Barriers to adolescent immunization: a survey of family physicians and pediatricians

BACKGROUND: Although early childhood vaccination rates have increased, many adolescents are not up to date on recommended vaccinations. We assessed attitudes and practices of family physicians and pediatricians regarding adolescent vaccination to identify provider-level barriers that may contribute to low immunization rates. METHODS: A 94-item self-report questionnaire was mailed to 400 physicians contracted with a managed care organization. Physicians were queried about demographic characteristics, source of vaccine recommendations, adolescent immunization practices, barriers to immunizing adolescents, and use of reminder/recall systems. RESULTS: Response rate was 59%. Most respondents reported routinely recommending vaccines for tetanus and diphtheria toxoids (98%), Hepatitis B (90%), and measles, mumps, and rubella (84%), whereas 60% routinely recommended varicella vaccine. Physicians reported that they were more likely to assess immunization status, administer indicated immunizations, and schedule return immunization visits to younger adolescents (11 to 13 years old) than to older adolescents (14 to 18 and 19 to 21 years old). CONCLUSION: Most respondents reported recommending the appropriate vaccinations during preventive health visits; however, older adolescents were least likely to be targeted for immunization assessment and administration of all recommended vaccines.     

Associations of daycare and school entry vaccination requirements with varicella immunization rates

School and daycare entry requirements have been credited with increasing immunization rates among school-age children, but no prior study has assessed the nationwide effects of entry requirements while controlling for individual, family, and household characteristics. The 2002 National Immunization Survey (NIS) is a nationally representative annual survey that includes provider record-verified immunization dates for 20,546 children aged 19-35 months without prior history of varicella. In weighted bivariate and multivariate logistic regression models, we examined the association of state entry mandate implementation with children's up-to-date (UTD) status for varicella vaccine, adjusted for sociodemographic characteristics of children, mothers, and household income and for children's UTD status for other recommended vaccines. In this national sample representative of 5.6 million children, 83.2% (95% CI: 82.3%-84.1%) were UTD for varicella vaccine. Between 1997 and 2002 inclusive, 33 states and the District of Columbia had implemented school and/or daycare entry immunization mandates for varicella. In bivariate analyses, 84.9% (83.9%-85.9%) of children in states with varicella entry mandates were UTD, compared to 76.8% (75.3%-78.4%) of children in states without such mandates. In multivariate analyses controlling for child and family characteristics, children living in states with varicella entry mandates remained significantly more likely to be UTD for varicella than children in states without mandates. These findings indicate that immunization entry requirements are associated with higher immunization rates among preschool-age children, and suggest that the effects of entry requirements are independent of other individual and household factors associated with childhood immunization.     

Are providers’ recommendation and knowledge associated with uptake of optional vaccinations among children? A multilevel analysis in three provinces of China

BackgroundImmunization services providers play a crucial role in the successful implementation of immunization, particularly for new vaccines. Several childhood vaccinations that are important for public health are not included in the National Immunization Programme in China, although they are available as optional and self-paid vaccines. Their coverage remains low.ObjectiveTo examine the association between providers’ knowledge and recommendations of optional vaccines, as well as other supply- and demand-side factors, and their uptake among children.MethodsA cross-sectional study, that included an in-person questionnaire survey for parents of children under-3 years and a self-administrative questionnaire survey for their vaccination services providers, was conducted in 36 townships or sub-districts in three provinces of China in 2013. Using a sample of 1791 household from 30 townships or sub-districts, we applied multilevel logistic analyses to examine the factors associated with the uptake of optional vaccines based on a hierarchal framework that combined demand-side and supply-side factors.ResultsCoverage of optional childhood vaccinations varied across small areas. Supply- and demand-side factors were both associated with the uptake of these vaccines. Immunization services providers’ recommendations and their knowledge about optional vaccination were positively and significantly associated with uptake. Children were more likely to receive the vaccines if they lived in communities with higher immunization worker density or larger immunization clinics. Several demand-side psychological factors about childhood vaccination were also associated with optional vaccinations.ConclusionsPromoting immunization services providers to conduct evidence-based recommendations about some important childhood optional vaccinations and enhancing their knowledge regarding optional vaccinations and communication skills are useful strategies to increase the coverage of these vaccinations.     

Pediatric Vaccination and Vaccine-Preventable Disease Acquisition: Associations with Care by Complementary and Alternative Medicine Providers

This study investigated provider-based complementary/alternative medicine use and its association with receipt of recommended vaccinations by children aged 1–2 years and with acquisition of vaccine-preventable disease by children aged 1–17 years. Results were based on logistic regression analysis of insurance claims for pediatric enrollees covered by two insurance companies in Washington State during 2000–2003. Primary exposures were use of chiropractic, naturopathy, acupuncture, or massage practitioner services by pediatric enrollees or members of their immediate families. Outcomes included receipt by children aged 1–2 years of four vaccine combinations (or their component vaccines) covering seven diseases, and acquisition of vaccine-preventable diseases by enrollees aged 1–17 years. Children were significantly less likely to receive each of the four recommended vaccinations if they saw a naturopathic physician. Children who saw chiropractors were significantly less likely to receive each of three of the recommended vaccinations. Children aged 1–17 years were significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care. Use of provider-based complementary/alternative medicine by other family members was not independently associated with early childhood vaccination status or disease acquisition. Pediatric use of complementary/alternative medicine in Washington State was significantly associated with reduced adherence to recommended pediatric vaccination schedules and with acquisition of vaccine-preventable disease. Interventions enlisting the participation of complementary/alternative medicine providers in immunization awareness and promotional activities could improve adherence rates and assist in efforts to improve public health.     

Information,education, and health behaviors: Evidence from the MMR vaccine autism controversy

In the wake of strong, although later refuted, claims of a link between autism and the measles‐mumps‐rubella (MMR) vaccine, I examine whether fewer parents immunized or delayed vaccinations for their children and if there was a differential response by mother's education level. Using various controls and a differencing strategy that compares in MMR take‐up with other vaccines, I find that the MMR–autism controversy led to a decline in the immediate years and that there were negative spillovers onto other vaccines. I also find evidence that more highly educated mothers responded more strongly to the controversy either by not immunizing their children altogether or, to a lesser degree, delaying vaccination. Moreover, the educational gap was greater in states where there was greater media attention devoted to the controversy. This is consistent with the health allocative efficiency hypothesis whereby part of the education gradient in health outcomes is due to more‐educated individuals absorbing and responding to health information more quickly. However, unlike in the United Kingdom, where previous studies find that the gap was eliminated after the link was refuted, the evidence for the United States suggests that the educational gap persisted.     

School staff and immunization governance: Missed opportunities for public health promotion

BackgroundIn US states, childhood immunization mandates are enforced for school registration by front-line school staff, usually secretaries. Despite substantial changes to mandate policies in several states and many countries, little attention has been paid to the people who enforce them. This qualitative pilot study aimed to uncover beliefs, attitudes, and practices regarding immunization governance of Michigan school staff.MethodFront-line administrative workers from Michigan schools and district offices were solicited by email. Sixteen were interviewed remotely.ResultsFront-line school staff believed in vaccines, but did not advocate for vaccination while registering children. Instead, they sought low-friction bureaucratic transactions, privileging the collection of data over the promotion of public health goals. This revealed a mismatch between the goals of the front-line staff who enforce vaccine mandates in schools and the goals of the policymakers who created school vaccine mandates.ConclusionsThis study found low mobilization of front-line enforcers of mandates in public-facing school administration roles, a problem likely to afflict the majority of American states with the ‘mandates + exemptions’ model of immunization governance. Schools would have stronger incentives to promote vaccination if state funding were better tied to immunization compliance. Front-line staff could better enforce vaccine mandates if they were provided with resources and training about vaccine promotion.     

An assessment of parents’ childhood immunization beliefs,intentions, and behaviors using a smartphone panel

IntroductionIt is important to quickly identify parent beliefs, intentions, and behaviors toward childhood vaccination, especially parents of children 19 to 35 months. This paper describes parental immunization beliefs, intentions, and behaviors; assesses the relationships between beliefs and intentions regarding child immunization and actual behaviors; and assesses whether beliefs, intentions, and/or behaviors varied across demographic subgroups.MethodsA sample of parents, ages 18 and older, from a mobile panel with people residing in the U.S. were invited to answer immunization behavior, intention, and belief questions using a smartphone app that was not vaccine specific. 10,000 panel members with a child under 18 were sent invitations. 1029 surveys were completed by a respondent with a child 19 to 35 months. The survey instrument replicated many NIS questions and had similar sequencing.FindingsRespondents reported that most children received all recommended vaccines, except flu vaccine, suggesting some may not understand the immunization schedule. Demographics closely associated with immunization behaviors were respondents’ education and household income. There is strong agreement that vaccines are effective, important to community health, and the child’s health. There is concern about the number of shots received, disease prevention, and ingredient safety. Some belief remains about vaccines causing learning disabilities. Positive beliefs about the benefits of childhood vaccines and concomitant risks vary with demographics.ConclusionsThis survey provided insights into beliefs and behaviors of parents regarding childhood vaccination. It found evidence of differences in beliefs, particularly related to delaying or declining recommended childhood vaccinations. The survey was conducted in a few days and at lower cost than traditional methods. This serves as a model for health agencies where rapid results or inexpensive approaches are needed.     

Examination of universal purchase programs as a driver of vaccine uptake among US States, 1995–2014

BackgroundImmunization against numerous potentially life-threatening illnesses has been a great public health achievement. In the United States, the Vaccines for Children (VFC) program has provided vaccines to uninsured and underinsured children since the early 1990s, increasing vaccination rates. In recent years, some states have adopted Universal Purchase (UP) programs with the stated aim of further increasing vaccination rates. Under UP programs, states also purchase vaccines for privately-insured children at federally-contracted VFC prices and bill private health insurers for the vaccines through assessments.MethodsIn this study, we estimated the effect of UP adoption in a state on children’s vaccination rates using state-level and individual-level data from the 1995–2014 National Immunization Survey. For the state-level analysis, we performed ordinary least squares regression to estimate the state’s vaccination rate as a function of whether the state had UP in the given year, state demographic characteristics, other vaccination policies, state fixed effects, and a time trend. For the individual analysis, we performed logistic regression to estimate a child’s likelihood of being vaccinated as a function of whether the state had UP in the given year, the child’s demographic characteristics, state characteristics and vaccine policies, state fixed effects, and a time trend. We performed separate regressions for each of nine recommended vaccines, as well as composite measures on whether a child was up-to-date on all required vaccines.ResultsIn the both the state-level and individual-level analyses, we found UP had no significant (p < 0.10) effect on any of the vaccines or composite measures in our base case specifications. Results were similar in alternative specifications.ConclusionsWe hypothesize that UP was ineffective in increasing vaccination rates. Policymakers seeking to increase vaccination rates would do well to consider other policies such as addressing provider practice issues and vaccine hesitancy.     

Scope and magnitude of private sector financing and provision of immunization in Benin,Malawi and Georgia

BackgroundLittle is known about the role of private sector providers in providing and financing immunization. To fill this gap, the authors conducted a study in Benin, Malawi, and Georgia to estimate (1) the proportion of vaccinations taking place through the private sector; (2) private expenditures for vaccination; and (3) the extent of regulation.MethodsIn each country, the authors surveyed a stratified random sample of 50 private providers (private for-profit and not-for-profit) using a standardized, pre-tested questionnaire administered by trained enumerators. In addition, the authors conducted 300 or more client exit interviews in each country.ResultsThe three countries had different models of private service provision of vaccination. In Malawi, 44% of private facilities, predominantly faith-based organizations, administered an estimated 27% of all vaccinations. In Benin, 18% of private for-profit and not-for-profit facilities provided vaccinations, accounting for 8% of total vaccinations. In Georgia, all sample facilities were privately managed, and conducted 100% of private vaccinations. In all three countries, the Ministries of Health (MoHs) supplied vaccines and other support to private facilities. The study found that 6–76% of clients paid nominal fees for vaccination cards and services, and a small percentage (2–26%) chose to pay higher fees for vaccines not within their countries’ national schedules. The percentage of private expenditure on vaccination was less than 1% of national health expenditures. The case studies revealed that service quality at private facilities was mixed, a finding that is similar to those of other studies on private sector vaccination. The three countries varied in how well the MoHs managed and supervised private sector services.Discussion/ConclusionThe private sector plays a growing role in lower-income countries and is expanding access to services. Governments’ ability to regulate and monitor immunization services and promote quality and affordable services in the private sector should be a priority.     

Do Insurance Mandates Affect Racial Disparities in Outcomes for Children with Autism?

Objective The study investigated whether state mandates for private insurers to provide services for children with autism influence racial disparities in outcomes. Methods The study used 2005/2006 and 2009/2010 waves of the National Survey of Children with Special Health Care Needs. Children with a current diagnosis of autism were included in the sample. Children residing in 14 states and the District of Columbia that were not covered by the mandate in the 2005/2006 survey, but were covered in the 2009/2010 survey, served as the mandate group. Children residing in 32 states that were not covered by a mandate in either wave served as the comparison group. Outcome measures assessed included care quality, family economics, and child health. A difference-in-difference-in-differences (DDD) approach was used to assess the impact of the mandates on racial disparities in outcomes. Results Non-white children had less access to family-centered care compared to white children in both waves of data, but this difference was not apparent across mandate and comparison states as only the comparison states had significant differences. Parents of non-white children reported paying less in annual out-of-pocket expenses compared to parents of white children across waves and groups. DDD estimates did not provide evidence that the mandates had statistically significant effects on improving or worsening racial disparities for any outcome measure. Conclusions This study did not find evidence that state mandates on private insurers affected racial disparities in outcomes for children with autism.     

Is reimbursement for childhood immunizations adequate? evidence from two rural areas in colorado.

OBJECTIVE: To assess adequacy of reimbursement for childhood vaccinations in two rural regions in Colorado, the authors measured medical practice costs of providing childhood vaccinations and compared them with reimbursement. METHODS: A "time-motion" method was used to measure labor costs of providing vaccinations in 13 private and public practices. Practices reported non-labor costs. The authors determined reimbursement by record review. RESULTS: The average vaccine delivery cost per dose (excluding vaccine cost) ranged from $4.69 for community health centers to $5.60 for private practices. Average reimbursement exceeded average delivery costs for all vaccines and contributed to overhead in private practices. Average reimbursement was less than total cost (vaccine-delivery costs + overhead) in private practices for most vaccines in one region with significant managed care penetration. Reimbursement to public providers was less than the average vaccine delivery costs. CONCLUSIONS: Current reimbursement may not be adequate to induce private practices to provide childhood vaccinations, particularly in areas with substantial managed care penetration.     

Knowledge,Attitudes and Perceptions About Routine Childhood Vaccinations Among Jewish Ultra-Orthodox Mothers Residing in Communities with Low Vaccination Coverage in the Jerusalem District

Background and aims Childhood vaccinations are an important component of primary prevention. Maternal and Child Health (MCH) clinics in Israel provide routine vaccinations without charge. Several vaccine-preventable-diseases outbreaks (measles, mumps) emerged in Jerusalem in the past decade. We aimed to study attitudes and knowledge on vaccinations among mothers, in communities with low immunization coverage. Methods A qualitative study including focus groups and semi-structured interviews. Results Low immunization coverage was defined below the district’s mean (age 2 years, 2013) for measles-mumps-rubella-varicella 1st dose (MMR1\MMRV1) and diphtheria-tetanus-pertussis 4th dose (DTaP4), 96 and 89%, respectively. Five communities were included, all were Jewish ultra-orthodox. The mothers’ (n?=?87) median age was 30 years and median number of children 4. Most mothers (94%) rated vaccinations as the main activity in the MCH clinics with overall positive attitudes. Knowledge about vaccines and vaccination schedule was inadequate. Of vaccines scheduled at ages 0–2 years (n?=?13), the mean number mentioned was 3.9?±?2.8 (median 4, range 0–9). Vaccines mentioned more often were outbreak-related (measles, mumps, polio) and HBV (given to newborns). Concerns about vaccines were obvious, trust issues and religious beliefs were not. Vaccination delay was very common and timeliness was considered insignificant. Practical difficulties in adhering to the recommended schedule prevailed. The vaccinations visits were associated with pain and stress. Overall, there was a sense of self-responsibility accompanied by inability to influence others. Conclusion Investigating maternal knowledge and attitudes on childhood vaccinations provides insights that may assist in planning tailored intervention programs aimed to increase both vaccination coverage and timeliness.     

Travel time to health facilities in Papua New Guinea: Implications for coverage and equity in child vaccinations

With infant and child mortality rates that are among the highest in the Pacific region, and basic vaccination coverage rates that are 39% among children 12–23 months, increased coverage of vaccines is a high priority investment for Papua New Guinea (PNG). Using recently gathered household survey data for PNG, this paper contributes to the evidence-base for enhancing investments in frontline facilities by examining the implications of travel time to health facilities for basic vaccination coverage among children in PNG. We find that vaccination coverage rates among children 12–23 months old in PNG are decreasing in distance to healthcare facilities; and this holds whether the outcome is receipt of basic vaccinations (BCG; 3 dose pentavalent; OPV3; Measles), or basic vaccinations-plus (basic vaccinations + Hepatitis B + PCV3). We also find that travel time to health facilities lowers vaccination rates among children 12–23 months old in poor households to a greater extent than for children from richer households. Thus, enhanced geographical access to and resourcing of frontline facilities is likely to expand not only immunization coverage, lower mortality and increase aggregate economic gains, but also improve the distribution of immunization coverage in PNG across socioeconomic groups.     

Parental perceptions,attitudes and acceptance of childhood immunization in Saudi Arabia: A cross sectional study

ObjectivesThe widespread availability and use of vaccines have tremendously reduced morbidity, mortality and health care costs associated with infectious diseases. However, parental beliefs about vaccination are one of the major factors in achieving high vaccination rates. Thus, this study aims to assess the perceptions and attitudes regarding routine childhood immunization among Saudi parents.MethodsA cross sectional study with a pre-tested 18-item questionnaire was conducted using 467 randomly selected parents from the Hail region of Saudi Arabia in the period between February 1st, 2016, and February 1st, 2017. The validated questionnaire consisted of three sections that collected information on participants’ demographics, parents’ awareness of vaccine benefits, and parents’ practices regarding the immunization of their children.ResultsFemale and male parents comprised 54.5% (255) and 45.5% (212) of the sample, respectively, and the response and completion rates were 97%. The majority of the respondents had received a formal education (94.1%, 439), were gainfully employed (62.9%, 294) and had a regular monthly income (73.3%). The majority of the respondents were aware of childhood vaccinations (78.9%), completed vaccinations mandated for children up to 5 years (86.2%), encouraged other parents to do so (89.9%), and had easy access to vaccines (90.5%). Sixty to ninety percent of the respondents were knowledgeable regarding the health benefits of vaccinations in children, even though 18.4% of their children had experienced vaccination-related minor adverse effects during or after vaccination of which 23.2% required doctor's visits. Health care professionals were the most frequent source of parents’ vaccine-related information (65.2%), and vaccination reminder services provided by the Ministry of Health (MOH) via mobile phones were cited by 57.5% of respondents.ConclusionsConfidence in and acceptance of childhood vaccinations, perceptions of vaccine-related health benefits and ease of access to immunizations appeared to be quite good among Saudi parents.     

What is ‘confidence’ and what could affect it?: A qualitative study of mothers who are hesitant about vaccines

BackgroundPublic confidence in immunization is critical to maintaining high vaccine-coverage rates needed to protect individuals and communities from vaccine-preventable diseases. Recent attention has been placed on factors influencing confidence in vaccination in the US and globally, but comprehensive understanding of what drives or hinders confidence in childhood vaccination is yet to be reached. As such, assessing parents' confidence in childhood vaccination and the ways in which educational materials affect confidence is needed.ObjectiveWe sought to (1) learn how mothers who are hesitant about vaccination characterize confidence in health-related products for young children, including the recommended vaccines; (2) gain insights on what influences vaccine confidence beliefs; and (3) assess whether short, education materials affect parental confidence in childhood vaccinations.MethodsEight moderator-lead focus groups (n = 61), stratified by socioeconomic status, were undertaken with mothers of children 5 years of age of less who are hesitant about vaccines. Four of the groups were held in the Philadelphia, PA area and four were held in the San Francisco/Oakland, CA area. Three educational material pairs, each consisting of a 2–3 min video and an infographic poster about an immunization-related topic, were reviewed and assessed for influence on confidence.ResultsQualitative data analysis was used to identify overarching themes across the focus groups. Themes, insights, and illustrative quotes were identified and provided for each of the major discussion areas: primary health concerns for young children; confidence beliefs and perceptions, including for recommended vaccines; facilitators and barriers to confidence; and reactions to the educational materials.ConclusionsResults provide helpful insights into how mothers who are hesitant about vaccines perceive confidence in childhood vaccines and health-related products, suggestions for how to improve confidence, and support for the value and use of short videos as part of vaccination education efforts. Findings can aid those developing vaccination education materials and resources designed to foster vaccine confidence.     

A pathway to developing and testing quality measures aimed at improving adult vaccination rates in the United States

Despite recommendations for vaccinating adults and widespread availability of immunization services (e.g., pharmacy venues, workplace wellness clinics), vaccination rates in the United States remain low. The U.S. National Adult Immunization Plan identified the development of quality measures as a priority and key strategy to address low adult vaccination coverage rates. The use of quality measures can provide incentives for increased utilization of preventive services. To address the lack of adult immunization measures, the National Adult and Influenza Immunization Summit, a coalition of adult immunization partners led by the Immunization Action Coalition, Centers for Disease Control and Prevention, and National Vaccine Program Office, spearheaded efforts to (1) identify gaps and priorities in adult immunization quality performance measurement; (2) explore feasibility of data collection on adult immunizations through pilot testing and engaging stakeholders; and (3) develop and test quality measure specifications. This paper outlines the process by which a public-private partnership drove the development of two adult immunization performance measures—an adult immunization status measure for influenza, tetanus and diphtheria (Td) and/or tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), herpes zoster and pneumococcal vaccines, and a prenatal immunization status measure for influenza and Tdap vaccinations in pregnant women. These measures have recently been added to the 2019 Healthcare Effectiveness Data and Information Set (HEDIS®), a widely used set of performance measures reportable by private health plans.     

How Might Immunization Rates Change if Cost Sharing Is Eliminated?

Objectives

There is a debate regarding the effect of cost sharing on immunization, particularly as the Affordable Care Act will eliminate cost sharing for recommended vaccines. This study estimates changes in immunization rates and spending associated with extending first-dollar coverage to privately insured children for four childhood vaccines.

Methods

We used the 2008 National Immunization Survey and peer-reviewed literature to generate estimates of immunization status for each vaccine by age group and insurance type. We used the Truven Health Analytics 2006 MarketScan Commercial Claims and Encounters Database of line-item medical claims to estimate changes in immunization rates that would result from eliminating cost sharing, and we used the Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey to determine the prevalence of coverage for patients with first-dollar coverage, patients who face office visit cost sharing, and patients who face cost sharing for all vaccine cost components. We assumed that once cost sharing is removed, coverage rates in plans that impose cost sharing will rise to the level of plans that do not.

Results

We estimate that immunization rates would increase modestly and result in additional direct spending of $26.0 million to insurers/employers. Further, these payers would have an additional $11.0 million in spending associated with eliminating cost sharing for children already receiving immunizations.

Conclusions

The effects of eliminating cost sharing for vaccines vary by vaccine. Overall, immunization rates will rise modestly given high insurance coverage for vaccinations, and these increases would be more substantial for those currently facing cost sharing. However, in addition to the removal of cost sharing for immunizations, these findings suggest other strategies to consider to further increase immunization rates.Immunization of children against potentially life-threatening illnesses has proved one of the greatest public health successes and one of the most cost-effective medical interventions of the 20th century.^1,2 One barrier to immunization is financial: enrollees seeking immunizations may be confronted with cost sharing (i.e., the contribution consumers make toward the cost of their health care as defined by their health insurance policy) that they are unable or unwilling to pay.^1–8 Approximately 7% of enrollees with private insurance face cost sharing for the administration of immunizations.⁹This barrier will be lowered as part of the Patient Protection and Affordable Care Act (hereafter, ACA), also referred to as the Health Reform Act.¹⁰ Subpart II Section 2713 of the Act, which was enacted in September 2010, requires first-dollar coverage for vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).¹¹ First-dollar coverage means that cost sharing in the form of copays, co-insurance, or deductibles will not apply for ACIP-recommended vaccines. The policy intent was to provide financial relief to patients who were previously deterred by financial barriers, encouraging them to obtain vaccinations once these financial barriers were removed.We examined immunization patterns among privately insured children and adolescents under different levels of cost sharing to estimate the effects of removing cost sharing for both the vaccine dose and administration. Children who are uninsured, underinsured for vaccines, or Medicaid eligible qualify for the Vaccines for Children (VFC) program, which offers vaccines at no cost, and were excluded from this analysis. With the passage of the ACA, children will primarily receive vaccines under private insurance or qualify through expanded Medicaid eligibility to receive vaccines through the VFC program. It is estimated that 89% of the population will have private health insurance coverage when health reform is fully implemented in 2022.^12,13 In 2010, 90% of children had health insurance coverage (public or private) at least some time during the year, of which 60% were covered by private insurance.¹⁴Our analysis focused on four vaccines: (1) measles, mumps, and rubella (MMR); (2) heptavalent pneumococcal conjugate (PCV7); (3) human papillomavirus (HPV); and (4) meningococcal conjugate (MCV4). These vaccines present different challenges to uptake based on age recommendation, cost, and integration in the immunization delivery system (15^–19 MMR is also less expensive than newer vaccines. PCV7, which was recommended by ACIP in 2000, is an example of a vaccine that signaled a new era of more expensive vaccines, though it is also integrated into well-child visits. In 2010, a next-generation PCV13 vaccine replaced PCV7, adding six serotypes to the vaccine. Finally, HPV vaccine, recommended for use in 2006, and MCV4, recommended by ACIP in 2005, highlight the challenges of vaccinating adolescents who sporadically access preventive health care.²⁰ HPV vaccine also highlights the challenges of introducing new vaccines that are not only more expensive but also raise questions about social norms and stigma.²¹

Table 1.

Vaccine product characteristics in the U.S. by licensure, indication, school requirement, and recent coverage levelsOpen in a separate window^aU.S. Food and Drug Administration licensure dates of selected vaccines^bCenters for Disease Control and Prevention (US). 2011 National Immunization Survey [cited 2013 Sep 19]. Available from: URL: http://www.cdc.gov/vaccines/stats-surv/nis/nis-2011-released.htm^cCoverage estimates are for PCV13 (surrogate for coverage, as PCV13 is a replacement product to PCV7 licensed in 2010).MMR = measles, mumps, and rubellaPCV7 = heptavalent pneumococcal conjugateMCV4 = meningococcal conjugateHPV = human papillomavirusPCV13 = 13-valent pneumococcal conjugateTo understand the role of cost sharing and its impact on vaccine coverage, we modeled the effects of eliminating cost sharing for select immunizations routinely recommended for children and adolescents and discuss other factors that may be important impediments to immunization.     

Cost utility of public clinics to increase pneumococcal vaccines in the elderly.

BACKGROUND: Pneumococcal immunization has been shown to be cost effective, is recommended by the Advisory Committee on Immunization Practices, and is covered by Medicare. Despite that, over 50% of the population aged > or =65 is not vaccinated, leading to significant mortality and morbidity. The objective of this study is to evaluate the costs and the cost utility of immunization in nontraditional settings (community clinics set up to provide influenza and pneumococcal vaccinations) as a strategy to increase pneumococcal immunization rates. METHODS: A cost-utility analysis of public immunization clinics in Monroe County, New York, during the fall of 1998. The study included 1207 adults aged > or =65. Costs of operating the clinics and of vaccine administration were measured. The cost of health sequela and estimates of quality-adjusted life years (QALYs) were obtained from prior studies. Sensitivity analyses were performed to test several important assumptions. RESULTS: Unlike immunizations in physician offices, immunizations in nontraditional settings are not cost saving. Estimates of incremental cost-utility ratios ranged from $4215 per QALY to $12,617 per QALY, depending on the underlying assumptions of the model. CONCLUSIONS: Clinics in nontraditional settings offering pneumococcal immunization have cost-utility ratios near and below those of other recommended vaccines. These results suggest that such clinics should be considered a viable strategy for increasing pneumococcal immunization rates.     

Confidence about vaccines in the United States: understanding parents' perceptions

The United States has made tremendous progress in using vaccines to prevent serious, often infectious, diseases. But concerns about such issues as vaccines' safety and the increasing complexity of immunization schedules have fostered doubts about the necessity of vaccinations. We investigated parents' confidence in childhood vaccines by reviewing recent survey data. We found that most parents--even those whose children receive all of the recommended vaccines--have questions, concerns, or misperceptions about them. We suggest ways to give parents the information they need and to keep the US national vaccination program a success.