the delivery room (WHO, 2006). When mothers were asked to take their newborns to a vaccination room for their hepatitis B vaccine birth dose, vaccine coverage was low.

Childhood Vaccination

ACIP recommends that unvaccinated children and adults under 19 years old be given the hepatitis B vaccine series (Mast et al., 2005). Studies have found racial and ethnic disparities in childhood vaccination rates: Asian and Pacific Islander (API), Hispanic, and black children had lower vaccination rates than non-Hispanic white children (CDC, 2000; Darling et al., 2005; Jenkins et al., 2000; Morita et al., 2008; Szilagyi et al., 2002). However, when poverty was controlled for, the estimates did not remain significantly lower for any racial or ethnic population than for non-Hispanic white children (CDC, 2009c).

Studies have also found geographic variability in vaccination coverage (Darling et al., 2005; Morita et al., 2008; Szilagyi et al., 2002). The disparities are seen state by state and within regions. For instance, in 2008, Maryland had the highest percentage of children who were up to date1 on their vaccinations with a rate of 82.3%, compared with Montana with a rate of 59.2% (CDC, 2009c). Szilagyi et al. (2002) looked at the use of reminder and recall interventions by primary-care providers to increase immunization rates for children under 2 years old. Before the intervention, the baseline geographic disparity was an 18% difference between innercity children (55%) and suburban children (73%). Within 3 years of the establishment of the intervention, the vaccination rates had increased in all areas, including 84% in the inner city and 88% in the suburbs.

All but three states—Alabama, Montana, and South Dakota—have a childhood hepatitis B vaccination mandate for daycare or school entry (Immunization Action Coalition, 2009). A retrospective cohort study of Chicago public-school children found that the hepatitis B vaccination school-entry mandate led to an increase in the vaccination rate among all children and substantially decreased the disparity in the vaccination rate between white children and black and Hispanic children (Morita et al., 2008). Before the school-entry mandate, the study found immunizations rates in non-Hispanic white, black, and Hispanic children of 89%, 76%, and 74%, respectively. After the mandate was enacted, the rates changed to


The immunization series used in these data includes the following vaccinations—4 or more doses of DTaP, 3 or more doses of poliovirus vaccine, 1 or more dose of any measles-containing vaccine, 3 or more doses of Hib vaccine, 3 or more doses of hepatitis B vaccine, as well as 1 or more dose of varicella vaccine (CDC, 2009c).

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