Assessment of vaccine exemptions among Wyoming school children, 2009 and 2011.

During 2010-2011, varicella vaccination was an added requirement for school entrance in Wyoming. Vaccination exemption rates were compared during the 2009-2010 and 2011-2012 school years, and impacts of implementing a new childhood vaccine requirement were evaluated. All public schools, grades K-12, were required to report vaccination status of enrolled children for the 2009-2010 and 2011-2012 school years to the Wyoming Department of Health. Exemption data were analyzed by exemption category, vaccine, county, grade, and rurality. The proportion of children exempt for ≥ 1 vaccine increased from 1.2% (1,035/87,398) during the 2009-2010 school year to 1.9% (1,678/89,476) during 2011-2012. In 2011, exemptions were lowest (1.5%) in urban areas and highest (2.6%) in the most rural areas, and varicella vaccine exemptions represented 67.1% (294/438) of single vaccination exemptions. Implementation of a new vaccination requirement for school admission led to an increased exemption rate across Wyoming.

Assessing the acceptability and feasibility of a school-located influenza vaccination program with third-party billing in elementary schools.

This study qualitatively assesses the acceptability and feasibility of a school-located vaccination for influenza (SLIV) project that was conducted in New York State in 2009-2011, from the perspectives of project participants with different roles. Fourteen in-depth semistructured interviews with participating schools' personnel and the mass vaccinator were tape-recorded and transcribed. Interviewees were randomly selected from stratified lists and included five principals, five school nurses, two school administrators, and two lead personnel from the mass vaccinator. A content analysis of transcripts from the interviews was completed and several themes emerged. All participants generally found the SLIV project acceptable. School personnel and the vaccinator viewed the SLIV project process as feasible and beneficial. However, the vaccinator identified difficulties with third-party billing as a potential threat to sustainability.

Improving immunization rates at 18 months of age: implications for individual practices.

OBJECTIVE: We sought to model the effect that a targeted immunization visit at 18 months of age could have on immunization rates of preschool-aged children in a sample of pediatric practices. METHODS: We conducted retrospective chart reviews in six practices of all active patients aged 18-30 months. Up-to-date (UTD) status was defined as receipt of four diphtheria-tetanus-acellular pertussis, three polio, one measles-mumps-rubella, three hepatitis B, and one varicella vaccines. Haemophilus influenza tybe b vaccine was not included due to a shortage in vaccine supply during the time of the study. Practice vaccination rates were determined at 17 months, 18 months, and the age at assessment. Of those not UTD at 17 months, the percentage of children who could be brought UTD with one visit was calculated for each practice. This calculated rate was compared with the measured rate at 18 months of age and at the age of assessment. RESULTS: At each practice, we reviewed 183-616 charts (median = 382). Observed UTD immunization rates at 17 months ranged from 26% to 64% (median = 38%) and increased 3 to 27 percentage points (median = 6) from age 17 months to 18 months and 9 to 39 percentage points (median = 17) from age 17 months to the age at assessment. A simulated vaccination visit at 18 months of age could improve the UTD rates from 27 to 61 percentage points (median = 44). CONCLUSION: Practice-based interventions aimed at encouraging an 18-month well-child visit that emphasizes delivery of vaccines have the potential to substantially increase timely vaccination rates among individual practices.

Do immunisation procedures match provider perception? A study from the South Carolina Pediatric Practice Research Network (SCPPRN).

OBJECTIVE: Immunisation coverage of children by 19 months of age in US primary care practices is below the desired goal of 80%. In order to improve this rate, primary care providers must first understand the specific processes of immunisation delivery within their office settings. This paper aims to identify key components in identifying strategies for quality improvement (QI) of immunisation delivery. METHODS: We surveyed a South Carolina Pediatric Practice Research Network (SCPPRN) representative for each of six paediatric practices. The surveys included questions regarding immunisation assessment, medical record keeping, opportunities for immunisation administration and prompting. Subsequently, research staff visited the participating practices to directly observe their immunisation delivery process and review patient charts in order to validate survey responses and identify areas for QI. RESULTS: Most survey responses were verified using direct observation of actual practice or chart review. However, observation of actual practice and chart review identified key areas for improvement of immunisation delivery. Although four practices responded that they prompted for needed immunisations at sick visits, only one did so. We also noted considerable variation among and within practices in terms of immunising with all indicated vaccines during sick visits. In addition, most practices had multiple immunisation forms and all administered immunisations were not always recorded on all forms, making it difficult to determine a child's immunisation status. CONCLUSIONS: For any QI procedure, including immunisation delivery, providers must first understand how the process within their practice actually occurs. Direct observation of immunisation processes and medical record review enhances survey responses in identifying areas for improvement. This study identified several opportunities that practices can use to improve immunisation delivery, particularly maintaining accurate and easy-to-locate immunisation records and prompting for needed immunisations during sick visits.

Provider chart audits and outreach to parents: impact in improving childhood immunization coverage and immunization information system completeness.

OBJECTIVE: Examine impact of provider chart audits and parental outreach in improving immunization coverage among children not up-to-date (NUTD) for immunizations in Philadelphia's immunization information system (IIS). METHODS: We identified 10-month-old children NUTD for age-appropriate immunizations using Philadelphia's IIS. Immunization rates at 10, 13, and 19 months were compared before and after contact with providers and parents. RESULTS: Of 5 610 children NUTD in the IIS at 10 months and living in areas with populations at risk for underimmunization, provider chart audits indicated that 3 612 (64%) were actually up-to-date (UTD); the majority of these (2 203) received additional age-appropriate immunizations and were also UTD at 19 months. Of 1 998 children truly NUTD at 10 months, half received overdue immunizations by 13 months following contact with parents via telephone, postcards, and home visits, but only 23 percent were UTD for age-appropriate vaccines at 19 months. CONCLUSIONS: Provider chart audits improved IIS data completeness, indicating that providers need to submit more complete and timely data to the IIS. Outreach to parents likely contributed to half of the children NUTD at 10 months receiving overdue immunizations by 13 months. However, most were again NUTD at 19 months, indicating that outreach efforts should be continued through 19 months or until children are brought UTD. Furthermore, in spite of outreach, about half of the NUTD children were not brought UTD by 13 or 19 months. New strategies should be developed to ensure that these children receive recommended vaccinations.

Hepatitis B Surface Antigen Testing Among Pregnant Women, United States 2014.

BACKGROUND: Post-exposure prophylaxis administered to infants shortly after birth prevents approximately 90% of cases of perinatal hepatitis B virus (HBV) transmission. The Advisory Committee on Immunization Practices recommends that all pregnant women be tested for hepatitis B surface antigen (HBsAg) at an early prenatal visit during each pregnancy to detect active infection with HBV. This study sought to determine the proportion and characteristics of pregnant women tested\not tested according to Advisory Committee on Immunization Practices recommendations. METHODS: We analyzed MarketScan databases to assess prenatal HBsAg testing among women with commercial and Medicaid health care coverage according to demographic and clinical characteristics. Pregnant women 15-44 years of age continuously enrolled in a health plan in the MarketScan database during 2013 and 2014 and with a live birth in 2014 were included. RESULTS: Among commercially insured women, 239,955 (87.7%) received HBsAg testing and 59.6% were tested during their first trimester. Among Medicaid-enrolled women, 57,268 (83.6%) received HBsAg testing and 39.4% were tested during their first trimester. Among women with high risk pregnancies, HBsAg testing occurred in 87.3% of those with commercial insurance and 84.8% with Medicaid. Testing also varied by maternal age; among women with commercial insurance, testing was greatest among women 26-44 years of age, and among women with Medicaid, testing was greatest among younger women (15-25 years). Testing was lowest among women residing in the Northeast (commercial insurance only). CONCLUSIONS: Prenatal HBsAg testing identifies HBV-infected pregnant women so their infants can receive timely immunoprophylaxis. Efforts to optimize HBsAg testing among all pregnant women are needed to further prevent perinatal HBV transmission.

How complete are immunization registries? The Philadelphia story.

OBJECTIVE: To assess accuracy and completeness of Philadelphia, Pa, registry data among children served by providers in areas at risk for underimmunization. METHODS: Philadelphia's Department of Public Health selected a simple random sample of 45 children age 19-35 months (or all children age 19-35 months if there were <45 children in the practice) from each of 30 private practices receiving government-funded vaccine and located in zip codes where children are at risk for underimmunization. Chart and registry data were compared with determine the proportion of children missing from the registry and assess differences in immunization coverage. RESULTS: Of 620 children reviewed, 567 (92%) were in the registry. Significant differences (P < .05) were observed in immunization coverage for 4 diphtheria-tetanus-acellular pertussis vaccinations, 3 polio vaccinations, 1 measles-mumps-rubella vaccination, and 3 Haemophilus influenzae type b vaccinations between the chart (80% coverage) and registry (62% coverage). Providers submitting electronic medical records or directly transferring electronic data to the registry had significantly more children in the registry and higher registry-reported immunization coverage than those whose data were entered from billing records or log forms. All practice types experienced difficulties in transferring complete data to the registry. CONCLUSIONS: Although 92% of study children were in the registry, immunization coverage was significantly lower when registry data were compared with chart data. Because electronic medical records and direct electronic data transfer resulted in more complete registry data, these methods should be encouraged in linking providers with immunization registries.

Immunization requirements for childcare programs. Are they enough?

BACKGROUND: School immunization legislation has resulted in high vaccination coverage rates and low rates of vaccine-preventable disease among school children. Similar legislation has been directed toward children in licensed and regulated childcare programs. The purpose of this investigation was to compare immunization coverage among children in and not in childcare. METHODS: For 18 months during 2001 and 2002, the National Immunization Survey (NIS), a random-digit-dialing telephone survey, collected information on children aged 19 through 35 months, including data on enrollment in childcare. Data were analyzed retrospectively to determine coverage at 24 months and at the time of the survey. Children were considered up-to-date if they had received all recommended immunizations for their age. RESULTS: Of the eligible NIS respondents, about 41% had a child in childcare at the time of or before the survey. Retrospective analysis of children at 24 months showed no significant differences in coverage between those in and not in childcare (73.1% vs 71.9%). Likewise, analysis of coverage at the time of the survey revealed no significant differences (76.4% vs 72.6%). CONCLUSIONS: Immunization legislation and regulations have been successful in increasing coverage rates in the school population. Similar legislation for childcare facilities appears not to have been as effective. Given these findings, it seems that new strategies are needed to increase coverage in preschool children.

Do laws bring children in child care centers up to date for immunizations?

BACKGROUND: Pennsylvania state law requires licensed child care centers (CCCs) to document that each enrolled child is up to date (UTD) for routine immunizations within 60 days of enrollment. This study evaluates the law's impact on immunization coverage among children aged

Assessing immunization interventions in the Women, Infants, and Children (WIC) program.

BACKGROUND: Vaccination promotion strategies are recommended in Women, Infants, and Children (WIC) settings for eligible children at risk for under-immunization due to their low-income status. PURPOSE: To determine coverage levels of WIC and non-WIC participants and assess effectiveness of immunization intervention strategies. METHODS: The 2007-2011 National Immunization Surveys were used to analyze vaccination histories and WIC participation among children aged 24-35 months. Grantee data on immunization activities in WIC settings were collected from the 2010 WIC Linkage Annual Report Survey. Coverage by WIC eligibility and participation status and grantee-specific coverage by intervention strategy were determined at 24 months for select antigens. Data were collected 2007-2011 and analyzed in 2013. RESULTS: Of 13,183 age-eligible children, 5,699 (61%, weighted) had participated in WIC, of which 3,404 (62%, weighted) were current participants. In 2011, differences in four or more doses of the diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine by WIC participation status were observed: 86% (ineligible); 84% (current); 77% (previous); and 69% (never-eligible). Children in WIC exposed to an immunization intervention strategy had higher coverage levels than WIC-eligible children who never participated, with differences as great as 15% (DTaP). CONCLUSIONS: Children who never participated in WIC, but were eligible, had the lowest vaccination coverage. Current WIC participants had vaccination coverage comparable to more affluent children, and higher coverage than previous WIC participants.

Seasonal influenza vaccination at school: a randomized controlled trial.

BACKGROUND: Influenza vaccination coverage for U.S. school-aged children is below the 80% national goal. Primary care practices may not have the capacity to vaccinate all children during influenza vaccination season. No real-world models of school-located seasonal influenza (SLV-I) programs have been tested. PURPOSE: Determine the feasibility, sustainability, and impact of an SLV-I program providing influenza vaccination to elementary school children during the school day. DESIGN: In this pragmatic randomized controlled trial of SLV-I during two vaccination seasons, schools were randomly assigned to SLV-I versus standard of care. Seasonal influenza vaccine receipt, as recorded in the state immunization information system (IIS), was measured. SETTING/PARTICIPANTS: Intervention and control schools were located in a single western New York county. Participation (intervention or control) included the sole urban school district and suburban districts (five in Year 1, four in Year 2). INTERVENTION: After gathering parental consent and insurance information, live attenuated and inactivated seasonal influenza vaccines were offered in elementary schools during the school day. MAIN OUTCOME MEASURES: Data on receipt of ≥1 seasonal influenza vaccination in Year 1 (2009-2010) and Year 2 (2010-2011) were collected on all student grades K through 5 at intervention and control schools from the IIS in the Spring of 2010 and 2011, respectively. Additionally, coverage achieved through SLV-I was compared to coverage of children vaccinated elsewhere. Preliminary data analysis for Year 1 occurred in Spring 2010; final quantitative analysis for both years was completed in late Fall 2012. RESULTS: Results are shown for 2009-2010 and 2010-2011, respectively: Children enrolled in suburban SLV-I versus control schools had vaccination coverage of 47% vs 36%, and 52% vs 36% (p<0.0001 both years). In urban areas, coverage was 36% vs 26%, and 31% vs 25% (p<0.001 both years). On multilevel logistic analysis with three nested levels (student, school, school district) during both vaccination seasons, children were more likely to be vaccinated in SLV-I versus control schools; ORs were 1.6 (95% CI=1.4, 1.9; p<0.001) and 1.5 (95% CI=1.3, 1.8; p<0.001). CONCLUSIONS: Delivering influenza vaccine during school is a promising approach to improving pediatric influenza vaccination coverage. TRIAL REGISTRY: ClinicalTrials.govNCT01224301.

Status of school entry requirements for varicella vaccination and vaccination coverage 11 years after implementation of the varicella vaccination program.

We reviewed progress toward adoption of day care and school entry requirements in each state and the District of Columbia (DC) and compared varicella vaccination coverage by state to year of implementation of day care entry requirements. By the start of the 2006-2007 school year, 46 states (92%) and DC had implemented entry requirements for varicella vaccination. Between 1997 and 2005, national varicella vaccination coverage among children 19-35 months of age increased from 25.8% to 87.9%. Implementation of day care entry requirements in 2000 or earlier was associated with higher vaccination coverage (> or =90%; P=.002). Implementation of day care and school entry requirements for varicella vaccination is an important strategy for achieving and maintaining high vaccination coverage among preschool- and school-aged children in the United States. The newly adopted vaccine policy recommendation of 2 doses of varicella vaccine for all school-aged children should be incorporated into the states' school entry requirements.

Influenza vaccination coverage rate among high-risk children during the 2002-2003 influenza season.

BACKGROUND: Influenza vaccination is the primary method for preventing influenza and its complications. Characteristics of influenza vaccination coverage among high-risk children (HRC) during the 2002-2003 influenza season are described. METHODS: Children aged 1 to 17 years continuously enrolled in private health insurance plans during the 2002-2003 influenza season and entered in MarketScan paid claims databases were included. Children were partitioned into 2 groups: high-risk children and nonhigh-risk children (non-HRC) based on their diagnosis history since 1998. The influenza vaccination coverage rates of both groups during the 2002-2003 influenza season were assessed by demographic, child, and provider-related variables. RESULTS: The influenza vaccination coverage rate was 4.63% among all sampled children. Overall, influenza vaccination coverage rates were higher among HRC (11.74%) than non-HRC (3.31%). Among children ages 12 to 23 months, HRC had lower coverage than non-HRC, but, from age 2 years onward, HRC consistently had higher coverage than non-HRC. Influenza vaccination coverage varied by geographic area, with higher coverage among children living within metropolitan areas and in the Western and the Northeast regions of the United States. Children receiving vaccination under a comprehensive insurance plan had significantly lower coverage than children served by all other plan types. CONCLUSION: Influenza vaccination coverage during the 2002-2003 influenza season was very low among all children, leaving many children at risk for influenza and influenza-related complications. Coverage was influenced by child age, insurance plan type, and area of residence.

Physician compliance with pneumococcal conjugate vaccine shortage recommendations in 2004.

OBJECTIVE: To assess pattern of pneumococcal conjugate vaccine (PCV) administration during periods of vaccine shortage and changing recommendations. METHODS: During 2004 PCV shortages, the Advisory Committee for Immunization Practices recommended delay of doses 3 and 4 (PCV3 and PCV4) to healthy children. A managed care health plan evaluated PCV doses administered to all enrolled children at ages 3, 5, 7, and 16 months in 2004; ICD9 codes were used to identify high-risk children. RESULTS: Immunization coverage for the first two PCV doses remained relatively stable throughout 2004 for both high-risk and healthy children. PCV3 coverage for healthy children dropped significantly from 63 percent preshortage (February 2004) to a low of 7 percent (June 2004), then rose to preshortage levels of 2 months after recommendations were made to resume PCV3 administration. Coverage of high-risk children followed a similar pattern as that for healthy children. PCV4 coverage showed similar declines and increases following shortage-related recommendations as PCV3. Most children whose PCV3 dose may have been delayed during the shortage did receive PCV3 after the shortage. CONCLUSIONS: Providers demonstrated rapid change in PCV administration in response to shortage-related recommendations. Little coverage difference was seen between healthy and high-risk children, possibly due to inadequate ability to determine which children truly are at high risk identified on the basis of ICD9 codes.

Practice-based electronic billing systems and their impact on immunization registries.

Many providers rely on electronic billing systems to report information to immunization registries. If billing data fail to capture some administered immunizations, the registry will not reflect a child's true immunization status. Our objective was to assess differences between immunizations administered and immunizations reported to a registry from electronic billing systems. Philadelphia's Department of Public Health conducted chart audits in 45 providers serving 50 or more children aged 7-35 months and using electronic billing systems to report data to Philadelphia's immunization registry in 2001-2003. Chart records were compared to registry records to identify immunizations administered in these practices but not reported to the registry. The study practices administered 256,969 immunizations to 20,611 children. Of these 256,969 administered immunizations, 62,213 (24%) were not in the registry. The electronic billing systems submitted data for all administered immunizations for 69% of immunization visits, some but not all for 11% of visits, and none for 20% of visits. Immunizations administered but not billed cost these providers up to $980,477 in lost revenue from administrative fees alone. Improvement of billing data quality would result in more complete registries, higher reported immunization coverage rates, and recovered revenue for immunization providers.

Progress toward implementation of a second-dose measles immunization requirement for all schoolchildren in the United States.

In 1998, the Advisory Committee on Immunization Practices and the American Academy of Pediatrics recommended that states ensure that all children in grades kindergarten through 12 receive 2 doses of measles-mumps-rubella (MMR) vaccine by 2001. In 2000, the National Immunization Program surveyed states, the District of Columbia, and United States territories, commonwealths, and protectorates to assess progress toward this goal. Almost all respondents (53 [98%] of 54) reported a second-dose requirement for entry to elementary school, middle school, or both. By fall of 2001, most (82%) school-aged children in the United States were in grades requiring a second dose of measles vaccine. For 29 responding programs, the requirement did not yet affect all grades. By 2009, 52 of 54 responding programs will require a second dose for all grades. Although not all states have achieved coverage of all schoolchildren with 2 doses of MMR vaccine, most states are well on their way toward this goal.