ASSESSING IMMUNIZATION COVERAGE IN PRIVATE PRACTICE: WHY ASSESSMENT IS IMPORTANT
There are at least three principal reasons for assessing immunization coverage: (1) national objectives for preventing childhood vaccine-preventable diseases exist; (2) suboptimal immunization coverage is a reality; and (3) effectiveness of the assessment strategy has been demonstrated.
NATIONAL HEALTH OBJECTIVES
As a nation we have established goals to achieve high levels of immunization in the population. Because our ultimate goal is to have a society free of most childhood vaccine-preventable diseases (zero cases), our objectives among children 19-35 months of age are to achieve immunization coverage levels of 90% with individual vaccines and 80% with all the recommended vaccines combined by the year 20101. There is not a specific coverage objective for older children because school-aged children have been highly vaccinated (>95% covered) since the early 1980s due to widespread state-based immunization laws for school enrollment. erectalis 20 mg
Though our goals are high, they are within our reach. Since 1996 we have sustained record high levels of immunization coverage among children 19-35 months of age with individual vaccines: diphtheria-tetanus toxoid and pertussis vaccine (DTP) (95%), poliovirus vaccine (91%), measles-containing vaccine (MCV) (91 %) and haemophilus influenzae type b vaccine (Hib) (92%). In addition, paralytic poliomyelitis caused by the wild type virus and tetanus among children 15 years of age or younger have been eliminated, while diphtheria, measles, rubella, and haemophilus influenzae type b invasive disease among children 5 years of age or younger are close to elimination.
SUBOPTIMAL IMMUNIZATION COVERAGE
Although we have achieved and sustained record high levels of immunization coverage and record low levels of disease, there is still a need to improve out record and to sustain very high coverage into the future. In 1998, immunization coverage was 73% with the combined series of four doses of DTP, three doses of polio, one dose of а МСУ three doses of Hib vaccine, and three doses of Hepatitis В vaccine, which was 7% below our 80% objective for the year 2010. When coverage with varicella vaccine of 43% is included in the combined series, we are at least 37% below our objective. Though providers are conscientious about offering vaccines to patients on time, during the past two decades the immunization schedule has undergone seven major changes, including the introduction of routine vaccination of infants with Hepatitis B, Hib, and varicella vaccines. It is to be expected that both parents and providers are confused about how well children are vaccinated. One study of private physicians in Massachusetts found that providers’ beliefs regarding how well patients in their practice were immunized led to overestimates of coverage compared with the measured coverage rate. Providers believed that 85% to 100% of patients were fully immunized, but only 61% were actually fully immunized (CDC, unpublished data). Age-appropriate immunization becomes even more challenging if a child is frequently ill or parents do not make all the scheduled appointments.
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We need to improve on our record to prevent outbreaks of vaccine-preventable diseases. For instance, although measles vaccination coverage across the United States is greater than 90%, it is lower in many urban centers. If high levels are not reached and sustained in all parts of the country, we could face another epidemic of measles within a few years of consistently low coverage, particularly in our urban areas. It was just ten years ago when the nation experienced the worst measles epidemic since the 1970s. The health burden was considerable. There were reports of tens of thousands of cases, thousands of hospitalizations, and more than 100 measles-associated deaths. One lesson learned was that a gap existed in our health care delivery system for providing vaccines on time to preschool-aged children younger than five years of age. Of the preschool-aged children at highest risk for measles, nearly all (93%) had been seen by a health care provider during their lifetime, primarily within the year before their illness when they were eligible for measles vaccine. In addition, nearly one-quarter (24%) of the children surveyed had health care providers who missed at least one opportunity to administer measles vaccine simultaneously with other vaccines before their illness, reasons for which were unclear.
Missed opportunities for immunization is an important reason for undervaccination, which have been documented in a number of studies in the US and in many other countries (both developed and developing countries). Reasons for missed opportunities include failure to administer immunizations simultaneously, false contraindications for vaccination, health worker beliefs about immunization practices, and parental refusal. The most common reason for a missed opportunity occurs during a visit for an illness that is not a contraindication for immunization, yet the eligible child is not immunized.
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