UNDER EMBARGO UNTIL APRIL 29, 2008, 12:01 AM LOCAL TIME
Compliance with Vaccination Recommendations for
U.S. Children
Elizabeth T. Luman, PhD, Kate M. Shaw, MS, Shannon K. Stokley, MPH
Background: Official recommendations for the routine vaccination of U.S. children, made by the
Advisory Committee on Immunization Practices (ACIP), specify the vaccines for administration, the number of doses that should be given, the age ranges for administration, the
minimum ages at which doses are considered valid, the minimum intervals between doses
within a series, and several additional vaccine-specific adjustments and exceptions.
Federally reported estimates of vaccination coverage measure only compliance with the
required number of doses; other recommendations are not routinely evaluated.
Methods:
Analysis of vaccination histories for 17,563 U.S. children aged 19 –35 months from the 2005
National Immunization Survey.
Main
Outcome
Measures:
Compliance with, and incremental impact of, each vaccination recommendation.
Results:
Estimated coverage was 72% for the standard vaccination series accounting for all
recommendations, 9 percentage points lower than coverage based solely on counting
doses. Overall, 19% of children were missing one or more doses, while 8% had received an
invalid dose, and 9% were affected by other recommendations. The proportion of
noncompliance due to missed doses versus other recommendations varied by state and by
antigen.
Conclusions: Approximately 28% of children were not in compliance with the official vaccination
recommendations. Missed doses accounted for approximately two thirds of noncompliance, with the remainder due to mis-timed doses and other requirements. Measuring
compliance with all ACIP recommendations provides a valuable tool to assess and improve
the quality of healthcare delivery and ensure that children and communities are optimally
protected from vaccine-preventable diseases.
(Am J Prev Med 2008;xx(xx):xxx) © 2008 American Journal of Preventive Medicine
Introduction
O
fficial recommendations for the routine vaccination of young children in the U.S. are made
annually by the Advisory Committee on Immunization Practices (ACIP), in collaboration with the
American Academy of Pediatrics and the American
Academy of Family Physicians. These recommendations specify the vaccines and the number of doses that
should be given, the ages or age ranges for routine
administration, the minimum ages at which doses are
considered valid, the minimum intervals between doses
within a series, and several additional vaccine-specific
adjustments and exceptions.1 The recommendations
are designed to ensure that vaccinations provide maxFrom the National Center for Immunization and Respiratory Diseases
(Luman, Stokley), and the National Center for Chronic Disease
Prevention and Health Promotion (Shaw), CDC, Atlanta, Georgia
Address correspondence and reprint requests to: Elizabeth T.
Luman, PhD, CDC, 1600 Clifton Road NE, MS E05, Atlanta GA
30333. E-mail: [email protected].
imum effectiveness and protection against vaccinepreventable diseases.2 Over the past few years, the
vaccination schedule has become increasingly complex
with the addition of new vaccines and vaccine-combination options; this ever-growing complexity poses logistical challenges for vaccination providers in ensuring
that their patients are appropriately vaccinated.
Vaccination coverage estimates are used widely by
national, state, and local public health departments, as
well as vaccination providers, as a basis for programmatic and policy decisions: to evaluate the quality of
vaccination services, to target additional services, and,
when linked to surveillance data, to assess the success of
vaccination strategies in preventing disease. Federally
reported estimates of early-childhood vaccination coverage in the U.S., published annually by the National
Center for Immunization and Respiratory Diseases of
the CDC, measure the percentage of children who have
received the appropriate number of doses of the recommended vaccines.3 This dose-counting measure of
Am J Prev Med 2008;xx(xx)
© 2008 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/08/$–see front matter
doi:10.1016/j.amepre.2008.01.033
1
vaccination coverage has been used for nearly 50 years
to evaluate the success of vaccination programs in
reaching children, to determine demographic risk factors for undervaccination, to identify geographic areas
of low coverage, and to examine trends over time.4 In
contrast, evaluation of the other components of the
ACIP recommendations has been less thorough, and
may give additional insight into the quality of healthcare services and any potential gaps in population
protection. By examining compliance with each recommendation, public health staff can pinpoint both
strengths and areas of improvement for individual
immunization providers and develop provider-specific
strategies to improve the delivery of vaccination
services.
This study evaluates compliance with ACIP recommendations, collectively and individually, to better understand the extent to which the recommendations are
being followed. These ACIP-compliant estimates are
compared with standard dose-counting estimates to
determine the incremental impact of each recommendation on overall vaccination coverage.
Methods
National Immunization Survey
Estimates of vaccination coverage among U.S. children aged
19 –35 months are derived annually from the National Immunization Survey (NIS). The NIS uses random-digit dialing to
survey households with age-eligible children followed by a
questionnaire mailed to the children’s vaccination providers
to validate vaccination information.5 The NIS was approved
by the CDC’s IRB, and caregivers provided verbal consent for
participation and provider contact.
This analysis was conducted in 2007 using data from the
2005 NIS, which included information for 17,563 children
with a completed interview (84% of households identified
with an age-eligible child, Council of American Survey Research Organizations [CASRO] response rate 65%) and
adequate vaccination history from the vaccination providers
(64% of children with a completed interview). Data were
weighted to account for nonresponding households and
vaccination providers, as well as lower vaccination coverage
among children in households without land-line telephones,
to ensure that estimates were representative of all children in
the U.S. Details of the NIS methods have been reported
elsewhere.5,6
Outcome Measures
The ACIP-specified number of vaccine doses, the minimum
ages at which doses are considered valid, the minimum
intervals between doses within a series, and additional requirements are presented in Table 1.2,7–11 Pneumococcal
conjugate vaccine was also recommended during the period
when children in the 2005 NIS were receiving vaccinations
(2002–2005); however, it was not included in this report
because widespread vaccine shortages resulted in several
temporary changes to the recommendations.12–19
2
The authors defined ACIP-compliant coverage as the percentage of children who did not need any additional vaccinations at the time of the interview. Vaccination doses administered more than 4 days prior to the approved minimumacceptable age were considered age-invalid. Similarly,
vaccinations administered more than 4 days prior to the
approved minimum interval between doses of a vaccine were
considered interval-invalid, as were doses of live vaccine
administered 1–27 days after another live vaccine. If a child
received age- or interval-invalid doses, these doses were
excluded as per ACIP standards, and status was determined
based on the remaining doses.
PEDIARIXTM vaccine (SmithKline Beecham Biologicals,
Rixensart, Belgium)9 is a combination of diphtheria and
tetanus toxoids and acellular pertussis vaccine (DTaP), poliovirus, and hepatitis B vaccines given at 2, 4, and 6 months.
Children receiving PEDIARIXTM who were given a birth dose
of hepatitis B vaccine thus receive an extra dose of hepatitis B
vaccine at 4 months. Administration of this extra dose is
acceptable,9,10 and the dose was not considered invalid.
However, for ACIP-compliant coverage, it is not counted as
one of the three required doses in the hepatitis B series, as
per the recommendations.
Additional adjustments were made for Haemophilus influenzae type b vaccine (Hib) and varicella vaccine. Fewer doses of
Hib were required for children who received their first dose
after age 6 months, as per ACIP recommendations. Also,
because the NIS does not collect vaccine-manufacturer information, lenient assumptions were made regarding the need
for the 6-month dose of Hib vaccine. If children who received
three Hib doses were given the third dose prior to age 12
months (the required minimum age for the final dose using
either the three- or four-dose schedule), they were considered
not compliant, whereas if the dose was administered at ⱖ12
months, they were considered compliant. The varicella vaccination requirement was satisfied if the child received the
vaccination, or if he or she had a history of varicella disease,
as reported by the caregiver. Varicella doses administered
during the 4-day grace period prior to age 12 months were
considered valid.
Dose-counting coverage for each vaccine was calculated
as consistent with methods for data annually reported by
CDC.3 The number of vaccine doses that each child had
received by the time of the interview was counted. With the
exception of varicella, all doses were included regardless of
age at receipt; for varicella vaccine, doses given before age
12 months were excluded. Three doses of Hib were
required.
In addition to coverage for individual vaccines, dose-counting and ACIP-compliant coverage for the 4:3:1:3:3 vaccination
series are reported. For dose-counting coverage, this series
consists of at least four doses DTaP; three doses of poliovirus;
one dose of measles, mumps, and rubella vaccine (MMR);
three doses of Hib; and three doses of hepatitis B vaccine. For
ACIP-compliant coverage, one to four doses of Hib vaccine
may be required, depending on age at first dose and age at
last dose, as previously discussed. Coverage with the 4:3:1:3:
3:1 series (4:3:1:3:3 plus one dose of varicella vaccine), which
became the primary federally reported series outcome in
2006,3 is also presented.
American Journal of Preventive Medicine, Volume xx, Number xx
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Table 1. Recommended and minimum ages and intervals for early-childhood vaccinations, 2005a
Vaccination
dose
Recommended age for
routine administration
(months)
Minimim
acceptable ageb
Diphtheria and tetanus toxoids and acellular pertussis
1
2
6 weeks
2
4
10 weeks
3
6
14 weeks
4
15–18
12 months
Poliovirus
1
2
6 weeks
2
4
10 weeks
3
6–18
14 weeks
Measles, mumps, and rubella
1
12–15
12 months
Haemophilus influenzae type be
1
2
6 weeks
2
4
10 weeks
(3)f
6
14 weeks
4
12–15
12 months
Hepatitis B
1
0–2
Birth
2
1–4
4 weeks
3g
6–18
6 months
Varicellah
1
12–18
12 months
Recommended interval
between doses (months)
Minimum acceptable
interval between dosesc
2
2
6–12
4 weeks
4 weeks
4 months
2
2–14
4 weeks
4 weeks
d
2
2
6–9
4 weeks
4 weeks
8 weeks
1–4
2–17
4 weeks
8 weeks
d
a
Approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatricians, and the American Academy
of Family Physicians. See also www.cdc.gov/mmwr/preview/mmwrhtml/mm5301-Immunizationa1.htm. Pneumococcal conjugate vaccine is also
recommended, but was not included in this analysis.2,7
b
Doses given within 4 days before the minimum age for all vaccines are considered acceptable; doses given prior to this must be repeated.2
c
Doses given within 4 days before the minimum interval are considered acceptable; doses given prior to this must be repeated.2
d
Live vaccines (e.g., MMR and varicella) not administered on the same day should be administered ⱖ4 weeks apart. If live vaccines are separated
by ⬍4 weeks, the vaccine administered second should not be counted as a valid dose and should be repeated.2
e
Fewer doses of Hib are required for children who received their first dose after age 6 months. If the first dose is administered at age 7–11 months,
two doses with a 2-month interval and a third dose at age 12–15 months are recommended; if the first dose is administered at age 12–14 months,
two doses with a 2-month interval are recommended; if the first dose is administered after age 14 months, one dose is recommended.8
f
In most cases, four doses with a third dose at age 6 months are recommended. However, the age 6-months dose is not required if
polyribosylribitol phosphate-meningococcal outer membrane protein (PRP-OMP, PedvaxHib, manufactured by Merck) is used for the first two
doses.8
g
An additional dose of hepatitis B may be administered to children aged 4 months via the combination vaccine PEDIARIX™; while
administration of this extra dose is acceptable, the minimum age for the final dose of hepatitis B vaccine is age 6 months.9,10
h
For susceptible children (i.e., children who lack a reliable history of chickenpox as judged by a clinician)11
Analysis
Estimates of percentages and SEs were calculated using
SUDAAN version 9.0.1. For all statistical tests, the level of
significance was set a priori at pⱕ0.05. All analyses were
weighted and account for the complex sampling design of the
NIS.5
Results
Vaccination Coverage
Estimated coverage in 2005 with the 4:3:1:3:3 vaccination series incorporating all ACIP recommendations
was 72% (Table 2). This is 9 percentage points lower
than coverage based solely on counting doses. ACIPcompliant coverage was lowest for DTaP and highest
for poliovirus vaccine. Differences between the ACIPcompliant and dose-counting coverage measures were
largest for Hib and hepatitis B, moderate for DTaP, and
negligible for poliovirus and MMR vaccines. ACIPMonth 2008
compliant coverage was slightly higher than dosecounting coverage for varicella vaccine.
Effect of Each Recommendation
Overall, 19% of children were missing one or more
doses in the 4:3:1:3:3 series at the time of the interview
(Table 3). Most commonly, children were missing the
fourth dose of DTaP (14%); the single dose of MMR
(9%); or the third dose of poliovirus vaccine (8%).
Approximately 6% of children received at least one
age-invalid vaccination in the 4:3:1:3:3 series, and 3%
received at least one interval-invalid vaccination (including 0.3% who received MMR too soon after varicella); 8% received one or the other. Approximately
14% of children had a third dose of hepatitis B vaccine
prior to the minimum valid age of 6 months; 11% went
on to receive a fourth dose, while the remaining 3% did
not. The incremental effect of excluding invalid doses,
Am J Prev Med 2008;xx(xx)
3
Table 2. Vaccination coverage among children aged 19 –35
months using ACIP-compliant and dose-counting coverage
measures, 2005
ACIP-compliant
coverage
95%CI
Dose-counting
coverage
Vaccine
%
%
95%CI
Diphtheria and tetanus
toxoids and acellular
pertussis
Poliovirus
Measles, mumps, and
rubella
Haemophilus influenzae
type b
Hepatitis B
Varicella
4:3:1:3:3a
4:3:1:3:3:1b
84.1 (83.1, 85.1) 85.7 (84.8, 86.6)
91.6 (90.9, 92.4) 91.7 (90.9, 92.4)
90.6 (89.8, 91.3) 91.5 (90.8, 92.2)
88.6 (87.8, 89.3) 93.9 (93.2, 94.4)
89.4
89.1
72.3
69.4
(88.6,
(88.3,
(71.1,
(68.2,
90.1)
89.9)
73.5)
70.6)
92.9
87.9
80.8
76.1
(92.3,
(87.0,
(79.7,
(75.0,
93.5)
88.7)
81.8)
77.2)
a
For dose-counting coverage, at least four doses of diphtheria and
tetanus toxoids and acellular pertussis vaccine; three doses of poliovirus vaccine; one dose of measles, mumps, and rubella vaccine; three
doses of Haemophilus influenzae type b (Hib) vaccine; and three doses
of hepatitis B vaccine. For ACIP-compliant coverage, one to four
doses of Hib may be needed, depending on age at first dose and age
at last dose.
b
4:3:1:3:3 plus one dose of varicella vaccine
ACIP, Advisory Committee on Immunization Practices
after accounting for missing doses, was a reduction in
4:3:1:3:3 coverage of 6 percentage points; estimates for
hepatitis B and DTaP vaccines were most affected (4%
and 2%, respectively).
The adjustment for children who received three
doses of Hib but should have received four doses
reduced the coverage estimate by 6 percentage points,
while allowing children who started the vaccine series
late to receive fewer doses increased the estimate by 2
percentage points (Table 4). For varicella vaccine,
allowing a 4-day grace period before age 12 months
increased the coverage estimate by 1 percentage point,
as did adjusting for a history of varicella disease.
Differential Effects Among States
The percentage of children who were missing one or
more vaccine doses in the 4:3:1:3:3 series ranged from
⬎30% in two states to ⱕ20% in 30 states, while the
percentage of children who were not ACIP compliant
ranged from ⬎30% in 13 states to ⱕ20% in two states
(Figure 1; Appendix, located online at www.ajpm-online.
net). After accounting for missed doses, the incremental decrease in vaccination coverage because of other
requirements ranged from 2% in Arkansas to 15% in
Colorado (median 9%; Appendix).
Discussion
More than one in four U.S. children aged 19 –35
months were not in compliance with official vaccination recommendations, half again as many as reflected
4
by the dose-counting method. Missed doses accounted
for approximately two thirds of non-adherence to recommendations; however, focusing only on missed
doses disregards a substantial number of children who
were not in compliance because of mis-timed doses and
other vaccine-specific requirements.
The ACIP recommendations for early-childhood vaccination are based on the number of doses and the ages
that have been shown to be safe and effective in
controlled clinical trials. The public health implications
of departure from the recommendations are not
known in all cases, and may vary by antigen and by dose.
For live vaccines such as MMR, a single dose is usually
sufficient to produce an immune response. By contrast,
inactivated vaccines require multiple doses; the first
dose primes the immune system, while the protectiveimmunity response develops after the second or third
dose. For example, as many as 20% of children who
receive two doses of poliovirus vaccine do not seroconvert, while virtually all recipients become seropositive
after three doses.20 Thus, children who receive fewer
than the recommended number of doses may not be
protected against the disease.
Similarly, mis-timed vaccinations can lead to the
reduced immunity of individuals and increased levels of
population susceptibility. For example, maternally derived measles antibodies persist in many infants until
age 11 months and may prevent the development of
immune response to vaccination, increasing the risk of
primary vaccine failure and subsequent infection in
children who receive the measles vaccine before age 12
months.21–23 Similarly, young infants respond infrequently and with low antibody levels to Hib24 and the
pertussis portion of DTaP,25 while this immune response improves with age. Allowing sufficient time
intervals between doses in multidose vaccines is also
necessary to produce adequate immune response.2 For
example, studies have shown that an interval of 2
months between doses of poliovirus vaccine is preferred to a 1-month interval.20
Other vaccine-specific exceptions and adjustments
are important as well. The two schedules for Hib
vaccine reflect the variability in formulation between
manufacturers.8 Adjustments for age at first dose of Hib
reflect the improved immune response and decreased
risk of disease among older children.8 Adjusting for a
history of varicella disease accounts for immunity conferred by the disease; however, as varicella disease
becomes less common,26 the importance of this adjustment is diminishing.27
Failure to account for invalid vaccinations and other
components of the ACIP recommendations has long
been acknowledged as a limitation of the dose-counting
method of assessing vaccination coverage.4 However,
dose-counting is a practical option as a primary surveillance measure because calculating it is substantially
simpler than calculating compliance with all recom-
American Journal of Preventive Medicine, Volume xx, Number xx
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Table 3. Percentage of children with missed and invalid doses, 2005
Did not receive dose
Dose
% (CI)
Diphtheria and tetanus toxoids and acellular pertussis
1
1.2 (1.0,1.5)
2
2.2 (1.9,2.6)
3
3.9 (3.5,4.5)
4
14.3 (13.4,15.2)
Series
Poliovirus
1
1.8 (1.6,2.2)
2
3.1 (2.7,3.5)
3
8.3 (7.6,9.1)
Series
Measles, mumps, and rubella
1
8.5 (7.8,9.2)
Haemophilus influenzae type b
1
1.4 (1.2,1.7)
2
2.7 (2.4,3.1)
(3)
NA (NA)
4
6.1 (5.6,6.8)
Series
Hepatitis B
1
1.4 (1.1,1.7)
2
2.8 (2.5,3.2)
3
7.1 (6.5,7.7)
Series
Varicella
1
10.6 (9.9,11.4)
4:3:1:3:3b
Series
19.2 (18.2,20.3)
Received invalid dose
% (CI)
Incremental effect on
coveragea % (CI)
0.3 (0.2,
0.2 (0.1,
0.1 (0.0,
2.2 (0.2,
2.5 (2.0,
0.5)
0.4)
0.2)
2.6)
3.0)
⫺1.6 (1.3, 2.1)
0.4 (0.3,
0.3 (0.2,
0.1 (0.1,
0.6 (0.4,
0.7)
0.5)
0.2)
0.8)
⫺0.1 (0.0, 0.2)
1.0 (0.8, 1.3)
⫺0.9 (0.7, 1.2)
0.5 (0.4,
0.3 (0.2,
0.1 (0.0,
1.1 (0.9,
1.5 (1.2,
0.7)
0.4)
0.2)
1.4)
1.7)
⫺0.1 (0.0, 0.2)
NA (NA)
0.2 (0.1, 0.4)
3.4 (3.0, 3.9)
3.6 (3.1, 4.1)
⫺3.6 (3.1, 4.1)
1.4 (1.1, 1.7)
⫺1.2 (1.0, 1.5)
7.9c (7.2, 8.7)
⫺6.2 (5.6, 6.9)
a
Incremental effect on coverage after accounting for doses not received
For standard coverage, at least four doses of diphtheria and tetanus toxoids and acellular pertussis vaccine; three doses of poliovirus vaccine;
one dose of measles, mumps, and rubella vaccine; three doses of Haemophilus influenzae type b (Hib) vaccine; and three doses of hepatitis B
vaccine. For ACIP-compliant coverage, one to four doses of Hib may be needed, depending on age at first dose and age at last dose.
c
6.2% of children received an age-invalid dose; 2.5% received an interval-invalid dose (including 0.3% who received MMR too soon after
varicella).
ACIP, Advisory Committee on Immunization Practices; NA, not applicable.
b
mendations, historical continuity allows evaluation of
trends over time, and missed doses account for the
majority of noncompliance.
Previous studies have examined specific components
of the ACIP recommendations, and additional meaTable 4. Percentage of children affected by other ACIP
recommendations, 2005
Vaccine
% (CI)
Incremental effect
on coverage %
(CI)
Haemophilus influenzae type b
Received 3 but needed 6.3 (5.7, 6.9)
⫺6.3 (5.7, 6.9)
4 doses
Needed fewer doses
15.2 (14.3, 16.2) ⫹1.8 (1.5, 2.2)
due to late first dose
Varicella
Vaccination not
2.6 (2.2, 3.1)
⫹0.9 (0.7, 1.1)
needed due to
history of varicella
disease
ACIP, Advisory Committee on Immunization Practices
Month 2008
sures of vaccination coverage have been proposed.28 –32
The WHO recommends routinely reporting coverage
estimates that exclude invalid doses, in addition to
those that include all doses33; in the U.S., several local
studies34 –36 and one national study37 have evaluated
coverage that excludes invalid doses. Recently, work has
been done to examine the timeliness of vaccinations
and to determine whether children in the U.S. are
adequately protected from vaccine-preventable diseases
during their first 2 years of life.38 – 44 Another study
compared varicella coverage among all children to that
among susceptible children, excluding those with a
history of varicella disease.27 However, to the authors’
knowledge, the current study is the first nationally
representative assessment of compliance with the complete set of ACIP recommendations.
The coverage estimates for Hib and hepatitis B
vaccines were most affected by the study’s adjustments.
The variability in recommendations for different formulations of Hib vaccine poses an analytic challenge,
because manufacturer information is not collected in
Am J Prev Med 2008;xx(xx)
5
Missing One or More Doses
>30%
(2 states)
21%–30%
(19 states)
11%–20%
(29 states)
0%–10%
(1 state)
11%–20%
(2 states)
0%–10%
(0 states)
Not ACIP-Compliant
>30%
(13 states)
21%–30%
(36 states)
Figure 1. Estimated percentage of children not in compliance with ACIP recommendations* by state, 2005
*For dose-counting, at least four doses of diphtheria and tetanus toxoids and acellular pertussis vaccine; three doses of
poliovirus vaccine; one dose of measles, mumps, and rubella vaccine; three doses of Haemophilus influenzae type b (Hib)
vaccine; and three doses of hepatitis B vaccine. For ACIP compliance, one to four doses of Hib may be needed, depending
on age at first dose and age at last dose.
the NIS. The standard dose-counting measure of coverage requires receipt of only three doses, differentially
inflating coverage among children who are following
6
the four-dose schedule; this analysis has shown that the
resulting inflation in coverage is substantial, even compared to the lenient definition used here. Second, the
American Journal of Preventive Medicine, Volume xx, Number xx
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exclusion of invalid doses had a relatively large effect
on hepatitis B vaccine coverage. Some early third doses
of hepatitis B vaccine were likely due to the use of
PEDIARIXTM vaccine. While the administration of an
extra dose of hepatitis B vaccine via PEDIARIXTM at 4
months is acceptable, counting it as one of the three
required doses in the hepatitis B series is not consistent
with ACIP recommendations.9
This study is subject to at least two limitations: First,
the NIS relies on identification of vaccination providers
by the household respondents and on the complete
and accurate reporting of vaccination histories by these
providers; inaccurately or incompletely reported dates
may have caused differential underestimation of ACIPcompliant coverage compared to dose-counting coverage. Second, the NIS does not collect information on
medical contraindications to vaccination, such as severe
allergic reaction after a prior dose of vaccine. However,
true contraindications to vaccination are few and most
are temporary,2 and would be equally reflected in
ACIP-compliant and dose-counting coverage measures.
The findings suggest that the number of children
who needed additional doses to bring them into compliance with ACIP recommendations at the time of the
interview was nearly 50% greater than dose-counting
alone would imply, and up to double that number in
some states. While priority should be given to ensuring
that children receive all of the recommended vaccine
doses, compliance with the remaining recommendations should not be overlooked. In practice, vaccination
providers must sometimes balance the competing goals
of administering valid vaccinations and reducing
missed opportunities. Administering a vaccination a
few days early is preferred to missing the opportunity to
vaccinate a child who is unlikely to return at the
appropriate time; however, the observance of both
age-appropriate vaccination and sufficient time between doses in a series maximizes the immune response
and the vaccine’s efficacy.45 In general, providers and
parents are advised to adhere to the specifics of published guidelines whenever possible.
Compliance with all ACIP recommendations is an
essential measure of the quality of healthcare service
delivery. Many state immunization programs use the
assessment, feedback, incentives, and exchange of information (AFIX) strategy to assist vaccination providers with improving the quality of service delivery.46,47
State health officials review a representative sample of
office-based charts to measure vaccination coverage
and to identify missed opportunities for vaccination.
The Comprehensive Clinic Assessment Software Application (CoCASA), which was designed to assist with
implementation of the AFIX strategy (www.cdc.gov/
nip/cocasa/default.htm), now evaluates compliance
with each component of the ACIP recommendations in
addition to dose-counting coverage. State immunization information systems may also be useful for evaluMonth 2008
ating compliance with ACIP recommendations. A comprehensive approach to vaccination-coverage assessment
that encompasses several measures, including both a
dose-counting measure and a measure of compliance
with all ACIP recommendations, may give immunization providers a more accurate picture of the quality of
care within their practices and provide a more complete evaluation of vaccination programs, revealing
their specific strengths and weaknesses and eliciting
data-driven solutions to ensure that children and communities are optimally protected from vaccine-preventable diseases.
Dr Luman had full access to all of the data in the study and
takes responsibility for the integrity of the data and the
accuracy of the data analysis.
This research and the National Immunization Survey were
conducted through funding by the CDC, USDHHS.
This study, including design and conduct, data collection,
analysis and interpretation of the data, and manuscript preparation, review, and approval, was conducted under the
auspices of the USDHHS and the CDC. CDC gave final
approval of the manuscript.
The authors gratefully acknowledge the contribution of
Lawrence Barker, Susan Chu, Diane Simpson, Jeanne Santoli,
Abigail Shefer, and Jim Singleton for their review and
suggestions.
The findings and conclusions in this report are those of the
author(s) and do not necessarily represent the views of the
CDC.
No financial disclosures were reported by the authors of
this paper.
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American Journal of Preventive Medicine, Volume xx, Number xx
www.ajpm-online.net
Appendix Percentage of children not in compliance with ACIP vaccination recommendations by state, 2005
Diphtheria and tetanus toxoids
and acellular pertussis
4:3:1:3:3a
Am J Prev Med 2008;xx(xx)
Not ACIPcompliantb
Missed
doses
National
27.7
19.2
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of
Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New
Hampshire
New Jersey
New Mexico
New York
North
Carolina
North Dakota
Ohio
Oklahoma
Oregon
26.8
28.2
30.4
34.6
31.6
31.2
23.1
25.1
36.5
Measles, mumps, and rubella
Haemophilus influenzae type b
Noncompliance
due to
Noncompliance
due to
Noncompliance
due to
Noncompliance
due to
Noncompliance
due to
State
Poliovirus
Not ACIPcompliant
Not ACIPcompliant
Missed
doses
Otherc
7.1
3.8
10.9
12.1
⫺1.2
9.0
14.6
13.4
13.4
11.6
12.7
12.7
15.6
19.5
5.6
11.9
9.0
12.1
7.4
4.6
8.8
8.8
14.0
3.4
2.7
4.4
1.3
4.2
8.1
3.9
6.8
5.5
5.5
15.6
15.9
13.1
10.3
11.0
7.6
9.8
9.5
6.5
18.8
16.4
14.1
10.5
12.8
9.0
10.5
9.4
⫺1.0
⫺3.2
⫺0.5
⫺1.0
⫺0.2
⫺1.8
⫺1.4
⫺0.7
0.1
5.8
2.5
4.4
9.3
7.7
8.1
3.1
0.8
7.6
6.1
8.2
4.7
1.6
6.7
4.6
0.9
6.6
6.0
8.8
10.0
5.4
12.3
8.8
13.7
16.0
9.3
8.3
8.1
16.6
7.9
12.5
13.3
15.0
3.6
7.3
7.3
13.4
10.3
10.8
9.4
19.1
12.2
8.7
6.6
9.6
8.1
5.0
4.8
5.5
9.5
7.0
7.0
10.0
7.4
2.1
4.5
5.3
7.1
5.9
9.0
5.0
16.8
6.7
3.6
2.2
4.1
7.9
4.3
3.5
2.6
7.1
0.9
5.5
3.3
7.6
1.5
2.8
2.0
6.3
4.4
1.8
4.4
2.3
5.5
9.4
5.5
10.4
20.4
9.8
14.7
12.9
15.9
14.0
9.9
15.0
9.2
4.6
5.5
11.8
9.9
10.2
19.5
9.7
14.8
15.1
8.9
8.1
10.6
22.6
13.7
17.2
16.6
18.5
16.7
11.0
15.8
9.3
4.6
6.6
13.3
11.6
12.1
24.5
10.1
15.6
17.1
0.5
⫺2.6
⫺0.2
⫺2.2
⫺3.9
⫺2.5
⫺3.7
⫺2.6
⫺2.7
⫺1.1
⫺0.8
⫺0.1
0.0
⫺1.1
⫺1.5
⫺1.7
⫺1.9
⫺5.0
⫺0.4
⫺0.8
⫺2.0
7.9
10.2
6.3
2.4
7.3
5.6
3.3
3.8
11.7
18.9
10.1
10.4
7.7
9.6
6.3
8.1
4.0
9.3
3.8
2.3
16.5
13.3
11.8
7.7
16.2
13.7
12.4
8.7
0.3
⫺0.4
⫺0.6
⫺1.0
3.8
5.7
10.7
12.7
6.0
3.8
2.2
6.8
9.9
8.2
14.8
19.8
3.7
4.5
11.3
15.7
6.2
3.7
3.5
4.1
11.3
12.7
14.5
20.2
12.8
13.7
14.2
23.8
⫺1.5
⫺1.0
0.3
⫺3.6
8.5
0.9
11.4
6.1
5.3
10.6
6.5
10.5
11.6
11.5
9.1
7.9
6.0
5.8
12.9
5.9
9.2
11.2
11.0
8.4
6.8
4.8
4.8
8.4
0.6
1.3
0.4
0.5
0.7
1.1
1.2
1.0
4.5
9.9
9.2
13.7
13.2
10.1
10.9
8.8
8.0
10.6
3.1
11.1
7.6
12.1
6.3
3.8
2.9
6.8
8.8
6.8
⫺1.9
6.1
1.1
3.8
7.1
5.9
1.2
1.8
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.3
0.0
0.0
0.0
0.2
0.0
0.0
0.0
0.4
0.0
0.0
0.0
9.8
7.2
10.5
13.4
7.0
9.0
8.3
8.4
10.7
11.3
7.8
9.3
3.0
7.0
10.0
10.8
10.0
7.9
6.2
15.4
12.4
8.0
7.1
10.3
13.5
7.0
8.8
8.3
7.3
9.8
10.8
7.8
6.4
3.0
6.3
8.6
9.0
9.7
6.4
5.2
14.3
11.7
1.8
0.1
0.2
0.0
0.0
0.2
0.0
1.1
0.9
0.5
0.0
2.9
0.0
0.7
1.4
1.8
0.3
1.5
1.0
1.1
0.7
12.1
8.0
13.0
16.6
12.3
14.1
9.7
7.8
12.8
11.8
11.8
8.9
2.2
11.4
11.4
11.5
12.1
14.5
12.1
20.6
9.1
6.3
5.5
8.6
7.3
4.6
6.0
6.6
7.0
5.2
5.7
3.6
4.2
0.6
4.7
6.8
10.6
5.5
8.5
3.3
10.6
3.7
13.6
8.4
8.0
5.5
0.8
0.0
0.0
0.0
17.4
10.4
9.4
6.4
14.7
8.8
7.1
5.6
2.7
1.6
2.3
0.8
15.2
15.8
9.6
6.2
3.4
6.8
9.1
12.7
0.0
0.0
0.0
0.0
8.4
7.5
11.2
17.6
7.7
6.9
10.2
17.3
0.7
0.6
1.0
0.3
9.8
9.5
12.9
19.5
Otherc
8.5
15.9
14.3
1.6
8.4
8.3
0.1
9.4
16.7
24.6
20.8
32.2
22.1
16.6
13.9
15.8
26.5
10.1
3.6
9.6
2.4
9.5
14.6
9.2
9.3
10.0
13.1
16.2
18.0
26.7
18.2
15.9
10.4
13.0
17.1
10.4
15.4
16.9
26.2
16.5
12.3
10.4
11.7
14.7
2.7
0.8
1.1
0.5
1.7
3.6
0.0
1.3
2.4
8.4
10.9
11.1
15.4
9.5
5.8
5.4
7.9
9.0
8.4
10.9
10.8
15.4
9.5
5.8
5.4
7.9
9.0
0.0
0.0
0.3
0.0
0.0
0.0
0.0
0.0
0.0
29.6
22.2
28.9
35.5
25.8
28.1
21.9
25.9
26.8
32.4
27.6
28.6
11.0
24.2
23.5
24.9
27.7
29.3
22.5
40.3
25.4
20.7
15.3
19.9
21.9
16.5
21.9
15.1
16.2
20.3
24.0
16.7
17.7
6.5
17.3
14.8
16.4
20.7
20.4
10.9
33.3
17.2
8.9
6.9
9.0
13.6
9.3
6.2
6.8
9.7
6.5
8.4
10.9
10.9
4.5
6.9
8.7
8.5
7.0
8.9
11.6
7.0
8.2
19.4
12.7
16.5
17.7
15.5
17.5
13.3
12.1
15.5
20.8
10.8
11.6
3.8
14.2
11.9
15.2
16.2
16.4
8.9
27.7
12.8
17.4
11.9
15.5
16.9
11.3
17.5
12.8
11.5
14.3
19.5
8.6
10.2
3.0
13.0
10.7
13.8
14.7
14.4
8.3
26.5
12.2
2.0
0.8
1.0
0.8
4.2
0.0
0.5
0.6
1.2
1.3
2.2
1.4
0.8
1.2
1.2
1.4
1.5
2.0
0.6
1.2
0.6
12.1
7.0
10.8
9.5
8.4
10.2
7.7
8.6
5.1
8.6
2.9
7.9
1.6
6.9
3.7
5.2
5.6
5.1
4.3
13.7
4.9
12.1
7.0
10.8
9.5
8.4
10.2
7.7
8.6
5.1
8.3
2.9
7.9
1.6
6.7
3.7
5.2
5.6
4.7
4.3
13.7
4.9
35.0
28.0
25.6
18.8
21.8
21.6
18.4
14.8
13.2
6.4
7.2
4.0
17.8
18.3
12.4
9.3
15.6
17.8
11.0
8.7
2.2
0.5
1.4
0.6
14.4
8.4
8.0
5.5
24.6
25.0
35.0
36.4
15.0
15.9
24.3
27.1
9.6
9.1
10.7
9.3
13.5
13.6
23.4
22.9
12.2
12.1
20.3
21.3
1.3
1.5
3.1
1.6
3.4
6.8
9.1
12.7
Missed
doses
Otherc
Missed
doses
Noncompliance
due to
Otherc
Not ACIPcompliant
Not ACIPcompliant
Missed
doses
Varicella
Noncompliance
due to
Otherc
Not ACIPcompliant
Not ACIPcompliant
Otherc
Hepatitis B
Missed
doses
Otherc
Missed
doses
8.e1
8.e2
American Journal of Preventive Medicine, Volume xx, Number xx
Appendix (continued)
Diphtheria and tetanus toxoids
and acellular pertussis
4:3:1:3:3a
Measles, mumps, and rubella
Haemophilus influenzae type b
Noncompliance
due to
Noncompliance
due to
Noncompliance
due to
Noncompliance
due to
Noncompliance
due to
State
Poliovirus
Not ACIPcompliantb
Missed
doses
Otherc
Not ACIPcompliant
Missed
doses
Otherc
Not ACIPcompliant
Missed
doses
Otherc
Not ACIPcompliant
Missed
doses
Otherc
Not ACIPcompliant
Missed
doses
Otherc
Hepatitis B
Varicella
Noncompliance
due to
Noncompliance
due to
Not ACIPcompliant
Missed
doses
Otherc
Not ACIPcompliant
Missed
doses
Otherc
Pennsylvania
Rhode Island
South
Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
22.4
28.1
28.1
16.8
16.9
21.5
5.6
11.2
6.6
12.2
13.8
18.5
12.2
12.1
17.4
0.0
1.7
1.1
9.2
4.8
10.7
9.2
4.4
10.7
0.0
0.4
0.0
6.7
6.2
13.2
6.4
4.8
12.7
0.3
1.4
0.5
8.6
7.5
16.0
6.3
5.8
9.8
2.3
1.7
6.2
7.6
10.1
8.3
4.3
3.7
5.9
3.3
6.4
2.4
13.4
4.0
13.0
10.8
3.8
12.6
2.6
0.2
0.4
23.8
28.2
29.3
31.1
30.4
24.7
30.9
34.6
25.1
30.4
13.1
17.1
21.6
25.9
18.5
14.2
22.2
25.1
17.8
21.4
10.7
11.1
7.7
5.2
11.9
10.5
8.7
9.5
7.3
9.0
10.9
15.6
18.7
19.7
15.3
15.8
18.3
19.3
13.7
19.1
10.3
14.3
16.3
19.1
13.8
13.3
14.9
17.4
13.4
16.9
0.6
1.3
2.4
0.6
1.5
2.5
3.4
1.9
0.3
2.2
5.9
5.5
7.3
13.6
3.9
7.0
12.1
7.6
5.1
7.9
5.9
5.4
7.3
13.6
3.9
7.0
11.6
7.6
5.1
7.9
0.0
0.1
0.0
0.0
0.0
0.0
0.5
0.0
0.0
0.0
6.2
8.0
12.1
11.9
7.8
6.7
10.0
14.3
9.3
12.5
5.6
8.0
10.9
11.0
7.4
6.7
9.4
14.3
8.4
10.6
0.6
0.0
1.2
0.9
0.4
0.0
0.6
0.0
0.9
1.9
9.6
13.5
15.0
12.9
10.1
14.7
11.4
13.3
9.7
10.7
5.9
6.5
7.2
9.0
2.5
2.8
6.4
4.7
7.7
5.3
3.7
7.0
7.8
3.9
7.6
11.9
5.0
8.6
2.0
5.4
14.9
12.1
11.7
11.0
13.4
6.2
14.7
15.7
9.9
16.6
4.7
5.3
8.5
8.7
6.0
2.7
12.6
8.2
7.4
9.6
10.2
6.8
3.2
2.3
7.4
3.5
2.1
7.5
2.5
7.0
12.8
9.2
10.5
15.2
27.9
7.5
19.9
18.5
9.3
19.6
14.3
10.2
11.1
18.8
31.5
10.1
23.4
18.9
13.0
22.8
⫺1.5
⫺1.0
⫺0.6
⫺3.6
⫺3.6
⫺2.6
⫺3.5
⫺0.4
⫺3.7
⫺3.2
Minimum
Maximum
Median
Range
11.0
40.3
28.1
29.3
6.5
33.3
18.4
26.8
2.4
14.6
9.0
12.2
3.8
27.7
15.6
23.9
3.0
26.5
13.8
23.5
0.0
4.2
1.3
4.2
1.6
15.4
7.9
13.8
1.6
15.4
7.9
13.8
0.0
0.8
0.0
0.8
3.0
17.6
9.3
14.6
3.0
17.3
8.4
14.3
0.0
4.5
0.7
4.5
2.2
20.6
11.4
18.4
0.6
12.7
6.3
12.1
⫺1.9
11.9
5.6
13.8
3.6
19.8
12.1
16.2
2.1
16.8
7.4
14.7
0.9
10.2
3.9
9.3
4.0
27.9
11.8
23.9
3.8
31.5
13.0
27.7
⫺5.0
2.6
⫺1.1
7.6
a
For dose-counting coverage, at least four doses of diphtheria and tetanus toxoids and acellular pertussis vaccine; three doses of poliovirus vaccine; one dose of measles, mumps, and rubella vaccine; three doses of Haemophilus influenzae type b vaccine; and three
doses of hepatitis B vaccine. For ACIP-compliant coverage, one to four doses of Haemophilus influenzae type b vaccine may be needed depending on age at first dose and age at last dose.
b
Half-width of the 95% CI for 4:3:1:3:3 non-compliance: 4%–9%
c
Incremental decrease in compliance due to other ACIP recommendations after accounting for doses not received. Negative values indicate compliance increased due to other recommendations.
ACIP, Advisory Committee on Immunization Practices; DTaP, diphtheria and tetanus toxoids and acellular pertussis vaccine; Hib, Haemophilus influenzae type b vaccine; MMR, measles, mumps, and rubella vaccine.