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

A comparison of electronic health records and the Oregon state immunization registry for human papilloma virus vaccine delivery (2005-2022)

INTRODUCTION

Immunization Information Systems (IIS) play an important information-sharing role at the point of care, and provide vital vaccination data for research studies and policy-makers. Previous validation studies comparing the accuracy of state registry data to health records have had mixed results.

METHODS

We conducted a retrospective review of EHR vaccination data for 9-17 year-old patients from 10 Oregon primary care clinics who had at least one ambulatory care visit in the past 3 years from the date of validation data collection. Data on 100 age eligible youth were captured per clinic. We compared HPV and Tdap vaccinations captured in the EHR to the Oregon ALERT IIS. All clinics were located in rural areas with both family medicine (n = 7) and pediatric (n = 3) primary care clinics.

RESULTS

Overall agreement for HPV vaccination between EHR and ALERT IIS was 89.4 % (k = 0.83; p < 0.05). For Tdap vaccination overall agreement was 80.8 % (k = 0.60; p < 0.05). Pediatric clinics showed a higher overall vaccine agreement for both HPV at 93.3 % (k = 0.89; p < 0.05) and Tdap at 95.3 % (k = 0.90; p < 0.05). Among clinics that used bidirectional data exchange (only family medicine clinics), HPV agreement was higher at 91 % (k = 0.85) versus 88 % (k = 0.81; p < 0.05) and was lower for Tdap 75 % with bidirectional data exchange (k = 0.50) versus 86 % without bidirectional data exchange (k = 0.70; p < 0.05). When the EHR and ALERT IIS disagreed, ALERT ISS usually had additional vaccines.

CONCLUSIONS

ALERT IIS data provides more accurate data than EHRs can provide when measuring vaccine delivery among adolescents in rural Oregon.

Roles of the Maternal and Child Health Handbook and Other Home-Based Records on Newborn and Child Health: A Systematic Review

Home-based records are paper or electronic records retained and used by mothers or caregivers to document the health services received for maternal, newborn, and child health. Little has been studied about the roles of these records on newborn and child health outcomes. Hence, we collated and summarized evidence concerning the roles of home-based records in improving newborn and child health. We conducted a systematic search in several databases: MEDLINE, Web of Science, CINAHL, PsycINFO, PsycARTICLES, Academic Search Complete, SocINDEX, CENTRAL, DARE, NHS EED, HTA, J-STAGE, Ichushi, and gray literature. We included original research articles of all study designs published in English or Japanese until January 2020. Owing to heterogeneity across the outcomes of included studies, we conducted a narrative synthesis. We included 55 studies (23 in Japanese) among 14,017 identified articles. We identified the following roles of home-based records on newborn and child health: promoted newborn/childcare seeking, improved knowledge and practices of newborn/childcare, encouraged home care for childhood illnesses, reduced child mortality and morbidity, and facilitated continuum of care. We observed a mixed effect on age-appropriate immunization (e.g., DTP3 completion) and no effect on the practice of immediate breastfeeding and prevention of perinatal mortality and morbidity. The findings highlighted the effectiveness and usefulness of home-based records to improve newborn and child health outcomes. However, only a few studies were available for each outcome category, limiting the certainty of evidence provided in this review. Therefore, we recommend further studies to explore the benefits of home-based records on improving newborn and child health.

Maternal and Child Health Handbook use for maternal and child care: a cluster randomized controlled study in rural Java, Indonesia

Background

Effectiveness of the Maternal and Child Health Handbook (MCHHB), a home-based booklet for pregnancy, delivery and postnatal/child health, was evaluated on care acquisition and home care in rural Java, a low service-coverage area.

Methods

We conducted a health centre-based randomized trial, with a 2-year follow-up. Intervention included (i) MCHHB provision at antenatal care visits; (ii) records and guides by health personnel on and with the MCHHB; and (iii) sensitization of care by volunteers using the MCHHB.

Results

The follow-up rate was 70.2% (183, intervention area; 271, control area). Respondents in the intervention area received consecutive MCH services including two doses of tetanus toxoid injections and antenatal care four times or more during pregnancy, professional assistance during child delivery and vitamin A supplements administration to their children, after adjustment for confounding variables and cluster effects (OR = 2.03, 95% CI: 1.19–3.47). In the intervention area, home care (continued breastfeeding; introducing complementary feeding; proper feeding order; varied foods feeding; self-feeding training; and care for cough), perceived support by husbands, and lower underweight rates and stunting rates among children were observed.

Conclusion

MCHHB use promoted continuous care acquisition and care at home from pregnancy to early child-rearing stages in rural Java.

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.

Adapting home-based records for maternal and child health to users' capacities

Home-based records have been used in both low- and high-income countries to improve maternal and child health. Traditionally, these were mostly stand-alone records that supported a single maternal and child health-related programme, such as the child vaccination card or growth chart. Recently, an increasing number of countries are using integrated home-based records to support all or part of maternal and child health-related programmes, as in the maternal and child health handbook. Policy-makers’ expectations of home-based records are often unrealistic and important functions of the records remain underused, leading to loss of confidence in the process, and to wasted resources and opportunities for care. We need to examine the gaps between the functions of the records and the extent to which users of records (pregnant women, mothers, caregivers and health-care workers) are knowledgeable and skilful enough to make those expected functions happen. Three key functions, with increasing levels of complexity, may be planned in home-based records: (i) data recording and storage; (ii) behaviour change communication, and (iii) monitoring and referral. We define a function–capacity conceptual framework for home-based records showing how increasing number and complexity of functions in a home-based record requires greater capacity among its users. The type and functions of an optimal home-based record should be strategically selected in accordance not only with demands of the health system, but also the capacities of the record users.

Are Parent-Held Child Health Records a Valuable Health Intervention? A Systematic Review and Meta-Analysis

Parent-held child health record (PHCHR), a public health intervention for promoting access to preventive health services, have been in use in many developed and developing countries. This review aimed to evaluate the use of the records toward promoting child health/development. We searched PubMed, PsycINFO, CINAHL, Cochrane Library and Google Scholar to identify relevant articles, of which 32 studies met the inclusion criteria. Due to considerable heterogeneity, findings were narratively synthesised. Outcomes with sufficient data were meta-analysed using a random-effects model. Odds Ratio (OR) was used to compute the pooled effect sizes at 95% confidence interval (CI). The pooled effect of the PHCHR on the utilisation of child/maternal healthcare was not statistically significant (OR = 1.31, 95% CI 0.92–1.88). However, parents who use the record in low- and middle-income countries (LMIC) were approximately twice as likely to adhere to child vaccinations (OR = 1.93, 95% CI 1.01–3.70), utilise antenatal care (OR = 1.60, 95% CI 1.23–2.08), and better breastfeeding practice (OR = 2.82, 95% CI 1.02–7.82). Many parents (average-72%) perceived the PHCHR as useful/important and majority (average-84%) took it to child clinics. Health visitors and nurses/midwives were more likely to use the record than hospital doctors. It is concluded that parents generally valued the PHCHR, but its effect on child health-related outcomes have only been demonstrated in LMIC.

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.

Strategies for addressing vaccine hesitancy - A systematic review

The purpose of this systematic review is to identify, describe and assess the potential effectiveness of strategies to respond to issues of vaccine hesitancy that have been implemented and evaluated across diverse global contexts.

METHODS

A systematic review of peer reviewed (January 2007-October 2013) and grey literature (up to October 2013) was conducted using a broad search strategy, built to capture multiple dimensions of public trust, confidence and hesitancy concerning vaccines. This search strategy was applied and adapted across several databases and organizational websites. Descriptive analyses were undertaken for 166 (peer reviewed) and 15 (grey literature) evaluation studies. In addition, the quality of evidence relating to a series of PICO (population, intervention, comparison/control, outcomes) questions defined by the SAGE Working Group on Vaccine Hesitancy (WG) was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria; data were analyzed using Review Manager.

RESULTS

Across the literature, few strategies to address vaccine hesitancy were found to have been evaluated for impact on either vaccination uptake and/or changes in knowledge, awareness or attitude (only 14% of peer reviewed and 25% of grey literature). The majority of evaluation studies were based in the Americas and primarily focused on influenza, human papillomavirus (HPV) and childhood vaccines. In low- and middle-income regions, the focus was on diphtheria, tetanus and pertussis, and polio. Across all regions, most interventions were multi-component and the majority of strategies focused on raising knowledge and awareness. Thirteen relevant studies were used for the GRADE assessment that indicated evidence of moderate quality for the use of social mobilization, mass media, communication tool-based training for health-care workers, non-financial incentives and reminder/recall-based interventions. Overall, our results showed that multicomponent and dialogue-based interventions were most effective. However, given the complexity of vaccine hesitancy and the limited evidence available on how it can be addressed, identified strategies should be carefully tailored according to the target population, their reasons for hesitancy, and the specific context.

Results from a survey of national immunization programmes on home-based vaccination record practices in 2013

Background

Data on home-based records (HBRs) practices within national immunization programmes are non-existent, making it difficult to determine whether current efforts of immunization programmes related to basic recording of immunization services are appropriately focused.

Methods

During January 2014, WHO and the United Nations Children's Fund sent a one-page questionnaire to 195 countries to obtain information on HBRs including type of record used, number of records printed, whether records were provided free-of-charge or required by schools, whether there was a stock-out and the duration of any stock-outs that occurred, as well as the total expenditure for printing HBRs during 2013.

Results

A total of 140 countries returned a completed HBR questionnaire. Two countries were excluded from analysis because they did not use a HBR during 2013. HBR types varied across countries (vaccination only cards, 32/138 [23.1%]; vaccination plus growth monitoring records, 31/138 [22.4%]; child health books, 48/138 [34.7%]; combination of these, 27/138 [19.5%] countries). HBRs were provided free-of-charge in 124/138 (89.8%) respondent countries. HBRs were required for school entry in 62/138 (44.9%) countries. Nearly a quarter of countries reported HBR stock-outs during 2013. Computed printing cost per record was <US$0.50 in 53/77 (69%) of countries providing information.

Conclusions

These results provide a basis for national immunization programmes to develop, implement and monitor corrective activities to improve the availability and utilization of HBRs. Much work remains to improve forecasting where appropriate, to prevent HBR stock-outs, to identify and improve sustainable financing options and to explore viable market shaping opportunities.

Developing a hand-held Pap test card to improve cervical cancer screening

We identified an educational deficit among clients at a community health clinic regarding the latest cervical cancer screening recommendations. A literature search on Pap testing and problems with compliance or screening indicated multiple barriers to cervical cancer screening. Education, health promotion and the use of a hand-held health card/record were identified as methods to educate women regarding cervical cancer prevention. We developed a hand-held Pap test card to be similar to an immunization card. The card was designed to fulfill the needs of both clients and practitioners.

Examining professionals' and parents' views of using transanal irrigation with children: Understanding their experiences to develop a shared health resource for education and practise

Irrigation as a bowel management approach has been reportedly used with children for more than 20 years. Parents managing their child's chronic bowel problem have previously been shown to have increased emotional stress. The aim of this study was to explore professionals' (n = 24) understanding and parents' (n = 18) experiences of using transanal irrigation with children at home as a mid to longer term bowel management approach. This study was underpinned by action research methodology and used mixed methods determined by an action research group of parents, professionals, researchers, a voluntary sector worker, commercial representative and independent observer. Data informed the study outcome which was the development and evaluation of a shared health resource to support professionals in their holistic approach when prescribing transanal irrigation and guide parents in the areas of education, management, problem solving, support and goal setting. The resource includes constructed case studies from parents of their experiences to inform choice and decision-making between parents and professionals. The shared health resource provides an approach to initiating and evaluating transanal irrigation and is available in a paper format from key Internet sites across hospital, community and voluntary services.

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.

ENCOURAGING RECORD USE FOR FINANCIAL ASSET QUESTIONS IN AWEB SURVEY

We report on two experiments to encourage record use by respondents in an Internet survey. The experiments were conducted in the 2009 Health and Retirement Study (HRS) Internet Survey, administered to those in the HRS panel with Internet access, and in the 2011 HRS Internet Survey. Encouraging respondents to consult records at the relevant point in the questionnaire significantly increased reported record use (from 39 percent to 47 percent), but was insufficient to produce significant changes in the precision (amount of rounding) of the information reported. Including the encouragement in the mailed invitation to the Web survey in 2011 resulted in a lower response rate (77 percent with encouragement, 80 percent without), but increased reported record use among respondents (from 46 percent to 55 percent). In neither case was the increase in reported record use large enough to produce significant differences in the precision of the information reported between the groups with and without encouragement.

Face to face interventions for informing or educating parents about early childhood vaccination

BACKGROUND

Childhood vaccination (also described as immunisation) is an important and effective way to reduce childhood illness and death. However, there are many children who do not receive the recommended vaccines because their parents do not know why vaccination is important, do not understand how, where or when to get their children vaccinated, disagree with vaccination as a public health measure, or have concerns about vaccine safety.Face to face interventions to inform or educate parents about routine childhood vaccination may improve vaccination rates and parental knowledge or understanding of vaccination. Such interventions may describe or explain the practical and logistical factors associated with vaccination, and enable parents to understand the meaning and relevance of vaccination for their family or community.

OBJECTIVES

To assess the effects of face to face interventions for informing or educating parents about early childhood vaccination on immunisation uptake and parental knowledge.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); MEDLINE (OvidSP) (1946 to July 2012); EMBASE + Embase Classic (OvidSP) (1947 to July 2012); CINAHL (EbscoHOST) (1981 to July 2012); PsycINFO (OvidSP) (1806 to July 2012); Global Health (CAB) (1910 to July 2012); Global Health Library (WHO) (searched July 2012); Google Scholar (searched September 2012), ISI Web of Science (searched September 2012) and reference lists of relevant articles. We searched for ongoing trials in The International Clinical Trials Registry Platform (ICTRP) (searched August 2012) and for grey literature in The Grey Literature Report and OpenGrey (searched August 2012). We also contacted authors of included studies and experts in the field. There were no language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster RCTs evaluating the effects of face to face interventions delivered to individual parents or groups of parents to inform or educate about early childhood vaccination, compared with control or with another face to face intervention. Early childhood vaccines are all recommended routine childhood vaccines outlined by the World Health Organization, with the exception of human papillomavirus vaccine (HPV) which is delivered to adolescents.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed database search results for inclusion. Grey literature searches were conducted and reviewed by a single author. Two authors independently extracted data and assessed the risk of bias of included studies. We contacted study authors for additional information.

MAIN RESULTS

We included six RCTs and one cluster RCT involving a total of 2978 participants. Three studies were conducted in low- or middle-income countries and four were conducted in high-income countries. The cluster RCT did not contribute usable data to the review. The interventions comprised a mix of single-session and multi-session strategies. The quality of the evidence for each outcome was low to very low and the studies were at moderate risk of bias overall. All these trials compared face to face interventions directed to individual parents with control.The three studies assessing the effect of a single-session intervention on immunisation status could not be pooled due to high heterogeneity. The overall result is uncertain because the individual study results ranged from no evidence of effect to a significant increase in immunisation.Two studies assessed the effect of a multi-session intervention on immunisation status. These studies were also not pooled due to heterogeneity and the result was very uncertain, ranging from a non-significant decrease in immunisation to no evidence of effect.The two studies assessing the effect of a face to face intervention on knowledge or understanding of vaccination were very uncertain and were not pooled as data from one study were skewed. However, neither study showed evidence of an effect on knowledge scores in the intervention group. Only one study measured the cost of a case management intervention. The estimated additional cost per fully immunised child for the intervention was approximately eight times higher than usual care.The review also considered the following secondary outcomes: intention to vaccinate child, parent experience of intervention, and adverse effects. No adverse effects related to the intervention were measured by any of the included studies, and there were no data on the other outcomes of interest.

AUTHORS' CONCLUSIONS

The limited evidence available is low quality and suggests that face to face interventions to inform or educate parents about childhood vaccination have little to no impact on immunisation status, or knowledge or understanding of vaccination. There is insufficient evidence to comment on the cost of implementing the intervention, parent intention to vaccinate, parent experience of the intervention, or adverse effects. Given the apparently limited effect of such interventions, it may be feasible and appropriate to incorporate communication about vaccination into a healthcare encounter, rather than conduct it as a separate activity.

A description of barriers and facilitators to childhood vaccinations in the military health system

PURPOSE

To perform a literature review of barriers to and facilitators of parents' decisions to have their children vaccinated. Both differences and similarities between the civilian sector and the military health system (MHS) were explored.

DATA SOURCES

Articles and documents were identified from the following databases: CINAHL, PubMed, Defense Technical Information Center (DTIC), ISI, and Google Scholar. Reference lists from articles were reviewed.

CONCLUSIONS

Common themes identified in the civilian sector and the MHS included an electronic registry, care access issues, provider characteristics, and child illness. Several themes served as a barrier in one system while being a facilitator in the other, such as provider characteristics. Literature addressing the MHS and factors affecting vaccine coverage is scant; however, a large disparity in vaccination coverage exists between the MHS and the civilian sector.

IMPLICATIONS

The theme of provider characteristics was seen as a barrier in both systems; a better understanding of this theme (i.e., provider effectiveness at interacting with parents) would benefit primary care practice. An electronic vaccine registry and targeted education and media campaign used to facilitate vaccinations in the MHS should be piloted in the civilian sector. Additionally, future studies should be performed on identified themes in the MHS.

Is the Maternal and Child Health (MCH) handbook effective in improving health-related behavior? Evidence from Palestine

OBJECTIVE

This study examines the effect of the Maternal and Child Health (MCH) handbook--a home-based health record--on women's knowledge and behavior in the Jericho and Ramallah Governorates of Palestine.

METHODS

This study uses a repeated, cross-sectional data set in which pre- and post-intervention situations are incorporated on two groups: those exposed and those not exposed to the MCH handbook. We employed a difference-in-difference regression analysis utilizing a pre-tested knowledge, attitude, and practice survey of women at 24 MCH 'treatment' centers (N=260, 270, pre-/post-) in comparison with the women at 6 MCH centers (N=70, 70, pre-/post-) where the MCH handbook was not released. A trained facilitator conducted a series of focus group discussions with 42 women who were the clients of MCH services and 25 health providers, both from the intervention area, to confirm the results obtained from the quantitative study.

FINDINGS

Knowledge related to MCH such as the importance of exclusive breastfeeding and how to cope with the risks of rupture of membranes during pregnancy increased among MCH handbook users, especially among less-educated women. The MCH handbook may be an effective tool for communication with health providers and husbands, for both highly educated and less-educated women during their first pregnancy. Our results suggest that although less-educated women rarely read the handbook themselves at home, they became familiar with health information and options related to MCH through personalized guidance that was provided by health providers at health facilities utilizing MCH handbook.

CONCLUSION

The MCH handbook may be an effective tool to improve (i) communication between the client and the health provider and (ii) women's knowledge- and health-seeking behaviors related to maternal, newborn, and child health.

Patient-Held Maternal and/or Child Health Records: Meeting the Information Needs of Patients and Healthcare Providers in Developing Countries?

Though improvements in infant and maternal mortality rates have occurred over time, women and children still die every hour from preventable causes. Various regional, social and economic factors are involved in the ability of women and children to receive adequate care and prevention services. Patient-held maternal and/or child health records have been used for a number of years in many countries to help track health risks, vaccinations and other preventative health measures performed. Though these records are primarily designed to record patient histories and healthcare information and guide healthcare workers providing care, because the records are patient-held, they also allow families a greater ability to track their own health and prevention strategies. A LITERATURE SEARCH WAS PERFORMED TO ANSWER THESE QUESTIONS: (1) What are maternal information needs regarding pregnancy, post-natal and infant healthcare, especially in developing countries? (2) What is known about maternal information seeking behavior in developing countries? (3) What is the history and current state of maternal and/or child patient-held healthcare records, do they provide for the information needs of the healthcare provider and what are the effects and outcomes of patient-held records in general and for maternal and/or child health in particular? Specific information needs of pregnant women and mothers are rarely studied. The small numbers of maternal information behavior results available indicate that mothers, in general, prefer to receive health information directly from their healthcare provider as opposed to from other sources (written, etc.) Overall, in developing countries, patient-held maternal and/or child healthcare records have a mostly positive effect for both patient and care provider. Mothers and children with records tend to have better outcomes in healthcare and preventative measures. Further research into the information behaviors of pregnant women and mothers to determine the extent of reliance on interpersonal information seeking is recommended before expending significant resources on enhanced patient-held maternal and/or child healthcare records including storage on mobile devices. In particular, research is needed to explore the utility of providing targeted health messages to mothers regarding their own health and that of their children; this might best be accomplished through mobile technologies.

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.

Extra-immunization as a clinical indicator for fragmentation of care

OBJECTIVES

We assessed whether extra-immunization can serve as a clinical indicator for fragmentation of care.

METHODS

Using public-use files of the 1999-2003 National Immunization Survey, we classified children 19-35 months of age by their vaccination providers for the degree of fragmentation of care as ordered from lowest with one vaccine provider, to increasing fragmentation with multiple providers in one facility type, to multiple providers in more than one facility type. Extra-immunization was defined conservatively based on the year-specific recommendations of the Advisory Committee on Immunization Practices (ACIP) for immunizations due before 18 months of age. Of note, 1999-2003 transitioned from oral to inactivated poliovirus vaccines.

RESULTS

The rate for extra-immunization was 9.4% (95% confidence interval [CI] 9.2, 9.7). Of single vaccines, the rate for polio vaccine was highest (5.7%, 95% CI 5.5, 6.0). Extra-immunization was lowest for the 69% of children with only one vaccination provider (6.4%, 95% CI 6.1, 6.7), was higher in children who had more than one vaccination provider with one vaccination facility type (13.9%, 95% CI 13.2, 14.6), and highest with more than one facility type (24.1%, 95% CI 22.5, 25.6). Logistic regression (including race/ethnicity, language, provider type, survey year, and a parent-held immunization record) confirmed that multiple providers (adjusted odds ratio [AOR] = 2.30), multipl facility types (AOR = 4.67), Spanish language (AOR = 1.29), and race/ethnicity (black AOR = 1.16, Hispanic AOR = 1.31) were each associated with extra-immunization. Excluding poliovirus vaccine from the analysis, AORs for multiple providers and multiple facility types increased to 3.64 and 8.95, respectively.

CONCLUSIONS

Extra-immunization is associated with receiving immunizations from multiple providers and multiple facility types.