Danni Daniels

Undervaccinated African-American preschoolers: A case of missed opportunities

OBJECTIVE To identify factors associated with undervaccination of African-American preschoolers, to describe the number of vaccination visits made by undervaccinated children and the number of visits needed to be series complete, and to describe the children who did not receive the single dose of measles-containing vaccine recommended for preschoolers. METHODS We used the 1999 National Immunization Survey (NIS) to describe vaccination coverage for the 4:3:1:3 vaccine series (four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, one dose of any measles-containing vaccine, and three doses of Haemophilus influenzae type b vaccine) among non-Hispanic, African-American preschoolers due to concerns that they may be at risk of undervaccination. Children who did not complete this basic vaccine series were classified for further analysis according to the number of doses they lacked (i.e., one dose missed, two or three doses missed, or four or more doses missed). Significant associations between demographic characteristics and vaccination status or degree of undervaccination were determined. RESULTS Of the 26.2% of African-American preschoolers who did not complete the 4:3:1:3 vaccine series, 40.3% lacked one, 35.3% lacked two or three, and 25.0% lacked four or more doses of vaccine. Children who did not complete the 4:3:1:3 vaccine series were less likely to have married mothers, were less likely to have mothers aged > or = 35 years, or were less likely to be up to date at age 3 months than the children who completed the 4:3:1:3 vaccine series. Among the undervaccinated, 63.7% had a sufficient number of vaccination visits to have completed the basic series. However, most (78.7%) of the severely undervaccinated (children who lacked more than three doses of vaccine) had three or fewer vaccination visits. For 72.6% of the undervaccinated preschoolers, only one additional vaccination visit was needed to complete the 4:3:1:3 vaccine series; among these, 78.3% had an adequate number of vaccination visits to have completed the series. Overall, 9.9% of the African-American children aged 19 to 35 months (i.e., approximately 85,000 African-American children aged 19 to 35 months) were at risk for measles. Among the children who lacked more than three doses of vaccine, 68.1% were at risk. CONCLUSIONS Our study suggests that the estimated coverage of 73.8% for the 4:3:1:3 vaccine series among African-American children aged 19 to 35 months was not a result of limited access to care. On the contrary, 90.5% of African-American children had enough vaccination visits to complete the series. To raise coverage and prevent potential outbreaks, providers should assess each childs vaccination status at every visit, and administer all needed vaccinations at that time. For the most severely undervaccinated children, this strategy may not be adequate, because they did not have the minimum number of vaccination visits required for series completion. For these children, other strategies are needed for increasing vaccination coverage.

Vaccination visits in early childhood: Just one more visit to be fully vaccinated

BACKGROUND This study characterizes the healthcare visits at which children receive vaccinations, including the number of these visits and the number of vaccinations that are administered. METHODS The 1999 National Immunization Survey (NIS) is a nationally representative sample of children aged 19 to 35 months, verified by provider records, that is conducted to obtain estimates of vaccination coverage rates. We describe the number of healthcare visits in which one or more vaccinations were given, the number of vaccinations given at these visits, and the number of visits and vaccinations needed for an underimmunized child to complete the recommended vaccination series. RESULTS Of the children who did not receive all doses of the recommended vaccinations (4:3:1:3:3 vaccination series), three fourths had four or more immunization visits. Vaccination coverage increased as the number of visits increased, and children who had completed the series were more likely to receive multiple vaccinations than those who had not. Most children (70.7%) received a maximum of four vaccinations in any immunization visit. The majority of children (73.5%) who had not completed the 4:3:1:3:3 vaccination series needed only a single visit to complete the series. The majority (61.7%) of children who needed only one visit also needed only one additional vaccination. CONCLUSIONS While estimated national coverage for all recommended vaccinations is considerably below the Healthy People 2000 and Healthy People 2010 goal of 90%, achieving this goal is in essence just one visit away. If all children who needed one more visit were to receive that final visit, the national coverage among children 19 to 35 months for all recommended vaccinations would be 93%.Abstract Background: This study characterizes the healthcare visits at which children receive vaccinations, including the number of these visits and the number of vaccinations that are administered. Methods: The 1999 National Immunization Survey (NIS) is a nationally representative sample of children aged 19 to 35 months, verified by provider records, that is conducted to obtain estimates of vaccination coverage rates. We describe the number of healthcare visits in which one or more vaccinations were given, the number of vaccinations given at these visits, and the number of visits and vaccinations needed for an underimmunized child to complete the recommended vaccination series. Results: Of the children who did not receive all doses of the recommended vaccinations (4:3:1:3:3 vaccination series), three fourths had four or more immunization visits. Vaccination coverage increased as the number of visits increased, and children who had completed the series were more likely to receive multiple vaccinations than those who had not. Most children (70.7%) received a maximum of four vaccinations in any immunization visit. The majority of children (73.5%) who had not completed the 4:3:1:3:3 vaccination series needed only a single visit to complete the series. The majority (61.7%) of children who needed only one visit also needed only one additional vaccination. Conclusions: While estimated national coverage for all recommended vaccinations is considerably below the Healthy People 2000 and Healthy People 2010 goal of 90%, achieving this goal is in essence just one visit away. If all children who needed one more visit were to receive that final visit, the national coverage among children 19 to 35 months for all recommended vaccinations would be 93%.

Immunogenicity of hepatitis B vaccine among hemodialysis patients: effect of revaccination of non-responders and duration of protection.

BACKGROUND Hepatitis B vaccination is recommended for patients on hemodialysis, however, seroprotection after a primary vaccine series is suboptimum. Limited data are available on the effect of revaccination of non-responders and on persistence of immunity in this population. METHODS Hepatitis B vaccine (40 μg/dose) was given to 77 susceptible patients on hemodialysis (0, 1, and 6 month schedule). Levels of hepatitis B surface antibody (anti-HBs) were tested ≥ 28 days after the third dose was administered, and non-responders revaccinated with an additional 3-dose series. Vaccine responders (anti-HBs ≥10 mIU/mL) were re-tested every 6 months and booster doses given as needed. Kaplan-Meier survival curve was used to estimate the probability of maintaining protective antibody level. Cox-proportional hazards models were used to assess the association between time to loss of protective antibody levels and certain explanatory variables. RESULTS Overall primary vaccine-induced response was 79.2% (95% CI 68.2%, 87.3%), including 49/77 (63.6%; 95% CI 51.8%, 74.7%) patients who received the initial primary hepatitis B vaccine series and 12/21 (57.1%; 95% CI 34.4%, 77.4%) non-responders who were revaccinated with an additional series. Among weak responders (anti-HBs level 10.0-99.9 mIU/mL), protective antibody levels persisted in 44% for 12 months post-vaccination; whereas among strong responders (anti-HBs level ≥100 mIU/mL), protective antibody levels persisted in 92% for 12 months, and 68% for 24 months post-vaccination. A weak post-vaccination response increased the risk of losing protective antibody levels (adjusted hazard ratio, 9.7; 95% confidence interval, 3.5-28.5; p<0.0001). CONCLUSION Revaccinating patients undergoing hemodialysis who do not respond to a primary vaccine series substantially increases the pool of protected patients. The threshold for defining hepatitis B vaccine-induced immunity should be revisited in this patient population to maximize the duration of protection.

Hepatitis B vaccination coverage among United States children.

Background. In 1991 the Advisory Committee on Immunization Practices recommended vaccination of all infants with three doses of hepatitis B virus vaccine (HepB) by 18 months of age as a key component of a comprehensive strategy to eliminate hepatitis B virus transmission in the United States. The American Academy of Pediatrics and the American Academy of Family Physicians published similar recommendations soon afterward. Methods. Data were obtained from the National Immunization Survey, a survey that began in 1994 and is conducted quarterly by the Centers for Disease Control and Prevention to estimate vaccination coverage among noninstitutionalized US children 19 to 35 months of age. Results. The 1999 National Immunization Survey data indicate that ∼88.1% (95% confidence interval, 87.4, 88.8) of children 19 to 35 months of age had received at least three doses of HepB (HepB3). There has been a consistent increase in HepB3 coverage since 1994. However, the rate of increase has slowed in recent years and HepB3 coverage remains lower than coverage attained with three doses of diphtheria-tetanus-pertussis and Haemophilus influenzae vaccines. HepB3 coverage varied slightly by race/ethnicity and was highest among white and Asian children (89%). Coverage also varied by state; 26 states had levels of at least 90%. Conclusions. Since the 1991 recommendations for universal hepatitis B vaccination, there has been a dramatic increase in coverage levels among children 19 to 35 months of age. However, the Childhood Immunization Initiative goal of 90% coverage has not been reached. Therefore continued efforts are needed to protect US children against this serious but preventable infection.

Undervaccination with hepatitis B vaccine: Missed opportunities or choice?

BACKGROUND An estimated 1 million to 1.25 million people in the United States are chronically infected with hepatitis B virus (HBV) and are at substantially increased risk of developing chronic liver disease, including cirrhosis and primary hepatocellular carcinoma. Immunization with hepatitis B vaccine (HepB) is the most effective means of preventing HBV infection and its consequences. METHODS To identify and describe children who had not completed the three-dose HepB series, we analyzed data from the 1999 National Immunization Survey (NIS). Among the 2648 children aged 19 to 35 months who did not complete the HepB series, we examined the relationship between the number of doses of HepB received and the number of vaccination visits made, receipt of the birth dose of HepB, age at the time of first vaccination visit (excluding that for the birth dose of HepB), and completion of the 4:3:1:3 series (four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, one dose of measles-containing vaccine, and three doses of Haemophilus influenzae type b vaccine [Hib]). RESULTS Overall, 11.8% of the children who were included in the 1999 NIS did not complete the HepB series. Among these series-incomplete children, most (79.8%; 95% CI, 77.4%-82.2%) did not receive the birth dose of HepB, and most (80.2%; 95% CI, 77.6%-82.8%) had three or more vaccination visits. Most of the series-incomplete children (87.3%; 95% CI, 85.1%-89.5%) who had three or more vaccination visits received one or two doses of HepB. Among series-incomplete children with at least three vaccination visits, those who did not receive any HepB were more likely to have completed the 4:3:1:3 series (67.1%; 95% CI, 58.8%-75.4%) than those who received at least one dose of HepB (52.7%; 95% CI, 49.0%-56.4%). CONCLUSIONS Children who did not complete the HepB series fell into three distinct groups: children who made at least three vaccination visits but did not begin the HepB series (n=326); children who made three or more vaccination visits and received one or two doses of HepB (n=1835); and children who made fewer than three vaccination visits (n=487). Different intervention strategies are needed to have an impact on each of these groups, including understanding why parents and providers may not be receptive to HepB, decreasing missed opportunities to administer HepB, and implementing tracking systems such as registries to identify and contact children who are due or overdue for vaccinations.Abstract Background: An estimated 1 million to 1.25 million people in the United States are chronically infected with hepatitis B virus (HBV) and are at substantially increased risk of developing chronic liver disease, including cirrhosis and primary hepatocellular carcinoma. Immunization with hepatitis B vaccine (HepB) is the most effective means of preventing HBV infection and its consequences. Methods: To identify and describe children who had not completed the three-dose HepB series, we analyzed data from the 1999 National Immunization Survey (NIS). Among the 2648 children aged 19 to 35 months who did not complete the HepB series, we examined the relationship between the number of doses of HepB received and the number of vaccination visits made, receipt of the birth dose of HepB, age at the time of first vaccination visit (excluding that for the birth dose of HepB), and completion of the 4:3:1:3 series (four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, one dose of measles-containing vaccine, and three doses of Haemophilus influenzae type b vaccine [Hib]). Results: Overall, 11.8% of the children who were included in the 1999 NIS did not complete the HepB series. Among these series-incomplete children, most (79.8%; 95% CI, 77.4%–82.2%) did not receive the birth dose of HepB, and most (80.2%; 95% CI, 77.6%–82.8%) had three or more vaccination visits. Most of the series-incomplete children (87.3%; 95% CI, 85.1%–89.5%) who had three or more vaccination visits received one or two doses of HepB. Among series-incomplete children with at least three vaccination visits, those who did not receive any HepB were more likely to have completed the 4:3:1:3 series (67.1%; 95% CI, 58.8%–75.4%) than those who received at least one dose of HepB (52.7%; 95% CI, 49.0%–56.4%). Conclusions: Children who did not complete the HepB series fell into three distinct groups: children who made at least three vaccination visits but did not begin the HepB series ( n =326); children who made three or more vaccination visits and received one or two doses of HepB ( n =1835); and children who made fewer than three vaccination visits ( n =487). Different intervention strategies are needed to have an impact on each of these groups, including understanding why parents and providers may not be receptive to HepB, decreasing missed opportunities to administer HepB, and implementing tracking systems such as registries to identify and contact children who are due or overdue for vaccinations.

Vaccination visits in early childhood33

BACKGROUND This study characterizes the healthcare visits at which children receive vaccinations, including the number of these visits and the number of vaccinations that are administered. METHODS The 1999 National Immunization Survey (NIS) is a nationally representative sample of children aged 19 to 35 months, verified by provider records, that is conducted to obtain estimates of vaccination coverage rates. We describe the number of healthcare visits in which one or more vaccinations were given, the number of vaccinations given at these visits, and the number of visits and vaccinations needed for an underimmunized child to complete the recommended vaccination series. RESULTS Of the children who did not receive all doses of the recommended vaccinations (4:3:1:3:3 vaccination series), three fourths had four or more immunization visits. Vaccination coverage increased as the number of visits increased, and children who had completed the series were more likely to receive multiple vaccinations than those who had not. Most children (70.7%) received a maximum of four vaccinations in any immunization visit. The majority of children (73.5%) who had not completed the 4:3:1:3:3 vaccination series needed only a single visit to complete the series. The majority (61.7%) of children who needed only one visit also needed only one additional vaccination. CONCLUSIONS While estimated national coverage for all recommended vaccinations is considerably below the Healthy People 2000 and Healthy People 2010 goal of 90%, achieving this goal is in essence just one visit away. If all children who needed one more visit were to receive that final visit, the national coverage among children 19 to 35 months for all recommended vaccinations would be 93%.Abstract Background: This study characterizes the healthcare visits at which children receive vaccinations, including the number of these visits and the number of vaccinations that are administered. Methods: The 1999 National Immunization Survey (NIS) is a nationally representative sample of children aged 19 to 35 months, verified by provider records, that is conducted to obtain estimates of vaccination coverage rates. We describe the number of healthcare visits in which one or more vaccinations were given, the number of vaccinations given at these visits, and the number of visits and vaccinations needed for an underimmunized child to complete the recommended vaccination series. Results: Of the children who did not receive all doses of the recommended vaccinations (4:3:1:3:3 vaccination series), three fourths had four or more immunization visits. Vaccination coverage increased as the number of visits increased, and children who had completed the series were more likely to receive multiple vaccinations than those who had not. Most children (70.7%) received a maximum of four vaccinations in any immunization visit. The majority of children (73.5%) who had not completed the 4:3:1:3:3 vaccination series needed only a single visit to complete the series. The majority (61.7%) of children who needed only one visit also needed only one additional vaccination. Conclusions: While estimated national coverage for all recommended vaccinations is considerably below the Healthy People 2000 and Healthy People 2010 goal of 90%, achieving this goal is in essence just one visit away. If all children who needed one more visit were to receive that final visit, the national coverage among children 19 to 35 months for all recommended vaccinations would be 93%.

Undervaccination with hepatitis B vaccine2

BACKGROUND An estimated 1 million to 1.25 million people in the United States are chronically infected with hepatitis B virus (HBV) and are at substantially increased risk of developing chronic liver disease, including cirrhosis and primary hepatocellular carcinoma. Immunization with hepatitis B vaccine (HepB) is the most effective means of preventing HBV infection and its consequences. METHODS To identify and describe children who had not completed the three-dose HepB series, we analyzed data from the 1999 National Immunization Survey (NIS). Among the 2648 children aged 19 to 35 months who did not complete the HepB series, we examined the relationship between the number of doses of HepB received and the number of vaccination visits made, receipt of the birth dose of HepB, age at the time of first vaccination visit (excluding that for the birth dose of HepB), and completion of the 4:3:1:3 series (four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, one dose of measles-containing vaccine, and three doses of Haemophilus influenzae type b vaccine [Hib]). RESULTS Overall, 11.8% of the children who were included in the 1999 NIS did not complete the HepB series. Among these series-incomplete children, most (79.8%; 95% CI, 77.4%-82.2%) did not receive the birth dose of HepB, and most (80.2%; 95% CI, 77.6%-82.8%) had three or more vaccination visits. Most of the series-incomplete children (87.3%; 95% CI, 85.1%-89.5%) who had three or more vaccination visits received one or two doses of HepB. Among series-incomplete children with at least three vaccination visits, those who did not receive any HepB were more likely to have completed the 4:3:1:3 series (67.1%; 95% CI, 58.8%-75.4%) than those who received at least one dose of HepB (52.7%; 95% CI, 49.0%-56.4%). CONCLUSIONS Children who did not complete the HepB series fell into three distinct groups: children who made at least three vaccination visits but did not begin the HepB series (n=326); children who made three or more vaccination visits and received one or two doses of HepB (n=1835); and children who made fewer than three vaccination visits (n=487). Different intervention strategies are needed to have an impact on each of these groups, including understanding why parents and providers may not be receptive to HepB, decreasing missed opportunities to administer HepB, and implementing tracking systems such as registries to identify and contact children who are due or overdue for vaccinations.Abstract Background: An estimated 1 million to 1.25 million people in the United States are chronically infected with hepatitis B virus (HBV) and are at substantially increased risk of developing chronic liver disease, including cirrhosis and primary hepatocellular carcinoma. Immunization with hepatitis B vaccine (HepB) is the most effective means of preventing HBV infection and its consequences. Methods: To identify and describe children who had not completed the three-dose HepB series, we analyzed data from the 1999 National Immunization Survey (NIS). Among the 2648 children aged 19 to 35 months who did not complete the HepB series, we examined the relationship between the number of doses of HepB received and the number of vaccination visits made, receipt of the birth dose of HepB, age at the time of first vaccination visit (excluding that for the birth dose of HepB), and completion of the 4:3:1:3 series (four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, one dose of measles-containing vaccine, and three doses of Haemophilus influenzae type b vaccine [Hib]). Results: Overall, 11.8% of the children who were included in the 1999 NIS did not complete the HepB series. Among these series-incomplete children, most (79.8%; 95% CI, 77.4%–82.2%) did not receive the birth dose of HepB, and most (80.2%; 95% CI, 77.6%–82.8%) had three or more vaccination visits. Most of the series-incomplete children (87.3%; 95% CI, 85.1%–89.5%) who had three or more vaccination visits received one or two doses of HepB. Among series-incomplete children with at least three vaccination visits, those who did not receive any HepB were more likely to have completed the 4:3:1:3 series (67.1%; 95% CI, 58.8%–75.4%) than those who received at least one dose of HepB (52.7%; 95% CI, 49.0%–56.4%). Conclusions: Children who did not complete the HepB series fell into three distinct groups: children who made at least three vaccination visits but did not begin the HepB series ( n =326); children who made three or more vaccination visits and received one or two doses of HepB ( n =1835); and children who made fewer than three vaccination visits ( n =487). Different intervention strategies are needed to have an impact on each of these groups, including understanding why parents and providers may not be receptive to HepB, decreasing missed opportunities to administer HepB, and implementing tracking systems such as registries to identify and contact children who are due or overdue for vaccinations.

Vaccine wastage in Nigeria: An assessment of wastage rates and related vaccinator knowledge, attitudes and practices

INTRODUCTION The introduction of new vaccines highlights concerns about high vaccine wastage, knowledge of wastage policies and quality of stock management. However, an emphasis on minimizing wastage rates may cause confusion when recommendations are also being made to reduce missed opportunities to routinely vaccinate children. This concern is most relevant for lyophilized vaccines without preservatives [e.g. measles-containing vaccine (MCV)], which can be used for a limited time once reconstituted. METHODS We sampled 54 health facilities within 11 local government areas (LGAs) in Nigeria and surveyed health sector personnel regarding routine vaccine usage and wastage-related knowledge and practices, conducted facility exit interviews with caregivers of children about missed opportunities for routine vaccination, and abstracted vaccine stock records and vaccination session data over a 6-month period to calculate wastage rates and vaccine vial usage patterns. RESULTS Nearly half of facilities had incomplete vaccine stock data for calculating wastage rates. Among facilities with sufficient data, mean monthly facility-level wastage rates were between 18 and 35% across all reviewed vaccines, with little difference between lyophilized and liquid vaccines. Most (98%) vaccinators believed high wastage led to recent vaccine stockouts, yet only 55% were familiar with the multi-dose vial policy for minimizing wastage. On average, vaccinators reported that a minimum of six children must be present prior to opening a 10-dose MCV vial. Third dose of diphtheria-tetanus-pertussis vaccine (DTP3) was administered in 84% of sessions and MCV in 63%; however, the number of MCV and DTP3 doses administered were similar indicating the number of children vaccinated with DTP3 and MCV were similar despite less frequent MCV vaccination opportunities. Among caregivers, 30% reported being turned away for vaccination at least once; 53% of these children had not yet received the missed dose. DISCUSSION Our findings show inadequate implementation of vaccine management guidelines, missed opportunities to vaccinate, and lyophilized vaccine wastage rates below expected rates. Missed opportunities for vaccination may occur due to how the health systems contradicting policies may force health workers to prioritize reduced wastage rates over vaccine administration, particularly for multi-dose vials.

Assessing strategies for increasing urban routine immunization coverage of childhood vaccines in low and middle-income countries: A systematic review of peer-reviewed literature.

INTRODUCTION Immunization programs in developing countries increasingly face challenges to ensure equitable delivery of services within cities where rapid urban growth can result in informal settlements, poor living conditions, and heterogeneous populations. A number of strategies have been utilized in developing countries to ensure high community demand and equitable availability of urban immunization services; however, a synthesis of the literature on these strategies has not previously been undertaken. METHODS We reviewed articles published in English in peer-reviewed journals between 1990 and 2013 that assessed interventions for improving routine immunization coverage in urban areas in low- and middle-income countries. We categorized the intervention in each study into one of three groups: (1) interventions aiming to increase utilization of immunization services; (2) interventions aiming to improve availability of immunization services by healthcare providers, or (3) combined availability and utilization interventions. We summarized the main quantitative outcomes from each study and effective practices from each intervention category. RESULTS Fifteen studies were identified; 87% from the African, Eastern Mediterranean and Southeast Asian regions of the World Health Organization (WHO). Six studies were randomized controlled trials, eight were pre- and post-intervention evaluations, and one was a cross-sectional study. Four described interventions designed to improve availability of routine immunization services, six studies described interventions that aimed to increase utilization, and five studies aiming to improve both availability and utilization of services. All studies reported positive change in their primary outcome indicator, although seven different primary outcomes indicators were used across studies. Studies varied considerably with respect to the type of intervention assessed, study design, and length of intervention assessment. CONCLUSION Few studies have assessed interventions designed explicitly for the unique challenges facing immunization programs in urban areas. Further research on sustainability, scalability, and cost-effectiveness of interventions is needed to fill this gap.

Using pneumococcal and rotavirus surveillance in vaccine decision-making: A series of case studies in Bangladesh, Armenia and the Gambia

Pneumonia and diarrhea are the leading causes of child morbidity and mortality globally and are vaccine preventable. The WHO-coordinated Global Rotavirus and Invasive Bacterial Vaccine-Preventable Disease Surveillance Networks support surveillance systems across WHO regions to provide burden of disease data for countries to make evidence-based decisions about introducing vaccines and to demonstrate the impact of vaccines on disease burden. These surveillance networks help fill the gaps in data in low and middle-income countries where disease burden and risk are high but support to sustain surveillance activities and generate data is low. Through a series of country case studies, this paper reviews the successful use of surveillance data for disease caused by pneumococcus and rotavirus in informing national vaccine policy in Bangladesh, Armenia and The Gambia. The case studies delve into ways in which countries are leveraging and building capacity in existing surveillance infrastructure to monitor other diseases of concern in the country. Local institutions have been identified to play a critical role in making surveillance data available to policymakers. We recommend that countries review local or regional surveillance data in making vaccine policy decisions. Documenting use of surveillance activities can be used as advocacy tools to convince governments and external funders to invest in surveillance and make it a priority immunization activity.