A Policy Analysis of the Childhood Immunization Initiative in Philadelphia
By Geoffrey Setswe MPH, DHSM
Citation: Setswe, G. A policy analysis of the childhood immunization initiative in Philadelphia. Internet Med J 2002;6(1).
Childhood immunization was one of the earliest
priorities of the Clinton Administration, which was
designed in response to disturbing gaps in the
immunization rates for young children in America. The
goals of the Childhood Immunization Initiative (CII)
were to increase vaccination coverage levels to about
90% by 1996 among children aged 2 years, and to reduce
and/or eliminate indigenous cases of diphtheria,
tetanus, pertussis, poliomyelities, Haemophilus
influenzae type b (Hib) invasive disease, measles,
mumps and rubella.
Data indicates that Philadelphia made significant
progress in achieving the 1996 CII goals and in
implementing the 5 areas of the program.
Philadelphia’s vaccination coverage for the 4:3:1
series increased significantly from 69% in 1995, to
79% in 1996, and to 81% in 1997. The latter is higher
than the rate in New York City (76%), Chicago (75%),
Los Angeles (78%), and the District of Columbia (75%).
Philadelphia’s success could be attributed to
aggressive involvement of communities in all aspects
of the initiative, stronger political commitment to
achieving the goals of the program, and the impact of
community-based health education and outreach programs
conducted by voluntary and formal organizations.
If political commitment and community participation
can be sustained in the next 5 years, most of the
diseases targeted for immunization will be eliminated
and/or reduced to negligible levels.
BACKGROUND OF THE CHILDHOOD IMMUNIZATION INITIATIVE
Immunization against diphtheria, tetanus, pertussis,
poliomyelitis, measles, mumps, rubella, and hepatitis
B are effective methods for preventing these diseases.
Epidemiologic data from many areas have demonstrated
increases in these diseases as immunization rates
fall. Immunization rates in the United States are
appallingly low when compared with other countries
with similarly high standards of living (Abbots &
Children require 12 - 16 vaccine doses by age 2, which
need about six visits to health care providers. This
is about 80 percent of all vaccine doses recommended
for children. Although children are required to be
immunized, in order to enter school, about one million
children not adequately protected against possibly
fatal illnesses. With increasing numbers of children
more readily exposed to infectious diseases in
day-care settings and elsewhere, complete immunization
by age 2 is critical. Failure to immunize can lead to
new outbreaks of disease. In 1989-91, a measles
epidemic resulted in more than 55,000 reported cases,
11,000 hospitalizations, and more than 120 deaths.
Over half of the deaths were children under 5 years of
age (CDC, 1997).
Childhood immunization was one of the earliest
priorities of the Clinton Administration. The
Administration designed a comprehensive Childhood
Immunization Initiative (CII) in response to
disturbing gaps in the immunization rates for young
children in America. This national initiative was
designed to address five areas:
* Improving the quality and quantity of immunization
* Reducing vaccine costs for parents
* Increasing community participation, education and
* Improving systems for monitoring diseases and vaccines
* Improving vaccines and vaccine use.
The Childhood Immunization Initiative was designed to
build a comprehensive vaccination delivery system,
which integrates the efforts of the public and private
sectors, health professionals and volunteer
organizations. The goals as set in 1993:
To ensure that at least 90 percent of all two-year
olds receive each of the initial and most critical
doses, and to reduce most diseases preventable by
childhood vaccination to zero.
By the year 2000, ensure that at least 90 percent of
all two-year olds receive the complete series of
vaccinations, and that a system is in place to sustain
high immunization coverage (CDC, 1997).
THE CHILDHOOD IMMUNIZATION INITIATIVE IN PHILADELPHIA
The Philadelphia early childhood immunization plan was
one of the six local area plans developed around the
country in 1991-1992. Philadelphia developed a city-
wide plan that represented a collaborative effort of
more than 75 major health, social, religious,
business, civic agencies/organizations in the region.
Representative of the noteworthy commitments in the
plan were the Children’s Hospital of Philadelphia and
the St. Christopher’s Hospital for Children who
pledged to make immunizations available to pediatric
inpatients before they were released from their care
In Philadelphia, the fifth largest city in the United
States, there are approximately 147,000 children aged
0 -5 years (Dichter, Redmond & Yanoff, 1997).
The measles epidemic of 1990-91, which killed nine
children and sickened more than 1,500 in Philadelphia,
was a wake-up call for the community and health
officials to do something serious about childhood
REVIEW OF THE LITERATURE ON CHILDHOOD IMMUNIZATIONS
Although the childhood vaccine-preventable diseases
have declined dramatically in the last few years, they
remain problems among certain high-risk,
underimmunized groups (USDHHS, 1990). In 1995, the
estimated immunization coverage levels with four doses
of DPT/DT, three doses of polio virus vaccine, one
dose on MMR, and three doses of Hib vaccine in the
Philadelphia county was 69 percent (MMWR, 1996). This
was far below the national goal of increasing
immunization of all two year olds to 90 percent by the
year 2000 (USDHHS, 1990).
A study conducted in Philadelphia on the aftermath of
the measles epidemic of 1990-91 which killed nine
children and sickened more than 1,500 found that about
45 percent of all 2 year olds were not up to date on
their shots, with rates even lower in some North
Philadelphia neighborhoods. Fitzgerald (1997) reported
that about 70% of the city’s prescholers were properly
immunized, but health officials wanted to get that
number to 90%.
Many factors affect whether a parent makes certain
his/her child is immunized. Afew studies have been
conducted to assess parents’ knowledge and opinions of
childhood immunizations. Setswe (1997) conducted a
study to evaluate parents’ knowledge of childhood
immunizations in Philadelphia, and found that only
50.4% of participants had knowledge of childhood
immunizations. Of these, 53.4% had knowledge of the
number of sets of shots required to fully immunize the
child, while only 47.6% had knowledge of the age at
which the child gets the measles vaccine. This was
disappointingly low and the author indicated that a
lot of work needed to be done to educate the public on
childhood immunizations. The low level of knowledge
about childhood immunizations in this study was
consistent with findings by McCormick, Bartholomew,
Lewis, Brown and Hanson (1997) which indicated that
while parents were aware that there is a schedule and
that their children needed to have different shots at
different times, they had little understanding of
A survey conducted by Fitzgerald and Glotzer (1995) to
assess the information needs of parents in Boston
regarding childhood immunizations, found that most
parents felt that it was “very important” to receive
information about immunizations. Eighty percent of
parents indicated that they wanted immunization
information discussed with each vaccination.
Abbotts and Osborne (1993) conducted a cross-sectional
survey in a White high-income area of Salt Lake City
to investigate reasons for childrn not being immunized
on schedule, and concluded that even in this low risk
population, parental misperception regarding
immunizations was a significant contributing factor to
low immunization rates. They recommended that public
educational programs directed at increasing parental
knowledge must be developed.
Lance Rodewald, an immunization expert at the Centers
for Disease Control and Prevention (CDC) said that if
children are taken to the doctor for their shots they
will also be tested for lead levels, anemia and
tuberculosis, and be weighed and measured to see
whether they are growing properly (Fitzgerald, 1997).
Robert Levenson, director of Philadelphia’s division
of disease control believes that immunizations are the
most cost-effective public health measure around, and
that it would be a shame if people were to forget that
in 1991 there were nine deaths from measles, and each
of these deaths was 100 percent preventable
(Fitzgerald, 1997). It is estimated that for every
dollar spent on measles, mumps, and rubella (MMR)
immunization, $14 in costs to society are saved
Otha Brown, who coordinates outreach volunteers for
HOPE for Kids - one of the largest volunteer outreach
organizations in Philadelphia- said that families
often are unaware that their children aren’t up to
date on their shots. He thinks that is not surprising
considering how complicated the vaccination schedule
has become. With the addition of vaccines against
Hepatitis B and Haemophillus influenzae type B (Hib),
a child can get as many as 19 vaccinations by the time
they get tokindergarten (Fitzgerald, 1997).
Michael Huff, director of the division of communicable
diseases prevention at the Pennsylvania Health
Department, said that parents need to take
responsibility by getting into the habit of asking at
every doctor’s visit if their kids need shots
* IMPLEMENTATION *
IMPROVING THE QUALITY AND QUANTITY OF VACCINATION DELIVERY SERVICES
The Centers for Disease Control and Prevention (CDC)
provides its primary support through state and local
Immunization Action Plans (IAP’s), which allow state
and local health agencies to determine the most
effective ways to meet their needs. Performance-based
funding rewards those IAP’s which meet or exceed
immunization targets (CDC, 1997).
REDUCE VACCINE COSTS FOR PARENTS
The Vaccines for Children program was designed to
provide free vaccine to the country’s eligible
children, starting in 1994. Eligible children include
those without insurance coverage, those who are
eligible for Medicaid, and American Indians and Alaska
Natives. In 1997, the Vaccine for Children program was
available in all 50 states. Enrollment of private
providers into the Vaccines for Children program had
almost doubled since the beginning of the program in
1994 (CDC, 1997).
INCREASE COMMUNITY PARTICIPATION, EDUCATION, AND PARTNERSHIPS
The CDC made significant progress over the last few
years in establishing public and private partnerships.
Community outreach activities have focused on
increasing parental awareness the need to immunize
children, improving community involvement in
immunization programs, expanding national
partnerships, and building coalitions to facilitate
prevention strategies (CDC, 1997).
HOPE for Kids, one of the largest volunteer outreach
progams in the US, recruited, trained, and mobilized
about 1,300 health volunteers on April 26, 1997 to
educate and raise public awareness in Philadelphia
about childhood immunizations, astham and lead
poisoning. The health education and outreach campaign
served as a kick-start to the Presidential Summit on
Volunteerism and entailed distribution of health
education packets to about 12,500 households in
selected neighborhoods of Philadelphia (Setswe, 1997).
The National Infant Immunization Week (NIIW) in April
1997 attracted media coverage in most state and local
markets across the country. Over 400 promotional
events took place in all 50 states (CDC, 1997). St.
Christopher’s Hospital for Children and Children’s
Hospital of Philadelphia held a joint press
conferencein August 1997 to promote the immunization
initiative. To bbost coverage, the hospitals put
information from the press conference in neighborhood
newspapers and also printed about 4,000 posters in
English, Spanish, and other Asian languages to be
distributed around the city. St. Christopher’s also
relied on its partnership with the ABC-TV “Children
First” campaign to get its immunization message out to
the community. Together with local ABC affiliate
WTVI-TV, St. Christopher’s developed immunization
brochures and a PSA that announced a hotline with shot
information. The hotline is currently working with
other community groups to develop hotline messages in
three languages. St. Christopher’s has also placed
immunization messages on directional signs to the
hospital (River-Urrutia, 1997).
The Department of Health and Human Services (HHS), the
Department of Housing and Urban Development and
Corporation for National Service joined forces to
increase immunization rates among children living in
public housing. The patnership focused on improving
information about immunization for public housing
residents, enlisting residents in designing outreach
strategies, and improving access to health services
for those in public housing. Philadelphia was selected
as one of the four cities for implementing the pilot
program (DHHS, 1997).
IMPROVE SYSTEMS TO MONITOR DISEASES AND VACCINATIONS
Improved monitoring systems for vaccine-preventable
disease help to spot problems early and enable action
a few cases from escalating into epidemics. An
electronic system for reporting supplemental
information on vaccine-preventable diseases using the
National Electronic Telecommunications System for
Surveillance (NETSS) was installed in 35 states (CDC,
The city of Philadelphia launched its immunization
database in 1993 with funding from the Robert Wood
Johnson Foundation. The database contained 121,000
children - a large majority of the city’s
preschool-age population. All children born in
Philadelphia since August 1992 have been registered.
Health providers at the city’s health centers and some
commuity health and hospital clinics can now tap into
the database to see what shots the child has had and
to update the record. The city’s health department is
analyzing how best to use a combination of letters,
telephone calls and community workers - both paid and
volunteer - to reach families whose children need
shots. The idea is not to be heavy-handed or
judgmental, but to offer a friendly reminder
Since 1994, the National Immunization Survey (NIS) has
been used to provide immunization coverage in all 50
states and 28 large urban areas. The NIS provides
states and cities with an accurate measure of
vaccination coverage rates compiled from a national
independent survey that allows a comparison of
immunization coverage levels. The NIS provides an
early warning system for potential problems and
monitors the introduction of new vaccines into the
childhood immunization schedule.
Assessments to measure immunization coverage in
clinics were conducted in all 50 states. These
assessments have led to increased coverage in many
areas (CDC, 1997). Several thousand pediatric
practices in Philadelphia do a systematic review of
charts to look for kids who need shots or use a recall
system to remind families when it is time for the
child’s shots. To help doctors change that, the
Pensylvania chapter of the American Academy of
Pediatrics offers a program in which it will send a
team of health professionals to talk with physicians’s
office staff, even setting up a computerized program
to generate reminder letters (Fitzgerald, 1997).
IMPROVE VACCINES AND VACCINE USE
The initiative supports research into new vaccines and
vaccine combinations to reduce the number of shots
children must get, to simplify the vaccine schedule,
and to ensure safe and effective vaccines (CDC, 1997).
FUNDING FOR THE CHILDHOOD IMMUNIZATION INITIATIVE
The national budget for 1997 Financial Year (FY)
included $88 million to continue service delivery
improvements, primarily through Immunization Action
Plans. This represented a 95 percent increase from the
$45 million provided in FY 1993 (CDC, 1997).
In FY 97, the city of Philadelphia received an amount
of $2 million (up from $1.75 million in FY 96), from
the federal government. The city allocated a further
$1.2 million (up from $.2 million in FY 96) from its
sources. These funds were all allocated for
immunization outreach, vaccinations and data
collection. 110,000 children (up from 95,000 in FY
96), were served during this period (Dichter, Redmond
& Yanoff, 1997).
Total federal vaccine purchases in FY 1997, including
grant funds for states as well as the VFC, were
estimated at $486 million, which included funds for
new vaccines not purchased in FY 1993 such as
Varicella, DTP/Hib combination, DTaP, Hepatitis A and
Influenza (CDC, 1997).
EVALUATION OF THE CHILDHOOD IMMUNIZATION INITIATIVE
In 1997, it was reported that the country had exceeded
its childhood vaccination goals for 1996, with 90
percent or more of children receiving the most
critical doses of most of the routinely recommended
vaccines for children by age 2. Also in 1996, reported
levels of disease were at or near record lows and 3
diseases reached the elimination targets. These were
tetanus under age 15, polio and mumps.
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and reasons for immunization delay among children
using public health immunization clinics. American
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Unpublished research report, Temple University.