Study Follow-Up Shows Big Increase in Preschooler Vaccinations

After a Medical College of Wisconsin study showed that nearly half of inner city preschool children who visited two Milwaukee health clinics were not given timely immunizations, proactive interventions by the research team cut the rate of “missed vaccination opportunities” at one of the clinics from 49% all the way down to 13%.

The initial study, first presented in 1996, focused on children under three years of age at the Downtown Health Center and the 16th St. Community Health Center. The follow-up efforts to reduce the rate of missed opportunities took place at the 16th St. clinic. The immunizations involved included those for diphtheria, tetanus, pertussis, polio, measles, mumps and rubella. (The vaccine for chickenpox was added to the list of required immunizations after the Medical College studies were completed.)

“First of all, we were looking at little children because those are the children at higher risk (for not receiving immunizations),” said Svapna S. Sabnis, MD, Medical College Assistant Professor of Pediatrics and one of the study authors who practices at the Downtown Health Center.

“The kids who are in school are less likely to be missed because the schools are required to see that vaccinations get done. And this was a study of children who have lower rates of immunization in general and don’t necessarily come in for regular checkups. The goal is to immunize them at any visit, whether it’s a checkup or a walk-in sick visit. What we need to remember as physicians is that we need to check the immunization status of children at each visit to see if they need anything.”

Making Immunization a Priority
Dr. Sabnis collaborated on the study with Albert J. Pomeranz, MD; Patricia S. Lye, MD, MS; and Margaret M. Amateau, MD. “What we were looking at was why these missed opportunities happened and how often they happened,” said Dr. Sabnis. “What we found, to our surprise, was that it happened even in our own clinic – a teaching clinic – much more often than we thought it did. Often it was just that a vaccination got left out, was forgotten, or just wasn’t a high priority at that point because of the nature of the visit.

“Other reasons that missed vaccination opportunities might be happening is that the physician or a parent thought a child was too sick at the time. But when we reviewed the charts we found that in most of the cases these were very minor illnesses, things like a rash or something non-infectious. Only a very small percentage of contraindications were what we would call ‘justified,’ where we had a good reason – such as moderate or severe illness – to hold back a vaccination. Even a low-grade fever is not a contraindication to immunization.”

As noted in the follow-up study, immunization of children aged 19-35 months is one of the priorities in the US Department of Health and Human Services publication Healthy People 2010. The Healthy People 2010 goal is to increase overall immunization rates from 73% to 80%.

“Of particular concern are urban pockets of under-immunization where the immunization levels fall significantly below national levels,” wrote the authors in the initial Medical College study. “In the city of Milwaukee, only 41% of children in a retrospective school survey in 1995 to 1996 had received the complete vaccination series…In contrast, 70% of the children in the Milwaukee suburbs had completed the series.”

“All children need these vaccines,” said Dr. Sabnis. “If they’re not immunized they’re at greater risk for vaccine-controllable diseases. And the later they wait, as the child gets older, the less likely people are to come in. If children have a late start to the immunizations they tend to remain delayed for longer periods of time and they might not get caught up.”

Breaking Down Barriers
Dr. Sabnis pointed to several barriers to vaccine delivery identified by the National Vaccine Advisory Committee and reported in the follow-up study. In addition to missed vaccination opportunities, these include system barriers such as long waiting periods, appointment-only services and pre-vaccination physical examination requirements.

“Several years ago there was a big measles outbreak that brought this whole immunization issue up,” said Dr. Sabnis. “These were children that had actually seen physicians but still had not gotten their measles shots for one reason or another. When the measles outbreak happened, Milwaukee and Chicago were hit pretty hard.”

The Follow-Up
According to the follow-up study, “Missed opportunities occur when a vaccine-eligible child does not receive the needed vaccines. Missed opportunities are usually provider-related, and are minimally influenced by parent education or case management.” In other words, Dr. Sabnis agreed, it is often the practitioner’s responsibility to see that children receive timely immunizations, regardless of the role parents may play in the process.

The 16th St. Community Health Center invited the research team back after the initial study to discuss the results and work with the staff to decrease missed vaccination opportunities. All clinic personnel involved in vaccine delivery were included in written and verbal feedback and education, including a group question-and-answer session. Doctors were told about their own missed vaccination opportunities and were asked to record and monitor the vaccine status of patients; nurses were taught to identify and tag the charts of children with vaccine opportunities; laminated pocket cards were given out listing the recommended vaccine schedule and contraindications.

The results were significant. Of 352 pre-school children in the earlier study, 173 (49%) with vaccine opportunities were not vaccinated, and of those 42% did not receive immunizations in the following six months. The first group of 352 children was compared to a similar group of 344 children who were seen after the work with the health center staff was completed. During the three-month period following the interventions, missed vaccination opportunities decreased to just 13%.

“If you look at immunization rates you’ll see they are steadily creeping up,” said Dr. Sabnis. “But when you look at inner cities and rural areas in relation to the suburbs, they tend to have lower rates. So there are still pockets where the rates are lower. Overall the trend has generally been heading in the right direction, including in those areas. There are a lot of different programs out there that are really working on it. Still, there’s lots of work to be done.”

Dan Ullrich
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.