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National, State, and Selected Local Area Vaccination Coverage Among Children Aged 19–35 Months — United States, 2013

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      National, State, and Local Area Vaccination Coverage Among Children Aged 19–35 Months — United States, 2012

      The National Immunization Survey (NIS) is a random-digit–dialed telephone survey used to monitor vaccination coverage among U.S. children aged 19–35 months. This report describes national, state, and selected local area vaccination coverage estimates for children born during January 2009–May 2011, based on results from the 2012 NIS. Healthy People 2020 * objectives set childhood vaccination targets of 90% for ≥1 doses of measles, mumps, and rubella vaccine (MMR); ≥3 doses of hepatitis B vaccine (HepB); ≥3 doses of poliovirus vaccine; ≥1 doses of varicella vaccine; ≥4 doses of diphtheria, tetanus, and pertussis vaccine (DTaP); ≥4 doses of pneumococcal conjugate vaccine (PCV); and the full series of Haemophilus influenzae type b vaccine (Hib). Vaccination coverage remained near or above the national Healthy People 2020 target for ≥1 doses of MMR (90.8%), ≥3 doses of poliovirus vaccine (92.8%), ≥3 doses of HepB (89.7%), and ≥1 doses of varicella vaccine (90.2%). Coverage increased from 68.6% in 2011 to 71.6% in 2012 for the birth dose of HepB.† Coverage was below the Healthy People 2020 target and either decreased or remained stable relative to 2011 for ≥4 doses of DTaP (82.5%), the full series of Hib (80.9%), and ≥4 doses of PCV (81.9%). Coverage also remained stable relative to 2011 and below the Healthy People 2020 targets of 85% and 80%, respectively, for ≥2 doses of hepatitis A vaccine (HepA) (53.0%), and rotavirus vaccine (68.6%). The percentage of children who had not received any vaccinations remained 15 weeks, and the final dose should be given by age 8 months (5). These age restrictions might preclude infants from starting or completing the series. Health-care providers should make every effort to start and complete administration of the rotavirus vaccine series on time. What is already known on this topic? Healthy People 2020 set childhood vaccination targets of 90% for ≥1 doses of measles, mumps, rubella vaccine (MMR); ≥3 doses of hepatitis B vaccine (HepB); ≥3 doses of poliovirus vaccine; ≥1 doses of varicella vaccine; ≥4 doses of diphtheria, tetanus, and pertussis vaccine; ≥4 doses of pneumococcal conjugate vaccine; and the full series of Haemophilus influenzae type b vaccine. The National Immunization Survey estimates coverage among U.S. children aged 19–35 months for these and other vaccines. What is added by this report? In 2012, childhood vaccination coverage remains near or above national target levels for ≥1 doses of MMR (90.8%), ≥3 doses of HepB (89.7%), ≥3 doses of poliovirus vaccine (92.8%), and ≥1 doses of varicella vaccine (90.2%); however, coverage varied by state and tended to be lower among children in families with incomes below the federal poverty level. What are the implications for public health practice? Sustaining current coverage levels and increasing coverage for those vaccines below national target levels is needed to maintain the low levels of vaccine-preventable diseases and prevent a resurgence of these diseases in the United States. Ensuring systems such as client reminder/recall and vaccination programs are in place in settings such as Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics and child-care facilities can help support high vaccination coverage. Although few differences in coverage by racial/ethnic group were observed after adjustment for poverty status, differences in coverage by poverty level remained for many vaccines. The Vaccines For Children program¶¶¶ has been successful in removing differences in coverage between children living above and below the poverty level that once existed for vaccines such as MMR, polio, and HepB (6); however, coverage among children living below the poverty level still lags behind coverage of children living at or above the poverty level for newer vaccines (HepA and rotavirus) and vaccines that require 4 doses to complete the series. Vaccination coverage continues to vary across states. Clusters of unvaccinated children leave communities vulnerable to outbreaks of disease. The continued occurrence of measles outbreaks among unvaccinated persons in the United States (7) underscores the importance of maintaining uniformly high coverage to prevent transmission of imported disease. Recent budget cuts to state and local health departments (8) as well as differences by state in factors such as population characteristics, immunization program activities, vaccination requirements for child-care centers, and vaccine financing policies might contribute to variations in vaccination coverage. The findings in this report are subject to at least four limitations. First, the proportion of the NIS sampled by cellular telephone in 2012 was about half compared with only 11% in 2011 and zero in earlier years. Living in a household with only cellular telephone service is associated with poverty and other demographic factors that might be related to vaccination status (3). Second, underestimates of vaccination coverage might have resulted from the exclusive use of provider-reported vaccination histories because completeness of these records is unknown. Third, bias resulting from nonresponse and exclusion of households without telephone service might persist after weighting adjustments, although estimated bias from these sources for the 2011 NIS was low for selected vaccines examined, ranging from 0.3 (for MMR) to 1.5 (for ≥4 DTaP) percentage points (9). The potential for nonresponse bias was increased in 2012 because of the lower response rate for the cellular telephone sample. However, a comparison of vaccination coverage estimates from the NIS from July 2011 through June 2012 with those from the National Health Interview Survey during the same period yielded similar results, both overall and for children living in cellular-only households, despite largely different response rates between the two surveys (Assessment Branch, Immunization Services Division, National Center for Immunization and Respiratory Diseases, and Survey Planning and Special Surveys Branch, Division of Health Interview Statistics, National Center for Health Statistics, CDC; unpublished data; 2013). Finally, although national coverage estimates are precise, estimates for state and local areas should be interpreted with caution because of smaller sample sizes and wider confidence intervals. High vaccination coverage among preschool-aged children has resulted in historically low levels of most vaccine-preventable diseases in the United States (1). The results of the 2012 NIS indicate that vaccination coverage among young children remained relatively stable and the proportion of children who do not receive any vaccinations has remained low. Slight decreases in coverage for some vaccines relative to 2011 cannot be immediately explained but could be attributable to a change in NIS methods. The 2012 results should be considered a baseline against which future trends in coverage can be evaluated. Careful monitoring of coverage levels overall and in subpopulations (e.g., racial/ethnic and geographic) is important to ensure that all children remain adequately protected. Parents and health-care providers should work to sustain high coverage and improve coverage for the more recently recommended vaccines and those that require booster doses after age 12 months. In addition to health system–based interventions previously described, national, state and local immunization programs should continue to partner with providers to implement the Guide to Community Preventive Services–recommended interventions aimed at increasing community demand for vaccination, such as client reminder/recall and client or family incentives. Enhanced access to health services also is recommended, through reduced out-of-pocket costs, home visits, and vaccination programs in child-care centers, schools, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) settings**** (4). Health insurance reforms of the Affordable Care Act require health plans to cover recommended immunizations without cost to the enrollee when administered by an in-network provider (10).††††
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        Benefits from Immunization During the Vaccines for Children Program Era — United States, 1994–2013

        The Vaccines for Children (VFC) program was created by the Omnibus Budget Reconciliation Act of 1993 (1) and first implemented in 1994. VFC was designed to ensure that eligible children do not contract vaccine-preventable diseases because of inability to pay for vaccine and was created in response to a measles resurgence in the United States that resulted in approximately 55,000 cases reported during 1989–1991 (2). The resurgence was caused largely by widespread failure to vaccinate uninsured children at the recommended age of 12–15 months. To summarize the impact of the U.S. immunization program on the health of all children (both VFC-eligible and not VFC-eligible) who were born during the 20 years since VFC began, CDC used information on immunization coverage from the National Immunization Survey (NIS) and a previously published cost-benefit model to estimate illnesses, hospitalizations, and premature deaths prevented and costs saved by routine childhood vaccination during 1994–2013. Coverage for many childhood vaccine series was near or above 90% for much of the period. Modeling estimated that, among children born during 1994– 2013, vaccination will prevent an estimated 322 million illnesses, 21 million hospitalizations, and 732,000 deaths over the course of their lifetimes, at a net savings of $295 billion in direct costs and $1.38 trillion in total societal costs. With support from the VFC program, immunization has been a highly effective tool for improving the health of U.S. children. Data from the 1980s suggested that measles outbreaks were linked to an ongoing reservoir of virus among high-density, low-income, inner-city populations (2). Although most children in these settings had a health-care provider, providers missed opportunities to give measles vaccine when children were in their offices, sometimes referring low-income children to another clinic where vaccines were available at no cost (3). Approximately 50% of children aged 70 million for measles. The highest estimated cumulative numbers of hospitalizations and deaths that will be prevented were 8.9 million hospitalizations for measles and 507,000 deaths for diphtheria. The routine childhood vaccines introduced during the VFC era (excluding influenza and hepatitis A) together will prevent about 1.4 million hospitalizations and 56,300 deaths. Vaccination will potentially avert $402 billion in direct costs and $1.5 trillion in societal costs because of illnesses prevented in these birth cohorts. After accounting for $107 billion and $121 billion in direct and societal costs of routine childhood immunization, respectively, the net present values (net savings) of routine childhood immunization from the payers’ and societal perspectives were $295 billion and $1.38 trillion, respectively. Discussion This report shows the strength of the U.S. immunization program since VFC began; coverage with new vaccines increased rapidly after introduction, and coverage for older childhood vaccines remains near or above 90%. The ability of VFC to remove financial and logistical barriers hindering vaccination for low-income children likely played a significant role in obtaining high coverage. Successful delivery of vaccines to children of all income levels relies on participation of public and private health-care providers, insurance companies, state and federal public health officials, vaccine manufacturers, and parents. For pediatric health-care providers, VFC supported the “medical home” and reduced barriers to integrated, quality pediatric care with immunizations as the backbone of well-child visits. VFC also supports state-based immunization programs, which have transitioned from service delivery in public health clinics to quality assurance of private sector immunization and oversight of approximately 90 million VFC and other public sector doses distributed annually (Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC, unpublished data, 2013). This analysis demonstrates the large number of illnesses, hospitalizations, and deaths prevented by childhood immunization. Because of sustained high coverage, many vaccine-preventable diseases are now uncommon in the United States. Measles was declared no longer endemic in the United States in 2000 (2), in contrast to model estimates that 71 million cases would have occurred in children born in the VFC era without immunization. Economic analysis for 2009 alone found that each dollar invested in vaccines and administration, on average, resulted in $3 in direct benefits and $10 in benefits when societal costs are included (5). Although the data presented here were generated with U.S. disease estimates and costs, the benefits are relevant to other countries where policymakers are considering return on investment in their immunization programs. The model estimated more illnesses prevented by vaccination during the lifetimes of 20 birth cohorts than a report published in 2013 that found 26 million illnesses prevented in the U.S. population over the last decade (7) and a report published in 2007 that found prevention of 1 million to 2 million illnesses per year (8). These earlier assessments used disease reported through passive public health systems for baseline burden estimates, did not adjust for the increase in U.S. population over time, and assessed fewer vaccines than the model presented here, all factors that could explain their lower estimates. The findings in this report are subject to at least three limitations. First, the benefits of hepatitis A vaccine, annual childhood influenza vaccine, and adolescent vaccines were not included. Second, the model did not account for all indirect vaccine effects on disease burden; for some vaccines, reduced transmission to unvaccinated populations has been a powerful driver of cost-effectiveness (9). Finally, for some diseases such as diphtheria, factors other than immunization might have contributed to lower disease risks in recent decades, and reductions resulting from these contributions have not been incorporated into the model; if such reductions were substantial, the model would overestimate the vaccine-preventable burden. However, a sensitivity analysis of the 2009 birth cohort model using the same methods suggested that, even with “worst case scenario” assumptions, early childhood immunization was cost-saving (5). Although VFC has strengthened the U.S. immunization program, ongoing attention is needed to ensure that the program addresses challenges and incorporates methods that could improve delivery. Approximately 4 million children are born in the United States each year, each of whom is vulnerable to vaccine-preventable pathogens that continue to circulate. Importations from areas where measles is endemic are an ongoing challenge for public health workers and clinicians. Coverage with human papillomavirus vaccine for adolescent girls has not yet reached optimal levels. Essential program functions such as monitoring vaccine safety, coverage, and effectiveness and managing supply interruptions need ongoing attention, although the VFC stockpile has helped mitigate the impact of shortages (10). VFC, in conjunction with provisions of the Affordable Care Act that eliminate many co-payments for ACIP-recommended vaccines, minimizes financial barriers and thereby helps protect children from vaccine-preventable diseases.
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          Progress in Immunization Information Systems — United States, 2012

          Immunization information systems (IIS) are confidential, computerized, population-based systems that collect and consolidate vaccination data from vaccination providers that can be used in designing and sustaining effective immunization strategies (1,2). To monitor progress toward achieving IIS program goals, CDC annually surveys immunization program grantees using the IIS Annual Report (IISAR). Results from the 2012 IISAR, completed by 54 of 56 grantees, indicate that 86% (19.5 million) of U.S. children aged <6 years, and 25% (57.8 million) of U.S. adults participated in IIS. Eight of 12 minimum functional standards for IIS published by the National Vaccine Advisory Committee (NVAC) (3,4) have been met by ≥90% of grantees. During 2011–2012, progress was also made in meeting three additional functional standards, including the presence of core data element fields, timeliness of vaccine records, and Health Level 7 (HL7) messaging, and will be monitored in new functional standards for IIS published in 2013 (5). Several new and ongoing initiatives, including interoperability between IIS and electronic health records (i.e., ensuring systems can work together and exchange information), the use of IIS to support vaccine ordering and inventory management, the use of two-dimensional barcodes to record vaccination information (1), and collaboration with pharmacies, federal agencies, and other adult vaccination providers, will support further progress in meeting functional standards and enhance reporting of adult vaccinations to IIS. Of the 56 immunization program grantees (50 states, five cities,* and the District of Columbia [DC]), 2012 IISAR data† were available for 54 grantees. DC did not report and New Hampshire was not eligible because it did not have an IIS in 2012. The self-administered survey asked about participation in IIS, data quality indicators, and IIS functionality (e.g., interoperability with electronic health records). Child and Adult Participation in IIS Child participation was defined as having two or more vaccinations for children aged <6 years documented in an IIS. Adult participation was defined as having one or more vaccinations administered to adults aged ≥19 years documented in an IIS. Participation was calculated by dividing the number of children or adults in an IIS who met their age group and vaccination criteria by the 2012 U.S. Census estimate of the same age group in the grantee’s geographic area (6). National estimates were calculated by summing the number of children or adults reported to be participating and dividing by the U.S. Census estimate for the total population for that age group. Nationally, 19.5 million U.S. children aged <6 years (86.2%) participated in an IIS in 2012. This child participation measure is used to track a Healthy People 2020 objective (IID-18) to increase to 95% the proportion of children aged <6 years whose immunization records are in fully operational, population-based IIS (7). Child participation in IIS has increased steadily, from 63% in 2006 to 86% in 2012 (1). Of the 54 grantees with available data in 2012, 26 (48%) reported that ≥95% of children aged <6 years in their geographic area participated in their IIS (Figure 1). Nationally, 57.8 million U.S. adults aged ≥19 years (24.5%) participated in an IIS in 2012 (Figure 2). Two IIS did not collect immunization information for adults. The Connecticut IIS includes only children aged <6 years, and the Rhode Island IIS includes only persons aged <19 years. Adult participation in IIS among the remaining 52 grantees responding in 2012 ranged from 0.5% (Houston) to 85.4% (Minnesota). Functional Standards for IIS Functional standards for IIS were developed in 2001 and revised in 2007. The standards have been approved by NVAC (3,4) for assessing IIS progress in meeting minimum functionalities. Substantial progress has been made in meeting these functional standards since inception, and in 2012, eight of 12 functional standards had been met by ≥90% of grantees (Figure 3). Increases were observed during 2011–2012 in the percentage of grantees meeting three of the four remaining functional standards. The percentage of grantees meeting functional standard (FS) 1 (i.e., reporting the presence of fields in their IIS for 18 required NVAC core data elements) increased from 57% in 2011 to 65% in 2012. Completeness of core data elements has been reported on previously (1). The percentage of grantees meeting FS 4 (i.e., percentage of grantees who reported receiving and processing ≥70% of vaccine and other immunization encounter information within 30 days of vaccine administration) increased from 63% in 2011 to 76% in 2012. The percentage of grantees meeting FS 7 (i.e., meeting basic HL 7 functionality§) increased from 58% in 2011 to 77% in 2012. The percentage of grantees meeting more advanced HL7 functionality¶ increased from 35% in 2011 to 37% in 2012. In 2012, 37% (19) of grantees were sending and receiving any HL7 v.2.5.1 messages, an increase from 17.3% (9) of grantees in 2011. The percentage of grantees meeting FS 2 (i.e., reporting the establishment of a birth record within an average time of ≤6 weeks) decreased from 85% in 2011 to 84% in 2012. This slight decline occurred because three grantees who previously met the functional standard in 2011 reported a decrease in timeliness in 2012 resulting from their acceptance of larger amounts of data, which slowed processing times; however, two grantees achieved the functional standard in 2012 who had not previously. Editorial Note Child participation in IIS increased steadily from 2006 to 2012, reaching 86%; adult participation, however, only reached 25% in 2012. Eight of 12 IIS functional standards were met by ≥90% of grantees in 2012. Increases in grantees meeting minimum functional standards for IIS data quality and interoperability, including the presence of core data element fields, timeliness for vaccination records, and HL7 messaging functionality, also have been demonstrated from 2011 to 2012, although challenges remain for IIS to reach their full potential in these areas, and for improving the timeliness of birth records in IIS. Historically, the primary focus of IIS and immunization programs has been pediatric populations. This focus was warranted because of the increasing complexity of the routine pediatric immunization schedule, mobility of children among different providers resulting in vaccination record scattering (8) that makes tracking and catch-up immunization challenging, and the role of the IIS in supporting the Vaccines for Children program through ordering and inventory management, report generation, and vaccine accountability. Nevertheless, interest is growing in ensuring that adult populations are included and vaccinations tracked in IIS. Adults are vaccinated by multiple and diverse providers, beyond traditional health-care providers (e.g., pharmacies, retail clinics, and subspecialists), and consolidated adult vaccination records maintained by IIS could play an instrumental role in providing clinical point-of-care support and population-level immunization coverage, particularly in special circumstances such as tracking doses administered during an influenza pandemic. Currently, 53 of 56 immunization program grantees have IIS with lifespan systems, yet adult participation in IIS remains low. Challenges to increase adult participation in IIS include 1) identifying and enrolling the diverse providers that serve adults, 2) a lack of adult immunization reporting mandates in many grantees’ jurisdictions, and 3) competing priorities for state and local immunization programs. To support increased adult provider participation in IIS, CDC is supporting several new initiatives, including partnering with the Veterans Administration, the Indian Health Service, and federal occupational health clinics; providing supplemental funding to IIS Sentinel Sites to support adult provider enrollment and completeness of adult data in IIS as part of pandemic preparedness; and collaborating with the American Immunization Registry Association to better understand barriers and opportunities for pharmacy reporting to IIS. CDC also has initiated the Clinical Decision Support for Immunization (CDSi) project for the adult vaccine schedule, which will provide a single, authoritative, software-independent foundation for development and maintenance of evaluation and forecast systems (9).** By capturing Advisory Committee on Immunization Practices (ACIP) recommendations for adult vaccination in an unambiguous manner, it will improve the uniform representation of vaccination decision guidelines, and the ability to automate vaccine evaluation and forecasting (9). CDSi for the childhood schedule was completed in October 2012 and has already proven successful in clarifying ACIP recommendations and designing new and existing computer systems. What is already known on this topic? In 2011, 84% of U.S. children aged <6 years (19.2 million) participated in immunization information systems (IIS). What is added by this report? In 2012, 86% of U.S. children aged <6 years participated in IIS. Adult participation (25%) in IIS lags behind. Eight of 12 minimum functional standards for IIS published by the National Vaccine Advisory Committee have been met by ≥90% grantees, but gaps still exist in meeting Health Level 7 (HL7) interoperability and some data quality standards. What are the implications for public health practice? To realize the full benefits of IIS, progress is needed to reach lifespan participation in IIS, advanced bidirectional HL7 messaging between IIS and electronic health records, and improved data quality in IIS. Initiatives designed to increase adult participation in IIS, and promote HL7 messaging and electronic health records use among providers, are expected to support progress in these areas. In addition to capturing the complete population of children and adults within each IIS jurisdiction, IIS must maintain and enhance system functionality to ensure that data quality is high, protect the confidentiality of data, and serve multiple stakeholders. Although IIS have made great strides in implementing functional standards, progress can still be made in areas such as timeliness of record submission, completeness of core data elements, and HL7 functionality. Several ongoing and new initiatives are expected to support these functional standards, including the use of IIS to support vaccine ordering and inventory management, the use of two-dimensional barcodes to record vaccination information, and interoperability between IIS and electronic health records (1). Implementation of stage 2 meaningful use criteria for the Medicare and Medicaid electronic health record incentive program (10), emphasizing use of HL7 version 2.5.1 and promotion of successful, ongoing submission from providers to IIS, is expected to increase child and adult participation in IIS and improve data quality in IIS, including completeness and timeliness of records. Stage 2 implementation was scheduled to launch in October 2013 for hospitals and January 2014 for providers. The findings in this report are subject to at least two limitations. First, although CDC provides guidance to grantees to validate IISAR responses, data are self-reported and self-validated, which might result in overestimation or underestimation of participation rates. Second, because two of the 56 grantees did not report data during the period studied, the percentage of grantees meeting each of the functional standards might be higher or lower than calculated. New functional standards for IIS for 2013–2017 have been developed by CDC through a consensus process involving input from IIS managers and technical experts nationwide (5). Those standards are intended to lay a framework for the development of IIS through 2017, and supersede the minimum functional standards for registries adopted by NVAC in 2001. These new functional standards encompass areas within the old functional standards where progress is still being achieved, including timeliness of records submission, completion of core data elements, and HL7 interoperability standards. They also include new areas, such as supporting the Vaccines for Children program and state vaccine purchase programs through vaccine inventory functions and capture of program eligibility at the dose-level, and enhanced data quality through patient- and vaccine-level de-duplication. Grantees meeting and exceeding these new functional standards will lead the way in realizing and demonstrating the full potential of IIS.
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            Affiliations
            [1 ]Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC
            Author notes
            Corresponding contributor: Laurie D. Elam-Evans, lxe1@ 123456cdc.gov , 404-718-4838
            Journal
            MMWR Morb Mortal Wkly Rep
            MMWR Morb. Mortal. Wkly. Rep
            MMWR
            MMWR. Morbidity and Mortality Weekly Report
            U.S. Centers for Disease Control
            0149-2195
            1545-861X
            29 August 2014
            29 August 2014
            : 63
            : 34
            : 741-748
            25166924
            5779444
            741-748

            All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.

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