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Journal Issue: Children and Divorce Volume 4 Number 1 Spring/Summer 1994

CHILD INDICATORS: Immunization of Young Children
Eugene M. Lewit John Mullahy


In response to unacceptably low levels of immunization among very young children, the federal government announced the President's Childhood Immunization Initiative in December of 1993.5 Designed to make immunization of preschool children one of the nation's highest priorities, the initiative attempts to marshal resources in the private sector and at all levels of the public sector to achieve 90% immunization coverage of preschool children by 1996. Previously, when the United States failed to achieve 90% immunization coverage of preschool children by 1990, this level of coverage was carried over as an objective for the year 2000. This new program attempts to accelerate that timetable.

One aspect of this initiative, simplifying the immunization schedule to improve compliance, has already been discussed. Other important components include the following:

  • National vaccine coverage goals are now provided for individual vaccines over several years (see Table 1). This is a change from a national objective which included 90% coverage with all vaccines by the year 2000. It is hoped that looking at coverage with individual vaccines one year at a time will allow programs to focus their efforts on the specific immunization practices that are most in need of improvement.
  • Measurement of vaccine coverage will be improved nationally through enhanced use of the NHIS and new random-digit dialing surveys to obtain immunization coverage levels for specific states and large urban areas. In addition, a method to conduct clinic-level assessments of immunization practices is being disseminated. Information from these site-specific audits can be used almost immediately to improve practices at clinics.
  • A National Immunization Outreach Campaign is planned to strengthen state and community-based mobilization programs and to promote targeted use of communications channels to increase awareness and improve education.
  • Beginning October 1, 1994, through the Vaccines for Children Program, the federal government will purchase vaccines directly and provide them free of charge to a variety of health care providers for administration at no cost (for the vaccine) to children eligible for Medicaid, children without health insurance, and Native American children. Insured children who do not have coverage for vaccines will also be able to obtain no-cost vaccinations at community health centers under this program.

In addition, the CDC will build on its experience with various demonstration projects to provide technical assistance to state and local immunization programs to improve their function.

The Childhood Immunization Initiative is an ambitious program. To get it under way, Congress increased the 1994 immunization budget of the CDC by almost 55% over its 1993 budget. However, relatively costless policy changes, such as revising the immunization schedule or disaggregating vaccine coverage goals, may be important factors in whether the program is ultimately judged a success.

Already, changing the methodology for recording parental recall information in the NHIS may have contributed substantially to reaching the objective of 90% coverage by 1996. In fact, data in Table 1 suggest that 1994 objectives had almost been reached in 1992, more than a year before the initiative was launched. Efforts to adjust future survey data for possible underreporting associated with relying on parental recall may boost reported coverage levels further toward the 90% objective.

The considerable changes in the methodology by which immunization status is measured, in vaccine coverage goals, and in the immunization schedule pose dilemmas for those concerned about children's health and health policy. If the process of moving toward national vaccination coverage goals relies too heavily on changing the way vaccination status is assessed, the new initiative may do little to actually improve the health status of children although the statistics may improve. If the new procedures result in an overestimate of the true immunization coverage rate among young children, then a large group of children may remain inadequately immunized and at risk for serious disease even if the initiative appears to reach its objectives.

If, however, immunization coverage rates had been underestimated in previous data, it may be difficult to assess the real impact of the program and resources may be wasted attempting to reach children who are already adequately immunized. In any event, it will be important to assess honestly the extent to which programmatic activities lead to substantial increases in immunization coverage and improvements in children's health and the extent to which the achievements result from changes in the way the score is kept.