Barriers to immunization and missed opportunities

Beyond Vaccination Coverage: Population-Based Measurement of Early Childhood Immunization Schedule Adherence

The immunization schedule recommended by the U.S. Advisory Committee on Immunization Practices (ACIP) provides a structure for how 10 different vaccine series should be administered to children in the first 18 months of life. Progress toward US early childhood immunization goals has largely focused on measuring vaccination coverage at age 24 months. However, standard vaccination coverage measures do not reflect whether children received vaccine doses by recommended ages, or whether vaccines were given concomitantly, per the schedule. In this paper, we describe innovations in population-level measurement of immunization schedule adherence through quantifying vaccination timeliness and undervaccination patterns. Measuring vaccination timeliness involves comparing when children received vaccine doses relative to ACIP age recommendations. To assess undervaccination patterns, children's vaccination histories are analyzed to determine whether they were vaccinated consistent with the ACIP schedule. Some patterns, such as spreading out vaccines across visits, are indicative of parental hesitancy. Other patterns, such as starting all recommended series but missing doses, are largely indicative of other immunization services delivery challenges. Since 2003, at least 12 studies have used National Immunization Survey-Child, immunization information system, or integrated health plan data to measure vaccination timeliness or undervaccination patterns at national or state levels. Moving forward, these novel measures can be leveraged for population-based surveillance of vaccine confidence, and for distinguishing undervaccination due to parental vaccine hesitancy from undervaccination due to other causes. Broader adoption of these measures can facilitate identification of targeted strategies for improving timely and routine early childhood vaccination uptake across the United States.

Determining the burden of missed opportunities for vaccination among children admitted in healthcare facilities in India: a cross-sectional study

OBJECTIVES

Children accessing healthcare systems represent a vulnerable population with risk factors for poor health outcomes, including vaccine-preventable diseases. We aimed to quantify missed vaccination opportunities among hospitalised children in India, and identify vaccination barriers perceived by caregivers and healthcare providers.

DESIGN

Cross-sectional study.

SETTING

Two public-sector tertiary-care hospitals in northern India, during November 2018 and March 2019.

PARTICIPANTS

We tracked 263 hospitalised children aged 1-59 months through hospital discharge, to assess vaccination status, and document catch-up vaccinations given during the hospital stay. We interviewed caregivers and healthcare providers to assess their perceptions on vaccination.

OUTCOMES

Proportion of hospitalised children considered under-vaccinated for their age; proportion of missed opportunities for vaccination among under-vaccinated children who were eligible for vaccination; and vaccine coverage by antigen.

RESULTS

We found that 65.4% (172/263) of hospitalised children were under-vaccinated for their age when they presented to the hospital. Among under-vaccinated children, 61.0% were less than 4 months old, and 55.6% reported prior contact with a health facility for a sick visit. The proportion of under-vaccinated children in hospitals were higher compared with the general population as indicated by regional vaccination coverage data. Among under-vaccinated children who were tracked till discharge, 98.1% (158/161) remained incompletely vaccinated at discharge and were considered 'missed opportunities for vaccination'. Perceived vaccination contraindications that are not part of established contraindications included in national and international guidelines was the most common reason for healthcare providers not to vaccinate children during hospital stay. Among caregivers of under-vaccinated children, 90.1% reported being comfortable having their children vaccinated while they were sick, if recommended by the healthcare provider.

CONCLUSION

This pilot study confirmed that hospitalised sick children had substantial missed vaccination opportunities. Addressing these opportunities through concerted actions involving caregivers, healthcare providers and healthcare systems can improve overall vaccination coverage.

Missed opportunities for human papillomavirus vaccination at office visits during which influenza vaccine was administered: An AAP pediatric research in office settings (PROS) national primary care research network study

INTRODUCTION

Little is known about missed opportunities (MOs) for HPV vaccination during primary care visits at which influenza vaccination is delivered.

METHODS

We extracted electronic health records for HPV vaccine-eligible 11-to-17-year-olds. We assessed the proportion of visits during which an influenza vaccine was given and an HPV vaccine was due, but not given (i.e., MOs).

RESULTS

Of 56,135 eligible visits, 57.5% represented MOs for HPV vaccination. MOs were more common at visits where an initial versus subsequent HPV vaccine dose was due (68.6% vs. 31.3%) and for acute/chronic and nurse-only visits compared to preventive visits (74.0% and 80.2% vs. 36.7%). In a multivariable model, MOs were more likely for the initial HPV dose and for non-preventive visits, but did not vary by patient sex/age.

CONCLUSIONS

HPV vaccine MOs were common during visits where influenza vaccine was administered. Increasing simultaneous administration of HPV and influenza vaccines could increase HPV vaccine coverage.

Using the theoretical domains framework to explore reasons for missed opportunities for vaccination among children in Kano, Nigeria: a qualitative study in the pre-implementation phase of a collaborative quality improvement project

Background: Missed opportunities for vaccination (MOV) have been identified as an important contributor to low childhood immunization coverage. In this study, we explore the reasons for MOV from the perspective of caregivers of children aged 0-23 months attending primary health care (PHC) facilities in Nassarawa Local Government Area (LGA) of Kano State, Nigeria. This was to inform the implementation of a quality improvement program to reduce MOV. Methodology: An exploratory qualitative research was conducted using focus group discussions (FGD) with caregivers of children aged 0-23 months that visited PHC facilities. The study was conducted in three purposively selected PHC facilities in Nassarawa, Kano. The caregivers were purposively selected from the three PHC facilities and were homogenous in terms of their place of residence. Each FGD was conducted face-to-face in a private room within the health facility. During the discussion, participants maintained a circular sitting arrangement. The FGD were audio-recorded, transcribed verbatim, and analyzed using template analysis approach through the lens of the theoretical domains framework (TDF) and the capability, opportunity, motivation - behavior (COM-B) model. The researchers that conducted this study are epidemiologists and implementation scientists with experience in immunization programs. They are multilingual, and some are fluent in both English and Hausa language. Although four of them are medical doctors, however, they do not have any affiliations or provide health services in any of the PHC facilities where this study was conducted. Result: Five FGD with 30 caregivers was conducted. The caregivers were aged between 19 and 32 years and lived within the LGA. Based on their lived experiences, several factors that are responsible for MOV were identified and categorized into three constructs based on the COM-B model. Capability encompassed caregiver's inadequate knowledge of the vaccines that children need. The opportunity included contextual factors such as non-screening of home-based records, health worker's refusal to offer immunization services, and husband's refusal due to socio-cultural beliefs. Finally, motivation included fear of the side effects of vaccination. Conclusion: This study identified a useful framework that aided deeper insights into caregiver-related factors responsible for MOV in Nassarawa, Kano. Some of the findings from this study can be used to inform change ideas in a quality improvement program and should be explored.

An Ounce of Prevention: Identifying Cues to (In)Action for Maternal Vaccine Refusal

Recent increases in childhood vaccine exemption rates are a source of concern within the public health community. Drawing from the health belief model and in-depth interviews with 50 mothers ( n = 50) who refused one or more vaccine, the aim of this study was to identify the specific reasons and the broader decision context(s) that underscored participants' vaccine refusal. Results indicate that the vast majority of participants supported vaccination until a particular cue motivated them to consider otherwise, and qualitative analysis identified three main categories into which these cues fell: perceived adverse reactions, endorsements from health care professionals, and perceived contradiction among expert-endorsed messages. These categories point to the central role of health communication in motivating vaccine refusal. Better understanding these cues can inform vaccine communication scholarship and practice, and also lend theoretical insight into the intertextual nature of controversial health messages and decisions.

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.

Evaluation of the first pharmacist-administered vaccinations in Western Australia: a mixed-methods study

OBJECTIVES

This study evaluated the uptake of Western Australian (WA) pharmacist vaccination services, the profiles of consumers being vaccinated and the facilitators and challenges experienced by pharmacy staff in the preparation, implementation and delivery of services.

DESIGN

Mixed-methods methodology with both quantitative and qualitative data through surveys, pharmacy computer records and immuniser pharmacist interviews.

SETTING

Community pharmacies in WA that provided pharmacist vaccination services between March and October 2015.

PARTICIPANTS

Immuniser pharmacists from 86 pharmacies completed baseline surveys and 78 completed exit surveys; computer records from 57 pharmacies; 25 immuniser pharmacists were interviewed.

MAIN OUTCOME MEASURES

Pharmacy and immuniser pharmacist profiles; pharmacist vaccination services provided and consumer profiles who accessed services.

RESULTS

15 621 influenza vaccinations were administered by immuniser pharmacists at 76 WA community pharmacies between March and October 2015. There were no major adverse events, and <1% of consumers experienced minor events which were appropriately managed. Between 12% and 17% of consumers were eligible to receive free influenza vaccinations under the National Immunisation Program but chose to have it at a pharmacy. A high percentage of vaccinations was delivered in rural and regional areas indicating that provision of pharmacist vaccination services facilitated access for rural and remote consumers. Immuniser pharmacists reported feeling confident in providing vaccination services and were of the opinion that services should be expanded to other vaccinations. Pharmacists also reported significant professional satisfaction in providing the service. All participating pharmacies intended to continue providing influenza vaccinations in 2016.

CONCLUSIONS

This initial evaluation of WA pharmacist vaccination services showed that vaccine delivery was safe. Convenience and accessibility were important aspects in usage of services. There is scope to expand pharmacist vaccination services to other vaccines and younger children; however, government funding to pharmacists needs to be considered.

Impact of pharmacist administration of influenza vaccines on uptake in Canada

BACKGROUND

Uptake of influenza vaccination in Canada remains suboptimal despite widespread public funding. To increase access, several provinces have implemented policies permitting pharmacists to administer influenza vaccines in community pharmacies. We examined the impact of such policies on the uptake of seasonal influenza vaccination in Canada.

METHODS

We pooled data from the 2007-2014 cycles of the Canadian Community Health Survey (n = 481 526). To determine the impact of influenza vaccine administration by pharmacists, we estimated the prevalence ratio for the association between the presence of a pharmacist policy and individual-level vaccine uptake using a modified Poisson regression model (dependent variable: vaccine uptake) with normalized weights while controlling for numerous health and sociodemographic factors.

RESULTS

Across all survey cycles combined, 28.8% of respondents reported receiving a seasonal influenza vaccine during the 12 months before survey participation. Introduction of a policy for pharmacist administration of influenza vaccine was associated with a modest increase in coverage (2.2%) and an individual's likelihood of uptake (adjusted prevalence ratio 1.05, 95% confidence interval 1.02-1.08).

INTERPRETATION

Uptake of influenza immunization was modestly increased in Canadian jurisdictions that allowed pharmacists to administer influenza vaccines.

Influenza vaccine: Delayed vaccination schedules and missed opportunities in children under 2 years old

INTRODUCTION

In Argentina respiratory disease is the third leading cause of death in children under 5 years. In 2011 influenza vaccination was included in the National Calendar for children between 6 and 24 months (two doses schedule). Influenza vaccine coverage for second dose was 46.1% in 2013. The aim was to determine the proportion of delayed schedules and missed opportunities, to assess the characteristics of missed opportunities for vaccination and to explore the perception of influenza disease and vaccination from the parents of children between 6 and 24 months in different regions of Argentina in 2013.

METHODS

Analytical observational multicenter cross-sectional study. Structured surveys were carried out to the children's parents who were between 6 and 24 months of age during the influenza virus vaccination season (April-October 2013). Chi-Square test was used to assess association and differences between proportions and categorical variables. A logistic regression model was built to identify delay predictor variables in the vaccination schedules. Missed opportunities for vaccination were characterized through the estimation of proportions.

RESULTS

1350 surveys were conducted in the three centers. We detected 65% (884/1340) of delayed influenza vaccination schedules, 97% of them associated with missed opportunities of vaccination. The independent protective factors associated with a decreases risk of delayed schedules were: (a) perception of the importance of influenza vaccination (OR=0.42(0.18-0.94); p=0.035), (b) having less than one year of age (OR=0.75(0.59-0.96); p=0.022), (c) to have received information in pediatric visits or in any media (OR=0.71(0.56-0.90); p=0.004). There was 38% of MOIV in 1st dose and 63.4% in 2nd dose. The main cause of MOIV in 1st dose was not detecting the need for vaccination (39%) and in 2nd dose the unknowledge of the vaccination schedule (35.3%). No cultural reasons were detected.

CONCLUSIONS

High frequency of delayed vaccination schedules and missed opportunities were detected. Parents had little concern about the safety of influenza vaccine.

Effect of provider prompts on adolescent immunization rates: a randomized trial

OBJECTIVE

Adolescent immunization rates are suboptimal. Experts recommend provider prompts at health care visits to improve rates. We assessed the impact of either electronic health record (EHR) or nurse- or staff-initiated provider prompts on adolescent immunization rates.

METHODS

We conducted a randomized controlled trial, allocating practices in 1 of 2 practice-based research networks (PBRN) to provider prompts or standard-of-care control. Ten primary care practices participated, 5 intervention and 5 controls, each matched in pairs on urban, suburban, or rural location and practice type (pediatric or family medicine), from a PBRN in Greater Rochester, New York (GR-PBRN); and 12 practices, 6 intervention, 6 controls, similarly matched, from a national pediatric continuity clinic PBRN (CORNET). The study period was 1 year per practice, ranging from June 2011 to January 2013. Study participants were adolescents 11 to 17 years attending these 22 practices; random sample of chart reviews per practice for baseline and postintervention year to assess immunization rates (n = 7,040 total chart reviews for adolescents with >1 visit in a period). The intervention was an EHR prompt (4 GR-PBRN and 5 CORNET practice pairs) (alert) that appeared on providers' computer screens at all office visits, indicating the specific immunizations that adolescents were recommended to receive. Staff prompts (1 GR-PBRN pair and 1 CORNET pair) in the form of a reminder sheet was placed on the provider's desk in the exam room indicating the vaccines due. We compared immunization rates, stratified by PBRN, for routine vaccines (meningococcus, pertussis, human papillomavirus, influenza) at study beginning and end.

RESULTS

Intervention and control practices within each PBRN were similar at baseline for demographics and immunization rates. Immunization rates at the study end for adolescents who were behind on immunizations at study initiation were not significantly different for intervention versus control practices for any vaccine or combination of vaccines. Results were similar for each PBRN and also when only EHR-based prompts was assessed. For example, at study end, 3-dose human papillomavirus vaccination rates for GR-PBRN intervention versus control practices were 51% versus 53% (adjusted odds ratio 0.96; 95% confidence interval 0.64-1.34); CORNET intervention versus control rates were 50% versus 42% (adjusted odds ratio 1.06; 95% confidence interval 0.68-1.88).

CONCLUSIONS AND RELEVANCE

In both a local and national setting, provider prompts failed to improve adolescent immunization rates. More rigorous practice-based changes are needed.

Outbreak of measles in a non-immunizing population, Alberta 2013

Background

An outbreak of measles was declared in southern Alberta on October 18, 2013, after a case had been reported to the local public health unit in a non-immunized teenager with recent travel to the Netherlands. The teenager had had contact with a large number of unimmunized people while infectious; therefore, the risk of spread was high. The potential for an outbreak of measles in this area had been identified by the lead Medical Officer of Health for South Zone, and planning for an outbreak had begun in August 2013.

Methods

Several public health measures were implemented to control the outbreak: mass immunization clinics; an outbreak dose of measles mumps and rubella (MMR) vaccine for infants 6-12 months old; communication within the affected and surrounding communities; a dedicated measles hotline; a Mobile Measles Assessment Team; and a Measles Assessment Centre.

Results

A total of 42 confirmed cases were identified during the outbreak between October 16 and November 25. Just over half the cases were male (52.4%). The average age was 12 (range < 1 to 24 years) and the median age 13 years. There was one hospitalization, and no deaths occurred. All cases were unimmunized. Cases were located in five communities immediately surrounding Lethbridge. All but two cases were epidemiologically linked within 10 households.

Conclusion

The planning that occurred before the outbreak was essential in containing the outbreak to 10 households. To prevent future outbreaks of measles, exploring strategies for increasing immunization coverage rates in unimmunized populations is essential. When immunization acceptance is not uniform, other public health strategies should be planned for and implemented in order to prevent additional spread.

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

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

Coverage for the entire population: tackling immunization rates and disparities in Saskatoon Health Region

OBJECTIVE

Our objective was to determine the effectiveness of an intervention, the Immunization Reminders Project, in terms of a) improving vaccination coverage rates for measles, mumps and rubella (MMR) among 2-year-olds and b) ameliorating geographical disparities in early childhood immunization coverage.

TARGET POPULATION

All 14-month-old and 20-month-old children in Saskatoon Health Region who were overdue for their immunizations.

SETTING

Saskatoon Health Region (SHR).

INTERVENTION

The intervention involved calling the parents/caregivers of the children in the target population with a reminder about immunizations. After five telephone calls and if the parent/caregiver could not be reached, a letter was mailed to the last known address. If there was no response to the letter, a reminder home visit was attempted for families residing in the low-income neighbourhoods in Saskatoon. Since January 2009, all reminders for families not residing in the low-income neighbourhoods in Saskatoon are made through mailed letters.

OUTCOMES

After the introduction of the Immunization Reminders Project, coverage rates among 2-year-olds for MMR increased significantly overall and in most geographical areas examined. Disparities between geographical subgroups appeared to be declining, but not significantly.

CONCLUSION

A universal approach to early childhood immunization can likely contribute to increases in coverage rates, but there is still room for improvement in SHR. These findings have prompted additional practice and policy changes.

Attitudes of pediatricians and primary health center physicians in India concerning routine immunization, barriers to vaccination, and missed opportunities to vaccinate

BACKGROUND

India has some of the lowest immunization rates in the world. The objective of this study was to determine the attitudes and practices of pediatricians and physicians working in primary health centers (PHCs) regarding routine immunization and identify correlates of missed opportunities to vaccinate children. We focused on Uttar Pradesh and Bihar, which has faced some of the greatest challenges to achieving high routine immunization coverage.

METHODS

A sample of pediatricians from Uttar Pradesh and Bihar was selected from the national membership of the Indian Academy of Pediatrics to participate in either a phone or mail survey. For the sampling frame, the PHCs within selected blocks were enumerated to provide a list from which individuals could be randomly sampled. In all, 614 PHCs in Uttar Pradesh and 159 PHCs were selected for in-person surveys.

RESULTS

The response rate for pediatricians was 47% (238/505) and 93% for PHC physicians (719/773). The greatest barrier to vaccinating children with routine immunizations, reported by both pediatricians (95.7%) and PHC physicians (95.1%), was parents' lack of awareness of their importance. Correlates of missing an opportunity to vaccinate for PHC physicians included holding other health care workers responsible for vaccination. PHC physicians were 50% to 70% less likely to vaccinate a child themselves if they thought another type of health care worker was responsible.

CONCLUSIONS

Future interventions to increase vaccination coverage should address parental knowledge about the importance of vaccines. Understanding and addressing factors associated with missed opportunities to vaccinate may help improve vaccine coverage in Uttar Pradesh and Bihar.

Assessment of parental report for 2009-2010 seasonal and monovalent H1N1 influenza vaccines among children in the emergency department or hospital

OBJECTIVE

To assess the validity of parental report for seasonal and monovalent H1N1 influenza vaccinations among children 6 months to <18 years who were recommended to receive both vaccines in 2009-2010.

METHODS

Children with fever or respiratory symptoms were prospectively enrolled in both emergency departments in Forsyth County, North Carolina, and the only pediatric hospital in the region. Enrollment occurred from September 1, 2009, through April 12, 2010, during the H1N1 influenza pandemic. A parental questionnaire was administered by trained interviewers to ascertain the status of seasonal and monovalent H1N1 influenza vaccines. Parental report was compared with that documented in the medical record and/or the North Carolina immunization registry.

RESULTS

Among 297 enrolled children 6 months to <18 years of age, 174 (59%) were 6 months to 4 years, 67 (23%) were 5-8 years, and 56 (19%) were 9 to <18 years. Parents reported that 140 (47%) children had received ≥1 dose of 2009-2010 influenza vaccine-128 (43%) for seasonal vaccine and 63 (21%) for H1N1 vaccine. Confirmed vaccination data indicated that 156 (53%) children had received ≥1 dose of any 2009-2010 vaccine-120 (40%) for seasonal vaccine and 53 (18%) for H1N1 vaccine. Parental report of any seasonal influenza vaccination was 92% sensitive and 86% specific and had a kappa of 0.76. Parental report for any H1N1 influenza vaccination was 88% sensitive and 92% specific with a kappa of 0.71.

CONCLUSIONS

Parental report of 2009-2010 seasonal and monovalent H1N1 influenza vaccinations was sensitive and specific and had reasonable agreement with the medical record and/or immunization registry.

Establishing the baseline burden of influenza in preparation for the evaluation of a countywide school-based influenza vaccination campaign

BACKGROUND

School-based influenza vaccination campaigns could mitigate the effects of influenza epidemics. A large countywide school-based vaccination campaign was launched in Knox County, Tennessee, in 2005. Assessment of campaign effects requires identification of appropriate control populations. We hypothesized that contiguous counties would share similar pre-campaign patterns of influenza activity.

METHODS

We compared the burden of influenza emergency department (ED) visits and hospitalizations between Knox County (Knox) and eight counties surrounding Knox (Knox-surrounding) during five consecutive pre-campaign influenza seasons (2000-01 through 2004-05). Laboratory-defined influenza seasons were used to measure the weekly incidence of medically attended acute respiratory illnesses (MAARI) attributable to influenza in school-aged children 5-17 years old (campaign target) as well as in other age groups. Seasonal rates of MAARI attributable to influenza for Knox and Knox-surrounding counties were compared using rate ratios.

RESULTS

During five consecutive influenza seasons, MAARI attributable to influenza showed synchronous temporal patterns in school-aged children from Knox and Knox-surrounding counties. The average seasonal rates of ED visits attributable to influenza were 12.37 (95% CI: 10.32-14.42) and 13.14 (95% CI: 11.23-15.05) per 1000, respectively. The respective average seasonal influenza hospitalization rates for Knox and Knox-surrounding were 0.38 (95% CI: 0-0.79) and 0.46 (95% CI: 0.07-0.85) per 1000 children. Rate ratio analyses indicated no significant differences in the incidence of MAARI attributable to influenza between school-aged children from Knox and Knox-surrounding counties. Estimates for other age groups showed similar patterns.

CONCLUSION

Before the Knox school-based influenza vaccination campaign, influenza resulted in an average of about 12 ED visits and 0.4 hospitalizations per 1000 school-aged children annually in Knox County. Since similar morbidity was observed in surrounding counties, they could serve as a control population for the assessment of the campaign effects.

Care of the underserved: faculty development needs assessment

INTRODUCTION

Because role models are crucial to training physicians to care for the underserved, we examined pediatric faculty's knowledge, attitudes, self-efficacy, skills, and precepting behaviors regarding care for this population.

METHODS

Faculty knowledge, attitudes, self-efficacy, and skills/precepting behaviors were surveyed.

RESULTS

Fifty-five (65%) of 85 faculty responded. The mean (standard deviation) knowledge score was 5.9 (1.3) of 8 possible. More than one-third of faculty did not recognize the eligibility criteria, services, and outcomes associated with common resources serving the underserved. Overall attitudes toward underserved families were positive, mean 3.3 (0.3), as was mean self-efficacy, 3.0 (0.7). Self-efficacy was lowest for accessing community resources for underserved families, 2.4 (0.7). Although most faculty performed the surveyed skills, fewer than 50% reported, precepting of these same skills with students. Precepting was lowest for accessing public and community resources.

CONCLUSIONS

Low rates of student precepting as well as specific knowledge and self-efficacy deficits highlight potential targets for faculty development.

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

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

Perceived frequency and impact of missing information at pediatric emergency and general ambulatory encounters

OBJECTIVE

To document the perceived frequency, type, and impact of unavailable ("missing") clinical information during pediatric emergency and general ambulatory encounters.

METHODS

This prospective cohort set in the Emergency Department and General Ambulatory Pediatric Clinic at The Children's Hospital, Aurora, CO, assessed pediatric attending physician perceptions regarding missing information at emergency and general ambulatory encounters. The main outcome measures were the frequency of perceived missing information; its presumed location; time spent seeking; and the perceived effects on resource utilization and overall quality of care.

RESULTS

Pediatric physicians reported missing information for 2% of emergency and 22% of general ambulatory encounters. Types of missing information at general ambulatory visits included immunization (34% of types), general past medical (29%), and disease or visit specific histories (13%). Missing information at ambulatory visits was sought 20% of the time, obtained 4% of the time, and rated "somewhat or very important for today's care" (73% of the time) and "somewhat or very important for future care" (84% of the time). For encounters with unattained missing information, physicians reported adverse affects on the efficiency of the visit (64%), physician's confidence in care (33%), patient/family satisfaction (17%), disposition decisions (8%), and recommended additional treatment (38%), laboratory studies (16%), and imaging (12%). For 57% of encounters with missing information, physicians perceived an adverse effect on overall quality of care. Missing information was associated with not having a primary care visit at TCH within 12 months of the encounter, (OR 2.8; 95% CI, 1.7, 4.5).

CONCLUSION

Pediatric physicians more commonly experience missing information at general ambulatory visits than emergency visits and report that missing information adversely impacts quality, efficiency, their confidence in care, patient and family satisfaction, and leads to potentially redundant resource utilization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Immunisation coverage in Australian Indigenous children: Time to move the goal posts

Childhood immunisation coverage reported at 12 to <15 months and 2 years of age, may mask deficiencies in the timeliness of vaccines designed to protect against diseases in infancy. This study aimed to evaluate immunisation timeliness in Indigenous infants in the Northern Territory, Australia. Coverage was analysed at the date children turned 7, 13 and 18 months of age. By 7 months of age, 45.2% of children had completed the recommended schedule, increasing to 49.5% and 81.2% at 13 and 18 months of age, respectively. Immunisation performance benchmarks must focus on improving the timeliness in these children in the first year of life.

Adolescent immunizations: missed opportunities for prevention

OBJECTIVES

The goals were (1) to describe immunization rates for tetanus-diphtheria, hepatitis B, and measles-mumps-rubella vaccines among 13-year-old adolescents; (2) to identify missed opportunities for tetanus-diphtheria immunization among adolescents 11 to 17 years of age; and (3) to evaluate the association between preventive care use and tetanus-diphtheria immunization.

METHODS

Adolescents born between January 1, 1986, and December 31, 1991, and enrolled in Harvard Pilgrim Health Care and Harvard Vanguard Medical Associates for >or=1 year in 1997-2004 were included. Immunization rates for tetanus-diphtheria, hepatitis B, and measles-mumps-rubella were assessed at 13 years of age. Missed opportunities for tetanus-diphtheria immunization within 14 days after a health care visit were measured. Multivariate models were used to determine predictors of timeliness of tetanus-diphtheria vaccination, particularly the use of preventive care services. RESULTS. A total of 23,987 eligible adolescents were enrolled in Harvard Pilgrim Health Care and Harvard Vanguard Medical Associates between 1997 and 2004. Among 13-year-old adolescents in the most recent birth cohort, 84%, 74%, and 67% were up to date for tetanus-diphtheria, hepatitis B, and measles-mumps-rubella, respectively. When the analysis was limited to those with >or=1 vaccine received before 2 years of age (a proxy measure for complete records), 92%, 82%, and 85% were up to date for tetanus-diphtheria, hepatitis B, and measles-mumps-rubella, respectively. Missed opportunities for tetanus-diphtheria immunization occurred at 84% of all health care visits. Adolescents who did not seek preventive care were less likely to receive tetanus-diphtheria in a timely manner.

CONCLUSIONS

Adolescent immunization rates lag far behind childhood rates, and missed opportunities are common. Additional strategies are needed to increase the use of preventive services among adolescents and to enable providers to vaccinate adolescents at every opportunity.

Determining immunisation coverage rates in primary health care practices: A simple goal but a complex task

PURPOSE

To explore the quality of data recording by practices and identify issues to be considered and addressed before such data can be used as a continuous measure of immunisation delivery.

METHODS

One hundred and twenty-four randomly selected general practices visited to measure immunisation coverage using the various practice management systems (PMS) in use. To capture all target children it was necessary to build two queries: one generated a list of all children aged between 6 weeks and 2 years who had been to the practice, regardless of enrollment status; the other asked dates and nature of all immunisations given. Each different PMS required a unique query to extract the necessary information.

RESULTS

Variability encountered included different types and versions of PMS and operating systems; variable degree of staff technical competence with their PMS; proportion of enrolled children ranging from nearly 0 to 100%; lack of consistency of the nature and location of data entry and coding; and unreliability of dates relating to some vaccination events.

RECOMMENDATIONS

To improve recording of immunisation coverage we recommend a standard early age of registration and enrollment; standard definitions of the denominator and of immunisation delay; greater uniformity of PMS; improved staff training; intrinsic data quality checks; integration of PMS with changes in the immunisation schedule; incentives and interval electronic checks to improve data quality.

Managed care organizations' performance in delivery of adolescent immunizations, HEDIS, 1999-2002

PURPOSE

The Health Plan Employer Data Information Set (HEDIS) provides comparative information across health plans to measure the quality of care and preventive services for health plan beneficiaries. We examined recent trends in adolescent immunizations recommended by the Advisory Committee for Immunization Practices (ACIP) measured through HEDIS and reported to the National Committee for Quality Assurance (NCQA).

METHODS

The study was based on a longitudinal regression analysis of commercial managed care organizations' HEDIS measures from 1999-2002. HEDIS performance measures and plan characteristics include a sample of approximately 100-400 enrollees per plan each year. The outcome measures were the proportions of enrollees aged 13 years sampled in the plan who received measles-mumps-rubella vaccine (MMR), hepatitis B vaccine, and varicella vaccine.

RESULTS

The immunization rates for all three antigens increased significantly from 1999 to 2002 (MMR: 57-68%; hepatitis B: 28-51%; and varicella: 21-38%). Factors in the final multivariable models that were found to be significantly associated with increased proportions immunized with MMR vaccine, hepatitis B vaccine, and varicella vaccine include year of report, presence of school entry laws, years in business up to 25 years, and operating in the northeastern U.S. region; the only factor associated with decreasing immunization rates for all antigens was the number of providers per 100 commercial enrollees.

CONCLUSIONS

Consistent with previous reports, adolescent immunization rates are improving yet remain suboptimal. Strategies to increase immunization rates, as well as to improve documentation of immunization status, among commercial health insurance plans need to be developed and implemented.

Private Pediatric Clinic Characteristics Associated with Influenza Immunization Efforts in the State of Georgia: A Pilot Evaluation

The Advisory Committee on Immunization Practices (ACIP) recently recommended that all children 6 months to 18 years be vaccinated annually against influenza. Because pediatricians will be critical for implementing this recommendation, we assessed the characteristics of immunization providers associated with the greatest efforts to vaccinate children against influenza. Using a cross-sectional survey of 35 private pediatric clinics in Georgia, we found that adding extra hours for immunization during the influenza vaccination season and having a policy of allowing six or more vaccines to be delivered at one appointment were characteristics associated with a greater intent to vaccinate children in the 2004-2005 influenza vaccination season. Most respondents indicated that for their clinic to implement a universal childhood vaccination policy it would be important to have a formal recommendation from the ACIP and American Academy of Pediatrics, and to be assured that they could receive credits or refunds for unused vaccine.

BCG immunization age in urban and rural areas of Akita Prefecture, Japan

BCG immunization, utilizing whole-body coordination, is a highly cost-effective means of health intervention for preventing miliary tuberculosis (TB) and TB meningitis. In this study, we investigated the appropriate age by which a child should have completed his or her BCG immunization and discuss the current BCG immunization rate in Akita Prefecture, Japan. BCG immunization rates in urban and rural areas were 90.1% and 80.7%, respectively. Our immunization data were lower than the World Health Organization's (WHO) recommended rate. Immunization coverage rates in urban settings were higher than those in rural areas among infants four months to fifteen months of age, except for those six months old. We recommend: (1) completing BCG immunization by the age of twelve months, (2) preparing and educating parents for BCG immunization by means of a health policy, and (3) changing BCG immunization methods from group to individual inoculation. Immunization coverage rates may be increased or maintained to prevent miliary TB and TB meningitis.

Additional health care visits needed among adolescents for human papillomavirus vaccine delivery within medical homes: a national study

OBJECTIVE

We estimated the additional number of primary care visits needed to deliver 3 doses of human papillomavirus vaccine to all US adolescents in medical homes. We determined adolescent and family factors associated with needing the greatest number of additional visits for full human papillomavirus vaccination.

METHODS

We performed a cross-sectional analysis of adolescents 11 to 21 years of age included in the 2002 and 2003 Medical Expenditure Panel Surveys (n = 2900) to measure existing primary care visits to pediatricians, family physicians, obstetrician/gynecologists, and internists. We then estimated additional visits needed for human papillomavirus vaccination. We determined the number of additional visits needed within a 6-, 12-, 18-, or 24-month vaccination window.

RESULTS

Within a 12-month period, 72% of female adolescents would need 3 visits for human papillomavirus vaccination if the vaccine was introduced at a preventive visit; 9% and 16% would need 1 and 2 more visits, respectively. Similarly, 79% of male patients would need 3 visits; 7% and 12% would need 1 and 2 more visits, respectively. If all opportunities to vaccinate were used, then 41% of female patients and 52% of male patients would need 3 additional visits within 12 months. With expansion of the window to 24 months and vaccination at every possible visit, 23% of female patients and 37% of male patients would need 3 additional visits. Factors that predicted needing more visits (2 or 3 vs 0 or 1 in 24 months) included being older, male, black, Hispanic, uninsured, and near-poor.

CONCLUSIONS

Most adolescents would require 2 or 3 additional primary care visits to receive 3 vaccines for human papillomavirus in the medical home. Strategies to minimize additional visits include vaccinating patients at all primary care visits and encouraging annual preventive visits.

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

OBJECTIVES

We examined the effects of maternal and provider characteristics on the up-to-date immunization status of children.

METHODS

We used data from the 2003 National Immunization Survey to determine variations in children's up-to-date status in the 4:3:1:3 immunization series.

RESULTS

Low maternal educational levels and low socioeconomic status were associated with high 4:3:1:3 series completion rates. Also, completion rates were high in Hispanic and non-Hispanic Black families with low income-to-poverty ratios.

CONCLUSIONS

We found that children of less educated mothers and children in Hispanic and non-Hispanic Black families with low income-to-poverty ratios were more likely to have completed the 4:3:1:3 series. Although the reasons for these results need further exploration in other data sets, possible factors are Hispanics' positive cultural attitudes regarding the needs and importance of young children and provision of information on immunizations to low-income minority mothers who access government-subsidized health care programs.

The impact of conjugate pneumococcal vaccination on routine childhood vaccination and primary care use in 2 counties

BACKGROUND

Pneumococcal conjugate vaccine immunization recommendations were rapidly implemented by primary care providers. Before the recommendations, concern was expressed that adding pneumococcal conjugate vaccine might result in delays in other vaccinations or preventive services.

OBJECTIVES

The study objectives were to measure whether incorporation of pneumococcal conjugate vaccine by primary care providers delayed other vaccinations or added primary health care visits.

DESIGN AND METHODS

In 2 counties surrounding Rochester and Nashville, we reviewed a representative sample of primary care charts for children born before and after licensure of pneumococcal conjugate vaccine. Receipt of vaccinations and health care visits were compared for the 2 age-matched cohorts.

RESULTS

We reviewed 1459 records from Rochester and 1857 records from Nashville. The pre-pneumococcal conjugate vaccine and post-pneumococcal conjugate vaccine cohorts had similar demographic characteristics. The median age for receipt of any vaccination was not older for the postvaccine cohort than for the prevaccine cohort in either community. The percentage of children up-to-date for vaccinations by 18 months for postvaccine versus prevaccine cohorts was similar in Rochester (72% in each cohort) and in Nashville (58% postvaccine and 65% prevaccine). The number of well-child care visits or other health care visits during the first 18 months of life was not statistically different between the 2 cohorts.

CONCLUSIONS

Implementation of pneumococcal conjugate vaccine was not associated with delays in other childhood vaccinations or more primary care visits.

Parents concerned about vaccine safety: Differences in race/ethnicity and attitudes

BACKGROUND

Parental concerns about immunization safety have been covered widely in the media and on the Internet and have been correlated in some studies with under-immunization and the late receipt of immunizations.

OBJECTIVES

Phase 1: To (1) measure the prevalence of parents with immunization safety concern, specifically those with high-level concern, (2) determine demographic characteristics and attitudes typical for this subgroup of parents, and (3) determine factors that influence such parents, nevertheless, to have their children immunized. Phase 2: To further explore the racial/ethnic difference found in the first-phase results, specifically to compare the immunization attitudes of Hispanic (both black and white) and non-Hispanic black parents with those of non-Hispanic white parents.

METHODS

ConsumerStyles (2004) survey data of a nationwide panel of U.S. adults were analyzed in January 2006. In Phase 1, bivariate and logistic regression analyses were used to identify factors associated with parental concerns about immunization safety. In Phase 2, logistic regression was used to compare immunization attitudes among non-Hispanic black; Hispanic (both black and white); and non-Hispanic white parents.

RESULTS

The response rate was 62% (6207/10,000); analysis was restricted to the 2937 (47%) respondents who were parents with a child aged 18 years or younger; 634 (21%) responded with the highest level of concern, 5 on a 1-to-5-point scale. Demographics (Hispanic ethnicity/nonwhite race, low income, and less education) and negative attitudes toward immunization and the child's healthcare provider were significantly associated with high-level concern. Seventy-two percent of parents with high-level concern responded that the risk of a child getting a disease was their primary reason for having their child immunized, while 17% listed state laws requiring immunizations for school/daycare entry. Importantly, black parents were more likely than white parents to have negative attitudes toward immunizations and their child's healthcare provider.

CONCLUSIONS

One fifth of parents reported high-level concern with the safety of childhood immunizations. To prevent the erosion of childhood immunization rates, healthcare providers need to learn how to recognize and address these concerns.

Vaccine shortages: history, impact, and prospects for the future

Vaccine shortages can result from higher-than-expected demand, interruptions in production/supply, or a lack of resources to purchase vaccines. Each of these factors has played a role in vaccine shortages in the United States during the past 20 years. Since 2000, the United States has experienced an unprecedented series of shortages of vaccines recommended for widespread use against 9 diseases, after more than 15 years without vaccine supply problems. In developing countries, the major cause of vaccine shortages is lack of resources to purchase them. Although there are several steps that could reduce the likelihood of future vaccine shortages, many would take several years to implement. Consequently, we will probably continue to see occasional shortages of vaccines in the United States in the next few years.

Influenza among healthy young children: changes in parental attitudes and predictors of immunization during the 2003 to 2004 influenza season

BACKGROUND

In Colorado, the 2003 to 2004 influenza season was unusually early and severe and received substantial media attention.

OBJECTIVES

Among parents of healthy young children, to determine how parental knowledge and attitudes regarding influenza infection and immunization changed during the 2003 to 2004 influenza season and to identify factors predictive of influenza immunization.

METHODS

The study was conducted in 5 metropolitan Denver pediatric practices. A total of 839 healthy children age 6 to 21 months and their parents were randomly selected for participation. Parents were surveyed by telephone before (August 18 to October 7, 2003) and after (March 31 to June 10, 2004) the influenza season.

RESULTS

Among 828 eligible parents, 472 (57%) completed the preseason survey; 316 (67%) of these parents subsequently completed the postseason survey. All analyses were performed for the 316 subjects who completed both preseason and postseason surveys. Compared with their attitudes before the influenza season, 48% of parents interviewed after the season viewed their child as more susceptible to influenza, 58% viewed influenza infections as more severe, and 66% perceived fewer risks associated with influenza vaccine. Ninety-five percent of parents reported hearing in the media about Colorado's influenza outbreak, and having heard about the outbreak in the media was associated with viewing influenza infections as more severe. A total of 258 parents (82%) immunized their child against influenza. In multivariate analyses, positive predictors of immunization included a physician recommendation for immunization and a preseason to postseason increase in the perception that immunization was the social norm. Negative predictors of immunization included high perceived barriers to immunization, less parental education, and preseason intention not to immunize.

CONCLUSIONS

Parent attitudes about influenza infection and immunization changed substantially during the 2003 to 2004 influenza season, with changes favoring increased parental acceptance of influenza vaccination for young children. During an intensively publicized influenza outbreak, a physician recommendation of vaccination was an important predictor of influenza immunization.

Patient reminder and patient recall systems to improve immunization rates

BACKGROUND

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result of low immunization rates, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care and large demands on primary care physicians, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. A common theme across immunization programs in all nations involves the challenge of determining the denominator of eligible recipients (e.g. all children who should receive the measles vaccine) and identifying the best strategy to ensure high vaccination rates. Strategies have focused on patient-oriented interventions (e.g., patient reminders), provider interventions and system interventions. One intervention strategy involves patient reminder and recall systems.

OBJECTIVES

To assess the effectiveness of patient reminder and recall systems in improving immunization rates and compare the effects of various types of reminders in different settings or patient populations.

SEARCH STRATEGY

A systematic search was performed for the initial review using MEDLINE (1966-1998) and four other bibliographic databases: EMBASE, PsychINFO, Sociological Abstracts, and CAB Abstracts. Authors also performed a search of The Effective Practice and Organisation of Care (EPOC) register in April 2001 to update the review. Two authors reviewed the lists of titles and abstracts and used the inclusion criteria to mark potentially relevant articles for full review. The reference lists of all relevant articles and reviews were back searched for additional studies. Publications of abstracts, proceedings from scientific meetings and files of study collaborators were also searched for references. In December 2004 the EPOC register was searched to identify relevant articles to update the review.

STUDY DESIGN

Randomized controlled trials (RCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies written in English.

TYPES OF PARTICIPANTS

Health care personnel who deliver immunizations and children (birth to 18 years) or adults (18 years and up) who receive immunizations in any setting.

TYPES OF INTERVENTIONS

Any intervention that falls within the EPOC scope (See Group Details) and that includes patient reminder or recall systems, or both, in at least one arm of the study.

TYPES OF OUTCOME MEASURES

Immunization rates or the proportion of the target population up-to-date on recommended immunizations. Outcomes were acceptable for either individual vaccinations (e.g. influenza vaccination) or standard combinations of recommended vaccinations (e.g. all recommended vaccinations by a specific date or age).

DATA COLLECTION

Each study was read independently by two reviewers. Disagreements between reviewers were resolved by a formal reconciliation process to achieve consensus.

ANALYSIS

Results are presented for individual studies as relative rates for randomized controlled trials and as absolute changes in percentage points for controlled before and after studies. Pooled results for RCTs only were presented using the random effects model.

MAIN RESULTS

Five new studies were added for this update. Increases in immunization rates due to reminders were in the range of 1 to 20 percentage points. Reminders were effective for childhood vaccinations (OR = 1.45, 95% CI =1.28, 1.66), childhood influenza vaccinations (OR = 2.87, 95% CI = 1.65, 4.98), adult pneumococcus, tetanus, and Hepatitis B (OR = 2.19, 95% CI = 1.21, 3.99), and adult influenza vaccinations (OR = 1.66, 95% CI = 1.31, 2.09). All types of reminders were effective (postcards, letters, telephone or autodialer calls), with telephone being the most effective but most costly.

AUTHORS' CONCLUSIONS

Patient reminder and recall systems in primary care settings are effective in improving immunization rates within developed countries.

Underimmunization among children: effects of vaccine safety concerns on immunization status

OBJECTIVE

To examine the attitudes, beliefs, and behaviors of parents whose children were underimmunized with respect to > or =2 vaccines that have recently received negative attention, compared with parents whose children were fully immunized with respect to the recommended vaccines.

DESIGN

Case-control study.

SETTING

A sample of households that participated in the National Immunization Survey were recontacted in 2001.

MAIN OUTCOME MEASURE

Vaccination status was assessed. Case subjects were underimmunized with respect to > or =2 of 3 vaccines (diphtheria-tetanus-pertussis or diphtheria-tetanus-acellular pertussis, hepatitis B, or measles-containing vaccines), and control subjects were fully immunized.

RESULTS

The response rate was 52.1% (2315 of 4440 subjects). Compared with control households, case households were more likely to make 0 dollar to 30,000 dollars (adjusted odds ratio [OR]: 2.7; 95% confidence interval [CI]: 1.5-4.6) than at least 75,000 dollars, to have > or =2 providers (OR: 2.0; 95% CI: 1.3-3.1) than 1, and to have > or =4 children (OR: 3.1; 95% CI: 1.5-6.3) than 1 child. With control for demographic and medical care factors, case subjects were more likely than control subjects to not want a new infant to receive all shots (OR: 3.8; 95% CI: 1.5-9.8), to score vaccines as unsafe or somewhat safe (OR: 2.0; 95% CI: 1.2-3.4), and to ask the doctor or nurse not to give the child a vaccine for reasons other than illness (OR: 2.7; 95% CI: 1.2-6.1). Among case subjects, 14.8% of underimmunization was attributable to parental attitudes, beliefs, and behaviors.

CONCLUSIONS

Attitudes, beliefs, and behaviors indicative of vaccine safety concerns contribute substantially to underimmunization in the United States. Although concerns were significantly more common among parents of underimmunized children, many parents of fully immunized children demonstrated similar attitudes, beliefs, and behaviors, suggesting a risk to the currently high vaccination levels. Efforts to maintain and improve immunization coverage need to target those with attitudes/beliefs/behaviors indicative of vaccine safety concerns, as well as those with socioeconomic and health care access problems.

Quality improvement in immunization delivery following an unsuccessful immunization recall

OBJECTIVES

Within a clinic serving disadvantaged children, 1) to evaluate a multifaceted quality improvement (QI) project to improve immunization (IZ) up-to-date (UTD) rates and 2) to assess the efficacy of IZ reminder/recall performed following QI.

METHODS

A year-long QI project followed by a trial of reminder/recall. QI interventions were targeted at previously identified barriers to IZ and were designed specifically to improve the efficacy of reminder/recall. QI interventions were designed to 1) increase the use of medical record releases to document IZs received elsewhere; 2) improve the accuracy of parental contact information; and 3) reduce missed opportunities by utilizing chart prompts, provider education, and provider reminders. Following QI, we conducted a randomized trial of reminder/recall.

RESULTS

UTD rates for 7-11 month olds increased from 21% before the QI project to 52% after (P <.0001); rates for 12-18 month olds increased from 16% before QI to 44% after (P <.0001); 19-25 month olds 18% before to 33% after (P <.001). After QI, an average of 61 records per month were updated with IZs received elsewhere. However, the accuracy of parental contact information worsened (29% unreachable before QI vs 44% after, P <.001) and missed opportunities did not improve (8% before vs 6% after, P = not significant [NS]). A subsequent trial of reminder/recall did not increase UTD rates, with 17% of recalled children brought UTD vs 16% of controls (P = NS).

CONCLUSIONS

Clinic-based QI increased documented UTD rates in a disadvantaged patient population. However, IZ reminder/recall did not further increase UTD rates above the rates achieved by the QI process.

Financing immunizations in the United States

Children in the United States receive immunizations through both private and public sectors. The federal government has supported childhood immunization since 1963 through the Vaccination Assistance Act (Section 317 of the Public Health Service Act). Since 1994, the Vaccines for Children (VFC) program has provided additional support for childhood vaccines. In 2002, 41% of childhood vaccines were purchased through VFC, 11% through Section 317, 5% through state and/or local governments, and 43% through the private sector. The recent introduction of more-expensive vaccines, such as pneumococcal conjugate vaccine, has highlighted weaknesses in the current system. Adult immunization is primarily performed in the private sector. Until 1981, there was no federal support for adult immunization. Since 1981, Medicare has reimbursed the cost of pneumococcal vaccine for its beneficiaries; influenza vaccine was added in 1993. This paper summarizes the history of financing immunizations in the United States and discusses some current problems and proposed solutions.

The role of pharmacists in the delivery of influenza vaccinations

OBJECTIVES

The purpose of this study is to determine whether influenza vaccine rates have increased in states where pharmacists can give vaccines.

METHODS

Secondary analysis of the Behavioral Risk Factor Surveillance System (BRFSS) from the years 1995 and 1999. Information regarding legislation allowing pharmacists to administer vaccines was obtained from the American Pharmaceutical Association.

RESULTS

Individuals aged 65 years and older who lived in states where pharmacists could provide vaccines had significantly higher (P < 0.01) influenza vaccine rates than individuals of this age who resided in states where pharmacists could not provide vaccines.

CONCLUSIONS

Allowing pharmacists to provide vaccinations is associated with higher influenza vaccination rates for individuals aged 65 years and older.

[Why are some children incompletely vaccinated at the age of 2?]

OBJECTIVE

A survey was conducted in the Province of Quebec to document the factors associated with an incomplete immunization status among 2-year-old children.

METHODS

Parents of 430 completely and 266 partially vaccinated children selected from the computerized vaccination register agreed to participate.

RESULTS

The non-simultaneous administration of the 2nd MMR and 4th DPT-P-Hib at 18 months of age was responsible for 46% of incompleteness. The following characteristics were significantly associated with an incomplete immunization status: being a single parent, > or = 2 children in the family, an older age at first immunization (> or = 3 months), parent's preference for postponing the second vaccine when two injections are scheduled for the same visit, perception of lack of information about vaccination, and disagreement with immunization recommendations.

CONCLUSION

One of the key points of this study is the impact of the non-simultaneous administration of the two vaccines at 18 months. Factors such as being a single parent and older age at first immunization might be used to design an early intervention for children who are most likely to be incompletely immunized. Even if parents are favourable towards immunization, they need to be well informed about the associated risks and benefits.

Developmental Specialists in Pediatric Practices: Perspectives of Clinicians and Staff

OBJECTIVE

To investigate how introducing early child-development specialists (Healthy Steps Specialists) and enhanced developmental services into routine pediatric care affects perspectives of clinicians and staff.

METHODS

Self-administered questionnaires were completed at baseline and at 30 months by clinicians, clinical staff, and nonclinical staff at pediatric sites participating in the evaluation of the Healthy Steps for Young Children Program. The evaluation included 6 randomization and 9 quasi-experimental sites. Barriers to providing well-child care, visit length, perceptions of care provided, and topics discussed with parents were assessed.

RESULTS

Over time, despite persistent barriers to delivering high-quality services, clinicians were more likely to report being satisfied with their clinical staff's ability to meet developmental and behavioral needs of children. Moreover, clinicians were more likely to report discussing the importance of routines with control rather than with intervention families, suggesting a reliance on Healthy Steps Specialists. There was no effect on visit length. Thirty months after introducing Healthy Steps Specialists and enhanced services, nearly all clinicians agreed or strongly agreed that the Healthy Steps Specialists talked with parents about their child's development, showed them activities to do with their child, and provided emotional support. Involvement of the Healthy Steps Specialist in these activities was reported more by clinicians than by clinical staff and least by nonclinical staff.

CONCLUSIONS

Clinicians acknowledged the activities performed by and contributions of the developmental specialists. Differences in perspectives of personnel may reflect different interactions among families, developmental specialists, and practice staff.

Potential burden of universal influenza vaccination of young children on visits to primary care practices

OBJECTIVE

To estimate the additional number of visits to primary care practices that would be required to deliver universal influenza vaccination to 6- to 23-month-old children.

METHODS

Children who were covered by commercial and Medicaid managed care plans (70% of children in the region; >8000 children in each of 3 consecutive influenza seasons) in the 6-county region surrounding and including Rochester, New York, were studied. An analysis was conducted of insurance claims for visits (well-child care [WCC]; all other visits) to primary care practices during 3 consecutive influenza vaccination seasons (1998-2001). We determined the proportion of children who made 1 or 2 visits during the potential influenza vaccination period, simulating several possible lengths of time available for influenza vaccination (2, 3, 4, or 5 months). We measured the proportion of children who were vaccinated during each influenza vaccination period. The added visit burden was defined as the number of additional visits that would be required to vaccinate all children, simulating 2 scenarios: 1) administering influenza vaccination only during WCC visits and 2) considering all visits as opportunities for influenza vaccination.

RESULTS

Results were similar for each influenza season. Considering a 3-month influenza vaccination window and assuming that no opportunities were missed, if only WCC visits were used for influenza vaccination, then 74% of 6- to 23-month-olds would require at least 1 additional visit for vaccination--39% would require 1 additional visit and 35% would require 2 additional visits. If all visits to the practice were used for influenza vaccination during the 3-month window, then 46% would require at least 1 additional visit--34% would require 1 additional visit and 12% would require 2 additional visits. Longer vaccination periods would require fewer additional visits; eg, if a 4-month period were available, then 54% of children would require 1 or 2 additional visits if only WCC visits were used and 29% would require 1 or 2 additional visits if all visits were used for influenza vaccinations. Younger children (eg, 6- to 11-month-olds) would require fewer additional visits than older children (12- to 23-month-olds) because younger children already have more visits to primary care practices.

CONCLUSIONS

Implementation of universal influenza vaccination will result in a substantial increased burden to primary care practices in terms of additional visits for influenza vaccination. Practice-level strategies to minimize the additional burden include 1) using all visits (not just WCC visits) as opportunities for vaccination, 2) providing influenza vaccination for the maximum possible time period by starting to vaccinate as early as possible and continuing to vaccinate as late as possible, and 3) implementing short and efficient vaccination-only visits to accommodate the many additional visits to the practice.

Parental knowledge, attitudes, and practices associated with not receiving hepatitis A vaccine in a demonstration project in Butte County, California

OBJECTIVE

To determine hepatitis A vaccination coverage and factors associated with not receiving hepatitis A vaccine among children.

METHODS

A random cluster sample survey was conducted of parents of children who attended kindergarten in Butte County, California, in 2000. Because of a history of recurrent epidemics, an aggressive hepatitis A vaccination program was ongoing during the time this study was conducted. Receipt of 1 or 2 doses of hepatitis A vaccine was studied.

RESULTS

Of 896 surveys sent, 648 (72%) were completed. The vaccination coverage for at least 1 dose of hepatitis A vaccine was 398 (62%) and for 2 doses was 272 (42%). Factors associated with not receiving the vaccine included lack of provider recommendation (vs having recommendation; odds ratio [OR]: 7.8; 95% confidence interval [CI]: 4.9-12.2), not having heard of the vaccine (OR: 2.4; 95% CI: 1.2-4.9), and parent's not perceiving child is likely to get hepatitis A (vs perceiving child might get disease; OR: 2.1; CI: 1.6-2.9).

CONCLUSIONS

Vaccination coverage among kindergartners did not reach high levels (ie, >90%), despite aggressive vaccination efforts in this community. Lack of provider recommendation and lack of parental awareness of hepatitis A vaccine were the 2 most significant factors associated with failure to receive vaccine. These findings will facilitate the development of vaccination strategies for communities in which hepatitis A vaccination is recommended.

Childhood immunizations: a parent education and incentive program

This article describes some strategies to help reduce the immunization barriers of parental knowledge deficits and transportation costs through a parent education and incentive program. A record review of 471 children in 22 licensed Norfolk, Virginia, day-care centers revealed that 141 (29.9%) had inadequate age-appropriate immunizations. Educational programs included depictions of preventable communicable diseases and their consequences. Upon completion of appropriate immunizations, parents received transportation vouchers and gifts. By June 2000, 255 parents, day-care administrators, teachers, and staff had participated in educational programs and seven day-care centers earned certificate awards for improved immunization rates among enrollees. Four centers had 100% age-appropriate immunization rate, and three had a rate of 92% to 95%.

Influence of insurance status and vaccine cost on physicians' administration of pneumococcal conjugate vaccine

OBJECTIVE

In 2000, heptavalent pneumococcal conjugate vaccine (PCV7) was recommended for children younger than 2 years, but its high cost relative to other universally recommended childhood immunizations and variability in insurance coverage for the vaccine raised concerns. We investigated the influence of PCV7 cost and insurance coverage on physician recommendation of PCV7 to their patients and administration of PCV7 in their practices.

METHODS

We conducted a mail survey from April to July 2001 of a random sample of 833 pediatricians and 788 family physicians in 24 states with different vaccine financing strategies (Vaccines for Children [VFC]-only; enhanced VFC; universal purchase). Physicians specified the proportion of children in their practice with insurance coverage for PCV7, where they recommend administering PCV7, and whether they have concerns about the cost of PCV7.

RESULTS

The response rate was 60%. Overall, 87% of physicians recommend PCV7 for children younger than 2 years (99% pediatricians; 68% family physicians). Among physicians who recommend PCV7, 98% said that they would administer the vaccine in their own practices for children whose insurance covers the vaccine. However, only 56% of physicians who recommend PCV7 reported that all children in their practices had insurance coverage for the vaccine, whereas 24% of physicians reported 86% to 99% of children with coverage and 20% reported <or=85% of children with coverage. Among physicians in the last group with the lowest PCV7 insurance coverage rates in their practices, only 44% said that they would administer the vaccine in their own practices to children without PCV7 coverage, compared with 62% of physicians who provide care to children with higher rates of PCV7 coverage. Physicians in states with VFC-only vaccine financing strategies for PCV7 are less likely to administer PCV7 in their own practices to children without coverage than physicians in states with enhanced VFC and universal purchase strategies (48% vs 64% vs 74%). Almost one third of physicians who recommend PCV7 are concerned about the cost of PCV7; those with cost concerns are more likely to recommend that children without insurance coverage for PCV7 receive the vaccine at a public health clinic rather than in their own practices (45% vs 29%). Physicians with cost concerns are also more likely to say that they now screen children for insurance coverage more than for previously recommended vaccines (52% vs 21% for physicians without cost concerns).

CONCLUSIONS

Nationwide, physician adoption of PCV7 recommendations is high, but where physicians recommend that PCV7 be administered differs significantly by children's variable insurance coverage for the vaccine and by state vaccine financing strategies. Physicians' concerns about the cost of PCV7 may foreshadow their responses to future children's vaccines that may be even more expensive.

Immunization issues for the 21st century

OBJECTIVE

Review and discuss major issues of vaccination and immunization. The development and application of vaccination and immunization is one of the most remarkable successes of the 20th century. This is true both in the United States and worldwide. In the United States, a number of vaccine-preventable diseases have been all but eliminated through the development of a recommended childhood immunization schedule by governmental and nongovernmental organizations, education of providers about these recommendations, and enforcement of these recommendations by school and day care entry mandates. Despite these successes, vaccine-preventable diseases continue to occur, in part because of missed opportunities by health care providers, antivaccine forces empowered by misguided mass media, and parental ignorance. Important aspects of the 2002 recommended childhood immunization schedule are reviewed, including: birth dose hepatitis B, diphtheria underimmunization and tetanus overimmunization, increasing pertussis disease, the success of conjugate vaccines, the change in poliovirus vaccines, measles vaccine and autism, the safety of varicella vaccine, and adult vaccination recommendations. Finally, future prospects for vaccination and immunization are discussed, including: combination vaccines, vaccines against new diseases such as rotavirus, new routes of delivery of immunizing agents, the use of computerized vaccine registries to prevent missed opportunities, and vaccines against bioterrorism agents.

CONCLUSIONS

A careful analysis of risk and benefit suggests that the benefit of vaccination far outweighs the risks from the utilization of immunizing agents. Vaccination delayed may be protection denied. The bottom line is that vaccines are good and disease is bad.

Immunization coverage of vulnerable children: a comparison of health center and national rates

Serving a predominantly poor and minority population, health centers are positioned to address national immunization disparities in the context of comprehensive primary care. Having demonstrated success in eliminating disparities for other preventive services, this study evaluates health center effectiveness in mitigating immunization disparities. Up-to-date health center and national immunization rates were obtained from the 1995 User and the 1995 National Health Interview Surveys. For the most part, national immunization disparities were not found among health center children. However, black children served at health centers were still significantly less likely to be vaccinated for polio and Medicaid children significantly less likely for measles. Health center outreach and enabling services are hypothesized to facilitate regular access to care and thus timely immunization. Additional health center analysis is necessary to establish factors responsible for the relative absence of disparties, uncover persistent barriers to immunization, and identify structural attributes that may further raise immunization coverage.