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Immunization and the Health Care System

The current array of vaccines recommended by the Advisory Committee on Immunization Practices provides a safe and cost-effective means of protecting children against diseases that in the past were serious threats to their health and sometimes their lives. State laws ensure that by the time children enter school, nearly all of them have received recommended immunizations against diphtheria, tetanus, pertussis, polio, measles, mumps, and rubella. Newer vaccines against Haemophilus influenzae type b (Hib) and hepatitis B have joined the list of recommended (but not universally required) childhood immunizations. Children should receive the majority of the recommended doses of these vaccines (the basic series) by the time they are 2 years of age (see Table 2-1 for the recommended schedule of immunizations).

Although more than 90 percent of all children have received at least one immunization by 2 years of age, the proportion of 2-year-olds in any state who had received all recommended immunizations in 1989 ranged from only 45 to 70 percent (CDC, unpublished data, 1993). 1 Coverage for specific immunizations varies as well. Walter Orenstein, Director of the National Immunization Program at CDC, reported that the 1991 National Health

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These rates are based on children receiving four doses of diphtheria-tetanus-pertussis (DTP) vaccine, three doses of oral polio vaccine, and one dose of measles-mumps-rubella vaccine. If the fourth dose of DTP vaccine is excluded, state immunization rates range from 56 to 81 percent. These retrospective data are derived from reviews of school health records of children entering school in 1992–1993. Hib and hepatitis B immunizations were not assessed because they were not required for school entry in every state.



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Overcoming Barriers to Immunization: A Workshop Summary 2 Immunization and the Health Care System The current array of vaccines recommended by the Advisory Committee on Immunization Practices provides a safe and cost-effective means of protecting children against diseases that in the past were serious threats to their health and sometimes their lives. State laws ensure that by the time children enter school, nearly all of them have received recommended immunizations against diphtheria, tetanus, pertussis, polio, measles, mumps, and rubella. Newer vaccines against Haemophilus influenzae type b (Hib) and hepatitis B have joined the list of recommended (but not universally required) childhood immunizations. Children should receive the majority of the recommended doses of these vaccines (the basic series) by the time they are 2 years of age (see Table 2-1 for the recommended schedule of immunizations). Although more than 90 percent of all children have received at least one immunization by 2 years of age, the proportion of 2-year-olds in any state who had received all recommended immunizations in 1989 ranged from only 45 to 70 percent (CDC, unpublished data, 1993). 1 Coverage for specific immunizations varies as well. Walter Orenstein, Director of the National Immunization Program at CDC, reported that the 1991 National Health 1   These rates are based on children receiving four doses of diphtheria-tetanus-pertussis (DTP) vaccine, three doses of oral polio vaccine, and one dose of measles-mumps-rubella vaccine. If the fourth dose of DTP vaccine is excluded, state immunization rates range from 56 to 81 percent. These retrospective data are derived from reviews of school health records of children entering school in 1992–1993. Hib and hepatitis B immunizations were not assessed because they were not required for school entry in every state.

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Overcoming Barriers to Immunization: A Workshop Summary Interview Survey (NHIS) found that 82 percent of 2-year-olds had received a measles vaccination, but only 53 percent had received the recommended third dose of polio vaccine. Recently published data from the 1992 NHIS show a similar measles vaccination rate and 72 percent with three doses of polio vaccine (CDC, 1994a). CDC notes that the improvement in coverage against polio may reflect the success of immunization efforts but that changes in survey methodology between 1991 and 1992 also may be a factor.2 Immunization levels among preschool children have long fallen short of the desired target of 90 percent (Stehr-Green et al., 1993b), but serious outbreaks of vaccine-preventable diseases have led to increased awareness of the problem. Delayed immunization of preschool children threatens the health of children of all racial, ethnic, and socioeconomic groups. Low immunization rates for African-American, Hispanic, and other minority children and children living in poverty must be improved but are not the only problem. Data for 1992 show that 75 percent of the 2-year-olds not immunized against measles were white, and 72 percent were in families with incomes at or above the poverty line (CDC, 1994a). FACTORS CURRENTLY CONTRIBUTING TO UNDERIMMUNIZATION No easily delineated system of primary care exists in the United States. For immunization and other services, providers in the public and private sectors deliver varying sets of services, under diverse systems of compensation, to which families have differing degrees of access. For immunization in particular, no consensus seems to exist as to how responsibility for ensuring that children receive the appropriate care should be shared among parents, providers, payers, and health departments. This can result in gaps in children's care. In considering the factors that contribute to delayed immunization of preschool children, the workshop focused on those that lie in the organization and delivery of immunization and other health care services and those that lie in families' incomplete or inaccurate understanding of children's health care needs. Other factors—poverty, homelessness, and changing family structure, for example—are much broader in scope than immunization services or health care per se. Addressing these issues was well beyond the scope of the workshop, but their impact on children and children's health care must be acknowledged and was touched on during the workshop. 2   In the 1991 survey, respondents were asked for the exact ages at which a child received a vaccine. In the 1992 survey, however, parental reports that children had received vaccines did not require information on the age at which the child was immunized. In 1994, provider records will be checked to establish the immunization status of 2-year-olds (specifically, any child who is 19 to 35 months of age) (CDC, 1994a).

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Overcoming Barriers to Immunization: A Workshop Summary TABLE 2-1  Recommended Schedule for Routine Active Immunization of Infants and Childrena Age DTPb OPVc MMRd Hibe Schedule Af Hibe Schedule Bg Hep Bh (Option 1) Hep Bh (Option 2) At birth (before hospital discharge)           Hep B   1–2 months           Hep B Hep B 2 monthsi DTP OPV   Hib A Hib B     4 months DTP OPV   Hib A Hib B   Hep B 6 months DTP OPVj   Hib A       6–18 months           Hep B Hep B 12–15 months     MMR Hib Ak Hib Bk     15 months DTaP/DTPl             4–6 years (before school entry) DTaP/DTP OPV MMRm         aFor details on each vaccine, on minimum age at first dose, and on minimum intervals between doses, consult the most recent recommendations of the Advisory Committee on Immunization Practices (CDC, 1994c). bDTP: Diphtheria, tetanus, and pertussis vaccine. cOPV: Live oral polio vaccine. dMMR: Measles, mumps, and rubella vaccine. eHib: Haemophilus influenzae type b conjugate vaccine. Combined DTP and Hib vaccines are also available. Recommended schedules vary by manufacturer. For recommendations specific to the vaccine being used, consult the package insert.

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Overcoming Barriers to Immunization: A Workshop Summary fSchedule A: HbOC (Lederle Praxis) or PRP-T (Pasteur Merieux). gSchedule B: PRP-OMP (Merck Sharp & Dohme). hHep B: Hepatitis B vaccine. For use among infants born to mothers seronegative for hepatitis B. (All infants born to seropositive mothers should receive immunoprophylaxis for hepatitis B virus as soon as possible after birth.) Hepatitis B vaccine can be given at the same visit with DTP (or DTaP), OPV, Hib and/or MMR vaccines. iCan begin at 6 weeks of age. jThe American Academy of Pediatrics recommends giving this OPV dose at 6–18 months of age. kAfter the primary infant vaccination series is completed, any of the licensed Hib conjugate vaccines may be used as a booster dose at age 12–15 months. lDTaP: Diphtheria, tetanus, and acellular pertussis vaccine. This dose of DTP can be administered as early as 12 months of age provided that the interval since the previous dose of DTP is at least 6 months. DTaP is currently recommended only for use as the fourth and/or fifth doses of the DTP series among children at ages 15 months through 6 years (before seventh birthday). Some experts prefer to administer these vaccines at 18 months of age. mThe American Academy of Pediatrics recommends giving this MMR dose at entry to middle school or junior high school. SOURCE: Adapted from CDC (1994c).

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Overcoming Barriers to Immunization: A Workshop Summary Broad Factors For some families, the complexities of daily living may mean that immunization in particular and preventive health care in general are a relatively low priority among other activities and obligations. Fernando Guerra, Director of Health for the San Antonio Metropolitan Health District, suggested that depression might be an obstacle to effective use of available health care and social services, particularly among inner-city and other disadvantaged populations. The mobility of families, even within a community, can make it difficult for health care providers to maintain contact with their patients and for families to establish a regular source of care for their children. When children are cared for by grandparents or other relatives, there may be uncertainty in the family over who is responsible for the children's health care. The health care system itself, which focuses on acute medical care, gives relatively little attention to any form of preventive health care (including immunizations). If families do not understand the distinction, they may not question a lack of preventive care. Specific Barriers to Immunization A variety of barriers hinder timely immunization of preschool children (see Orenstein et al., 1990; NVAC, 1991, 1992; Cutts et al., 1992). They can be grouped into three broad categories: (1) the health care system, (2) the provider setting, and (3) personal and cultural factors related to families. The Health Care System One of the most fundamental barriers is the current lack of systematic information on immunization needs—which children are not immunized and why—and on the resources available to meet those needs. Providers must be available to deliver care, but shortages exist in some settings. David Wood, from the University of California, Los Angeles, School of Medicine, pointed to a recent assessment of ambulatory care capacity in Los Angeles that found a need for 2 million to 6 million more visits than can be accommodated by the current system. Such shortages may leave children with acute care services but few preventive care services, including immunizations. Workshop participants also expressed concern that the quality of care available in many inner cities is poor. Serious provider shortages affect many rural areas as well. David Smith, the Texas Health Commissioner, observed that the state 's 26 community and migrant health centers were insufficient to meet the needs of the rural population, which is spread over a large geographic area and served by few other providers.

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Overcoming Barriers to Immunization: A Workshop Summary Although most children seem to have some nominal source of preventive care, it may be difficult to use those services. Clinics can be hard to reach or have limited hours or long waiting times. Some providers give immunizations only by appointment or as part of health supervision (or well child) visits. Elizabeth Holt, from the Johns Hopkins School of Hygiene and Public Health, noted that the study of inner-city Baltimore for CDC found that 25 percent of families had no telephone in their homes. These families may have problems making appointments and are more difficult to contact if appointments are missed. Cost has been an increasing concern for families and for those purchasing vaccines (states, clinics, health maintenance organizations [HMOs], individual providers) (Freeman et al., 1993). Immunizations are generally covered by HMO plans but not by most indemnity health insurance plans. Some private providers have cited the cost for families who lack insurance coverage for immunization as a reason that children are referred to public clinics (Schulte et al., 1991; Liu and Rosenbaum, 1992). Families, including those with private insurance, also cite cost as an important reason for using public clinics (Abbotts and Osborn, 1993; Lieu et al., 1994). Private providers may refer their Medicaid patients to health department clinics because reimbursements for immunization are too low, sometimes not even covering the cost of the vaccine (Liu and Rosenbaum, 1992). Some providers also have found that the up-front cost to purchase vaccine for Medicaid patients is too great. Thomas Vernon, with the Merck Vaccine Division, described a program operating in four states that reduces this problem: providers receive vaccine for Medicaid patients from Merck at no cost; as the vaccine is administered to children, Medicaid reimbursements for the cost of the vaccine are paid directly to Merck. The new federal vaccine purchase program will reduce the financial burden on providers (see below). The Provider Setting Some children use health care services but still are not fully immunized. Providers who do not have information about the immunization status of the children in their practice may not be aware that some of their patients are underimmunized. Workshop discussions highlighted the importance of missed opportunities to immunize children who use the health care system. Missed opportunities can arise when providers have no access to a child's immunization records, do not review or incorrectly assess a child's immunization status, do not administer all medically indicated vaccines during a single visit, or do not immunize a child with a mild illness, even though that illness does not constitute a valid contraindication to immunization. Lance Rodewald, from the University of Rochester School of Medicine and Dentistry, reported that the CDC-sponsored study found that eliminating missed

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Overcoming Barriers to Immunization: A Workshop Summary opportunities for immunization in a neighborhood health center in Rochester, New York, would reduce from 38 percent to 14 percent the proportion of 12-month-olds who were behind on their third dose of DTP vaccine. In Rochester overall, missed immunization opportunities accounted for about half of the amount of time children remained late for scheduled immunizations (Szilagyi et al., 1993). Elizabeth Holt noted that in inner-city Baltimore, elimination of missed immunization opportunities would reduce from 42 percent to 20 percent the proportion of 24-month-olds who had not received their fourth dose of DTP vaccine. Allan Arbeter and David Wood observed that substantial numbers of the inner-city families that they studied in Philadelphia and Los Angeles, respectively, receive care from private providers. Generally, those children were less well immunized than others in the community. These private providers need to improve their immunization practices, but the weak ties that some of them have to the larger health care community may make it harder to influence their practices. Personal and Cultural Factors Some families may not appreciate the risk and severity of vaccine-preventable diseases and may not understand the importance of immunization or the importance of early and complete immunization. Other families may delay or avoid having their children immunized because of concerns about the safety and effectiveness of specific vaccines or objections to all immunizations as unnatural. Differences in the languages spoken by families and health care providers can hinder the use of immunization services. Cultural and community factors can affect whether families are willing to use available immunization services. For example, the CDC-sponsored study in Los Angeles found that in specific inner-city neighborhoods, Latinos made much greater use of county health clinics than African-Americans, who relied more on private providers (Wood et al., 1993). Predicting Underimmunization Underimmunization is associated with families' knowledge, attitudes, and demographic and socioeconomic characteristics plus the characteristics of the providers they use. Reliable predictors of underimmunization have proved elusive, however. For example, Tracy Lieu, from the Northern California Kaiser Permanente HMO, reported that without its separate immunization tracking system, Kaiser was unable to predict delayed immunization from information routinely available in their HMO database (Lieu et al., 1993). The four CDC diagnostic studies found that the factors that were significant predictors of immunization levels differ with the age of the child and differ

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Overcoming Barriers to Immunization: A Workshop Summary among various communities and subpopulations. David Wood suggested that the Los Angeles data indicate that family characteristics such as number of children, employment status, social networks, and sources of information about immunization are the principal influences on whether children receive initial immunizations. Age-appropriate immunization among 2-year-olds is related more strongly to factors such as health insurance status, source of health care, and immunization status at younger ages. These factors suggest that use of the health care system is a key to immunization status. CURRENT AND ANTICIPATED FEATURES OF IMMUNIZATION SERVICES Current Features Across the United States, immunization services are delivered by a diverse array of public and private health care providers, with the assistance of an equally diverse array of federal, state, local, and private programs. Overall, private providers administer about half of all immunizations. Patterns vary among states and communities, however. In Massachusetts, for example, state immunization director Susan Lett estimates that private providers deliver 85 percent of immunizations because there is no system of county-based public health clinics such as those found in most other states. In contrast, some southern states report that about 80 percent of immunizations are provided in local health department clinics (Freeman et al., 1993). Foundations and companies (including insurers and vaccine companies) provide funding and other assistance to support projects aimed at improving immunization rates. Professional organizations also promote immunization services through national, state, and local activities. In many communities, volunteer organizations, such as the Junior League or the Rotary Club, help publicize and staff special immunization efforts. Ideally, these activities should promote better primary care as well. At the federal level, several agencies in the Department of Health and Human Services (DHHS) have important immunization-related responsibilities. The National Vaccine Program Office (NVPO) is overseeing implementation of the President's Childhood Immunization Initiative and is coordinating the efforts of other federal agencies. The National Immunization Program at CDC directs many other federal immunization activities. Among its responsibilities are managing federal funds for vaccine purchase, administering grants to states (including those for Immunization Action Plans), providing technical assistance, conducting disease surveillance, and measuring immunization levels. In the Health Resources and Services Administration (HRSA) at DHHS, immunization-related activities are conducted by the Maternal and Child Health

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Overcoming Barriers to Immunization: A Workshop Summary Bureau, the community and migrant health centers of the Bureau of Primary Health Care, and the Vaccine Injury Compensation Program. Other DHHS agencies involved in immunization activities include the Indian Health Service, the Health Care Financing Administration (Medicaid), and the Administration for Children and Families (Child Care Block Grant and Aid to Families with Dependent Children [AFDC]). The Department of Agriculture (Special Supplemental Food Program for Women, Infants, and Children [WIC] and the Cooperative Extension Service) and the Department of Housing and Urban Development also contribute to these efforts. State responsibilities and participation in immunization-related activities vary. Common roles include establishing immunization requirements for day-care and school entry, setting Medicaid reimbursement levels, and distributing publicly purchased vaccines. Most states purchase vaccines for their public health clinics at a federally negotiated contract price for bulk quantities. Grants from CDC provide some of the funds that states use for these purchases. Twelve states purchase vaccines at the contract price for all of their participating providers. In most states, however, individual providers must purchase vaccines at higher catalog prices. Beginning in October 1994, under the Vaccines for Children Program of the Childhood Immunization Initiative, the federal government will purchase vaccines to immunize children who are (1) eligible for Medicaid (even if not enrolled in the Medicaid program), (2) without health insurance, (3) insured but have no coverage for immunization and obtain immunizations at federally qualified health centers or rural health clinics, or (4) Native Americans. States will distribute the vaccine to participating providers without charge. Although the vaccines will be free, providers will be permitted to charge limited fees for administering them. States are expected to apply CDC funds previously spent on vaccine purchase to improving the infrastructure for delivering immunization services. Anticipated Features with Health Care Reform In the longer term, immunization services and efforts to improve the primary care environment in which they should be delivered will be shaped by the health care reform measures that are finally implemented. Although the details of those measures remain to be settled, the committee agreed that certain features with implications for immunization are likely to appear in any comprehensive reform legislation. A uniform benefits package will include immunizations for children, and financial barriers to primary care services will be removed for children covered by the system. Workshop participants noted, however, that experiences in HMOs and communities such as Rochester, New York, where the availability of care is already assured, have shown that removing financial barriers to services does not ensure that families use them,

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Overcoming Barriers to Immunization: A Workshop Summary nor does the use of primary care services ensure that children receive timely immunizations. Further steps will be needed to establish links between families and providers and to encourage providers to immunize all children for whom they are responsible. Health care reform is also likely to reduce the delivery of personal health services by public health departments and shift those services to the private sector. This may not be the case, however, for special populations such as illegal immigrants, who may be hard reach. Public health departments will remain responsible for developing policy, assessing the need for individual and community health services, and assuring that those services are provided (IOM, 1988). With better information about a community's needs, health departments also are likely to assume an enhanced role in outreach and education. As private providers become the principal source of services such as immunization, they will play an increasingly important role in meeting the community 's public health needs. Private providers, especially in capitated health care plans, are also likely to become more accountable for the delivery of those services. THE COMMITTEE'S ASSESSMENT The committee found that the workshop presentations and discussions indicate that efforts to improve immunization rates for preschool children should focus on five specific concerns: leadership for action on immunization; accountability and responsibility for providing immunizations; support for improving provider practices; effective communication with families and the community; and development of better information and more effective information tools. The remainder of the report addresses these issues. For each topic, steps that could be taken to improve immunization services in the short term and in the longer term also are discussed.