1. Assessing Immunization Coverage Among Children Attending Licensed Child Care Centers, New York City
New York City Department of Health and Mental Hygiene
(NYC DOHMH)
Bureau of Immunization
Ayaan Gedi, MPH
Sharon Spence, MPH, EdD, CHES
Christopher Zimmerman, MD, MPH

2. New York City Background
Population of 8.3 million*
Annual birth cohort ~127,000*
238,911 children in child care programs **
Accounts for 37% of all children < 6 years of age
*Source: U.S. Census Bureau, Population Division U.S. Census 2008 Population Estimates
* * New York City Administration for Children’s Services, June 2008

3. Two Types of Centers Assessed
Home-based centers
4,500 private centers
23,565 children enrolled
Maximum of 16 children per site
Children aged six weeks to 12 years
Commercial centers
1,600 private/public centers
101,000 children enrolled
Includes Universal Pre-Kindergarten and Head Start programs
Ages of children vary by license type

4. Child Care Centers NYC Bureau of Child Care (BCC)
Provides oversight, licensing and registration
Conduct inspections for new/renewal permits
Issues violations for non-compliance
NYC Bureau of Immunization (BOI)
Responsible for monitoring compliance with state immunization law in child care settings
Tools used to assess coverage
An annual mandated state survey
Limited audits conducted at centers
BCC Permit requirements include minimum standards for health examinations and immunizations for the staff and children. inspectors are unannounced. Violations cited during an inspection must be corrected either immediately or between two and four weeks, depending on the type of violation. A child care service cannot obtain a new or renewed permit until all violations have been corrected. The Bureau assigns an Early Childhood Education Consultant to each child care service to assist with with issues or concerns that may arise during these inspections.

5. New York State (NYS) Public Health Law (PHL) §2164
Defines immunization requirements for schools and child care programs
Requires age-appropriate immunizations for children in child care including:
4 DTaP,3 Polio,1MMR,3 HepB,3 Hib,1 Var ,4 PCV* (4:3:1:3:3:1:4)
Requires child care programs to submit an annual self-reported immunization coverage survey to the state
Required immunization for children in Day dare and pre-schools include:
PCV for children born on or after 1/1/2008
Forgiven at age-appropriate times and intervals
Additionally all preschool programs are
Pre-school defined as any private or public child care centers which include:
Nurseries
Head Start, UPK
Daycares,
Group family child cares (GFC) - Licensed home-based centers
*Requirement starting 2006

6. Pre-school Age Immunization Coverage in NYC
2009 NIS coverage for the 4:3:1:3:3:1 series among children months in NYC was 74.2% ±6.8*
NYC BOI has been exploring ways to improve coverage among pre-school age children
*2009 National Immunization Survey, CDC

7. Previous Analysis of Pre-school Age Coverage
Assess geographic differences in coverage
Identify neighborhoods for targeted outreach
Used NYC Department of Education immunization data
Assessed students entering kindergarten during the SY
Retrospectively determined their DTaP4 coverage at 2 years of age
In 2010 last year the NYC BOI conducted a geographic analysis of to identify low coverage areas. The goal of assessment was to identity and target neighborhoods for assessment. To identify areas with the highest number of children not up-to-date, coverage was weighted by number of children born in each zip code in 2008 using CIR birth record data.
*Immunization data from Automate the Schools, a computerized system maintained by the NYC Department of Education

8. Identified 10 zip codes with highest number of children missing DTaP4
6 in Brooklyn
4 in Bronx
Bronx
Zip codes with highest number of children missing DTap4

9. Goal
Assess immunization coverage of children attending licensed child care centers located in 10 targeted zip codes
To determine whether enhanced enforcement of state immunization requirements in child care settings can be used to improve vaccination coverage among pre-school children

10. Methods
Obtained list from BCC for centers located in the targeted zip codes
Excluded centers that:
Did not respond to NYS survey during the SY
Had only one child attending
Visited sites during summer and fall 2010
Collected all immunization records on file
For home-based centers we knew that there were many sites that did not report children or just had one child. We also knew from experience that sites that report at least 2 children generally enroll more children during the course of the year. So we included in the study centers that reported and had 2 or more children.

11. Methods Entered data into CoCASA* v.5.1
Searched NYC’s Immunization Information System (IIS), the Citywide Immunization Registry (CIR)**
Missing records/doses
Invalid doses
Used CoCASA to calculate up-to-date (UTD) status
Only valid doses used for analysis
PCV coverage not assessed
The CIR was which is populations based immunization registry
PCV Born on or after 1/1/08 4 doses by 15 months of age (verbalize it)
*Comprehensive Clinic Assessment Software Application (CDC)
** The CIR is a mature population based immunization registry

12. Analysis
Evaluated age-appropriate UTD coverage at the time of assessment
Assessed 4:3:1:3:3:1 for those19-35 months of age
Retrospective coverage for two vaccine series at specific age milestones
3:3:1:3:3:1 at 13 months for those >13 months
4:3:1:3:3:1 at 19, 24 & 35 months
Assess to compliance with state laws
Compare with NIS
Timeliness of vaccination. Assessed retrospective retrospectively. So for all children assessed 13 months and older know how well immunized children were at 13. For all children in these respective age groups and older.
Compare to our previous analysis

13. Results

14. Commercial Centers Home-based Centers 613 99 94 397 Visited 155 120
Excluded
Excluded
613
sites identified
216
Not responded
NYS survey 99
sites identified 5
closed/moved 94
Visited
397
Responded
to NYS survey
242
<2 children
155
w/>2 children 35
closed/moved
120
Visited

15. Average # children/site
Summary of Centers
214 centers visited
7,751 children <6 years of age identified
Type of centers
Total centers visited
Children
# (%)
Average # children/site
Home-based
120
956 (12%) 8
(range 4-12)
Commercial 94
6,795 (88%) 92
(range )

16. Age Distribution of Children Assessed
Median age= 37 months (range=2-71 months)
Age Group
# (%)
0-12 months
71 (1)
13-19 months
114(1)
20-23 months
92 (1)
24-35 months
1,369 (18)
36-71 months (3-<6 yrs)
6,105 (79)
Narrative: 3% of children identified were less than 24 months of age. 18% of the children were between 2-3 years of age and 79% of children in child care were between 3 yrs and 5 yrs.

17. UTD Status at Time of Assessment (n=7,751)
Received immunization by assessment date
86% (6,642)
Of those NOT UTD and eligible to receive a vaccination on their last visit
11%(770)
Need 1 dose
85% (657)
Need 2 doses
1% (83)
Needed 3+ doses
<1%(30)
86% pf children of children assessed were UTD for age appropriate vaccines at time of assessment. Of the 11% of the were eligible but not UTD, 85% needed just one additional dose to become UTD
UTD for age-appropriate for DTaP, Polio, MMR, HepB, Hib, Var

18. UTD Status at Time of Assessment by Type of Center
UTD for age-appropriate for DTaP, Polio, MMR, HepB, Hib, Var

19. Single Antigen Coverage of Children 19-35 months of age (n=1,102)
We also looked at the UTD of children who were months of age. For the this age cohort, the expectation is that they would have completed all due recommended vaccines. For , 79 % of children in this cohort has completed the series. When we compare to NIS data you can see that the covergae is slighly higher but when you account for the confidence interval the difference disappreas.
By Antegin, you can see that the lowest coverage is for 4th Dtap and 3rd HepB.

20. Timeliness of Vaccination Retrospective UTD Status at Specific Age Milestones
3:3:1:3:3:1
4:3:1:3:3:1

21. Summary of Findings Majority of children were 3 yrs and older
14% of all children assessed were not in compliance with immunization requirements at the time of assessment
Of these, the majority were just one dose away from being UTD
Delays in completing vaccine series
Coverage increased at months of age which is when children appear to be entering day care in the targeted areas
Coverage was lower in home-based centers
Each bullet point what we thought and what we got

22. Challenges/Limitations
Specific challenges with home-based centers
Numerous centers
More resources required for assessments
Fewer number of children enrolled
Incomplete immunization records on site
Necessary to conduct CIR (IIS) look-ups
Data was manually entered into CoCASA
Time consuming effort

23. Conclusions
Day care immunization requirements are important to ensure children are UTD
Increased compliance activities are needed
Commercial centers have the most children and are the most efficient place to target activities
Challenges in conducting assessments in home-based centers where coverage is lower

24. Next Steps
Coordinate with BCC to identify ways to better enforce immunization requirements in licensed child care centers
Develop better monitoring tools to assess coverage
Examine the role of using the CIR (IIS) for compliance activities

25. Acknowledgements Bureau of Immunization Bureau of Child Care
Program Support Staff
Grecia Caines, PHA
Mirleine Joseph, PHA
Emily Le, PHA
Osayuki Oshodin, PHA
Jane Tubridy, SPHA
Nancy Villanueva, PHA
Sharon Spence, PHE
Betty Sanchez, PAA
Medical Director
Christopher Zimmerman, MD, MPH
Bureau of Child Care
Ann Nazitto, HSM