Influenza vaccine coverage and missed opportunities among inner-city children aged 6 to 23 months: 2000-2005.

OBJECTIVE: In 2002, the Advisory Committee on Immunization Practices recommended universal influenza vaccination of 6- to 23-month-olds. Little is known about coverage and missed opportunities for influenza vaccination at inner-city practices. The objective of this study was to assess the 2000-2001 to 2004-2005 coverage and the prevalence of missed opportunities for influenza vaccination among inner-city children. METHODS: We conducted a retrospective review for the 2000-2001 to 2004-2005 influenza seasons at a practice network in New York City. The study population included 5 annual cohorts of 6- to 29-month olds as of March 31 of each year with > or = 1 visit to the network in the previous 12 months (n = 7063). Immunization data were obtained from the network registry and the New York Citywide Immunization Registry. Coverage levels were estimated for 1 dose (partial) and 2 doses (full). Missed opportunities were assessed for visits within each influenza season. RESULTS: Coverage rose steadily throughout the 5 years (full: 1.6% to 23.7%; partial: 1.5% to 18.1%). The relationship between year and coverage was linear. Missed opportunities occurred in 82% of visits and were more common for first (89%) than for repeat doses (38%). Missed opportunities per child per season decreased from 2.9 to 2.0 during the study period. CONCLUSIONS: Influenza vaccine coverage among 6- to 23-month-olds at inner-city practices increased steadily from 2000-2001 through 2004-2005, and the prevalence of missed opportunities per child decreased. However, coverage remained suboptimal, with most of children not vaccinated or undervaccinated. Missed opportunities were major contributors to low coverage.

The impact of DTaP-IPV-HB vaccine on use of health services for young infants.

BACKGROUND: In 2003, a pentavalent vaccine (diphtheria, tetanus and acellular pertussis, injectable polio and hepatitis B) was introduced into the childhood vaccination schedule. A premarketing study showed a higher incidence of fever than with the vaccines administered separately. Because fevers in young infants prompt medical evaluations, this study examines the impact of this vaccine (DTaP-IPV-HB) on subsequent use of health services. METHODS: We compared use of health services among 6- to 10-week-old infants receiving DTaP-IPV-HB (n = 1776) with a historical control receiving the prior schedule (n = 2162) at an inner-city practice network. Data sources included a hospital immunization registry and medical records. Outcome measures were visits to the emergency department and ambulatory practices, fever, tests, antibiotics and hospitalizations. Outcomes were stratified by age (<8, 8-10 weeks) and days since vaccination (3, 7). RESULTS: Infants vaccinated with DTaP-IPV-HB were more likely to visit the ED (1.2% versus 0.6%, P = 0.03) and receive tests (47.6% versus 8.3%, P = 0.03) within 3 days of vaccination compared with the controls. Multivariate analysis showed infants vaccinated with DTaP-IPV-HB had a 7-fold increased risk of receiving a full sepsis workup and a 3-fold increased risk of receiving antibiotics within 7 days of vaccination. Medical evaluations decreased over time after implementation of the DTaP-IPV-HB vaccine. Concurrently, the rate of vaccination for infants <8 weeks markedly dropped. CONCLUSIONS: The DTaP-IPV-HB vaccine was associated with increased use of health services in the emergency department, but these associations lessened over time. These findings reveal a conflict between the obligation of timely and efficient vaccination with the medical management of febrile young infants.

Community-based strategies to reduce childhood immunization disparities.

This study demonstrates how community-based immunization promotion reduced immunization disparities. In 2002 to 2004, the coalition enrolled 3,748 children younger than 5, with 1,502 aged 19 to 35 months in April 2004. Disparity reduction was assessed by comparing coalition immunization coverage rates (4:3:1:3:3) to the National Immunization Survey 2003 rates. Logistic regression was used to assess factors contributing to up-to-date immunizations. Coverage increased from 46.0% at enrollment to 80.5%, matching nationwide rates for all (t = 0.87) or White (t = 1.99) children. The 78% for African Americans was higher than 73% for U.S. African American children (t = 2.90); 84% for Latinos was higher than 77% for U.S. Latinos (t = 2.32). Being current with age-appropriate immunizations at enrollment (OR = 9.8), being Latino (OR = 1.6), and participating through child health insurance enrollment (OR = 4.9), Women, Infants, and Children (OR = 3.1), or child care or parenting (OR = 1.9) programs increased immunization coverage. Embedding immunization promotion into existing community programs was successful in eliminating immunization disparities. Most effective programs were those with direct linkages to health care systems or that targeted young children.

Challenges and successes of immunization registry reminders at inner-city practices.

OBJECTIVES: To assess the effectiveness of two serial registry reminder protocols and the interactive effects of reminders with child characteristics on immunization rates. METHODS: At an inner city practice network in New York City we randomized 1662 children aged 6 weeks-15 months due or late for a diphtheria-tetanus-pertussis (DTaP) to 3 groups: continuous reminders (as needed), limited reminders (up to 3) and controls, for 6 months. Reminders were triggered by the hospital registry and immunizations were tracked with both the hospital and city registries. Analyses were based on intention to treat. RESULTS: At randomization, the study groups were comparable (9.2 months of age, 77% Latino, 86% Medicaid, 49.3% up-to date). A quarter of the children were sent false reminders, 15% had incorrect contact information, and 15% had missed opportunities for vaccination. In the univariate analysis, reminders improved coverage rates, but only for the children sent continuous reminders (51.2% vs. 44.9% controls, p < .01). Multivariate analysis showed reminders had no independent effect on immunization outcomes. Age, up-to-date and Medicaid status at randomization were strong predictors of a child receiving any subsequent immunization. However, reminders interacted synergistically with Medicaid to increase the likelihood of receiving an immunization. CONCLUSION: At an inner city practice network, registry reminders were not effective at improving immunization outcomes due to major system barriers. Immunization registries are powerful vehicles for identifying children in need of immunizations and generating reminders but system challenges must be addressed if this promise is to be achieved in inner city practices.

Community empowerment to reduce childhood immunization disparities in New York City.

This paper reports on the impact of the community-based Start Right program on childhood immunization coverage in 2 communities of color in New York City. Fully launched in 2002, Start Right operates through the major social service programs of its 23 member organizations. Immunization promotion strategies are based on the following guiding principles: community leadership; integration with community programs; parental empowerment; peer health educators; tracking and feedback; and linkage with health providers. By September 2003, 2,433 children under age 5 years (14% of that age group in the community) were enrolled in Start Right. The rates for the cohort of children enrolled in 2003 were substantially higher than for those enrolled in 2002. Among the 2003 cohort of 19- to 35-month-old children, the coverage rate was 88%, significantly more than national rates: 75% for total population, 68% for African Americans, and 73% for Hispanics. The rate for our 2003 enrollment cohort exceeded the rate for New York City (78%) but did not exceed the New York City average for Hispanics (79%). Of the 2003 enrollment cohort, the Washington Heights children had the highest rates for enrollment (89.6%), exceeding New York City rates. Parents reported a high level of satisfaction with the program.