Increasing immunization rates among inner-city, African American children. A randomized trial of case management.

CONTEXT: Immunization rates in the inner city remain lower than in the general US population, but efforts to raise immunization levels in inner-city areas have been largely untested. OBJECTIVE: To assess the effectiveness of case management in raising immunization levels among infants of inner-city, African American families. DESIGN: Randomized controlled trial with follow-up through 1 year of life. SETTING: Low-income areas of inner-city Los Angeles, Calif. PATIENTS: A representative sample of 419 African American infants and their families. INTERVENTIONS: In-depth assessment by case managers before infants were 6 weeks of age, with home visits 2 weeks prior to when immunizations were scheduled and additional follow-up visits as needed. MAIN OUTCOME MEASURES: Percentage of children with up-to-date immunizations at age 1 year, characteristics associated with improved immunization rates, and cost-effectiveness of case management intervention. RESULTS: A total of 365 newborns were followed up to age 1 year. Overall, the immunization completion for the case management group was 13.2 percentage points higher than the control group (63.8% vs 50.6%; P=.01). In a logistic model, the case management effect was limited to the 25% of the sample who reported 3 or fewer well-child visits (odds ratio, 3.43; 95% confidence interval, 1.26-9.35); for them, immunization levels increased by 28 percentage points. Although for the case management group intervention was not cost-effective ($12022 per additional child immunized), it was better ($4546) for the 25% of the sample identified retrospectively to have inadequate utilization of preventive health visits. CONCLUSIONS: A case management intervention in the first year of life was effective but not cost-effective at raising immunization levels in inner-city, African American infants. The intervention was demonstrated to be particularly effective for subpopulations that do not access well-child care; however, currently there are no means to identify these groups prospectively. For case management to be a useful tool to raise immunizations levels among high-risk populations, better methods of tracking and targeting, such as immunization registries, need to be developed.

Inappropriately timed immunizations: types, causes, and their relationship to record keeping.

OBJECTIVES: This study examined inappropriately timed immunizations and their relationship to record keeping practices in Los Angeles public health centers. METHODS: Records of children's visits were reviewed at four public health centers maintaining separate records. RESULTS: One third of all children seen at both immunization-only and well child clinics were given inappropriately timed immunizations. Almost half of the immunizations were not transferred between sets of records. Children seen in both clinics were more than twice as likely to receive at least one inappropriately timed immunization as those seen only at the well child clinic. CONCLUSIONS: Keeping separate immunization records at separate clinics leads to inappropriately timed immunizations.

Knowledge of the childhood immunization schedule and of contraindications to vaccinate by private and public providers in Los Angeles.

BACKGROUND: Missed opportunities to vaccinate occur commonly and contribute to the underimmunization of young children. They are related to provider knowledge of the immunization schedule and contraindications to vaccination. METHODS: We surveyed private physicians (n = 50) and public health department physicians and nurses (n = 47). The questionnaire presented two sets of clinical scenarios in which they had to assess what immunizations were due and assess whether there were any contraindications to vaccination. RESULTS: The mean percent correct responses on the immunization schedule questions was 64% (sd = 3.6%) for the private physicians, 71% (SD = 4.7%) for the public physicians and 78% (SD = 2.8%) for the public nurses (P = 0.04). The mean percent correct responses on the contraindications to vaccinate questions was 73% (SD = 5.4%) for public physicians, 58% (SD = 3.3%) for private physicians, and 55% (SD = 4.7%) for public health nurses (P = 0.02). CONCLUSIONS: Our survey shows that providers in the public and private sectors have important deficits in their knowledge of the immunization schedule and the appropriate contraindications to vaccinate which might lead to missed opportunities to vaccinate and low immunization coverage.

Factors related to immunization status among inner-city Latino and African-American preschoolers.

OBJECTIVE: To identify factors associated with undervaccination at 3 months and 24 months among low-income, inner-city Latino and African-American preschool children. DESIGN: Interviews with a representative sample of inner-city families using a cross-sectional, multi-stage, cluster-sample design combined with a replicated quota sampling approach. SETTING: South Central and East Los Angeles areas in inner-city Los Angeles. POPULATION: Eight hundred seventeen Latino and 387 African-American families with children between 12 and 36 months of age. MAIN OUTCOME VARIABLES: Being fully immunized or up-to-date (UTD) at 3 months (1 diphtheria-tetanus-pertussis vaccine and 1 oral polio vaccine) and 24 months of age (4 diphtheria-tetanus-pertussis vaccines, 3 oral polio vaccines, and 1 measles-mumps-rubella vaccine). METHODS: Logistic regressions of UTD immunization status at 3 and 24 months by population and health care system factors. RESULTS: Seventy percent of Latino children and 53% of African-American children were UTD at 3 months of age. At 24 months of age, 42% of Latino children and 26% of African-American children were UTD on their immunizations. Receipt of the first immunizations by 3 months was associated with smaller family size, and evidence of connection to prenatal care. Latino children were less likely to be UTD at 24 months if they obtained well child care from private providers versus public clinics (odds ratio [OR] = 0.45, 95% confidence interval [CI] = 0.26, 0.79). There was also a trend for Latino children to be less well immunized if they were in health maintenance organizations versus public clinics (0.31, 0.05 < P < .1). African-American children were more likely to be UTD at 24 months if they were UTD at 3 months (OR = 5.56, 95% CI = 1.43, 21.6), had more health visits (OR = 1.13, 95% CI = 1.01, 1.27), and were less likely to be UTD at 24 months if they were on Medicaid versus private insurance (OR = 0.26, 95% CI = 0.08, 0.90). IMPLICATIONS: Both African-American and Latino children in inner-city Los Angeles have low immunization rates at 3 and 24 months. Prenatal care and family size are strongly associated with being UTD by 3 months; however, family and child characteristics are relatively unimportant predictors of being UTD at 24 months of age. Important risk factors for underimmunization at 2 years of age in the inner-city, low-income communities studied include type of health insurance and source of well child care, with the public sector having higher rates than private doctors' offices or health maintenance organization/managed care plans.

Lead-contaminated soil abatement and urban children's blood lead levels.

OBJECTIVE: To test the hypothesis that a reduction of 1000 ppm or more of lead in soil accessible to children would result in a decrease of at least 0.14 mumol/L (3 micrograms/dL) in blood lead levels. SETTING: Urban neighborhoods with a high incidence of childhood lead poisoning and high soil lead levels. DESIGN: Randomized controlled trial of the effects of lead-contaminated soil abatement on blood lead levels of children followed up for approximately 1 year after the intervention. PATIENTS: A total of 152 children less than 4 years of age with venous blood lead levels of 0.34 to 1.16 mumol/L (7 to 24 micrograms/dL). Children were largely poor and had a mean age at baseline of 32 months, a mean blood lead level of 0.60 mumol/L (12.5 micrograms/dL), and a median surface soil lead level of 2075 ppm. INTERVENTIONS: Children were randomized to one of three groups: the study group, whose homes received soil and interior dust abatement and loose paint removal; comparison group A, whose homes received interior dust abatement and loose paint removal; and comparison group B, whose homes received only interior loose paint removal. MAIN OUTCOME MEASURES: Change in children's blood lead levels from preabatement levels to levels approximately 6 and 11 months after abatement. RESULTS: The mean decline in blood lead level between preabatement and 11 months after abatement was 0.12 mumol/L (2.44 micrograms/dL) in the study group (P = .001), 0.04 mumol/L (0.91 microgram/dL) in group A (P = .04), and 0.02 mumol/L (0.52 microgram/mL) in group B (P = .31). The mean blood lead level of the study group declined 0.07 mumol/L (1.53 micrograms/dL) more than that of group A (95% confidence interval [CI], -0.14 to -0.01 mumol/L [-2.87 to -0.19 micrograms/dL]) and 0.09 mumol/L (1.92 micrograms/dL) more than group B (95% CI, -0.16 to -0.03 mumol/L [-3.28 to -0.56 micrograms/dL]). When adjusted for preabatement lead level, the 11-month mean blood lead level was 0.06 mumol/L (1.28 micrograms/dL) lower in the study group as compared with group A (P = .02) and 0.07 mumol/L (1.49 micrograms/dL) lower than in group B (P = .01). The magnitude of the decline independently associated with soil abatement ranged from 0.04 to 0.08 mumol/L (0.8 to 1.6 micrograms/dL) when the impact of potential confounders, such as water, dust, and paint lead levels, children's mouthing behaviors, and other characteristics, was controlled for. CONCLUSIONS: These results demonstrate that lead-contaminated soil contributes to the lead burden of urban children and that abatement of lead-contaminated soil around homes results in a modest decline in blood lead levels. The magnitude of reduction in blood lead level observed, however, suggests that lead-contaminated soil abatement is not likely to be a useful clinical intervention for the majority of urban children in the United States with low-level lead exposure.