1. Are US Children In Compliance with Vaccination Recommendations?
National Immunization Conference, March 2008
Elizabeth Luman
Kate Shaw
Shannon Stokley
S A F E R ● H E A L T H I E R ● P E O P L E

2. Survey
Learn more about your perceptions regarding vaccination coverage…

3. 1: What recommendations are made by the ACIP about routine early childhood vaccinations?
Vaccines and number of doses
Ages for those doses
Minimum ages and intervals considered valid
Other vaccine-specific recommendations
All of the above

4. 2: What do you think it means for a 2-year-old child to be “up-to-date” on their vaccinations?
They have received all the recommended doses of each vaccine
They have received all the recommended doses, after excluding doses that are considered invalid by the ACIP
They are not currently behind for any vaccines, after accounting for all ACIP recommendations

5. 3: What is meant by “vaccination coverage” for the standard vaccine series?
Percent of children who received the number of the vaccines in the series
Percent of children who received these doses, after excluding doses that are considered invalid by the ACIP
Percent of children who are not currently behind for any vaccines in the series, after accounting for all ACIP recommendations
Last question…

6. Vaccination Coverage Estimates
Widely used
Programmatic and policy decisions
Evaluate quality of services
Target additional services
Federally-reported coverage estimates
Annually by CDC in the MMWR
Compliance with number of doses
Other recommendations not routinely evaluated

10. Compliance with All ACIP Recommendations
Purpose
Pinpoint strengths and weaknesses
Strategies to improve services
Specifics
Missing doses
Invalid doses
Other vaccine-specific recommendations
In this analysis, we looked at…
Strengths and weaknesses of vaccination programs…
We looked at Missing doses, as are evaluated with official coverage, as well as…

11. Methods 2005 National Immunization Survey Analysis
17,500+ children aged months
Completed household interview
Vaccination history information from providers
Analysis
SUDAAN, weighted
Weighted to account for different probabilities of selection, and to ensure that results are representative of all US children

12. Outcome variables Individual vaccines 4:3:1:3:3 series
DTaP, polio, MMR, Hib, HepB, varicella
4:3:1:3:3 series
Above except varicella
PCV excluded due to shortages and recent introduction
Vaccines received by the age at interview (19-35 months)

13. Outcome variables ACIP-compliant coverage
Child did not need additional vaccinations at time of interview
Excludes invalid doses with 4-day grace period
Minimum age
Minimum interval between doses
Minimum interval between live vaccines (MMR & Varicella)
Last HepB dose at 6+ months
3-4 doses of Hib, last dose at 12+ months
Fewer Hib doses if first dose after 6 months
Varicella vaccine or history of disease
The primary outcome was…
So we didn’t look at whether they got vaccinated on time – just if they didn’t need any more vaccines by the time of the interview
HepB – accounts for extra HepB given with Pediarix at 4 months
We also account for variability in number of hib doses required for different manufacturers by requiring the last dose to be given at 12 or later, as is required for either formulation.
For Varicella, we accepted either receipt of vaccine or history of vrc disease
Number of doses regardless of age at receipt except that varicella has to be given at 12 months or later

14. Outcome variables Dose-counting coverage
Standard CDC method reported in the MMWR
Number of doses regardless of age at receipt
Except varicella at 12+ months
3 doses of Hib
The primary outcome was…
HepB – accounts for extra HepB given with Pediarix at 4 months
We also account for variability in number of hib doses required for different manufacturers by requiring the last dose to be given at 12 or later, as is required for either formulation.
For Varicella, we accepted either receipt of vaccine or history of vrc disease
Number of doses regardless of age at receipt except that varicella has to be given at 12 months or later

15. Results

17. 81%
72%
Differences in coverage estimates for specific vaccines were generally small – biggest decreases for hib and hepb. Varicella increased slightly.
But coverage for the series was more affected, with 72% of children in compliance with ACIP recommendations vs 81% who were not missing any doses.

18. And if we look at the corresponding percent of children who needed to re-visit their provider because they were NOT up-to-date on their vaccinations, we have

19. 19%
19% based on standard dose-counting. But when you account for all ACIP recommendations

20. 28%
19%
there are 50% more children who are not UTD, or 28%. So more than 1 in 4 children aged months were not in compliance with recommendations at the time of the interview.

21. Effect of Each Recommendation on Coverage
Next we’ll take a closer look at the effect of each of the recommendations on coverage

22. 1.6%
For DTaP, about 14% of children were missing a dose, and about 2 and a half percent had an invalid dose, further reducing coverage about 1 and a half percentage points.

23. 0.1%
Fewer children missed a dose of poliovirus vaccine, and less than 1% received an invalid dose, reducing coverage only negligibly.

24. 0.9%
Results were similar for MMR

25. 0.1%
For Hib, few received an invalid dose,

26. 6.3%
but >6% received 3 doses but needed 4 because they didn’t have the 3rd after age 12 months, as is required by the recommendations.

27. 1.8%
On the other hand, many children started hib after 6 months, which meant that they needed fewer doses, increasing coverage almost 2 percentage points.

28. 3.6%
For HepB, 14% of children received a 3rd dose prior to the minimum 6 months. 11% went on to receive a 4th dose, while the remaining 3 and a half percent did not, and thus were counted as up-to-date by the dose-counting method but were not compliant with ACIP recommendations.

29. 1.2%
About 10% of children did not receive varicella vaccine, and 1% received an invalid dose.

30. 0.9%
But 3% had history of disease, increasing coverage by about 1%.

31. 6.2%
Finally, for the series, about 19% of children were missing one or more doses, and 8% received an invalid dose, including about 6% with a dose too early and 2 and a half % with a dose too soon after a previous dose.

32. “OK, but how does this affect children in MY state?”
OK, so those are national results, but you might ask how…

33. Missing One or More Doses in 4:3:1:3:3 Series
0%–10%
(1 state)
11%–20%
(29 states)
21%–30%
(19 states)
>30%
(2 states)
This map shows the percentage of children who are not UTD by the standard definition of dose-counting. You can see that most of the states – 30 – are shaded blue or green, indicating that <20% of their children were not UTD, while only 21 states are shaded yellow or red, indicating that >20% were not UTD. And just 2 states had >30% of children not UTD.

34. Missing One or More Doses in 4:3:1:3:3 Series
0%–10%
(1 state)
11%–20%
(29 states)
21%–30%
(19 states)
>30%
(2 states)
0%–10%
(0 states)
11%–20%
(2 states)
>30%
(13 states)
21%–30%
(36 states)
Not ACIP-Compliant 4:3:1:3:3 Series
By comparison, this map shows the percent of children who are not compliant with ACIP recommendations. You can see that now only 2 states are shaded blue or green with <20% not compliant, wile the remaining 49 states have > 1 in 5 children non-compliant. And 13 states are in red, showing that >30% of children are not compliant with the recommendations.

35. Conclusions Dose-counting  Simple and time-tested
 Accounts for 2/3 of non-compliance with ACIP recommendations
 Disregards substantial number of children who are not in compliance with recommendations
“Percent of children in compliance with recommendations” is an essential measure of the quality of healthcare service delivery
So, we can see that…
Disregards… at the time of the interview
I believe that…
A comprehensive approach to measuring coverage, including a dose-counting measure as well as measures of overall compliance, timeliness, etc. can help us to…

36. Conclusions Comprehensive approach to measuring coverage May help to
Series and individual vaccines
Dose-counting and ACIP-compliance
Timeliness and coverage at various ages
May help to
Determine quality of care
Evaluate programs
Reveal strengths and weaknesses
Elicit data-driven solutions

37. Ensure that children and communities are optimally protected from vaccine-preventable diseases
To help us all
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38. For more information: Manuscript in press AJPM June 2008 Thank You!
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The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.