Effects of maternal and provider characteristics on up-to-date immunization status of children aged 19 to 35 months

Spatial distribution and determinants of childhood vaccination refusal in the United States

Parental refusal and delay of childhood vaccination has increased in recent years in the United States. This phenomenon challenges maintenance of herd immunity and increases the risk of outbreaks of vaccine-preventable diseases. We examine US county-level vaccine refusal for patients under five years of age collected during the period 2012-2015 from an administrative healthcare dataset. We model these data with a Bayesian zero-inflated negative binomial regression model to capture social and political processes that are associated with vaccine refusal, as well as factors that affect our measurement of vaccine refusal. Our work highlights fine-scale socio-demographic characteristics associated with vaccine refusal nationally, finds that spatial clustering in refusal can be explained by such factors, and has the potential to aid in the development of targeted public health strategies for optimizing vaccine uptake.

Newborn medication adherence and childhood under-immunization in military beneficiaries

BACKGROUND

The American Academy of Pediatrics recommends birth doses of vitamin K, erythromycin ointment, and the hepatitis B vaccine, but the relationship between birth medication administration and childhood immunization compliance is understudied. The objective of this study is to evaluate rates of newborn medication administration, and risk factors for refusal in military beneficiaries and determine the relationship between medication refusal and under-immunization at 15 months.

METHODS

A retrospective chart review was completed for all term and late preterm infants born at Brooke Army Medical Center, San Antonio, TX, from January 1, 2016, to December 31, 2019. The electronic medical record was queried for birth medication administration, maternal age, active-duty status, rank, and birth order. Childhood immunization records were extracted for all patients who continued care at our facility. A patient was considered completely immunized if they had received at least 22 vaccines by 15 months: three doses of the hepatitis B vaccine [Pediarix^TM], two doses of the rotavirus vaccine [Rotarix^TM], four doses of the DTAP vaccine [Pediarix^TM and Acel-Immune^TM], three doses of Haemophilus influenza B vaccine [Pedvaxhib^TM], four doses of pneumococcal [Prevnar 13^TM], three doses of IPV [Pediarix^TM], one dose of measles, mumps, and rubella [MMR^TM], one dose of varicella [Varivax^TM] and one dose of hepatitis A vaccine [Harvix^TM].

RESULTS

Seven thousand one hundred and forty infants were included; 99.3% received vitamin K, 98.8% received erythromycin ointment, and 93.8% received the hepatitis B vaccine. Refusal of the erythromycin ointment and hepatitis B vaccine was associated with older maternal age and higher birth order. Childhood immunization records were available for 607 infants; 7.2% (n = 44) were under-immunized by 15 months, with no infants being non-immunized. Refusal of the hepatitis B vaccine (RR: 2.9 (CI 1.16-7.31)) only at birth was associated with a higher risk of being under-immunized.

CONCLUSIONS

Refusal of the hepatitis B vaccine in the nursery is associated with a risk of being under-immunized in childhood. Obstetric and pediatric providers should be aware of this association for appropriate family counseling.

Injecting fun? Humour, conspiracy theory and (anti)vaccination discourse in popular media

Conspiracy theories have accompanied vaccination since its mass introduction, circulating, among other forms, in humour - such as cartoons, and now, memes. Importantly, humour has targeted both vaccination and anti-vaccination stances. In this study, we discuss the peculiarities of humorous content within the vaccination debate and uncover the most popular thematic categories, forms and logical mechanisms of humour. We show that humorous and serious discussions on vaccination go hand-in-hand, but playfulness and ambiguity of humour complicate public understanding of the vaccination debate. Our analysis shows that vaccination humour often simplifies the complex issue of vaccination and makes it more understandable and more tangible for a broad audience.

Socioeconomic Inequalities and Vaccine Uptake: An Umbrella Review Protocol

The effectiveness of immunization is widely accepted: it can successfully improve health outcomes by reducing the morbidity and mortality associated with vaccine-preventable diseases. In the era of pandemics, there is a pressing need to identify and understand the factors associated with vaccine uptake amongst different socioeconomic groups. The knowledge generated from research in this area can be used to inform effective interventions aimed at increasing uptake. This umbrella systematic review aims to determine whether there is an association between socioeconomic inequalities and rate of vaccine uptake globally. Specifically, the study aims to determine whether an individual's socioeconomic status, level of education, occupation, (un)-employment, or place of residence affects the uptake rate of routine vaccines. The following databases will be searched from 2011 to the present day: Medline (Ovid), Embase (Ovid), CINAHL (EBSCO), Cochrane CENTRAL, Science Citation Index (Web of Science), DARE, SCOPUS (Elsevier), and ASSIA (ProQuest). Systematic reviews will be either included or excluded based on a priori established eligibility criteria. The relevant data will then be extracted, quality appraised, and narratively synthesised. The synthesis will be guided by the theoretical framework developed for this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Equity extension (PRISMA-E) guidance will be followed. This protocol has been registered on PROSPERO, ID: CRD42022334223.

Hesitancy in the time of coronavirus: Temporal, spatial, and sociodemographic variations in COVID-19 vaccine hesitancy

Leveraging nationally representative survey data on 443,680 respondents from January to March 2021, this study examines the temporal, spatial, and sociodemographic variations in COVID-19 vaccine hesitancy in the U.S. Findings reveal multidimensional determinants of vaccination intentions involving confidence, complacency, and circumspection factors. Using descriptive analyses and multilevel mixed-effects regression models, we find persistent partisan divide across states and significant racial disparities, with Blacks more likely to develop vaccine hesitancy due to confidence and circumspection than Whites. Vaccine hesitancy among Blacks declines dramatically across time but varies little across states, indicating new directions to effectively address inequalities in vaccination. Results also show nuanced gender differences, with women more likely to develop hesitancy due to circumspection and men more likely to have hesitancy due to complacency. Moreover, we find important intersection between race, gender, and education that calls for efforts to adequately address the concerns of the most vulnerable and disadvantaged groups.

Encountering Parents Who Are Hesitant or Reluctant to Vaccinate Their Children: A Meta-Ethnography

(1) Background: Health professionals play an important role in addressing parents who are hesitant or reluctant to immunise their children. Despite the importance of this topic, gaps remain in the literature about these experiences. This meta-ethnography aimed to synthesise the available body of qualitative work about the care experiences of community and hospital health professionals in encounters with parents hesitant or reluctant to vaccinate their children. The aim is to provide key information for the creation of strategies that address vaccine hesitancy or refusal and ensure public trust in vaccination programs, which are required in a pandemic context such as the current one. (2) Methods: Noblit and Hare’s interpretive meta-ethnography of 12 studies was followed. A line of argument synthesis based on a metaphor was developed. (3) Results: The metaphor “The stone that refuses to be sculpted”, accompanied by three themes, symbolises the care experiences of health professionals in their encounters with parents that hesitate or refuse to vaccinate their children. (4) Conclusions: The creation of clearer communication strategies, the establishment of a therapeutic alliance, health literacy and the empowerment of parents are recommended. The incorporation of health professionals in decision making and the strengthening of multidisciplinary teams interacting with such parents are also included.

Prevalence and correlates of vaccine attitudes and behaviors in a cohort of low-income mothers

The US is facing a rise in vaccine hesitancy, delay, and refusal, though little is known about these outcomes in socio-economically disadvantaged populations. This study examines the prevalence and correlates of vaccine attitudes and behaviors in a diverse cohort of low-income mothers receiving home visiting services. Survey data were collected from 813 recipients of evidence-based home visiting services in Wisconsin from 2013 to 2018. Analyses were performed to describe outcome measures of vaccine attitudes and self-reported completion, and multivariate regressions were used to test associations between vaccine-related outcomes and hypothesized correlates. Most women (94%) reported their children were up to date on vaccines; 14.3% reported having ever delayed vaccination. A small minority disagreed that vaccines are important (5.0%), effective (5.4%), and safe (6.2%), though a larger proportion responded ambivalently (10.9%–21.9%). Participants with greater trust in health care providers reported more positive overall vaccine attitudes (B = 0.24; 95% CI = 0.17, 0.31), a lower likelihood of vaccine delay (OR = 0.57; 95% CI = 0.46, 0.73), and a greater likelihood of being up to date on vaccines (OR = 1.79, 95% CI = 1.30, 2.44). Women with greater trust in a home visitor also rated vaccines more positively (B = 0.09; 95% CI = 0.02, 0.15), and women who reported better mental health were more likely to report their children were up to date (OR = 1.05; 95% CI = 1.02, 1.09). Compared to non-Hispanic whites, American Indians and non-Hispanic blacks had poorer vaccine-related outcomes. More research on vaccine attitudes and behaviors among higher-risk populations is needed to develop tailored strategies aimed at addressing vaccine hesitancy and underimmunization.

Immunized against science: Narrative community building among vaccine refusing/hesitant parents

Recent outbreaks of measles have centered in specific communities, pointing to the influence of social ties on vaccination practices. This study adds to the conversation on public understanding of vaccine-related science, documenting how the individualist epistemologies highlighted in prior research are externalized and validated in communication with others, focusing on how the narrative strategies used to do so contribute to community building among vaccine refusing and hesitant parents. Through qualitative content analysis of testimonials given to the creators of the anti-vaccination documentary VaxXed, we identify how the common narrative strategies used to question the scientific consensus on vaccines-distrust of doctors, self-diagnosis, building credibility, advocacy, and community building-build a competing consensus based on personal expertise. With this approach, we are better able to understand how participation in online communities strengthens the privileging of individualist epistemologies among vaccine refusing and hesitant parents.

Hepatitis B Birth Dose Effects on Childhood Immunization in the U.S

INTRODUCTION

The Advisory Committee on Immunization Practices recommends administering the first dose of hepatitis B vaccine at birth, making it the first vaccine that many children receive. However, few studies examine whether children who miss the birth dose are at increased risk of vaccination delay. This study investigates birth dose as a determinant of up-to-date immunization status at age 18 months, considering 7 core childhood vaccine series: diphtheria, tetanus, and acellular pertussis; polio; measles, mumps, and rubella; Haemophilus influenzae type B; varicella; hepatitis B; and pneumococcal conjugate vaccine.

METHODS

Cross-sectional data were collected in 2017 by National Immunization Survey-Child, a nationally representative survey of children aged 19-35 months living in the U.S., and were analyzed in 2019. The primary outcome was combined 7-vaccine series (4:3:1:3:3:1:4) up-to-date status at 18 months. Doubly robust estimates of association were calculated using survey logistic regression and propensity scores estimated with boosted classification and regression trees.

RESULTS

Children who received the birth dose had 2.01 (95% CI=1.74, 2.33) times the odds of being up-to-date on the combined 7-vaccine series as children who did not. ORs for all the 7 individual vaccine series were positive, ranging from 1.59 (95% CI=1.28, 1.97) for measles, mumps, and rubella to 4.97 (95% CI=3.97, 6.24) for hepatitis B.

CONCLUSIONS

Receiving the birth dose is positively associated with up-to-date status later in childhood, highlighting the importance of starting vaccination early. The association is insensitive to confounding by factors observed in National Immunization Survey-Child, but investigation of unobserved factors such as vaccine hesitancy could provide critical information to guide intervention strategy.

Austerity, measles and mandatory vaccination: cross-regional analysis of vaccination in Italy 2000-14

Background

Italy has experienced a resurgence in measles since 2015. Although much emphasis has been placed on the role of individuals opting out of vaccination, here we test the hypothesis that large budget reductions in public health spending were also a contributing factor.

Methods

Multi-variate statistical models were used to assess the relationship between measles, mumps and rubella (MMR) coverage and real public health expenditure per-capita across Italy's 20 regions covering the period 2000-14.

Results

Between 2010 and 2014 Italy's public health expenditure fell by over 2%, although varying among regions. Fixed effects models estimate that each 1% reduction in per-capita public health expenditure was associated with a decrease of 0.5 percentage points (95% CI: 0.36-0.65 percentage points) in MMR coverage, after adjusting for time and regional-specific time trends. The consequences can be illustrated by comparing two regions, Lazio, where public health spending fell by 5% and MMR coverage by over 3 percentage points, and Sardinia, a historically deprived region, where public health spending partly rose and MMR rates remained approximately steady.

Conclusion

Adoption of austerity policies in the Italian health system was found to be significantly associated with declining vaccination rates for MMR. However, the recent introduction of mandatory vaccination for Italian children may help counteract this trend.

Factors influencing the routine immunization status of children aged 2-3 years in China

Objectives

To examine the factors associated with the routine immunization status of children aged 2–3 years in China for gaining a better understanding of the Expanded Program on Immunization and to provide evidence for formulating specific strategies to guide the allocation of health resources.

Methods

We analyzed data from 45095 children aged 2–3 years in the 2013 National Immunization Coverage Survey to identify the sociodemographic and provider-associated factors affecting the full immunization status of children. Univariate and multiple logistic regression analyses were performed.

Results

The immunization rate for children aged 2–3 years ranged from 95.9% (diphtheria and tetanus toxoid with pertussis vaccine, 4^th dose) to 99.5% (Japanese encephalitis vaccine, 1^st dose) and was 93.1% for full immunization. In terms of sociodemographic factors, male children [adjusted OR (AOR): 1.115; 95% confidence interval(CI):1.016–1.222], minority children (AOR: 1.632; 95% CI: 1.457–1.828), children of fathers with less than high school education (AOR: 1.577; 95% CI: 1.195–2.081), those born at home (AOR: 4.655; 95% CI: 3.771–5.746), those who immigrated from an adjacent county (AOR: 2.006; 95% CI: 1.581–2.546), and those living in urban-rural fringe areas (AOR: 1.807; 95% CI: 1.475–2.214) or mountainous areas (AOR: 1.615; 95% CI: 1.437–1.814) had significantly increased odds of not being fully immunized. In terms of provider-associated factors, administration of vaccines at home (AOR: 2.311; 95% CI: 1.316–4.059), household reminders (AOR: 2.292; 95% CI: 1.884–2.789), and travel time to vaccination providers of >40 minutes (AOR: 1.622; 95% CI: 1.309–2.010) were negatively associated with immunization rates. In addition, compared to 3-year-old years, 2-year-old children (AOR: 1.201; 95% CI: 1.094–1.318) were less likely to be fully immunized.

Conclusions

All included factors except maternal education level and distance from home to vaccination providers significantly affected immunization rates. Appropriate reminders and accessibility of immunization services played key roles in improving the immunization status. More attention to high-risk groups identified in this study may reduce the disparities in routine childhood immunization in China.

Understanding women's, caregivers', and providers' experiences with home-based records: A systematic review of qualitative studies

Mothers, caregivers, and healthcare providers in 163 countries have used paper and electronic home-based records (HBRs) to facilitate primary care visit. These standardized records have the potential to empower women, improve the quality of care for mothers and children and reduce health inequities. This review examines experiences of women, caregivers and providers with home-based records for maternal and child health and seeks to explore the feasibility, acceptability, affordability and equity of these interventions. We systematically searched MEDLINE, MEDLINE In-Process, MEDLINE Ahead of Print, Embase, CINAHL, ERIC, and PsycINFO for articles that were published between January 1992 and December 2017. We used the CASP checklist to assess study quality, a framework analysis to support synthesis, and GRADE-CERQual to assess the confidence in the key findings. Of 7,904 citations, 19 studies met our inclusion criteria. In these studies, mothers, caregivers and children shared HBR experiences in relation to maternal and child health which facilitated the monitoring of immunisations and child growth and development. Participants' reports of HBRs acting as a point of commonality between patient and provider offer an explanation for their perceptions of improved communication and patient-centered care, and enhanced engagement and empowerment during pregnancy and childcare. Healthcare providers and nurses reported that the home-based record increased their feeling of connection with their patients. Although there were concerns around electronic records and confidentiality, there were no specific concerns reported for paper records. Mothers and other caregivers see home based records as having a pivotal role in facilitating primary care visits and enhancing healthcare for their families. The records' potential could be limited by users concerns over confidentiality of electronic home-based records, or shortcomings in their design. Health systems should seize the opportunity HBRs provide in empowering women, especially in the contexts of lower literacy levels and weak health care delivery systems.

The effect of maternal decisional authority on children's vaccination in East Asia

Even though they are important determinants for increasing vaccination rates in advanced and developing nations alike, maternal capacity and decisional authority have not been fully elucidated in diverse countries and cultural spheres. This study examined the effects of South Korean, Chinese, and Japanese mothers' health literacy, self-efficacy, mass media use, and decisional authority on their children's vaccination after adjustment for their socioeconomic statuses. Computer-assisted web interviews were conducted with married women in their 20s-40s of South Korean, Chinese, or Japanese nationality (n = 1,571). Dependent variables were generated for the following four vaccinations: BCG, diphtheria+pertussis+tetanus (DPT), poliomyelitis (polio), and measles. For statistical processing, cases where all four types of vaccines had been recorded were scored as 1 and other cases were processed as 0. According to the results of the pooled model, we found that for East Asian mothers, decisional authority, self-efficacy, and health literacy all increased the likelihood that they would vaccinate their children. Furthermore, women who searched for health information through media such as the radio were more likely to vaccinate their children. However, when elaborate analyses were conducted by country, there were considerable differences in those characteristics by country. Therefore, this study showed that it is necessary to establish locally tailored strategies in order to raise vaccination rates in the Global Vaccine Action Plan. This study also showed that social contexts must be taken into consideration in order to raise vaccination rates.

Mind the Gap: What explains the education-related inequality in missed opportunities for vaccination in sub-Saharan Africa? Compositional and structural characteristics

Missed opportunities for vaccination (MOV) is an important barrier hindering full immunisation coverage among eligible children. Though factors responsible for MOV are well documented in literature, little attention has been paid to the role of inequalities. The aim of this study is to examine the association between structural or compositional factors and education inequalities in MOV. Blinder-Oaxaca decomposition technique was used to explain the factors contributing to the average gap in missed opportunities for vaccination between uneducated and educated mothers in sub-Saharan Africa using DHS survey data from 35 sub Saharan African countries collected between 2007 and 2016. The sample contained 69,657 children aged 12 to 23 months. We observed a wide variation and inter-country differences in the prevalence of missed opportunity for vaccination across populations and geographical locations. Our results show that the prevalence of MOV in Zimbabwe among uneducated and educated mothers was 9% and 21% respectively while in Gabon corresponding numbers were 85% and 89% respectively. In 15 countries, MOV was significantly prevalent among children born to uneducated mothers (pro-illiterate inequality) while in 5 countries MOV was significantly prevalent among educated mothers (pro-educated inequality). Our results suggest that education-related inequalities in missed opportunities for vaccination are explained by compositional and structural characteristics; and that neighbourhood socio-economic status was the most important contributor to education-related inequalities across countries followed by either the presence of under-five children, media access or household wealth index. The results showed that differential effects such as neighbourhood socio-economic status, presence of under-five children, media access and household wealth index, primarily explained education-related inequality in MOV. Interventions to reduce gaps in education-related inequality in MOV should focus on social determinants of health.

Prevalence of Vaccine Hesitancy Among Expectant Mothers in Houston, Texas

OBJECTIVE

Nonmedical exemptions continue to rise because of increasing proportions of vaccine-hesitant parents. The proportion of expectant parents who are vaccine-hesitant is currently unknown. We assessed the prevalence of vaccine hesitancy among expectant parents receiving care at an obstetrics clinic in Houston, Texas.

METHODS

We conducted a cross-sectional survey of expectant parents between 12 and 31 weeks gestation who received care at Texas Children's Pavilion for Women between July 2014 and September 2015. Using convenience sampling, participants completed a questionnaire that included questions on demographic items, self-assessed pregnancy risk, receipt of annual influenza vaccine, and the 15-item Parents Attitudes About Childhood Vaccines survey, a validated tool to identify vaccine-hesitant parents. We used multivariable logistic regression to determine the association of demographic characteristics, pregnancy risk, and influenza vaccine receipt with vaccine hesitancy after controlling for variables significant in univariable analyses.

RESULTS

Six hundred ten expectant mothers and 38 expectant fathers completed the Parents Attitudes About Childhood Vaccines survey. Overall, 50 of 610 expectant mothers (8.2%; 95% confidence interval [CI], 6.1%-10.7%) were vaccine-hesitant. Expectant mothers were primarily non-Hispanic white, 30 years old or older, and married. The odds of being vaccine-hesitant were 2.2 times greater (95% CI, 1.2-4.1) among expectant mothers with a college level of education or less compared with those with more than a 4-year degree. The odds of being vaccine-hesitant were 7.4 times greater (95% CI, 3.9-14.0) among expectant mothers who do not receive an annual influenza vaccine compared with those who do.

CONCLUSIONS

Our findings suggest the need to identify and address vaccine hesitancy among expectant parents before birth.

Using State Administrative Data to Identify Social Complexity Risk Factors for Children

PURPOSE

Screening for social determinants of health is challenging but critically important for optimizing child health outcomes. We aimed to test the feasibility of using an integrated state agency administrative database to identify social complexity risk factors and examined their relationship to emergency department (ED) use.

METHODS

We conducted a retrospective cohort study among children younger than 18 years with Washington State Medicaid insurance coverage (N = 505,367). We linked child and parent administrative data for this cohort to identify a set of social complexity risk factors, such as poverty and parent mental illness, that have either a known or hypothesized association with suboptimal health care use. Using multivariate analyses, we examined associations of each risk factor and of number of risk factors with the rate of ED use.

RESULTS

Nine of 11 identifiable social complexity risk factors were associated with a higher rate of ED use. Additionally, the rate increased as the number of risk factors increased from 0 to 5 or more, reaching approximately twice the rate when 5 or more risk factors were present in children aged younger than 5 years (incidence rate ratio = 1.92; 95% CI, 1.85-2.00) and in children aged 5 to 17 years (incidence rate ratio = 2.06; 95% CI, 1.99-2.14).

CONCLUSIONS

State administrative data can be used to identify social complexity risk factors associated with higher rates of ED use among Medicaid-insured children. State agencies could give primary care medical homes a social risk flag or score to facilitate targeted screening and identification of needed resources, potentially preventing future unnecessary ED use in this vulnerable population of children.

Socioeconomic differences in childhood vaccination in developed countries: a systematic review of quantitative studies

INTRODUCTION

The reasons for vaccine hesitancy and its relation to individual socioeconomic status (SES) must be better understood. Areas covered: This review focused on developed countries with programs addressing major financial barriers to vaccination access. We systematically reviewed differences by SES in uptake of publicly funded childhood vaccines and in cognitive determinants (beliefs, attitudes) of parental decisions about vaccinating their children. Using the PRISMA statement to guide this review, we searched three electronic databases from January 2000 through April 2016. We retained 43 articles; 34 analyzed SES differences in childhood vaccine uptake, 7 examined differences in its cognitive determinants, and 2 both outcomes. Expert commentary: Results suggest that barriers to vaccination access persist among low-SES children in several settings. Vaccination programs could be improved to provide all mandatory and recommended vaccines 100% free of charge, in both public organizations and private practices, and to reimburse vaccine administration. Multicomponent interventions adapted to the context could also be effective in reducing these inequalities. For specific vaccines (notably for measles, mumps, and rubella), in UK and Germany, uptake was lowest among the most affluent. Interventions carefully tailored to respond to specific concerns of vaccine-hesitant parents, without reinforcing hesitancy, are needed.

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.

A Tale Of Two States: Mississippi, West Virginia, And Exemptions To Compulsory School Vaccination Laws

School-based compulsory vaccination laws have provoked debates over the legitimacy of government coercion versus the scope of parental rights. A key point of contention in these school vaccination laws are provisions known as exemption clauses that allow some parents to enroll their children in school unimmunized for reasons other than medical conditions. For more than three decades Mississippi and West Virginia stood apart as the only two US states that did not offer nonmedical exemptions to school vaccination laws. But other states seem to be moving in this direction, such as California, which in 2015 eliminated nonmedical exemptions following the Disneyland measles outbreak. The apparent shift creates an opportune moment to look at the experiences of Mississippi and West Virginia. Through a review of legislative histories, legal rulings, media accounts, and interviews with health officials in the two states, we consider the reasons for and consequences of their allowing only medical exemptions and the prospects their approach holds out for other states that may wish to emulate it. The experiences of these two states suggest that contrary to conventional wisdom, it may be politically tenable to limit exemptions to only medical reasons without damaging either the stature of public health or the immunization system.

Knowledge, attitudes, and practices about influenza illness and vaccination: a cross-sectional survey in two South African communities

BACKGROUND

Understanding knowledge and sentiment toward influenza and vaccination is important for effective health messages and prevention strategies. We aimed to characterize knowledge, attitudes, and practices surrounding influenza illness and vaccination in two South African communities and explore reasons for vaccine hesitancy.

METHODS

Household primary caregivers in Soweto and Klerksdorp townships were interviewed about knowledge of influenza and intention to receive an influenza vaccine using a structured questionnaire. Factors associated with unwillingness to receive vaccine were explored using multivariable regression.

RESULTS

We interviewed representatives of 973 households in Soweto and 1,442 in Klerksdorp. Most respondents in Soweto (692, 71%) and Klerksdorp (1247, 87%) thought weather or cold caused influenza. While most would get a free influenza vaccine, those unwilling to receive vaccine had concerns about efficacy (Soweto: 19%; Klerksdorp: 19%) and safety (Soweto: 17%; Klerksdorp: 10%). In Soweto, females (aRR 2·0, 95% CI 1·3-3·2) and those with higher household income (aRR 1·8, 95% CI 1·2-2·7) were less willing to receive vaccine. In Klerksdorp, more educated respondents (aRR 1·6, 95% CI 1·1-2·4) were less willing to receive vaccine; households reporting an HIV-positive member were more willing to receive vaccine (aRR 0·3, 95% CI 0·1-0·8).

CONCLUSIONS

Although findings suggest most community participants were amenable to influenza vaccination, knowledge gaps were present. Emphasizing the importance of influenza as a health problem and addressing vaccine safety and efficacy concerns may improve uptake. Populations less amenable to vaccination, including those with higher education and income, may benefit from targeted messaging efforts.

Forecasted trends in vaccination coverage and correlations with socioeconomic factors: a global time-series analysis over 30 years

BACKGROUND

Incomplete immunisation coverage causes preventable illness and death in both developing and developed countries. Identification of factors that might modulate coverage could inform effective immunisation programmes and policies. We constructed a performance indicator that could quantitatively approximate measures of the susceptibility of immunisation programmes to coverage losses, with an aim to identify correlations between trends in vaccine coverage and socioeconomic factors.

METHODS

We undertook a data-driven time-series analysis to examine trends in coverage of diphtheria, tetanus, and pertussis (DTP) vaccination across 190 countries over the past 30 years. We grouped countries into six world regions according to WHO classifications. We used Gaussian process regression to forecast future coverage rates and provide a vaccine performance index: a summary measure of the strength of immunisation coverage in a country.

FINDINGS

Overall vaccine coverage increased in all six world regions between 1980 and 2010, with variation in volatility and trends. Our vaccine performance index identified that 53 countries had more than a 50% chance of missing the Global Vaccine Action Plan (GVAP) target of 90% worldwide coverage with three doses of DTP (DTP3) by 2015. These countries were mostly in sub-Saharan Africa and south Asia, but Austria and Ukraine also featured. Factors associated with DTP3 immunisation coverage varied by world region: personal income (Spearman's ρ=0·66, p=0·0011) and government health spending (0·66, p<0·0001) were informative of immunisation coverage in the Eastern Mediterranean between 1980 and 2010, whereas primary school completion was informative of coverage in Africa (0·56, p<0·0001) over the same period. The proportion of births attended by skilled health staff correlated significantly with immunisation coverage across many world regions.

INTERPRETATION

Our vaccine performance index highlighted countries at risk of failing to achieve the GVAP target of 90% coverage by 2015, and could aid policy makers' assessments of the strength and resilience of immunisation programmes. Weakening correlations with socioeconomic factors show a need to tackle vaccine confidence, whereas strengthening correlations point to clear factors to address.

FUNDING

UK Engineering and Physical Sciences Research Council.

Two Birds With One Stone: Estimating Population Vaccination Coverage From a Test-negative Vaccine Effectiveness Case-control Study

Vaccination program evaluation includes assessment of vaccine uptake and direct vaccine effectiveness (VE). Often examined separately, we propose a design to estimate rotavirus vaccination coverage using controls from a rotavirus VE test-negative case-control study and to examine coverage following implementation of the Quebec, Canada, rotavirus vaccination program. We present our assumptions for using these data as a proxy for coverage in the general population, explore effects of diagnostic accuracy on coverage estimates via simulations, and validate estimates with an external source. We found 79.0% (95% confidence interval, 74.3%, 83.0%) ≥2-dose rotavirus coverage among participants eligible for publicly funded vaccination. No differences were detected between study and external coverage estimates. Simulations revealed minimal bias in estimates with high diagnostic sensitivity and specificity. We conclude that controls from a VE case-control study may be a valuable resource of coverage information when reasonable assumptions can be made for estimate generalizability; high rotavirus coverage demonstrates success of the Quebec program.

Should professionals caring for children be vaccinated? Community perspectives on health care and child care worker immunisation

OBJECTIVE

Several immunisations including influenza and pertussis are specifically recommended for healthcare workers (HCW) and childcare workers (CCW). This study aimed to assess community attitudes to HCW and CCW immunisation recommendations for pertussis and seasonal influenza.

METHODS

A cross-sectional study was conducted by Computer Assisted Telephone Interviewing (CATI) from April to May 2011. Statistical analyses used data weighted to the South Australian population by probability of selection, age, gender and geographical location using benchmarks derived from the 2009 Census population figures.

RESULTS

Almost all respondents supported vaccination of HCWs and CCWs against pertussis and influenza. For pertussis, 95.3% agreed nurses, 94.9% agreed doctors and 94.7% agreed CCWs have an obligation to be vaccinated. For influenza, 91.4% agreed nurses, 90.7% agreed doctors and 89.9% agreed CCWs have an obligation to be vaccinated. We identified higher support for protection against pertussis compared to influenza for all three groups of workers (p<0.001). There were higher concerns if CCWs compared to HCWs were not vaccinated against pertussis (OR=2.78) and influenza (OR=1.99). Young (18-30 years) and older age (60+ years) and lower educational attainment were predictors of support for HCWs and CCWs to be vaccinated against influenza. For pertussis, lower educational attainment was a predictor of support for HCWs immunisation.

CONCLUSIONS

Community support for CCW and HCW immunisation is strong with CCW immunisation was considered a priority. Pertussis immunisation was considered a higher priority than influenza immunisation for HCWs and CCWs. CCW immunisation should be considered for inclusion in public health immunisation programmes.

Health literacy and infectious diseases: why does it matter?

OBJECTIVES

Multifactorial interventions are crucial to arrest the threat posed by infectious diseases. Public involvement requires adequate information, but determinants such as health literacy can impact on the effective use of such knowledge. The influence of health literacy on infectious diseases is examined in this paper.

METHODS

Databases were searched from January 1999 through July 2015 seeking studies reporting on health literacy and infections such tuberculosis, malaria, and influenza, and infection-related behaviours such as vaccination and hand hygiene. HIV was excluded, as comprehensive reviews have already been published.

RESULTS

Studies were found on antibiotic knowledge and use, the adoption of influenza and MMR immunizations, and screening for sexually transmitted and viral hepatitis infections. There was a lack of investigations on areas such as tuberculosis, malaria, hand hygiene, and diarrhoeal diseases.

CONCLUSIONS

Limited or insufficient health literacy was associated with reduced adoption of protective behaviours such as immunization, and an inadequate understanding of antibiotics, although the relationship was not consistent. Large gaps remain in relation to infectious diseases with a high clinical and societal impact, such as tuberculosis and malaria.

Childhood vaccination coverage rates among military dependents in the United States

BACKGROUND AND OBJECTIVES

The Military Health System provides universal coverage of all recommended childhood vaccinations. Few studies have examined the effect that being insured by the Military Health System has on childhood vaccination coverage. The purpose of this study was to compare the coverage of the universally recommended vaccines among military dependents versus other insured and uninsured children using a nationwide sample of children.

METHODS

The National Immunization Survey is a multistage, random-digit dialing survey designed to measure vaccination coverage estimates of US children aged 19 to 35 months old. Data from 2007 through 2012 were combined to permit comparison of vaccination coverage among military dependent and all other children.

RESULTS

Among military dependents, 28.0% of children aged 19 to 35 months were not up to date on the 4:3:1:3:3:1 vaccination series excluding Haemophilus influenzae type b vaccine compared with 21.1% of all other children (odds ratio: 1.4; 95% confidence interval: 1.2-1.6). After controlling for sociodemographic characteristics, compared with all other US children, military dependent children were more likely to be incompletely vaccinated (odds ratio: 1.3; 95% confidence interval: 1.1-1.5).

CONCLUSIONS

Lower vaccination coverage rates among US military dependent children might be due to this population being highly mobile. However, the lack of a military-wide childhood immunization registry and incomplete documentation of vaccinations could contribute to the lower vaccination coverage rates seen in this study. These results suggest the need for further investigation to evaluate vaccination coverage of children with complete ascertainment of vaccination history, and if lower immunization rates are verified, assessment of reasons for lower vaccination coverage rates among military dependent children.

A systematic review of the medical home for children without special health care needs

To conduct a systematic review of the evidence associating the medical home with beneficial health outcomes in healthy children. The English-language pediatric literature 1975-2011 was searched via PubMed, Embase and CINAHL. Inclusion criteria (the medical home as an independent variable, individual-level quantitative analysis, outpatient setting in the US, healthy children) and exclusion criteria (age >18, medical home operationalized with only one American Academy of Pediatrics component) were determined a priori. Presence of a medical home was examined in relation to three outcome measures: primary care services, health care utilization, and child well-being. Of 4,856 unique citations, 9 studies were included in the final systematic review, amassing 290,180 children from 6 data sources. Two drew on prospective cohort data; the remainder, on cross-sectional design. Children with a medical home were more likely to receive preventive medical care (2 studies), anticipatory guidance (1 study), and developmental screening (1 study); to have higher health-related quality of life (1 study); and were less likely to seek care in the emergency department (2 studies). The medical home was associated with full immunization status in only 1 of 4 studies examining this outcome. No protective effect of the medical home was found with regard to preventable hospitalization (1 study). The medical home is associated with beneficial health outcomes among healthy children. However, the evidence is limited in comparison with that for children with special health care needs. As healthy children represent the majority of the pediatric population, this lack of evidence represents a significant knowledge gap.

Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007-2012

Vaccine "hesitancy" is an emerging term in the literature and discourse on vaccine decision-making and determinants of vaccine acceptance. It recognizes a continuum between the domains of vaccine acceptance and vaccine refusal and de-polarizes previous characterization of individuals and groups as either anti-vaccine or pro-vaccine. The primary aims of this systematic review are to: 1) identify research on vaccine hesitancy; 2) identify determinants of vaccine hesitancy in different settings including its context-specific causes, its expression and its impact; and 3) inform the development of a model for assessing determinants of vaccine hesitancy in different settings as proposed by the Strategic Advisory Group of Experts Working Group (SAGE WG) for dealing with vaccine hesitancy. A broad search strategy, built to capture multiple dimensions of public trust, confidence and hesitancy around vaccines, was applied across multiple databases. Peer-reviewed studies were selected for inclusion if they focused on childhood vaccines [≤ 7 years of age], used multivariate analyses, and were published between January 2007 and November 2012. Our results show a variety of factors as being associated with vaccine hesitancy but they do not allow for a complete classification and confirmation of their independent and relative strength of influence. Determinants of vaccine hesitancy are complex and context-specific - varying across time, place and vaccines.

Epidemiology of vaccine hesitancy in the United States

Vaccines are among the most effective public health interventions against infectious diseases. However, there is evidence in the United States for parents either delaying or refusing recommended childhood vaccination. Exemptions to school immunization laws and use of alternative schedule from those recommended by the Advisory Committee on Immunization Practices and the American Academy of Pediatrics cannot only increase the risk of children contracting vaccine-preventable diseases but also increases the risk of infecting others who are either too young to be vaccinated, cannot be vaccinated for medical reasons or did not develop a sufficient immunological response to the vaccine. Healthcare providers are cited as the most influential source by parents on vaccine decision-making. Vaccine hesitancy needs to be addressed by healthcare providers and the scientific community by listening to the parental concerns and discussing risks associated with either delaying or refusing vaccines.

Improving immunisation timeliness in Aboriginal children through personalised calendars

Background

Delayed immunisation and vaccine preventable communicable disease remains a significant health issue in Aboriginal children. Strategies to increase immunisation coverage and timeliness can be resource intensive. In a low cost initiative at the Aboriginal Medical Service Western Sydney (AMSWS) in 2008–2009, a trial of personalised calendars to prompt timely childhood immunisation was undertaken.

Methods

Calendars were generated during attendances for early childhood immunisations. They were designed for display in the home and included the due date of the next immunisation, a photo of the child and Aboriginal artwork. In a retrospective cohort design, Australian Childhood Immunisation Register data from AMSWS and non-AMSWS providers were used to determine the delay in immunisation and percentage of immunisations on time in those who received a calendar compared to those who did not. Interviews were undertaken with carers and staff.

Results

Data on 2142 immunisation doses given to 505 children were analysed, utilising pre-intervention (2005–2007) and intervention (2008–2009) periods and a 2 year post-intervention observation period. 113 calendars were distributed (30% of eligible immunisation attendances). Improvements in timeliness were seen at each schedule point for those children who received a calendar. The average delay in those who received a calendar at their previous visit was 0.6 months (95% CI -0.8 to 2.6) after the due date, compared to 3.3 months (95% CI −0.6 to 7.5) in those who did not. 80% of doses were on time in the group who received a calendar at the preceding immunisation, 66% were on time for those who received a calendar at an earlier point and 57% of doses were on time for those who did not receive a calendar (P<0.0001, Cochran-Armitage trend test). Interview data further supported the value and effectiveness of the calendars as both a prompt to timely immunisations and a community health education project without undue resource implications.

Conclusions

Personalised calendars can increase the timeliness of immunisations in Aboriginal children. This simple, low cost tool appears practicable and effective in an Aboriginal community setting in improving early childhood vaccination timeliness and has high potential for local adaptation to suit the needs of diverse communities.

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.

Immunization completeness of children under two years of age in Nova Scotia, Canada

OBJECTIVES

Canada's progress in establishing a national immunization registry and coordinated immunization schedule across provinces has been slow. The absence of a centralized registry means there are only limited data available on childhood immunization coverage in Canada. The aim of this study was to estimate the completeness and timeliness of immunization for two year-old children in Nova Scotia.

METHODS

The study included 8,245 babies born in Nova Scotia during 2006. Immunization data were derived from three sources: Provincial Medical Insurance Physician Billing data, public health records, and self-report by parents. Immunization uptake rates for vaccines included in the Nova Scotia immunization schedule were calculated at ages 12, 18 and 24 months. Logistic regression was used to analyze vaccine uptake in relation to socio-economic factors. A telephone survey of a sample of parents of study children was completed.

RESULTS

The overall immunization completeness rate was 49% at 12 months, 40% at 18 months and 58% at 24 months of age. Immunization completeness was significantly higher in more socially disadvantaged communities.

CONCLUSIONS

Nova Scotia spends many millions of dollars on vaccine purchase and administration, but, as with numerous Canadian jurisdictions, there is no accurate system for monitoring or evaluating the program. The timeliness and completeness of immunization administration to pre-school children in Nova Scotia is inadequate. Further work should elucidate the barriers and enablers to immunization to ensure that public health education targets those most likely to be under-immunized. A provincial vaccination database should be established to monitor and evaluate the system.

Correlates for second-dose varicella vaccination in school-age children in a managed care organization in California

OBJECTIVE

To identify correlates of nonadherence to the recommendation for routine second-dose varicella vaccination in a diverse sample of school-age children.

METHODS

A total of 67,977 children of 4-6 years (51% male, 50% Hispanic) were included in this retrospective cohort study. The second-dose varicella vaccination history was evaluated by using the Kaiser Immunization Tracking System. Correlation and multivariable regression analyses were used to test the association between potential correlates and nonadherence to the second-dose varicella vaccination.

RESULTS

Four-year-old children had a significantly higher vaccination rate (76.1%) than 5-year-olds (43.2%) and 6-year-olds (17.3%) by 12 months after the implementation of routine second-dose varicella vaccination. Non-Hispanic white race [rate ratio (RR): 1.13 (95% CI: 1.11-1.15)], living in an area of >75% adults with a high-school diploma [RR: 1.17 (95% CI: 1.14-1.20)], and having a primary care provider specializing in family medicine [RR: 1.15 (95% CI: 1.11-1.18)] significantly correlated with nonadherence. Missed opportunity was found in 59.7% (n=20,465) of children who did not receive the second-dose varicella vaccine in spite of at least 1 outpatient visit and in 15.8% (n=5407) who received some other vaccines during the follow-up period.

CONCLUSIONS

Efforts targeting non-Hispanic white and black children, parents with a high education level and family medicine physicians might improve uptake of the routine 2-dose varicella vaccination. Incorporation of a requirement for the second-dose varicella vaccine into the school law might help achieve high adherence to the routine 2-dose varicella vaccination in school-age children.

Clinical quality performance in U.S. health centers

OBJECTIVE

To describe current clinical quality among the nation's community health centers and to examine health center characteristics associated with performance excellence.

DATA SOURCES

National data from the 2009 Uniform Data System.

DATA COLLECTION/EXTRACTION METHODS

Health centers reviewed patient records and reported aggregate data to the Uniform Data System.

STUDY DESIGN

Six measures were examined: first-trimester prenatal care, childhood immunization completion, Pap tests, low birth weight, controlled hypertension, and controlled diabetes. The top 25 percent performing centers were compared with lower performing (bottom 75 percent) centers on these measures. Logistic regressions were utilized to assess the impact of patient, provider, and institutional characteristics on health center performance.

PRINCIPAL FINDINGS

Clinical care and outcomes among health centers were generally comparable to national averages. For instance, 67 percent of pregnant patients received timely prenatal care (national = 68 percent), 69 percent of children achieved immunization completion (national = 67 percent), and 63 percent of hypertensive patients had blood pressure under control (national = 48 percent). Depending on the measure, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well.

CONCLUSIONS

Health centers provide quality care at rates comparable to national averages. Performance may be improved by increasing insurance coverage among patients and increasing the ratios of physicians and enabling service providers to patients.

Second-dose varicella vaccination coverage in children and adolescents in a managed care organization in California, 2006-2009

We assessed trends of second-dose varicella-containing vaccine coverage among children and adolescents in Kaiser Permanente Southern California health plan since the Advisory Committee on Immunization Practices recommendation of 2-dose varicella vaccination in 2006. The overall second-dose coverage increased rapidly from 42.1% in 2007 to 74.6% in 2009. The increasing trend was observed in all strata defined by age and race/ethnicity, with the highest coverage among children aged 5 to 6 years old. However, non-Hispanic White race/ethnicity and living in a neighborhood with higher education level were inversely associated with the second-dose uptake.

Vaccination coverage and risk factors for incomplete vaccination in children with recurrent wheeze

AIM

To determine the possible impact of recurrent wheeze on immunisation status in the first three years of life.

METHOD

A cross-sectional case control study of 288 children less than three years of age with a history of recurrent wheezing, hospitalised at a single centre for wheeze; and a control group of 190 children with no prior history of wheezing. Vaccination charts of all children were analysed according to the National Immunisation Schedule. Additionally, some associated data were collected through a questionnaire to the parents.

RESULTS

Children with recurrent wheezing during the first three years of life were less likely to be vaccinated against BCG (Bacillus-Calmette-Guerin), hepatitis B, Hib (Haemophilus influenza type B), and MMR (Measles, Mumps, Rubella) (p < 0.001). A significant inverse association was also found between the number of wheezy episodes and the number of vaccine doses received. The odds ratio of incomplete vaccination in children with recurrent wheeze was 10.6 (95% CI, 2.96 to 38.1).

CONCLUSION

Children under three years of age with recurrent wheeze run a high risk of incomplete immunisation. Efforts should be therefore made to insure that such children receive adequate vaccination.

Closing the immunization gap

Current vaccination rates are falling with a new group of unimmunized children. Since some parents are unaware of the diseases and potential health threats, many are often influenced by the media and myths, choosing to delay or avoid vaccinations. NP providers must be prepared to confront these myths with facts to help parents make informed decisions. Vaccine-preventable diseases, popular myths, and evidence-based research findings are reviewed in this manuscript.

[Risk factors for delayed or missed measles vaccination in young children]

Because of low measles vaccine coverage rates, measles outbreaks have been observed several times during recent years in Germany. The aim of this study is to identify parents' attitudes and beliefs towards immunisations and socio-economic factors which are associated with delayed or missed first measles vaccination in young children. We used data from a representative German-wide immunisation survey on 2116 children born between 1 January 2002 and December 2004 by collecting precise vaccination information from vaccination cards. The influence of socio-economic determinants and parental attitudes towards immunisations on the timing of the first measles dose was analysed by using multivariable Cox regression. Of these children 46.8% (95% CI: 44.5-49.1) received their first measles dose according to the recommendations of the standing committee on vaccination (STIKO) by month 15. In multivariable analysis, fathers aged 28-33 years and birth order as well as parents' belief in homeopathy and other parental attitudes indicating lack of knowledge about the importance of vaccinations significantly influenced an early immunisation. Not general opposition, but insufficient parental knowledge about the harmfulness of measles infection seemed to be responsible for the low measles vaccination rates.

Parental hesitation as a factor in delayed childhood immunization

INTRODUCTION

One reason for lower immunization rates is that some parents hesitate to have their children immunized. A hesitancy questionnaire was developed to identify reasons parents hesitate in having their children immunized.

METHODS

The hesitancy questionnaire was distributed from local pediatric and family practice offices and from the area's county health department. To be eligible, participants needed to be present in the clinic with a child needing a minimum of one immunization that was at least 6 months overdue.

RESULTS

When questioned why their child was overdue for immunizations, the most common response was that participants were confused about the immunization schedule and not sure when to return. Of the participants who reported having concerns regarding immunizations, the child's pain/crying/anxiety was the most commonly occurring answer. When asked where they receive the majority of childhood immunization information, participants frequently identified their health care provider as the main source of information.

DISCUSSION

Health care providers may be missing opportunities to educate hesitant parents about immunizations. Parents may not have ample opportunities to discuss their immunization concerns in detail with their health care provider during regularly scheduled clinic visits. It is important for health care providers to suggest ways parents can cope with their child's pain/crying/anxiety when receiving immunizations.

Vaccination coverage by special health care needs status in young children

OBJECTIVE

The purpose of this study was to compare vaccination coverage among children 19 to 35 months of age with and without special health care needs overall and among demographic subgroups.

METHODS

Data are from the National Survey of Children With Special Health Care Needs, a module of the State and Local Area Integrated Telephone Survey, which was sponsored by the Health Resources and Services Administration Maternal and Child Health Bureau and conducted in 2000-2002 by the Centers for Disease Control and Prevention National Center for Health Statistics. We used data from the National Immunization Survey and the National Survey of Children With Special Health Care Needs to examine immunization coverage rates for individual vaccines and an array of combined series vaccinations. The relationship between special needs and immunization status was analyzed by age, gender, and race or ethnicity of the child; the child's health insurance type; the mother's educational attainment and presence in the household; and household income relative to the federal poverty level.

RESULTS

Overall, there were no significant differences between children with and without special needs for any of the individual antigens or combined immunization series. Some significant differences by special needs status were found within certain demographic subgroups.

CONCLUSIONS

Our results suggest that, generally children with special health care needs have immunization rates that are very similar to typically developing children. There is some evidence that children with special health care needs are at risk for underimmunization if they are non-Hispanic white or live in an affluent household and are more likely to be immunized if they are Hispanic, poor, publicly insured, or if their mothers did not complete high school. These findings may be due to outreach or support programs that target disadvantaged children. However, it is important to note that the majority of comparisons within demographic subgroups show no significant differences between children with special health care needs and children without special health care needs.