CITATION: Setswe, G. A policy analysis of the childhood immunization initiative in Philadelphia. Internet Med J 2002;6(1).

ABSTRACT

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 & Osborne, 1993).

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 services

* Reducing vaccine costs for parents

* Increasing community participation, education and partnerships

* 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 (DHHS, 1992).

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 immunizations.

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 schedule parameters.

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 (DHHHS, 1992).

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 (Fitzgerald, 1997).

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, 1997).

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 (Fitzgerald, 1997).

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.

REFERENCES

Abbotts, B & Osborne, LM (1993). Immunization status and reasons for immunization delay among children using public health immunization clinics. American Journal of the Diseases of the Child 147, 965-968.

Centers for Disease Control and Prevention (1997). Facts about the Childhood

Immunization Initiative. Fact sheet (July 24, 1997).

Department of Health and Human Services (1992). Philadelphia Childhood Immunization. HHS Press release, February 13, 1992.

Dichter, H., Redmond, P & Yanoff, S. (1997). The bottom line is... children. Philadelphia Citizens for Children and Youth (PCCY). Philadelphia: Yoder and Armstrong.

Fitzgerald, S (1997, April 23). Volunteers track children’s health. The Philadelphia Inquirer, B1, B7-B8.

MMWR Weekly report (1997). Status report on the Childhood Immunization Initiative: National, state and urban area vaccination coverage levels. MMWR, 46, 29.

MMWR Weekly report (1997). Status report on the Childhood Immunization Initiative: Reported cases of selected vaccine-preventable diseases, United States, 1996. MMWR, 46, 29.

Setswe, G.K (1997). Evaluation of the HOPE for Kids health education and outreach program in Philadelphia. Unpublished research report, Temple University.