidence for Public Health Systems to Battle Vaccine Preventable Disease at the Local Level: Data Challenges and Strategies for Advancing Research

CONTEXT

Generally decreasing local health department (LHD) resources devoted to immunization programs and changes in LHD roles in immunization services represent major shifts in a core LHD service.

OBJECTIVE

Within a rapidly changing immunization landscape and emerging vaccine preventable disease outbreaks, our objective was to examine how LHD immunization expenditures are related to county-level immunization coverage and pertussis rates.

DESIGN

We used a practice-based approach in which we collaborated with practice partners and uniquely detailed LHD immunization expenditure data. Our analyses modeled the ecologic relationship between LHD immunization expenditures and LHD system performance and health outcomes.

SETTING

This study was launched through a consortium of public health Practice-Based Research Network states as part of a suite of studies examining the relationship between various LHD service-related expenditures and health outcomes.

PARTICIPANTS

We investigated and sought to include all LHDs in the states of Florida, New York (except New York City's LHD), and Washington.

OUTCOME MEASURES

With LHD immunization expenditures as our independent variable, our outcomes were 1 year of jurisdiction-level rates of toddler immunization completeness, to measure immunization system performance, and 11 years of annual jurisdiction-level numbers of pertussis cases per 100 000 population, to measure related health outcomes.

RESULTS

Immunization completeness and pertussis rates varied greatly, but our models did not produce significant results despite numerous analytic approaches and while controlling for other factors.

CONCLUSION

While our study was part of a suite of studies using similar methods and producing significant results, this study was instead challenged by serious data limitations and highlighted the gap in consistent, standardized data that can support critically needed evidence regarding immunization rates and disease. With LHDs at the epicenter of reducing vaccine preventable disease, it is vital to utilize emerging opportunities to understand the nature of their efforts in immunization coverage and disease prevention.

Immunization Data Exchange With Electronic Health Records

OBJECTIVE

To assess the impact of exchange of immunization information between an immunization information system (IIS) and an electronic health record on up-to-date rates, overimmunization, and immunization record completeness for low-income, urban children and adolescents.

METHODS

The New York City Department of Health maintains a population-based IIS, the Citywide Immunization Registry (CIR). Five community clinics in New York City implemented direct linkage of immunization data from the CIR to their local electronic health record. We compared immunization status and overimmunization in children and adolescents 19 to 35 month, 7 to 10 year, and 13 to 17 year-olds with provider visits in the 6-month period before data exchange implementation (2009; n = 6452) versus 6-months post-implementation (2010; n = 6124). We also assessed immunization record completeness with and without addition of CIR data for 8548 children and adolescents with visits in 2012-2013.

RESULTS

Up-to-date status increased from before to after implementation from 75.0% to 81.6% (absolute difference, 6.6%; 95% confidence interval [CI], 5.2% to 8.1%) and was significant for all age groups. The percentage overimmunized decreased from 8.8% to 4.7% (absolute difference, -4.1%; 95% CI, -7.8% to -0.3%) and was significant for adolescents (16.4% vs 1.2%; absolute difference, -15.2%; 95% CI, -26.7 to -3.6). Up-to-date status for those seen in 2012 to 2013 was higher when IIS data were added (74.6% vs 59.5%).

CONCLUSIONS

This study demonstrates that data exchange can improve child and adolescent immunization status. Development of the technology to support such exchange and continued focus on local, state, and federal policies to support such exchanges are needed.

Fully immunized child: coverage, timing and sequencing of routine immunization in an urban poor settlement in Nairobi, Kenya

BACKGROUND

More efforts have been put in place to increase full immunization coverage rates in the last decade. Little is known about the levels and consequences of delaying or vaccinating children in different schedules. Vaccine effectiveness depends on the timing of its administration, and it is not optimal if given early, delayed or not given as recommended. Evidence of non-specific effects of vaccines is well documented and could be linked to timing and sequencing of immunization. This paper documents the levels of coverage, timing and sequencing of routine childhood vaccines.

METHODS

The study was conducted between 2007 and 2014 in two informal urban settlements in Nairobi. A total of 3856 children, aged 12-23 months and having a vaccination card seen were included in analysis. Vaccination dates recorded from the cards seen were used to define full immunization coverage, timeliness and sequencing. Proportions, medians and Kaplan-Meier curves were used to assess and describe the levels of full immunization coverage, vaccination delays and sequencing.

RESULTS

The findings indicate that 67 % of the children were fully immunized by 12 months of age. Missing measles and third doses of polio and pentavalent vaccine were the main reason for not being fully immunized. Delays were highest for third doses of polio and pentavalent and measles. About 22 % of fully immunized children had vaccines in an out-of-sequence manner with 18 % not receiving pentavalent together with polio vaccine as recommended.

CONCLUSIONS

Results show higher levels of missed opportunities and low coverage of routine childhood vaccinations given at later ages. New strategies are needed to enable health care providers and parents/guardians to work together to increase the levels of completion of all required vaccinations. In particular, more focus is needed on vaccines given in multiple doses (polio, pentavalent and pneumococcal conjugate vaccines).

Improving Immunization Rates Through Community-Based Participatory Research: Community Health Improvement for Milwaukee's Children Program

BACKGROUND

Nationally, immunization coverage for the DTaP/3HPV/1MMR/3HepB/3Hib/1VZV antigen series in children ages 19-35 months are near or above the Healthy People 2020 target (80%). However, children in lower socioeconomic families experience lower coverage rates.

OBJECTIVE

Using a community-based participatory research (CBPR) approach, Community Health Improvement for Milwaukee Children (CHIMC) intervened to reduce disparities in childhood immunizations.

METHODS

The CHIMC adopted a self-assessment to examine the effectiveness of adhering to CBPR principles. Using behavior change models, CHIMC implemented education, social marketing campaign, and theory of planned behavior interventions. Community residents and organizational representatives vetted all processes, messages, and data collection tools.

RESULTS

Adherence to the principles of CBPR was consistently positive over the 8-year period. CHIMC enrolled 565 parents/caregivers with 1,533 children into educational and planned behavior change (PBC) interventions, and enrolled another 406 surveyed for the social marketing campaign. Retention rate was high (80%) with participants being predominately Black females (90%) and the unemployed (64%); children's median age was 6.2 years. Increased knowledge about immunizations was consistently observed among parents/caregivers. Social marketing data revealed high recognition (85%) of the community-developed message ("Take Control: Protect Your Child with Immunizations"). Barriers and facilitators to immunize children revealed protective factors positively correlated with up-to-date (UTD) status (p<0.007). Ultimately, children between the ages of 19 and 35 months whose parents/caregivers completed education sessions and benefitted from a community-wide social marketing message increased their immunization status from 45% baseline to 82% over 4 years.

CONCLUSIONS

Using multilayered interventions, CHIMC contributed to the elimination of immunization disparities in children. A culturally tailored CBPR approach is effective to eliminate immunization disparities.

Does a pay-for-performance program for primary care physicians alleviate health inequity in childhood vaccination rates?

Introduction

Childhood vaccination rates in Manitoba populations with low socioeconomic status (SES) fall significantly below the provincial average. This study examined the impact of a pay-for-performance (P4P) program called the Physician Integrated Network (PIN) on health inequity in childhood vaccination rates.

Methods

The study used administrative data housed at the Manitoba Centre for Health Policy. We included all children born in Manitoba between 2003 and 2010 who were patients at PIN clinics receiving P4P funding matched with controls at non-participating clinics. We examined the rate of completion of the childhood primary vaccination series by age 2 across income quintiles (Q1–Q5). We estimated the distribution of income using the Gini coefficient, and calculated concentration indices for vaccination to determine whether the P4P program altered SES-related differences in vaccination completion. We compared these measures between study cohorts before and after implementation of the P4P program, and over the course of the P4P program in each cohort.

Results

The PIN cohort included 6,185 children. Rates of vaccination completion at baseline were between 0.53 (Q1) and 0.69 (Q5). Inequality in income distribution was present at baseline and at study end in PIN and control cohorts. SES-related inequity in vaccination completion worsened in non-PIN clinics (difference in concentration index 0.037; 95 % CI 0.013, 0.060), but remained constant in P4P-funded clinics (difference in concentration index 0.006; 95 % CI 0.008, 0.021).

Conclusions

The P4P program had a limited impact on vaccination rates and did not address health inequity.

Factors Affecting Timeliness of Immunization Coverage Among Children of Assam, India

This article attempts to estimate timeliness of vaccination coverage and to model the pattern of timeliness of vaccination using techniques of survival analysis in order to trace the determinants of age-appropriate immunization status of children. Multistage cluster sampling has been used to collect information on immunization and other related variables using a pre-tested questionnaire from the universe of children of age between 12 and 36 months of two districts of Assam, India. At first, the Kaplan–Meier product limit estimator has been applied to estimate the age-appropriate immunization coverage. Though the immunization coverage as a whole is quite satisfactory in the study area, the Kaplan–Meier estimator shows poor age-appropriate immunization coverage which necessitates studying the impact of different demographic and socio-economic factors on this problem. In this context, the Cox proportional hazard model has been used which is found to be a good fit. The findings of this model show that education of mother, caste, religion and socio-economic status of the family have significant impact on the age-appropriate immunization coverage of children. Thus, it can be concluded that though the child immunization coverage in Assam has been inclining, there is still a lot of concern over the timeliness of vaccination coverage.

Urban and Rural Differences in Parental Attitudes About Influenza Vaccination and Vaccine Delivery Models

OBJECTIVES

To assess and compare among parents of healthy children in urban and rural areas: (1) reported influenza vaccination status; (2) attitudes regarding influenza vaccination; and (3) attitudes about collaborative models for influenza vaccination delivery involving practices and public health departments.

METHODS

A mail survey to random samples of parents from 2 urban and 2 rural private practices in Colorado from April 2012 to June 2012.

RESULTS

The response rate was 58% (288/500). In the prior season, 63% of urban and 41% of rural parents reported their child received influenza vaccination (P < .001). No differences in attitudes about influenza infection or vaccination between urban and rural parents were found, with 75% of urban and 73% of rural parents agreeing their child should receive an influenza vaccine every year (P = .71). High proportions reported willingness to participate in a collaborative clinic in a community setting (59% urban, 70% rural, P = .05) or at their child's provider (73% urban, 73% rural, P = .99) with public health department assisting. Fewer (36% urban, 53% rural, P < .01) were likely to go to the public health department if referred by their provider. Rural parents were more willing for their child to receive vaccination outside of their provider's office (70% vs. 55%, P = .01).

CONCLUSIONS

While attitudes regarding influenza vaccination were similar, rural children were much less likely to have received vaccination. Most parents were amenable to collaborative models of influenza vaccination delivery, but rural parents were more comfortable with influenza vaccination outside their provider's office, suggesting that other venues for influenza vaccination in rural settings should be promoted.

Evaluation of invalid vaccine doses in 31 countries of the WHO African Region

We examined (a) the fraction of and extent to which vaccinations were administered earlier than recommended (age-invalid) or with too short intervals between vaccine doses (interval-invalid) in countries of the World Health Organisation (WHO) African Region and (b) individual- and community-level factors associated with invalid vaccinations using multilevel techniques. Data from the Demographic and Health Surveys conducted in the last 10 years in 31 countries were used. Information about childhood vaccinations was based on vaccination records (n=134,442). Invalid vaccinations (diphtheria, tetanus, pertussis [DTP1, DTP3] and measles-containing vaccine (MCV)) were defined using the WHO criteria. The median percentages of invalid DTP1, DTP3 and MCV vaccinations across all countries were 12.1% (interquartile range, 9.4-15.2%), 5.7% (5.0-7.6%), and 15.5% (10.0-18.1%), respectively. Of the invalid DTP1 vaccinations, 7.4% and 5.5% were administered at child's age of less than one and two weeks, respectively. In 12 countries, the proportion of invalid DTP3 vaccinations administered with an interval of less than two weeks before the preceding dose varied between 30% and 50%. In 13 countries, the proportion of MCV doses administered at child's age of less than six months varied between 20% and 45%. Community-level variables explained part of the variation in invalid vaccinations. Invalid vaccinations are common in African countries. Timing of childhood vaccinations should be improved to ensure an optimal protection against vaccine-preventable infections and to avoid unnecessary wastage in these economically deprived countries.

Unmet needs in respiratory diseases : "You can't know where you are going until you know where you have been"--Anonymous

The care of patients with respiratory diseases has improved vastly in the past 50 years. In spite of that, there are still massive challenges that have not been resolved. Although the incidence of tuberculosis has decreased in the developed world, it is still a significant public health problem in the rest of the world. There are still over 2 million deaths annually from tuberculosis, with most of these occurring in the developing world. Even with the development of new pharmaceuticals to treat tuberculosis, there is no indication that the disease will be eradicated. Respiratory syncytial virus, severe acute respiratory syndrome, and pertussis are other respiratory infectious diseases with special problems of their own, from vaccine development to vaccine coverage. Asthma, one of the most common chronic diseases in children, still accounts for significant mortality and morbidity, as well as high health care costs worldwide. Even in developed countries such as the USA, there are over 4,000 deaths per year. Severe asthma presents a special problem, but the question is whether there can be one treatment pathway for all patients with severe asthma. Severe asthma is a heterogeneous disease with many phenotypes and endotypes. The gene for cystic fibrosis was discovered over 24 years ago. The promise of gene therapy as a cure for the disease has fizzled out, and while new antimicrobials and other pharmaceuticals promise improved longevity and better quality of life, the average life span of a patient with cystic fibrosis is still at about 35 years. What are the prospects for gene therapy in the twenty-first century? Autoimmune diseases of the lung pose a different set of challenges, including the development of biomarkers to diagnose and monitor the disease and biological modulators to treat the disease.

Influenza vaccination of Michigan children by provider type, 2010-2011

BACKGROUND

Influenza vaccination for all children aged 6 months to 18 years has been recommended since 2008 to prevent flu-related morbidity and mortality. However, 2010-2011 influenza vaccine coverage estimates show under-vaccination in children of all ages. We examined predictors of influenza vaccination in Michigan during the 2010-2011 influenza season.

PURPOSE

To determine whether immunization provider type was associated with a child's influenza vaccination in Michigan and assess whether county-level factors were confounders of the association.

METHODS

Influenza vaccinations reported to the Michigan Care Improvement Registry from the 2010-2011 influenza season were analyzed in 2012 to estimate ORs for the association between immunization provider type and influenza vaccination.

RESULTS

Among 2,373,826 Michigan children aged 6 months through 17 years, 17% were vaccinated against influenza and lower vaccination rates were observed for public compared to private providers (13% vs 18%). In the unadjusted model, public providers had lower odds of vaccinating children compared to private providers (OR=0.60, 95% CI=0.60, 0.61). County-level factors, including percentage of families living below the poverty line, median household income, and percentage black race, were not shown to confound the association. In the adjusted models, public providers had lower odds of vaccinating children compared to private providers (OR=0.87, 95% CI=0.86, 0.88).

CONCLUSIONS

Although a child's likelihood of influenza vaccination in Michigan varies by provider type, more effective strategies to improve influenza vaccination rates for all Michigan children are needed.

Comparison of patients from Nigeria and the USA highlights modifiable risk factors for sickle cell anemia complications

To identify factors that affect manifestations of sickle cell anemia we compared patients 11-30 years of age from University of Ibadan, Ibadan, Oyo, Nigeria (n = 214) and University of Illinois at Chicago, Chicago, IL, USA (n = 209). Paralleling findings in the general populations of the two countries, the Chicago patients were more often overweight or obese as defined by the Centers for Disease Control and Prevention (Atlanta, GA, USA) guidelines, and more often had elevated blood pressure (BP) as defined by the National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD, USA guidelines. The Ibadan patients did not receive the pneumococcal vaccine or hydroxyurea (HU) therapy as frequently as the Chicago patients. Consistent with lower rates of elevated BP and increased body mass index (BMI), stroke history was less frequent in the Ibadan patients ≥18 years old. Furthermore, in combined analyses, systolic and diastolic BP directly correlated with BMI, and elevated weight status independently associated with history of stroke. Our findings are consistent with the possibility that higher values for BMI and BP in Chicago sickle cell anemia patients may contribute to an increased risk of stroke and highlights the need for measures to reduce these risk factors. On the other hand, lower pneumococcal vaccination and HU therapy rates in Ibadan patients highlights the need for more improved vaccination coverage and for studies to define the role of HU therapy in Africa.

Parent perspectives on the design of a personal online pediatric immunization record

OBJECTIVE

To examine desired characteristics of an online immunization record for parents from a predominantly Latino, low-income population.

METHODS

Four focus groups were conducted with parents (n = 29) from an urban, primarily Latino, low-income population in New York. The data were collected and analyzed during winter 2008-2009.

RESULTS

Participants expressed interest in using an online immunization record that has the ability to show a child's immunization status and to access consumer health information related to vaccinations. Participants suggested that the online record be translated into multiple languages and provide user-friendly interfaces. Participants were enthusiastic about the benefits offered by the online immunization record, highlighting having an electronic copy of their child's immunization record available. Concerns over disclosing personal information were raised, and safeguards to protect confidentiality were requested.

CONCLUSIONS

If concerns about privacy are adequately addressed, parents of low-income, urban children are likely to use and benefit from an online immunization record.

Reaching hard-to-reach individuals: Nonselective versus targeted outbreak response vaccination for measles

Current mass vaccination campaigns in measles outbreak response are nonselective with respect to the immune status of individuals. However, the heterogeneity in immunity, due to previous vaccination coverage or infection, may lead to potential bias of such campaigns toward those with previous high access to vaccination and may result in a lower-than-expected effective impact. During the 2010 measles outbreak in Malawi, only 3 of the 8 districts where vaccination occurred achieved a measureable effective campaign impact (i.e., a reduction in measles cases in the targeted age groups greater than that observed in nonvaccinated districts). Simulation models suggest that selective campaigns targeting hard-to-reach individuals are of greater benefit, particularly in highly vaccinated populations, even for low target coverage and with late implementation. However, the choice between targeted and nonselective campaigns should be context specific, achieving a reasonable balance of feasibility, cost, and expected impact. In addition, it is critical to develop operational strategies to identify and target hard-to-reach individuals.

The health care home model: primary health care meeting public health goals

In November 2010, the American Public Health Association endorsed the health care home model as an important way that primary care may contribute to meeting the public health goals of increasing access to care, reducing health disparities, and better integrating health care with public health systems. Here we summarize the elements of the health care home (also called the medical home) model, evidence for its clinical and public health efficacy, and its place within the context of health care reform legislation. The model also has limitations, especially with regard to its degree of involvement with the communities in which care is delivered. Several actions could be undertaken to further develop, implement, and sustain the health care home.

The value of the medical home for children without special health care needs

OBJECTIVE

Although the medical home is promoted by the American Academy of Pediatrics and the Affordable Care Act, its impact on children without special health care needs is unknown. We examined whether the medical home is associated with beneficial health care utilization and health-promoting behaviors in this population.

METHODS

This study was a secondary data analysis of the 2003 National Survey of Children's Health. Data were available for 70 007 children without special health care needs. We operationalized the medical home according to the National Survey of Children's Health design. Logistic regression for complex sample surveys was used to model each outcome with the medical home, controlling for sociodemographic characteristics.

RESULTS

Overall, 58.1% of children without special health care needs had a medical home. The medical home was significantly associated with increased preventive care visits (adjusted odds ratio [aOR]: 1.32 [95% confidence interval (CI): 1.22-1.43]), decreased outpatient sick visits (aOR: 0.71 [95% CI: 0.66-0.76), and decreased emergency department sick visits (aOR: 0.70 [95% CI: 0.65-0.76]). It was associated with increased odds of "excellent/very good" child health according to parental assessment (aOR: 1.29 [95% CI: 1.15-1.45) and health-promoting behaviors such as being read to daily (aOR: 1.46 [95% CI: 1.13-1.89]), reported helmet use (aOR: 1.18 [95% CI: 1.03-1.34]), and decreased screen time (aOR: 1.12 [95% CI: 1.02-1.22]).

CONCLUSIONS

For children without special health care needs, the medical home is associated with improved health care utilization patterns, better parental assessment of child health, and increased adherence with health-promoting behaviors. These findings support the recommendations of the American Academy of Pediatrics and the Affordable Care Act to extend the medical home to all children.

Validity of parent-reported vaccination status for adolescents aged 13-17 years: National Immunization Survey-Teen, 2008

OBJECTIVE

The validity of parent-reported adolescent vaccination histories has not been assessed. This study evaluated the validity of parent-reported adolescent vaccination histories by a combination of immunization card and recall, and by recall only, compared with medical provider records.

METHODS

We analyzed data from the 2008 National Immunization Survey-Teen. Parents of adolescents aged 13-17 years reported their child's vaccination history either by immunization card and recall (n = 3,661) or by recall only (n = 12,822) for the hepatitis B (Hep B), measles-mumps-rubella (MMR), varicella (VAR), tetanus-diphtheria/tetanus-diphtheria-acellular pertussis (Td/ Tdap), meningococcal conjugate (MCV4), and quadrivalent human papillomavirus (HPV4) (for girls only) vaccines. We validated parental report with medical records.

RESULTS

Among the immunization card/recall group, vaccines with > 20% false-positive reports included MMR (32.3%) and Td/Tdap (36.9%); vaccines with > 20% false-negative reports included VAR (35.2%), MCV4 (36.0%), and Tdap (41.9%). Net bias ranged from -25.0 to -0.1 percentage points. Kappa values ranged from 0.22 to 0.92. Among the recall-only group, vaccines with > 20% false-positive reports included Hep B (33.9%), MMR (61.4%), VAR (26.2%), and Td/Tdap (60.6%); vaccines with > 20% false-negative reports included Hep B (58.9%), MMR (33.7%), VAR (51.6%), Td/Tdap (25.5%), Tdap (50.3%) MCV4 (63.0%), and HPV4 (20.5%). Net bias ranged from -46.0 to 0.5 percentage points. Kappa values ranged from 0.03 to 0.76.

CONCLUSIONS

Validity of parent-reported vaccination histories varies by type of report and vaccine. For recently recommended vaccines, false-negative rates were substantial and higher than false-positive rates, resulting in net underreporting of vaccination rates by both the immunization card/recall and recall-only groups. Provider validation of parent-reported vaccinations is needed for valid surveillance of adolescent vaccination coverage.

A brief review of vaccination coverage in immunization registries

Immunization registries are effective electronic tools for assessing vaccination coverage, but are only as good as the information reported to them. This review summarizes studies through August 2010 on vaccination coverage in registries and identifies key characteristics of successful registries. Based on the current state of registries, paper-based charts combined with electronic registry reporting provide the most cohesive picture of coverage. To ultimately supplant paper charts, registries must exhibit increased coverage and participation.

Estimation of nationwide vaccination coverage and comparison of interview and telephone survey methodology for estimating vaccination status

This study compared interview and telephone surveys to select the better method for regularly estimating nationwide vaccination coverage rates in Korea. Interview surveys using multi-stage cluster sampling and telephone surveys using stratified random sampling were conducted. Nationwide coverage rates were estimated in subjects with vaccination cards in the interview survey. The interview survey relative to the telephone survey showed a higher response rate, lower missing rate, higher validity and a less difference in vaccination coverage rates between card owners and non-owners. Primary vaccination coverage rate was greater than 90% except for the fourth dose of DTaP (diphtheria/tetanus/pertussis), the third dose of polio, and the third dose of Japanese B encephalitis (JBE). The DTaP4: Polio3: MMR1 fully vaccination rate was 62.0% and BCG1:HepB3:DTaP4:Polio3:MMR1 was 59.5%. For age-appropriate vaccination, the coverage rate was 50%-80%. We concluded that the interview survey was better than the telephone survey. These results can be applied to countries with incomplete registry and decreasing rates of landline telephone coverage due to increased cell phone usage and countries. Among mandatory vaccines, efforts to increase vaccination rate for the fourth dose of DTaP, the third dose of polio, JBE and regular vaccinations at recommended periods should be conducted in Korea.

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

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

DISCUSSION

Barriers to successful immunization practices and strategies to overcome those barriers are discussed.

CONCLUSION

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.

Medical homes: "where you stand on definitions depends on where you sit"

The medical home is a potentially transformative strategy to address issues of access, quality, and efficiency in the delivery of health care in the United States. While numerous organizations support a physician-driven definition, it is by no means the universally accepted definition. Several professional groups, payers, and researchers have offered differing, or nuanced, definitions of medical homes. This lack of consensus has contributed to uncertainty among providers about the medical home. We conducted a systematic review of the literature on the medical home and identified 29 professional, government, and academic sources offering definitions. While consensus appears to exist around a core of selected features, the medical home means different things to different people. The variation in definitions can be partly explained by the obligation of organizations to their members and whether the focus is on the patient or provider. Differences in definitions have implications at both the policy and practice levels.

Are patient-held vaccination records associated with improved vaccination coverage rates?

OBJECTIVE

The goal was to determine whether patient-held vaccination records improve vaccination rates.

METHODS

The public-use files of the 2004-2006 National Immunization Survey, a national, validated survey of households with children 19 to 35 months of age, were used. The main outcome was up-to-date (UTD) vaccination status (4 diphtheria-tetanus-acellular pertussis/diphtheria-tetanus vaccine, 3 poliovirus vaccine, 1 measles vaccine, 3 Haemophilus influenza type B vaccine, and 3 hepatitis B vaccine doses), and the main predictor was the use of a vaccination record. Control variables were race/ethnicity, maternal education, poverty status, language, number of children in the home, state of residence, and number of health care providers.

RESULTS

Overall, 80.8% of children were UTD, and 40.8% of children had vaccination records. Children with vaccination records were more likely to be UTD (83.9% vs 78.6%; P < .0001). The largest effects associated with vaccination records were seen for children with multiple providers, comparing with and without a vaccination record (82.8% vs 71.9%; P < .0001), those with low maternal education, (81.6% vs 72.9%; P < .0001), and those with > or =4 children in the household, (76% vs 69.6%; P < .004). Logistic regression predicting UTD status and controlling for race/ethnicity, maternal education, poverty level, language, number of children in the home, and number of vaccine providers revealed the vaccination record to be associated with a 62% increase in the odds of UTD status (odds ratio: 1.62 [95% confidence interval: 1.49-1.77]).

CONCLUSIONS

Use of patient-held vaccination records is an easily implemented strategy that is associated with increased immunization rates. A greater effect was seen in groups at risk for underimmunization. Methods to incorporate and to ensure effective use of these records should be implemented.

Meningococcal conjugate vaccination among adolescents aged 13-17 years, United States, 2007

BACKGROUND

An estimated 1000-2000 cases of invasive meningococcal diseases occur annually in the United States. In 2005, a new quadrivalent meningococcal conjugate vaccine (MCV4) was approved and, because of supply constraints, was recommended for routine vaccination of some groups of adolescents. In August 2007, vaccination recommendations were expanded for all adolescents 11-18 years.

METHODS

We analyzed data from the 2007 National Immunization Survey-Teen (NIS-Teen), a nationally representative random digit dialed telephone survey. Estimates of MCV4 coverage were assessed from provider-reported vaccination histories. A multivariable logistic regression analysis and predictive marginal model were performed to identify factors independently associated with MCV4 vaccination.

RESULTS

Provider-reported vaccination histories were available for 2947 adolescents aged 13-17 years with a response rate of 55.9%. Overall, MCV4 coverage was 32.4% (95% confidence interval (CI)=30.2-34.7%) in 2007. Vaccination coverage was similar among adolescents aged 13-14 years compared to those aged 15-17 years (32.1% vs. 32.6%, respectively). Coverage was 30.6% for non-Hispanic whites, 35.9% for non-Hispanic blacks, and 36.1% for Hispanics; however, these variations were not statistically significant. Characteristics independently associated with a higher likelihood of MCV4 vaccination included having > or =2 physician contacts in the past year, having a well child visit at age 11-12 years, and ever having a doctor recommendation for meningitis vaccination of the adolescent.

CONCLUSIONS

In 2007, MCV4 coverage among 13-17 years old increased 20.7 percentage points from 2006. Achieving high vaccination coverage among adolescents will be challenging. Targeting adolescents with no health insurance and no recent healthcare provider visits may be important to increase coverage.

Determinants of third dose of diphtheria-tetanus-pertussis (DTP) completion among children who received DTP1 at rural immunization centres in Pakistan: a cohort study

OBJECTIVE

In Pakistan, a high proportion of children fail to complete third dose of diphtheria-tetanus-pertussis (DTP3) after having received the first dose (DTP1). A cohort study was conducted to identify the factors predicting three doses of diphtheria-tetanus-pertussis (DTP3) completion among children who have received DTP1 at six centres of Expanded Programme on Immunization (EPI) in rural Pakistan.

METHOD

We analyzed a cohort of mother-child pairs enrolled at DTP1 between November 2005 and May 2006 in the standard care group of a larger randomized controlled trial. Data were collected from mothers on a structured questionnaire at enrollment, and each child was followed up at clinic visits for 90 days to record dates of DTP2 and DTP3. Multivariable log-binomial regression analysis was performed to identify the independent predictors of DTP3 completion.

RESULTS

Only 39% (149/378) of enrolled children completed DTP3 during the follow-up period. After adjusting for the centre of enrollment in multivariable analysis, DTP3 completion was higher among children who were < or =60 days old at enrolment [adjusted risk ratio (Adj. RR) 1.39, 95% confidence interval (CI): 1.06-1.82], who were living in a household with monthly household income >Rs. 3000 (US$ 50) (Adj. RR 1.76, 95% CI: 1.16-2.65), and who were living < or =10 min away from EPI centre (Adj. RR 1.31, 95% CI: 1.04-1.66).

CONCLUSIONS

Interventions targeting childhood immunization dropouts should focus on bringing more children to EPI centres on-time for initial immunization. Relocation of existing EPI centres and creation of new EPI centres at appropriate locations may decrease the travel time to the EPI centres and result in fewer immunization dropouts.

Disparities in preschool immunization coverage associated with maternal age

Associations between maternal age and preschool immunization coverage are unclear. This study aimed to determine if maternal age is associated with preschool immunization coverage and the importance of maternal age compared with other factors affecting vaccination coverage. Data from the 2001-2003 National Immunization Survey (NIS) were used to estimate vaccine coverage. Children were considered up-to-date (UTD) if they received > or =4 doses of DTaP, > or =3 doses of polio, > or =1 doses of MMR, > or =3 doses of Hib and > or =3 doses of Hep B. Bivariate and multivariate relationships between UTD coverage and maternal, child and household factors were evaluated. Classification tree analysis assessed complex interactions between maternal, child and household factors associated with UTD coverage and isolated the most important factors in predicting UTD coverage. UTD coverage was significantly associated with maternal age: coverage increased as maternal age increased. Coverage among children with 17 year old mothers was 64%; coverage among children of mothers 17-26 years old increased by 16.3% overall (approximately 1.8% per year). After 26 years of age, coverage did not increase significantly as maternal age increased. The relationship between maternal age and UTD coverage remained statistically significant after adjusting for a broad range of maternal, child and household factors. Classification tree analysis suggested that maternal age is the most important factor associated with vaccine coverage. More research is needed to determine the reasons for underimmunization of children born to young mothers.

Changes in childhood immunization disparities between central cities and their respective states, 2000 versus 2006

Central cities have lower childhood immunization coverage rates than states in which they are located. We conducted a secondary analysis of the National Immunization Survey (NIS) 2000 and 2006 of children 19-35 months old for 26 NIS-defined central cities and the rest of their respective states in order to examine patterns in early childhood immunization disparities between central cities and their respective states and the contextual factors associated with these disparities. We examined three measures of immunization disparities (absolute, difference, and ratio of change) and the patterns of disparity change with regard to selected contextual factors derived from the census. In 2000, immunization coverage in central cities was 68.3% and 74.7% in the rest of their states, a 6.4% disparity (t = 3.82, p < 0.000). Between 2000 and 2006, the overall city/state disparity narrowed to 3.5%, with the central city coverage up to 78.7% vs. 82.5% for the rest of state (t = 2.48, p = 0.017). However, changes in immunization disparities were not uniform: six cities narrowed, 14 had minimal change, and six widened. Central cities with a larger share of Hispanics experienced less reduction in disparities than other cities (beta = -4.2, t = -2.11, p = 0.047). Despite overall progress in childhood immunization coverage, most central cities still show significant disparities with respect to the rest of their states. Cities with larger Hispanic populations may need extra help in narrowing their disparities.

Vaccination coverage against measles in German-born and foreign-born children and identification of unvaccinated subgroups in Germany

Data from the representative German Health Interview and Examination Survey for Children and Adolescents were used to identify unvaccinated subgroups that should be targeted by vaccination programmes in order to interrupt measles transmission. Measles vaccination coverage was low among children below the age of 3, having > or =3 siblings and in foreign-born migrants. Multivariate analyses show that vaccination coverage was strongly related to the place of birth in migrants: foreign-born children have a three-fold odds of being unvaccinated. Odds were also higher in children living in former West Germany, having > or =3 siblings, and it was especially high in children with parents reporting reservations against vaccinations.

The influence of public or private paediatric health care on vaccination coverages in children in Catalonia (Spain)

BACKGROUND

Maintaining high vaccination coverages is necessary in order to control vaccine-preventable diseases. We studied vaccination coverages in a representative sample of 630 children aged <3 years in Catalonia in order to determine the relationship between vaccination coverages and socioeconomic factors.

METHODS

Sampling was carried out in a representative sample of the health regions in Catalonia stratified according to habitat. A sample of 630 parents of children aged <3 years born in October 2001 were interviewed by telephone. Information collected included sociodemographic data, type of health care provider (public or private) and information on vaccination coverage for the basic plus booster immunization series (BBI) which consisted of: four DTP, four OPV, one MMR and the doses of Hib and MenC necessary according to age of administration of the first dose.

RESULTS

A total of 87.62% of the children were vaccinated with the BBI series, and no statistically significant differences in coverage between public (87.93%) and private (88.30%) paediatric providers, or between social classes (high: 87.58%, low: 88.81%) were found. Vaccination coverage was associated with attending a day-care centre (OR: 1.89; 95% CI: 1.12-3.21) and maternal university education (OR: 1.84; 95% CI: 1.01-3.33).

CONCLUSION

Vaccination coverages are high and are similar between types of provider, probably due to preventive policies which have made a concerted effort to ensure universal vaccination.

Determinants of the uptake of the full dose of diphtheria-pertussis-tetanus vaccines (DPT3) in Northern Nigeria: a multilevel analysis

OBJECTIVES

Health behaviors are influenced by an array of factors at the individual, household, community and societal levels. This paper examines the relative contribution of child's characteristics, mother's attributes, household profiles and community factors on the probability that a child will receive the full series of diphtheria-pertussis-tetanus vaccines (DPT3) as a proxy for full immunization.

METHODS

We used data from a 2004 household survey conducted in three northern Nigeria states: Borno, Kano and Yobe. We estimated multilevel models with fixed effects specified at the individual, household and community levels, and random effects at the community level.

RESULTS

Overall, only 16.0% of the children aged 12-35 months had received DPT3. The data show that a significant amount of the variation in DPT3 uptake occurs at the community level. The most significant predictors of the uptake of DPT3 are found at multiple levels and include child's place of birth, presence of an immunization card, mother's ideation, mother's decision-making power and perceived social approval of immunization. The data further show that significant community-level variations in immunization uptake remain even after individual and household factors have been considered.

CONCLUSIONS

The data reveal that childhood immunization is influenced by norms and unmeasured factors at the community level in addition to factors operating at the level of the individual child and the household. Strategies for improving the uptake of immunization should include culturally appropriate interventions that target multiple levels of influences. Improving parental attitudes towards immunization without addressing the issue of community norms is not likely to yield significant results.

Timeliness of vaccination and its effects on fraction of vaccinated population

Delayed vaccination against childhood diseases may lead to increased mortality and morbidity among children and also affect the fraction of vaccinated population necessary for elimination of a disease. The purpose of this study was to assess the extent of the delay in vaccinations in four countries belonging to Commonwealth of Independent States and to assess how the timeliness of vaccination affects the vaccination coverage. The fraction of children vaccinated with delay was substantial in all the studied countries, and the impact of differences between countries was stronger than individual risk factors assessed in this study. In presence of vaccination delay, up-to-date vaccination is a biased estimator of the fraction of vaccinated population. Age-appropriate vaccination should be taken into account when assessing vaccination coverage.

Hepatitis A 2004 vaccination in children: methods and findings of a survey in two states

BACKGROUND

Hepatitis A vaccine coverage estimates needed for surveillance and vaccine policy decisions are not readily available for children older than 35 months or for adolescents. This article reports methodology developed for obtaining such estimates by telephone survey with and without provider record verification.

METHODS

A random-digit-dial telephone survey with provider verification was conducted in Arizona and Oregon in 2004-2005 to obtain coverage estimates for children aged 2.5 to 15 years based on parental reports from telephone survey data alone, and from multiple logistic regressions using both telephone survey and provider data. Analysis was performed during 2006.

RESULTS

Vaccination information was collected from parents of 1266 children, and provider verification from 488. Telephone survey and provider record-based hepatitis A vaccine coverage (one or more doses) was 60% and 65%, respectively, in Arizona, and 39% and 26%, respectively, in Oregon. Children who were younger, lived in metropolitan areas, or were Hispanic or nonwhite had significantly higher coverage; parents with immunization records provided more-accurate information. While a logistic model-based estimator developed using both parent and provider data performed slightly better than the estimator based on parent data alone, they differed mostly in the subgroups that had small sample sizes.

CONCLUSIONS

These are the first statewide provider-verified hepatitis A vaccine coverage estimates for children older than 35 months and indicate that telephone survey estimates as developed using this methodology could prove useful for immunization surveillance activities if interpreted cautiously.

Identifying risk factors for underimmunization by using geocoding matched to census tracts: a statewide assessment of children in Hawaii

OBJECTIVE

Obtaining childhood immunization coverage data for small geographic areas is difficult and resource-intensive, especially in the absence of comprehensive immunization registries. To identify factors that are associated with delayed immunization, we collected school-entry immunization records statewide and used geocoding to link to publicly available census tract sociodemographic data.

METHODS

Immunization records were reviewed for children who were enrolled in all public and private school kindergarten programs in Hawaii in the 2002-2003 school year; immunization status at the time of the second birthday was determined. The main outcome variable was up-to-date status for the 4:3:1:3:3 vaccination series (4 doses of diphtheria-tetanus-pertussis, 3 doses of polio, 1 dose of measles-mumps-rubella, 3 doses of Haemophilus influenzae type b, and 3 doses of hepatitis B vaccines). Children's home addresses were geocoded to census tracts; coverage rates by tract were mapped, and sociodemographic data from Census 2000 files were used to identify factors that were associated with delays in immunization.

RESULTS

Records were obtained for 15,275 of 15,594 children registered in Hawaii kindergartens. Overall, 78% had completed their 4:3:1:3:3 series by their second birthday. Risk factors for delayed immunization included delayed immunization at 3 months of age, living in Maui County, living in a neighborhood where a low proportion of adults had postsecondary education, and living in a neighborhood where a high proportion of households spoke a language other than English at home. The majority (80%) of underimmunized children would have required only 1 additional visit to bring them up-to-date.

CONCLUSIONS

Retrospective review of kindergarten-entry immunization data revealed geographic areas with lower immunization coverage, and geocoding to census tracts identified associated sociodemographic risk factors. This is a practical method for state or city health departments to identify pockets of need and to direct resources appropriately.

Infant vaccination coverage in 2005 and predictive factors for complete or valid vaccination in Flanders, Belgium: an EPI-survey

To assess changes in infant vaccination coverage in Flanders since 1999, an EPI-survey was performed in 2005. The parents of 1354 children aged 18-24 months were interviewed at home and the vaccination documents were checked. Several factors possibly related to vaccination status were examined with parametric and non-parametric methods. The coverage rate of recommended vaccines, i.e. poliomyelitis, tetanus-diphtheria-pertussis, H. influenzae type b (Hib), hepatitis B, measles-mumps-rubella (MMR) and meningococcal C, reached at least 92.2%, which is a significant rise for MMR, hepatitis B and Hib since 1999. The vaccinating physician, the employment situation of the mother and the family income were significant predictive factors for having received all recommended vaccine doses (complete schedule), also when considering only doses that were according to minimal age and interval criteria (valid schedule).

Determinants of childhood vaccination coverage in Kazakhstan in a period of societal change: Implications for vaccination policies

After the fall of the Soviet Union countries in Central Asia have undergone large changes. In Kazakhstan the vaccination coverage decreased between 1990 and 1995, which resulted in an increased incidence of some vaccine-preventable diseases, e.g. diphtheria and measles. In this study we examined which factors affected the vaccination status of children in Kazakhstan and whether they resemble patterns observed in developing or developed countries. We found a mixed pattern of risk factors, consistent with the status of Kazakhstan as a transitional economy. Especially prominent was the relatively high education of the women and good access to the medical care system.