The impact of record scattering on the measurement of immunization coverage.

BACKGROUND: Lack of a consolidated immunization record may lead to problems with determining individual immunization needs at office visits as well as measuring vaccination coverage levels of a clinician's practice or a community's population. OBJECTIVES: For children with multiple immunization providers, evaluate the difference in coverage levels using data from all responding immunization providers compared with: 1) the most recent immunization provider's records, 2) the first immunization provider's records, and 3) a randomly selected immunization provider's records. Identify characteristics of the most recent provider that may be associated with reporting incomplete immunization histories. METHODS: Data from the 1995 National Immunization Provider Record Check Study (NIPRCS) were used for analysis. The NIPRCS is a provider validation study of the household reported immunization histories of all children 19 to 35 months of age included in the National Health Interview Survey (NHIS). Providers identified by the child's parent during the NHIS interview are mailed a 2-page survey to report all immunizations (type and date) the child received, regardless of the provider who administered the shots, and child's first and most recent visit dates to the practice. RESULTS: Of the 1352 children with provider data, 304 (22%) had received immunizations from more than one provider. Compared with information from all providers and depending on the vaccine, the most recent provider records underestimated coverage by 9.6 to 13.4 percentage points; the initial provider records underestimated coverage by 15.6 to 34.6 percentage points; and the randomly selected provider records underestimated coverage by 10.0 to 20.7 percentage points. Public facilities and having an immunization summary sheet in the patient's chart were associated with having complete records. CONCLUSION: Scattered immunization records significantly compromise the ability of clinicians to determine the immunization status of their patients who received immunizations at other sites of health care. Routinely assessing immunization coverage levels at the practice level, implementing a recall system, and developing community-wide immunization registries are some strategies to reduce the problem of scattered immunization records.immunization, assessment, provider validation, record scattering.

National, state, and urban area vaccination coverage levels among children aged 19-35 months--United States, 1998.

PROBLEM/CONDITION: High vaccination levels in the population are necessary to decrease disease transmission and prevent disease; therefore, an important component of the U.S. vaccination program is the assessment of vaccination coverage. Current goals are for > or = 90% coverage with recommended vaccines during the first 2 years of life. REPORTING PERIOD: January-December 1998. DESCRIPTION OF SYSTEMS: The National Immunization Survey (NIS) is an ongoing, random-digit-dialed telephone survey that gathers vaccination coverage data for children aged 19-35 months in all 50 states and 28 urban areas. Vaccination coverage rates derived from NIS data are adjusted statistically for households with multiple telephone lines, household nonresponse, the proportion of households without telephones, and vaccination provider nonresponse. The results were also adjusted to match the known total population of children in each survey area. RESULTS: On the basis of NIS data, national coverage was > or = 90% for three doses of poliovirus vaccine (Polio), three doses of Haemophilus influenzae type b vaccine (Hib), and one dose of measles-containing vaccine (MCV). Coverage was the highest ever reported for four doses of any diphtheria and tetanus toxoids and pertussis vaccine (DTP) (i.e., diphtheria and tetanus toxoids and pertussis vaccine, diphtheria and tetanus toxoids [DT], or diphtheria and tetanus toxoids and acellular pertussis vaccine [DTaP]) (83.9%), three doses of hepatitis B vaccine (Hep B, 87.0%), and one dose of varicella vaccine (43.2%). The number of states achieving the > or = 90% goal was 47 for three doses of Hib, 40 for three doses of Polio, 40 for one dose of MCV, nine for three doses of Hep B, and seven for four doses of DTP. Proportionally fewer urban areas achieved the > or = 90% goal: 23 of 28 for three doses of Hib, 13 for three doses of Polio, 16 for one dose of MCV, five for three doses of Hep B, and one for four doses of DTP. No state or urban area has yet achieved the > or = 90% goal for varicella. INTERPRETATION: Findings from the 1998 NIS indicate that national vaccination coverage levels for routinely recommended childhood vaccines are at the highest levels ever reported. However, substantial variation in coverage remains at the state and urban area levels. PUBLIC HEALTH ACTIONS: The public health community and vaccination providers in areas with low coverage should intensify their efforts to implement recommended strategies for increasing vaccination coverage to ensure that children are equally well protected throughout the United States.

Progress in coverage with hepatitis B vaccine among US children, 1994-1997.

OBJECTIVES: This study was done to assess progress in hepatitis B vaccination of children from 1994 through 1997. METHODS: We used data from the National Immunization Survey (NIS), a random-digit-dialed telephone survey that includes a mail survey to verify vaccination providers' records. The NIS is conducted in 78 geographic areas (50 states and 28 selected urban areas) in the United States. RESULTS: A total of 32,433 household interviews were completed in the 1997 NIS. An estimated 83.7% of children aged 19 to 35 months received 3 or more doses of hepatitis B vaccine. Coverage with 3 doses was greater (86.7%) among children in states that had day care entry requirements for hepatitis B vaccination than among children in states without such requirements (83.0%) and was greater among children from families with incomes at or above the poverty level (85.0%) than among children below the poverty level (80.6%). Hepatitis B vaccination of children increased from 1994 through 1996, from 41% to 84%, but coverage reached a constant level of 84% to 85% in 1996/97. CONCLUSION: Although substantial progress has been made in fully vaccinating children against hepatitis B, greater efforts are needed to ensure that all infants receive 3 doses of hepatitis B vaccine.

Vaccines for Children program, United States, 1997.

OBJECTIVES: 1) To determine the proportion of preschool children receiving immunizations from providers enrolled in the Vaccines for Children (VFC) program; 2) to assess whether their immunization providers serve as their medical home for primary care; and 3) to examine the relationship between various provider characteristics and immunization status. DESIGN: Two-phase national survey consisting of parent interviews verified by provider record check. SETTING: A total of 78 survey areas (50 states, the District of Columbia, and 27 urban areas). PATIENTS OR OTHER PARTICIPANTS: Noninstitutionalized children from 19 to 35 months of age in 1997. INTERVENTIONS: None. OUTCOME MEASURES: VFC penetration rate (the percentage of children who received all or some vaccines from a VFC-enrolled provider); the frequency with which children received all or some vaccines within a medical home; the number of parent-reported immunization providers; and 4:3:1:3 up-to-date status at 19 to 35 months of age. RESULTS: OFF 28 298 children interviewed for whom consent to contact providers was obtained, complete provider data were available for 21 522 (76%). Of these children, approximately 75% received all or some immunizations from a VFC-enrolled provider, 73% received all or some immunizations within a medical home, and 75% had one immunization provider. Children received all or some immunizations from a VFC-enrolled provider more frequently when vaccinated by pediatricians versus family physicians or in public facilities versus private practice. After controlling for poverty, immunization coverage varied only slightly with receipt of vaccines from a VFC-enrolled provider, receipt of vaccines within a medical home, and the number of parent-reported providers. Among children vaccinated within a medical home, those vaccinated solely by pediatricians were 1.63 times as likely to be 4:3:1:3 up-to-date than were those vaccinated solely by family physicians after removing the effects of poverty. RECOMMENDATIONS: Greater numbers of children are likely to benefit from an even higher participation rate among immunization providers in the VFC program, particularly among family physicians and private physicians. The public-private collaboration developed by the VFC program should be capitalized on so that public sector resources can help pediatricians and family physicians practice according to the Standards for Pediatric Immunization Practices.

Diagnosis of measles with an IgM capture EIA: the optimal timing of specimen collection after rash onset.

The optimal timing for collection of a single serum specimen to diagnose measles by using a monoclonal antibody-capture EIA was evaluated. Results of testing paired serum samples from 166 measles cases with at least 1 IgM-positive specimen were analyzed. Among persons whose second samples were IgM-positive, the seropositivity rate for first samples was 77% when collected within 72 h and 100% when collected 4-11 days after rash onset. Among unvaccinated persons whose first samples were IgM-positive, the rate for IgM positivity of second specimens declined from 100% at 4 days to 94% at 4 weeks after rash onset, then declined further to 63% at 5 weeks. Some previously vaccinated persons became IgM-negative during the third week after rash onset. In general, a single serum specimen collected between 72 h and 4 weeks after rash onset can be used to diagnose most cases of measles with an IgM capture EIA.

A model immunization demonstration for preschoolers in an inner-city barrio, San Diego, California, 1992-1994.

An immunization demonstration project was conducted in an inner-city Latino neighborhood in San Diego to address underimmunization of children of preschool age. The project attempted interventions on consumer, provider, and system levels to reduce barriers to immunization and raise immunization rates. Free walk-in immunization clinics with emphasis on cultural sensitivity and that incorporated computerized reminder/recall were established. An educational series was offered to community health center (CHC) providers, and extensive community-based outreach and education took place in schools, churches, a WIC site, etc. Evaluation activities included preintervention and postintervention provider knowledge, attitudes, and practice surveys, CHC chart audits, and household surveys in the intervention ZIP code area and a control ZIP code area. Immunization coverage for 4DPT, 3OPV, and 1MMR (4:3:1) among two-year-olds increased significantly from 37% to 50% overall, and to 59% in the 1991 birth cohort in the intervention area compared to a one percentage point overall increase in the control area. Coverage improved significantly and missed opportunities decreased in one intervention CHC that participated most actively in educational inservices. While the Year 2000 U.S. Public Health Service objective of 90% 4:3:1 coverage for two-year-olds was not achieved over the 21-month course of the project, the results approached the 1996 single-antigen objectives. This demonstration underscores the importance of multilevel interventions including low cost, no appointment, and culturally appropriate immunization services for the indigent; the use of computerized reminder systems; and provider assessment, education, and feedback in the effort to raise preschool immunization levels. Medical Subject Headings (MeSH): immunization, preschool-age children, health promotion, provider education, immunization monitoring and follow-up systems, pediatric immunization standards, household surveys.

Changing levels of measles antibody titers in women and children in the United States: impact on response to vaccination. Kaiser Permanente Measles Vaccine Trial Team.

OBJECTIVES: In the United States, younger women are more likely to have immunity to measles from vaccination and are less likely to have been exposed to the wild virus than are older women. To evaluate changes in measles antibody titers in women in the United States and children's responses to measles vaccination, we analyzed data from a measles vaccine trial. METHODS: Sera collected from children before vaccination at 6, 9, or 12 months of age and from their mothers were assayed for measles antibodies by plaque reduction neutralization. Responses to vaccination with Merck Sharp & Dohme live measles virus vaccines at 9 months (Attenuvax) and 12 months (M-M-R II) were also analyzed. RESULTS: Among women born in the United States (n = 614), geometric mean titers (GMTs) of measles antibodies decreased with increasing birth year. For those born before 1957, 1957 through 1963, and after 1963, GMTs were 4798, 2665, and 989, respectively. Among women born outside of the United States (n = 394), there were no differences in GMTs by year of birth. Children of younger women born in the United States were less likely than those of older women to be seropositive at 6, 9, or 12 months. The response to the vaccines varied by maternal birth year for children of women born in the United States. Among 9-month-old children, 93% of those whose mothers were born after 1963 responded, compared with 77% and 60% of those whose mothers were born in 1957 through 1963 and before 1957, respectively. Among 12-month-old children, 98% of those born to the youngest mothers responded, compared with 90% and 83% of those whose mothers were born in 1957 through 1963 and before 1957. The responses of children of women born outside of the United States were not associated with maternal year of birth. CONCLUSIONS: An increasing proportion of children in the United States will respond to the measles vaccine at younger ages because of lower levels of passively acquired maternal measles antibodies.

The geographic distribution of measles in the United States, 1980 through 1989.

OBJECTIVE: To describe the geographic distribution of measles cases in the United States by county for the 10-year period from 1980 through 1989. DESIGN: Ecological analysis of national measles surveillance data. METHODS: Measles cases reported to the Morbidity and Mortality Weekly Report from 1980 through 1989 were analyzed. Data from the 1980 and 1990 US censuses were used to produce demographic profiles for each of the 3137 countries. Outcome variables examined included mean annual incidence and number of years reporting measles, with use of Spearman's rank correlation coefficients to examine the association between the demographic and the two outcome variables. RESULTS: A total of 56,775 measles cases were reported during the decade. Of the nation's 3137 counties, 1690 (53.9%) did not report any cases; only 17 (0.5%) reported measles in all 10 years. Counties reporting measles more frequently during the decade had higher median populations, population densities, and percentage of black and Hispanic populations than those counties reporting less frequently. Population size, population density, and percentage of Hispanic population were associated with number of years reporting measles and mean annual measles incidence rate. Measles cases in counties reporting measles every year predominantly occurred in unvaccinated preschoolers; cases in counties reporting less frequently predominantly occurred in vaccinated school-aged children. CONCLUSIONS: This analysis illustrates the focal nature of measles in the United States during the past decade. Most counties have not reported a single case of measles during the entire decade, and only 17 counties reported measles every year. Targeted strategies are needed to improve age-appropriate immunization levels among preschool-aged children living in large inner-city areas.

Evaluation of the erythrocyte protoporphyrin test as a screen for elevated blood lead levels.

To study the effect of lowering the definition of an elevated blood lead level on the performance of the erythrocyte protoporphyrin screening test and the number of children who would require follow-up, we collected laboratory data from a screening program. The estimated sensitivity of an erythrocyte protoporphyrin level greater than or equal to 35 micrograms/dl for identifying children with elevated blood lead levels was 73% when we used 1985 Centers for Disease Control guidelines (elevated blood lead level greater than or equal to 25 micrograms/dl). Eight percent of the tests showed positive results. When we redefined an elevated blood lead level as greater than or equal to 15 micrograms/dl, the sensitivity estimate was reduced to 37% and the number of positive test results increased fourfold.

Eosinophilia-myalgia syndrome. Results of national surveillance.

Eosinophilia-myalgia syndrome, a newly recognized disorder that occurred in epidemic proportions during 1989, is associated with ingestion of manufactured tryptophan. A case is defined by debilitating myalgias and absolute eosinophilia greater than or equal to 1.0 x 10(9) cells/L. As of July 10, 1990, a total of 1531 cases had been reported nationwide, including 27 deaths. The highest rates of reported illness are concentrated in the western states, 68% are non-Hispanic white women aged 35 years and older, and data on associated clinical findings suggest a multisystemic disorder. The most frequent features include arthralgia (73%), rash (60%), cough or dyspnea (59%), peripheral edema (59%), elevated aldolase level (46%), and elevations in the results of liver function tests (43%). Neuropathy or neuritis, resulting in paralysis and death in some patients, was seen in 27%, and chest roentgenogram abnormalities were noted in 21% of those tested. Ninety-one percent reported onset of symptoms during or after May 1989, and 97% reported having taken tryptophan before the onset of symptoms. Since the recall of over-the-counter preparations of tryptophan in November 1989, the number of new cases of this potentially fatal disorder has fallen dramatically.

Estrogen replacement therapy and the risk of endometrial cancer: remaining controversies.

To examine the relationship between exogenous estrogen administration and endometrial cancer, we used data from the Cancer and Steroid Hormone Study, a multicenter, population-based case-control study. Estrogen replacement therapy for greater than or equal to 2 years was associated with an increased risk of both localized and extrauterine cancer (relative risk = 2.8, 95% confidence limits 1.6, 4.6; relative risk = 2.9, 95% confidence limits 0.9, 9.4, respectively). However, the latter finding was based on a small number of cases in which estrogen was used. Women who underwent estrogen replacement therapy for greater than or equal to 2 years had significantly elevated risks of endometrial cancer (2.1 for 2 to 5 years and 3.5 for greater than or equal to 6 years). An elevated risk persisted for greater than or equal to 6 years after discontinuation of therapy. Women who exclusively used conjugated equine estrogen preparations less than or equal to 0.625 mg had no increased risk of endometrial cancer. A history of oral contraceptive use appeared to reduce the risk of endometrial cancer associated with estrogen replacement therapy. However, these latter two potentially important findings were based on a small number of cases in which hormones were used.

Mortality due to all causes and to cardiovascular diseases among seven race-ethnic populations in Los Angeles County, 1980.

Mortality rates during 1980 in Los Angeles County are presented for Whites, Blacks, Hispanics, and Americans of Japanese, Chinese, Philippine, and Korean descent, seven groups with varying patterns of migration during the prior decade. For all causes of death, age- and sex-adjusted rates were highest among Blacks, intermediate among Whites and Hispanics, and substantially lower among Asians and Pacific Islanders. A similar observation was made for the major cardiovascular diseases and for diseases of the heart. In contrast, the mortality rates for cerebrovascular diseases exhibited a slightly different pattern, with Blacks again highest, Whites and Japanese being intermediate, and Hispanics, Filipinos, Chinese, and Koreans being lowest. The descriptive information suggests several areas for further research into the effect of various cultural or lifestyle patterns on the occurrence of cardiovascular disease.

Effect of corticosteroid treatment and enucleation on the visual prognosis of sympathetic ophthalmia.

A retrospective clinicopathologic study, conducted to determine the course of disease in 30 cases of sympathetic ophthalmia with clinical follow-up of at least six months (average, 12.7 years), showed that 21 of 30 patients retained visual acuities of 20/50 or better in the sympathizing eye. The severity of inflammation graded histologically in the exciting eye did not correlate with the clinical course of final visual acuity in the sympathizing eye. Enucleation of the exciting eye within two weeks of the onset of symptoms was associated with a relatively benign clinical course (P = .008). Corticosteroid treatment in patients who underwent enucleation more than two weeks after the onset of symptoms was associated with a good visual outcome (P = .009). Early enucleation of a blind exciting eye and corticosteroid treatment appear to be important variables that influence the visual prognosis in the sympathizing eye.