By the time that children in the United States enter school, more than 95 percent of them have received all recommended immunizations. This impressive level of compliance, among the highest immunization rates in the world, is in sharp contrast to the unacceptably low immunization rates for U.S. children under 2 years of age. National estimates for 1992 indicate that only about 70 percent of these younger children have received the recommended three doses of oral polio vaccine (CDC, 1994a). About 80 percent have received at least three doses of the diphtheria-tetanus-pertussis vaccine, but the reported data do not indicate how many have received all four doses recommended by the Advisory Committee on Immunization Practices (CDC, 1994a).
Epidemic levels of measles between 1989 and 1991 and subsequent outbreaks of pertussis and other vaccine-preventable diseases have made low immunization rates among preschool children an especially serious concern (Orenstein et al., 1990; NVAC, 1991). The measles epidemic, which resulted in about 55,000 cases and 132 measles-related deaths (CDC, 1993a), was tragic evidence that vaccine-preventable diseases such as measles, rubella, diphtheria, and pertussis remain a threat.
Efforts to improve immunization levels among preschool children have been substantially expanded and made more visible during the past year (Shalala, 1993). The President's Childhood Immunization Initiative is giving greater support to ongoing activities and is the basis for new efforts to ensure the universal availability of affordable vaccines, increase public awareness of the
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Overcoming Barriers to Immunization: A Workshop Summary 1 Introduction THE CHALLENGE TO IMPROVE IMMUNIZATION RATES AMONG PRESCHOOL CHILDREN By the time that children in the United States enter school, more than 95 percent of them have received all recommended immunizations. This impressive level of compliance, among the highest immunization rates in the world, is in sharp contrast to the unacceptably low immunization rates for U.S. children under 2 years of age. National estimates for 1992 indicate that only about 70 percent of these younger children have received the recommended three doses of oral polio vaccine (CDC, 1994a). About 80 percent have received at least three doses of the diphtheria-tetanus-pertussis vaccine, but the reported data do not indicate how many have received all four doses recommended by the Advisory Committee on Immunization Practices (CDC, 1994a). Epidemic levels of measles between 1989 and 1991 and subsequent outbreaks of pertussis and other vaccine-preventable diseases have made low immunization rates among preschool children an especially serious concern (Orenstein et al., 1990; NVAC, 1991). The measles epidemic, which resulted in about 55,000 cases and 132 measles-related deaths (CDC, 1993a), was tragic evidence that vaccine-preventable diseases such as measles, rubella, diphtheria, and pertussis remain a threat. Efforts to improve immunization levels among preschool children have been substantially expanded and made more visible during the past year (Shalala, 1993). The President's Childhood Immunization Initiative is giving greater support to ongoing activities and is the basis for new efforts to ensure the universal availability of affordable vaccines, increase public awareness of the
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Overcoming Barriers to Immunization: A Workshop Summary need for immunization, and improve measurement of immunization levels. States and some major cities are receiving additional federal funds from the Centers for Disease Control and Prevention (CDC) to support Immunization Action Plans that should improve the systematic delivery of immunization services. Legislation before Congress proposes the development of state-based immunization registries. Among the activities in the private sector, national organizations are promoting community-level efforts to improve immunization services, and vaccine companies have started pilot projects to improve the availability of vaccines to Medicaid-eligible children. In 1990, the U.S. Public Health Service, in Healthy People 2000, set a national objective for the year 2000 that 90 percent of 2-year-olds complete the basic immunization series against the major preventable childhood illnesses (USDHHS, 1991). Under the President's Childhood Immunization Initiative, a 90-percent immunization target has now been set for 1996 (Table 1-1).1 This target presents a formidable challenge that requires an urgent response. The children who will need to be immunized by 1996 are already being born. The question must not be whether better immunization rates can be attained but how to attain them. Reaching and sustaining a commitment to universal and systematic delivery of immunization services to preschool children will require addressing many problems: for example, costs of vaccine and of delivery of services, the inaccessibility of services, complexities of the immunization schedule, missed opportunities for immunization at health care visits, incomplete information about children's immunization status, apprehensions about the safety of vaccines, and lack of appreciation for the risks of vaccine-preventable diseases. Families, health care providers, communities, and states also face larger social, economic, and political challenges that affect their ability to respond to the specific problems of immunization. 1 The immunization schedule recommended by the Advisory Committee on Immunization Practices and the American Academy of Pediatrics calls for children to receive by 2 years of age four doses of diphtheria-tetanus-pertussis (DTP) vaccine, three doses of oral polio vaccine, one dose of measles-mumps-rubella vaccine, three to four doses of Haemophilus influenzae type b vaccine, and three doses of hepatitis B vaccine. For the 1996 immunization target, assessment of DTP coverage will be based on the proportion of 2-year-olds who have received at least three doses of DTP vaccine. Recent CDC reports (e.g., CDC, 1994a) also use this reference point. Coverage rates based on three doses of DTP vaccine will be higher than rates based on four doses.
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Overcoming Barriers to Immunization: A Workshop Summary TABLE 1-1 Immunization Rates for Children 2 Years of Age, by Vaccine: 1992 Baselines and 1996 Targetsa Vaccine 1992 Baseline (%) 1996 Target (%) Diphtheria, tetanus, and pertussis (at least 3 doses) 83 90 Poliomyelitis (3 doses) 72 90 Measles, mumps, and rubella (1 dose) 83 90 Haemophilus influenzae type b (at least 3 doses) —b 90 Hepatitis B (3 doses) —b 70c aSurveys will assess children 19–35 months of age. bNot available. cTarget is 90 percent coverage in 1998. SOURCE: Adapted from CDC (1994a,b).
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Overcoming Barriers to Immunization: A Workshop Summary ORIGINS AND PURPOSE OF THE IOM WORKSHOP Following the President's initial proposals regarding immunization, public attention focused on the cost of vaccines and provisions for purchasing and distributing them. These financial factors are significant barriers, but removing them is not sufficient to achieve full immunization of preschool children. Even in states that currently make vaccines available to health care providers free of charge, fewer than 70 percent of 2-year-olds have received all recommended vaccine doses (CDC, unpublished data, 1993). Other significant barriers to full immunization lie in the organization and delivery of primary care, including immunization services, the practices of individual health care providers, and the knowledge, attitudes, and behavior of children's families (NVAC, 1991, 1992). The Institute of Medicine (IOM) felt that it was important to examine these other, largely nonfinancial barriers to immunization of preschool children. It also felt that identifying opportunities to overcome these barriers should not be deferred until the anticipated but indeterminate arrival of health care reform. To pursue these issues, an eight-member steering committee (see the committee roster at the beginning of the report) was appointed to oversee a 2-day invitational workshop, held on December 8–9, 1993 (see the Appendix for the workshop agenda). Funding was provided by the Carnegie Corporation of New York, the CDC, and the IOM's Board on Health Promotion and Disease Prevention. The National Vaccine Program Office strongly encouraged the IOM to conduct the workshop and provided valuable advice throughout the planning process. Workshop participants included leaders of programs that have tried various approaches to reducing barriers to immunization, experts in the social and behavioral sciences, and pediatricians and other health care practitioners, including those familiar with providing health care to underserved populations. Among the participants were investigators from CDC-funded “diagnostic” projects in Baltimore, Los Angeles, Philadelphia, and Rochester, New York. These health services research projects have examined the immunization services in their communities and assessed the impact of provider practices and family characteristics on immunization levels of children up to 2 years of age. THE COMMITTEE'S ASSUMPTIONS The committee's charge also called for overseeing preparation of this report. Several assumptions about immunization and immunization services underlie the committee's assessment of the workshop discussions.
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Overcoming Barriers to Immunization: A Workshop Summary All children living in the United States should be immunized in a timely manner. Each child, regardless of ability to pay or immigration status, should receive all recommended and medically appropriate immunizations on time. (For a few children, acute or chronic conditions make immunization inappropriate, or inappropriate at particular times.) Immunizations are among the safest and most cost-effective measures available for preventing illness. They protect the health of individual children and, by preventing outbreaks of infectious diseases, protect the health of other children and adults who may be susceptible to those diseases. Thus, immunization of individual children contributes to the common good. The environment for delivering vaccines is rapidly changing. Efforts to improve immunization rates among preschool children must take into account developments that are occurring on many fronts. The immunization schedule changes frequently as new vaccines and new formulations of existing vaccines are introduced. Increased public and private funding is allowing some states and communities to develop new health promotion and outreach programs for immunization and new immunization registry projects. Beginning in October 1994, the federal government will assume increased responsibility for purchasing vaccines for Medicaid-eligible and uninsured children. States will be responsible for distributing the vaccines to appropriate health care providers. Under pressure to control costs, many states are turning to managed care programs to deliver services to patients enrolled in the Medicaid program. The greatest changes in the health care environment are likely to come with passage of some version of the national health care reform measures now before Congress. Some see the renewed federal immunization activities, which reflect an investment in prevention, as a first step in health care reform. Immunization can best be seen as part of primary care. Better immunization services are needed within an overall system of primary care that provides a medical home for every child. A freestanding “immunization system” is not an appropriate objective. Referring children to separate immunization providers disrupts the continuity and comprehensiveness of their primary care and may keep them from receiving other primary care services. It also makes obtaining necessary services more burdensome for families and increases the likelihood that a child will not receive immunizations on schedule. Furthermore, as more and different vaccines are introduced, a medical home that provides comprehensive primary care will be able to coordinate a child's immunizations more effectively than separate providers can. Some workshop participants suggested that the attention focused on immunization could provide an opportunity to improve the overall integration of preventive care into primary care services. Currently, however, the absence of an adequate primary care system leads to the delivery of immunization services by a variety of providers in a variety of settings, including special immunization clinics.
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Overcoming Barriers to Immunization: A Workshop Summary The reduced financial barriers to primary care expected with health care reform should give the United States an opportunity to apply some lessons from the highly successful immunization program in the United Kingdom. There, every child is registered in a health district and is assigned to a primary care provider. Each provider is accountable for the immunization status of all children assigned to the practice and receives substantial incentive payments for achieving specific levels of immunization coverage among those children. Even with health care reform, however, the United States will not have a system comparable to the United Kingdom's unified National Health Service through which to work. Primary care will continue to be provided by a mix of providers in the public and private sectors. The United States also does not currently have a comprehensive registry system that can account for the immunization status of every child. Such differences will make it more complicated to establish the population-based accountability and rewards that are so important in the U.K. program. The United States cannot wait for health care reform to address its immunization problems. Although enactment of major health care reform measures appears likely, no one can be certain when they will take effect or what their final form will be. In the meantime, over 4 million children are being born each year. At current levels of immunization, about 1 million of them join the pool of underimmunized preschool children who remain susceptible to serious illnesses. Furthermore, health care reform is not necessary to begin improving immunization rates among preschool children. Steps such as those discussed at the workshop—that some states, communities, and providers are already taking—can make important contributions to more complete immunization coverage. THE WORKSHOP REPORT This report reflects the committee's assessment of the problem of underimmunization and the scope of the response that is needed. It makes no formal recommendations, but it draws on the analysis, experience, and insight of workshop participants to identify opportunities to achieve more complete immunization of preschool children in the near term. Other improvements may take longer to implement or will depend on the enactment of anticipated health care reform measures. Readers familiar with immunization issues will find in this report much that has been said before. The value of both the workshop discussions and this report lies in reiterating the seriousness of the problem of underimmunization and emphasizing the special importance of nonfinancial barriers to immunization. In particular, the report emphasizes establishing accountability for delivery of
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Overcoming Barriers to Immunization: A Workshop Summary immunization services, improving and protecting public health resources to assess immunization needs and ensure the delivery of immunization services, greatly expanding effective collaboration between providers in the public and private sectors, and increasing the public's awareness of the importance of immunizations and the seriousness of vaccine-preventable illnesses. Although this report focuses on nonfinancial factors that affect immunization rates, many important issues have significant economic dimensions. Those that were discussed at the workshop (e.g., Medicaid reimbursement and the cost of vaccine services to families) are included in the report. The committee's primary aim is to address those issues that require the attention of state-level decisionmakers, including government officials, public health officials, and leadership in the health professions. It also intends for the report to be useful to local government and public health officials, national leaders in government and the health professions, and public- and private-sector developers of health care reform plans.