States with a low rank in childhood immunizations look for a way up

Physicians in Texas are studying the impact an expanded vaccine exemption law and cuts to the Children's Health Insurance Program may be having on their state's vaccination rates.

In recognition that too many children are getting their fourth DTaP shot late or not at all, the Oklahoma State Dept. of Health is urging that in some instances the shot be given at age 1, the earliest time recommended, rather than the preferred age of 15 to 18 months.

In Alaska, the public health department is considering a media campaign to encourage parents to bring their kids in. "We need to do this all the time," said Richard Mandsager, MD, the state's director of public health. "We can't ever take a breath."

These are a few of the efforts that public health officials and physicians in states with lower vaccination rates are taking in light of National Immunization Survey statistics released by the Centers for Disease Control and Prevention in July.

"We are making some significant strides," said James W. Hendricks, MD, a pediatrician from Tulsa, Okla. "No one's giving up."

For the first time, the country as a whole exceeded by one percentage point the Healthy People 2010 goal of 80% coverage for the baseline series of childhood immunizations, but rates varied widely across the country. To be fair, it appears that the majority of children do get most of their shots no matter where they are, but timeliness is more of a problem in some states than others. And not every child is getting every single shot.

"We're very pleased with the overall findings, but the survey also shows there are places where we have work to do," said Stephen L. Cochi, MD, MPH, acting director of the CDC's National Immunization Program. "If we want to prevent the return of diseases that are currently rare in the United States, we must maintain our high immunization rates, and work to ensure those rates are high in all states and communities."

For example, Texas ranked near the bottom of the list with 73% of children receiving this series on time. Physicians in Texas are particularly concerned because not only were their numbers low to begin with, they declined from 2003 to 2004. In response, the Texas Medical Assn. pledged to investigate the cause and give more of a push to their "Be Wise -- Immunize" program.

"We feel there's a potential for these infectious diseases to get a stronghold here," said TMA President Robert T. Gunby Jr., MD. "This threatens whole communities, and we want to nip this in the bud before it gets any worse."

Other states are also taking action, too, much of it based on what has worked in the past.

Alaska, in addition to launching its campaign to encourage parents to bring children in for these immunizations, also plans to promote the importance of on-time vaccinations to doctors and other vaccine providers.

Sometimes, the steps are a bit controversial. The Oklahoma effort, which encourages physicians to give young patients their fourth DTaP a little early, is not completely out of line with official recommendations. It just bends them a bit.

"The fourth DTaP is really our problem," said Don Wilber, MD, a pediatrician from Midwest City, Okla., and chair of the state's vaccine advisory committee. "We want to make it less likely to miss that opportunity."

Still, some physicians and public health officials are concerned that some young patients may receive the shot too early and may not receive the full benefit, although most are waiting for more data before endorsing or condemning the practice.

"It's a clever idea that may be beneficial in some cases," said Lance Rodewald, MD, director of the immunization services division at the CDC's National Immunization Program. "But they do need to evaluate these programs for effectiveness."

What's driving the numbers?

But the big question that physicians and public health officials struggle with is why. And theories abound.

Some blame the recent vaccine shortages and a lack of coordination between public health, physicians, schools and day care centers.

Some blame state-specific factors. Officials in Nevada, which has the lowest rate in the nation at 68%, is also the fastest growing state. The large number of new arrivees may not yet have contact with the health system. Meanwhile, experts in Utah, also near the bottom with a rate of 71%, blame this standing on large families, which tend to be common there.

"By the time the third child comes along, parents are so busy and overwhelmed that they don't come in for well-child visits," said William Cosgrove, MD, a pediatrician from Salt Lake City and chair of Utah's Every Child By Two coalition.

But while physicians and public health officials are deciding what to do about these numbers, there is also some question over how accurate they may be. The CDC's National Immunization Survey is viewed as one of the best ways to compare states, but as a random-digit telephone survey, it is far from perfect. Downward numbers are causing some concern, but most public health officials feel that within a certain range, some of the variation can be blamed on sampling error. In Texas, for example, numbers may have gone down from 2003 to 2004 but they went up from 2002 to 2003.

"My hope is that it's not a trend," said Kimberly Avila Edwards, MD, a pediatrician from Austin who is featured in TMA's public service announcements on the issue. "But there's just such a discrepancy between states. It's heartbreaking."

Experts agree, though, that what is clear is that children in some areas of the country are not as well vaccinated as others, and, this can be dangerous for the whole country.

"Until we have immunization for all kids, we are at risk," said Louis Cooper, MD, professor emeritus of pediatrics at Columbia University College of Physicians and Surgeons in New York. "Children in Texas today are in Maine or in Connecticut tomorrow."