Preschool children at high risk for measles: opportunities to vaccinate.

OBJECTIVES: In 1989 and 1990 the United States experienced a measles epidemic with more than 18,000 and 27,000 reported cases, respectively. Nearly half of all persons with measles were unvaccinated preschool children under 5 years of age. We sought to identify potential sites for vaccine delivery. METHODS: Preschool children with measles were surveyed in five inner cities with measles outbreaks in 1989 to 1990 to assess the children's use of health care services and federal assistance programs before contracting measles. RESULTS: Of 972 case children surveyed, 618 (64%) were eligible for measles vaccination at measles onset. Of those, 93% had previously visited a health care provider (private physician, public clinic, hospital emergency department, or hospital outpatient department) and 65% were enrolled in a federal assistance program (AFDC, WIC, or food stamps). Based on parent-reported reasons for health care visits, in Dallas and New York City, health care providers of 24% of 172 children may have missed at least one opportunity to administer measles vaccine. CONCLUSIONS: Many potential opportunities exist to raise the vaccination coverage of unvaccinated preschool children. These opportunities depend on (1) health care providers taking advantage of all opportunities to vaccinate, and (2) immunization services being linked to federal assistance programs.

Successes and failures in vaccine delivery: evaluation of the immunization delivery system in Puerto Rico.

The objective of this study was to evaluate immunization delivery and determine reasons for low coverage among preschool-age public clinic attendees in Puerto Rico. In 25 randomly selected clinics, coverage and missed immunization opportunities were assessed in 273 children aged 2 to 59 months, exist interviews were conducted with parents, and providers were interviewed. Two neighborhoods close to the clinics were surveyed to determine parental knowledge about immunizations, and the vaccination status of children in these neighborhoods was assessed. Two hundred seventy-three clinic attendees were interviewed. Among 229 (84%) with vaccination cards, only 126 (55%) had received all indicated vaccines by completion of the clinic visit. Forty-five percent of children with cards in the household survey were not up-to-date. Of 171 (75%) clinic attendees eligible for vaccination at the visit, 118 (69%) missed one or more immunizations at the visit. In addition, half of all children had previously missed one or more immunizations when they had received another vaccine. Missed opportunities occurred because of nonavailability of vaccines, lack of integration of services, provider misconceptions about contraindications, and failure to administer vaccines simultaneously. Other problems included barriers to immunization services and lack of information and education activities. It is concluded that deficiencies in immunization delivery substantially delay immunization and reduce coverage.

Predictive utility, sex of rater differences, and interrater reliabilities of the NOSIE-30.

Results suggest that the NOSIE-30 may have predictive utility. Twelve Token Economy patients rated by nine staff members were followed for 1 year. Patients discharged within a year after the NOSIE-30 was administered had higher scores on Social Competence, Personal Neatness, Total Positive Factors, Total Patient Assets and a lower score on Total Negative Factors than patients who remained hospitalized. Generally, there were higher interrater reliabilities on subscales for which behaviors could be observed easily, such as social competence, neatness, and irratability, and less agreement on subscales such as manifest psychosis and social interest. Sex differences found in the raters' perception of a patient behavior indicated that male raters tend to be more tolerant of a patient's negative behaviors. The NOSIE-30 can be a useful tool in staff training and in patient evaluation with a multidisciplinary approach.