Vaccines are one of the greatest public health achievements, preventing both mortality and morbidity. However, overall immunization rates are still below the 90% target for Healthy People 2020. There remain significant disparities in immunization rates between children of different racial/ethnic groups, as well as among economically disadvantaged populations. There are systemic issues and challenges in providing access to immunization opportunities. In addition, vaccine hesitancy contributes to underimmunization. Multiple strategies are needed to improve immunization rates, including improving access to vaccines and minimizing financial barriers to families. Vaccine status should be assessed and vaccines given at all possible opportunities.
Key points
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Multiple strategies should be considered to address improving immunization rates and decreasing disparities.
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These may be at a physician or patient level, practice or health systems level, community level, as well as at a state and national level.
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Use of immunization information systems is vital in effectively implementing these strategies.
Introduction
Vaccines are one of the greatest public health achievements and are one of most cost-effective ways to prevent diseases and advance global welfare. Although immunization coverage rates have been steadily increasing in the United States, overall rates are still less than the 90% target for Healthy People 2020. In 2013, vaccination coverage for children 19 to 35 months old reached the 90% national Healthy People 2020 target for measles, mumps, and rubella vaccine (MMR), hepatitis B vaccine (Hep B), poliovirus vaccine, and varicella vaccine. However, coverage rates were below target levels for diphtheria, tetanus, and pertussis vaccine (DTaP), pneumococcal conjugate vaccine (PCV), Haemophilus influenzae type b vaccine (Hib), hepatitis A vaccine (Hep A), rotavirus, and the hepatitis B birth dose. For the combined series recommended for children aged 19 to 35 months (4:3:1:3*:3:1:4) 1
1 Combined vaccine series for 19 to 35 months includes greater than or equal to 4 doses of DTaP, greater than or equal to 3 doses of poliovirus vaccine, greater than or equal to 1 dose of measles-containing vaccine, full series of Hib vaccine (≥3 or ≥4 doses, depending on product type), greater than or equal to 3 doses of Hep B, greater than or equal to 1 dose of varicella vaccine, and greater than or equal to 4 doses of PCV.
national rates were 70.4%.Increasing rates have led to dramatic declines in illness and mortality related to vaccine-preventable illness ( Table1 ). Routine childhood vaccinations also significantly decrease costs to society. However, disparities remain with significantly less vaccination coverage for black children (65%) and children living below the federal poverty level (64.4%). DTaP, PCV, Hib, and rotavirus in particular had lower immunization rates, suggesting that these children had difficulty in maintaining regular and on-time well-child visits.
Vaccine-preventable Disease a | Cases Prevented (in Thousands) | ||
---|---|---|---|
Illnesses | Hospitalizations | Deaths | |
Diphtheria | 5073 | 5073 | 507.3 |
Tetanus | 3 | 3 | 0.5 |
Pertussis | 54,406 | 2697 | 20.3 |
Hib | 361 | 334 | 13.7 |
Polio | 1244 | 530 | 14.8 |
Measles | 70,748 | 8877 | 57.3 |
Mumps | 42,704 | 1361 | 0.2 |
Rubella | 36,540 | 134 | 0.3 |
Congenital rubella syndrome | 12 | 17 | 1.3 |
Hep B | 4007 | 623 | 59.7 |
Varicella | 68,445 | 176 | 1.2 |
Pneumococcus-related diseases b | 26,578 | 903 | 55.0 |
Rotavirus | 11,968 | 327 | 0.1 |
Total | 322,089 | 21,055 | 731.7 |
a Vaccines were considered as preventing disease for birth cohorts born in all years during 1994 to 2013 except for the following, which were only in use for part of the 20-year period: varicella, 1996 to 2013; 7-valent and 13-valent pneumococcal conjugate vaccines, 2001 to 2013; and rotavirus, 2007 to 2013.
b Includes invasive pneumococcal disease, otitis media, and pneumonia.
Adolescent immunization rates have also increased for routinely recommended vaccines to 86.0% for greater than or equal to 1 tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (TdaP) vaccine; 77.8% for greater than or equal to 1 meningococcal conjugate vaccine for serotypes A, C, Y and W (MenACWY) vaccine; 57.3% human papillomavirus (HPV) vaccine dose among female patients, and 34.6% for greater than or equal to 1 HPV dose among male patients. Completion rates for 3 doses of HPV vaccine are only 37.6% for girls and 13.9% for boys. Lower vaccination rates for HPV compared with TdaP and MenACWY are concerning. For children living below the poverty level and for black adolescents, TdaP and MenACWY vaccination rates were similar, and rates for an initial dose of HPV were higher for boys and girls, but completion rates for the HPV series were lower. Coverage for Hispanic adolescents was generally higher. However, rates for all groups are still below the goals for Healthy People 2020 of greater than 90%.
Despite overall increases in immunization rates, there remain significant disparities in childhood immunization rates between racial/ethnic groups and among economically disadvantaged populations. In these areas of underimmunization (pockets of need), which are often poor urban areas with significant barriers to immunization and limited health care resources, disease introduction could have vast impact because of low herd immunity and opportunity for widespread outbreaks. Pediatricians can play a vital role in helping to narrow the gap in immunization coverage rates.
Broader immunization coverage results in decreased prevalence of vaccine-preventable disease. With less experience with these infections, there is both less fear of the diseases and a gradual devaluing of the importance of vaccines in the public consciousness. As real or perceived concerns about vaccine side effects are perpetuated by media, or spread in communities through word of mouth, there is the emergence of vaccine hesitation. Although this may be seen more commonly in a different demographic group, in which parents may be more educated and more affluent, similar issues of fear and misinformation can emerge in any setting. Under immunization rates and vaccine refusals have been noted to occur in geographic clusters. Children living in these clusters are at higher risk for individual disease, and the community at risk for disease outbreaks.
Introduction
Vaccines are one of the greatest public health achievements and are one of most cost-effective ways to prevent diseases and advance global welfare. Although immunization coverage rates have been steadily increasing in the United States, overall rates are still less than the 90% target for Healthy People 2020. In 2013, vaccination coverage for children 19 to 35 months old reached the 90% national Healthy People 2020 target for measles, mumps, and rubella vaccine (MMR), hepatitis B vaccine (Hep B), poliovirus vaccine, and varicella vaccine. However, coverage rates were below target levels for diphtheria, tetanus, and pertussis vaccine (DTaP), pneumococcal conjugate vaccine (PCV), Haemophilus influenzae type b vaccine (Hib), hepatitis A vaccine (Hep A), rotavirus, and the hepatitis B birth dose. For the combined series recommended for children aged 19 to 35 months (4:3:1:3*:3:1:4) 1
1 Combined vaccine series for 19 to 35 months includes greater than or equal to 4 doses of DTaP, greater than or equal to 3 doses of poliovirus vaccine, greater than or equal to 1 dose of measles-containing vaccine, full series of Hib vaccine (≥3 or ≥4 doses, depending on product type), greater than or equal to 3 doses of Hep B, greater than or equal to 1 dose of varicella vaccine, and greater than or equal to 4 doses of PCV.
national rates were 70.4%.Increasing rates have led to dramatic declines in illness and mortality related to vaccine-preventable illness ( Table1 ). Routine childhood vaccinations also significantly decrease costs to society. However, disparities remain with significantly less vaccination coverage for black children (65%) and children living below the federal poverty level (64.4%). DTaP, PCV, Hib, and rotavirus in particular had lower immunization rates, suggesting that these children had difficulty in maintaining regular and on-time well-child visits.
Vaccine-preventable Disease a | Cases Prevented (in Thousands) | ||
---|---|---|---|
Illnesses | Hospitalizations | Deaths | |
Diphtheria | 5073 | 5073 | 507.3 |
Tetanus | 3 | 3 | 0.5 |
Pertussis | 54,406 | 2697 | 20.3 |
Hib | 361 | 334 | 13.7 |
Polio | 1244 | 530 | 14.8 |
Measles | 70,748 | 8877 | 57.3 |
Mumps | 42,704 | 1361 | 0.2 |
Rubella | 36,540 | 134 | 0.3 |
Congenital rubella syndrome | 12 | 17 | 1.3 |
Hep B | 4007 | 623 | 59.7 |
Varicella | 68,445 | 176 | 1.2 |
Pneumococcus-related diseases b | 26,578 | 903 | 55.0 |
Rotavirus | 11,968 | 327 | 0.1 |
Total | 322,089 | 21,055 | 731.7 |
a Vaccines were considered as preventing disease for birth cohorts born in all years during 1994 to 2013 except for the following, which were only in use for part of the 20-year period: varicella, 1996 to 2013; 7-valent and 13-valent pneumococcal conjugate vaccines, 2001 to 2013; and rotavirus, 2007 to 2013.
b Includes invasive pneumococcal disease, otitis media, and pneumonia.
Adolescent immunization rates have also increased for routinely recommended vaccines to 86.0% for greater than or equal to 1 tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (TdaP) vaccine; 77.8% for greater than or equal to 1 meningococcal conjugate vaccine for serotypes A, C, Y and W (MenACWY) vaccine; 57.3% human papillomavirus (HPV) vaccine dose among female patients, and 34.6% for greater than or equal to 1 HPV dose among male patients. Completion rates for 3 doses of HPV vaccine are only 37.6% for girls and 13.9% for boys. Lower vaccination rates for HPV compared with TdaP and MenACWY are concerning. For children living below the poverty level and for black adolescents, TdaP and MenACWY vaccination rates were similar, and rates for an initial dose of HPV were higher for boys and girls, but completion rates for the HPV series were lower. Coverage for Hispanic adolescents was generally higher. However, rates for all groups are still below the goals for Healthy People 2020 of greater than 90%.
Despite overall increases in immunization rates, there remain significant disparities in childhood immunization rates between racial/ethnic groups and among economically disadvantaged populations. In these areas of underimmunization (pockets of need), which are often poor urban areas with significant barriers to immunization and limited health care resources, disease introduction could have vast impact because of low herd immunity and opportunity for widespread outbreaks. Pediatricians can play a vital role in helping to narrow the gap in immunization coverage rates.
Broader immunization coverage results in decreased prevalence of vaccine-preventable disease. With less experience with these infections, there is both less fear of the diseases and a gradual devaluing of the importance of vaccines in the public consciousness. As real or perceived concerns about vaccine side effects are perpetuated by media, or spread in communities through word of mouth, there is the emergence of vaccine hesitation. Although this may be seen more commonly in a different demographic group, in which parents may be more educated and more affluent, similar issues of fear and misinformation can emerge in any setting. Under immunization rates and vaccine refusals have been noted to occur in geographic clusters. Children living in these clusters are at higher risk for individual disease, and the community at risk for disease outbreaks.
Barriers to immunization
Provider/System Barriers
Financial barriers
Vaccine costs and copays are potential barriers to vaccination. Vaccine costs have increased dramatically with the development of new vaccines and expansion of the vaccine schedule. In 1987, the entire vaccine series cost $37 for an individual in the public sector and $116 in the private sector. According to prices updated in January 2015, the series from birth to adulthood costs approximately $1452 per individual in the public sector and $2012 in private sector.
As a means to help provide vaccines for underserved groups, in 1963 Section 317 of the Public Service Act was launched. This program provided discretionary grants to states, select large cities, and territories to conduct routine childhood and adult immunization programs in a partnership model with local health departments. However, following the measles outbreak of 1989 to 1991, it was clear that there were large populations who were still underserved by immunization programs. In 1994, Congress passed the Omnibus Reconciliation Act, which created the Vaccines for Children program. This federal entitlement program was designed to address these issues by providing vaccines free of cost to uninsured and underinsured children 18 years of age and younger ( Fig. 1 ).
More recently, the Affordable Care Act (ACA) requires that vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) before September 2009 be administered without copayments or other cost-sharing requirements when those services are delivered by an in-network provider. However, health plans are not required to cover vaccinations delivered by an out-of-network provider, which may place a cost-sharing burden on families. Pharmacists and health departments may be considered out of network, thus preventing families from being able to use these as immunization sites.
Access to immunization
At present, the US Centers for Disease Control and Prevention (CDC) recommends vaccination against 16 different vaccine-preventable diseases for children. The vaccine schedule was intended to be coordinated with the well-child visit. In the past, vaccines have been administered in a primary care physician’s office and usually during scheduled appointments. This approach may affect the parents’ ability to bring a child in for vaccinations because of parent work schedules and inability to take time off from work.
Missed opportunities for immunization
Missed opportunities for immunizations are a well-documented cause for underimmunization. They occur when a child who is eligible for a vaccine and has no medical contraindications to vaccination fails to be immunized during a provider visit. These missed opportunities may occur because the physician does not immunize at acute care visits or because of misunderstandings about contraindications, such as during mild illness. It may occur because of providers’ reluctance to give multiple shots at 1 visit, or simply from oversight. Vaccine shortages, which occur intermittently, also contribute to underimmunizations or delayed immunizations by missed opportunities. During a shortage of Hib vaccine (December 2007 to September 2009) there was an interim recommendation to defer the booster dose, but to continue the primary series. This recommendation resulted in a decrease in the percentage of fully vaccinated children from 66% to 39.5%. Despite interim recommendations, the primary series coverage was also affected and was reduced by 7 percentage points. Similar national shortages have occurred with PCV (2001 and 2003–2004), varicella vaccine (2002), and influenza vaccine (2004–2005). The impact of local or clinic-level vaccine shortages are not well measured but are also likely to be significant.
Family/Social Barriers
Socioeconomic barriers
Children living below the poverty level and black children are documented to consistently have lower vaccination coverage rates. Factors associated with underimmunization include having public or no insurance, belonging to a family with 2 or more children living in the household, and having parents who are unmarried. Children who were enrolled in Women, Infants, and Children (WIC) during the first year of life, and children who were not eligible for WIC, tended to have higher vaccination coverage than those who were WIC eligible but not enrolled. Younger maternal age, history of fewer maternal prenatal care visits, higher birth order, and receiving care at public health clinics were also associated with late initiation of immunizations.
Vaccine hesitancy
In contrast with the families described earlier, a growing group of parents are refusing vaccines. These families refuse or defer vaccines for a growing variety of reasons. Many parents are worried about unsubstantiated vaccine side effects such as autism. Concerns also include a fear of overwhelming the child’s immune system with too many antigens, leading to parents’ requests for an alternate or delayed vaccination schedule (eg, the Dr Sears schedule). Parents may have objections to a specific vaccine because of personal beliefs or certain components of the vaccine (eg, adjuvants). Other reasons include distrust toward vaccine manufacturers, the government, and health care providers, and a preference for natural immunity.
Vaccine exemptions are a growing problem. Allowable reasons for exemption vary from state to state, with all states allowing medical exemptions. Religious exemptions to vaccination are granted in 48 states and Washington, DC. In addition, 20 states allow philosophic, or personal-belief, exemptions. Only Mississippi and West Virginia do not allow either type of nonmedical exemption. The ease of obtaining exemptions can also vary ( Fig. 2 ). Personal-belief exemptions in particular, when easily obtained, are predictive of increased disease risk among exempt children and in their communities. Parents of children with exemptions are more likely to perceive low susceptibility to vaccine-preventable disease, low vaccine efficacy and safety, and less trust in the government compared with parents who have vaccinated their children. Although parents who vaccinate their children may have similar concerns, these tend to be less frequent or manageable. Parents of children with exemptions are less likely to consider medical and public health authorities to be trusted sources for vaccine information and were more likely to trust and use practitioners of complimentary or alternative medicine.
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