Inadequate levels of immunization against childhood diseases remain a significant public health problem in resource-poor areas of the globe. Nonetheless, the reasons for incomplete vaccination and non-uptake of immunization services are poorly understood. This study aimed at finding out the reasons for non-vaccination and the magnitude of missed opportunities for vaccination in children less than two years of age in a rural area in southern Mozambique.
Mothers of children under two years of age (N = 668) were interviewed in a cross-sectional study. The Road-to-Health card was utilized to check for completeness and correctness of vaccination schedule as well as for identifying the appropriate use of all available opportunities for vaccination. The chi-square test and the logistic regression were used for statistical analysis.
We found that 28.2% of the children had not completed the vaccination program by two years of age, 25.7% had experienced a missed opportunity for vaccination and 14.9% were incorrectly vaccinated. Reasons for incomplete vaccination were associated with accessibility to the vaccination sites, no schooling of mothers and children born at home or outside Mozambique.
Efforts to increase vaccination coverage should take into account factors that contribute to the incomplete vaccination status of children. Missed opportunities for vaccination and incorrect vaccination need to be avoided in order to increase the vaccine coverage for those clients that reach the health facility, specially in those countries where health services do not have 100% of coverage.
To estimate the impact of missed opportunities on influenza vaccination coverage among 6 through 23 month old children who sought medical care during the 2004–2005 influenza season.
Retrospective cohort study
Fifty two primary care practice sites located in Rochester New York, Nashville Tennessee and Cincinnati Ohio
Children 6 through 23 months of age
Charts were reviewed and data collected on influenza vaccinations, type of health care visit (well-child or other), and presence of illness symptoms. Missed opportunity was defined as a practice visit by an eligible child during influenza season, when vaccine was available, but during which the child did not receive an influenza vaccination. Vaccine was assumed to be available between the first and last dates influenza vaccination was recorded at that practice. Each child was classified as fully vaccinated, partially vaccinated or unvaccinated.
Data were analyzed for 1724 children 6 through 23 months. Most children (62.0%) had at least one missed opportunity during this period. Among children with any missed opportunities, 12.8% were fully and 29.8% were partially vaccinated. Overall, 33.6% of missed opportunities occurred during well child visits and 66.4% during other types of visits; 75% occurred when no other vaccines were given. Eliminating all missed opportunities would have increased full vaccination coverage from 30.3% to 49.9%.
Missed opportunities for influenza vaccination are frequent. Reducing missed opportunities could significantly increase influenza vaccination rates and should be a goal in each practice.
vaccination; child health services; influenza; human
At the inception of a general practice well child clinic, a checklist card was introduced into the clinic notes to summarize specific and relative contraindications to immunizations. This card was used by the practice nurses as they ran the immunization procedures during the clinic. A failure on the checklist led to a consultation with the clinic doctor who decided whether to proceed with the immunization. Of 155 immunizations given during the six-month period, only 23 (15%) failed the checklist and required the child to be assessed by the clinic doctor. Of these, nine (39%) were for simple upper respiratory tract infection. All the children were deemed fit to receive immunization. Only one child was found to have a specific contraindication to pertussis. The checklist cards allowed the smooth operation of the immunization procedures by practice nurses who were able to check comprehensively whether there were any contraindications and whether immunizations were being inappropriately refused.
This prospective study reports the immunization status of uninsured or Medicaid-funded, high-risk urban preschool-aged children hospitalized at the District of Columbia General Hospital in Washington, DC, and the reasons for delays as identified by their parents or guardians. There were 602 consecutive admissions of preschool-aged children over a 29-month period. One hundred seventy-five questionnaires were adequately completed for analysis. Thirty-four percent of parents cited problems that have social implications as the main reasons for their children's lack of immunizations. It is important to note that missed opportunities by health-care providers also contributed to the immunization delay in this patient population. Based on these results, it is important that each patient encounter be used to ensure parent education so that each child is appropriately immunized.
The objective of this study was to examine missed opportunities for participation in a prevention of mother-to-child transmission (PMTCT) programme in three sites in South Africa. A rapid anthropological assessment was used to collect in-depth data from 58 HIV-positive women who were enrolled in a larger cohort study to assess mother-to-child HIV transmission. Semi-structured interviews were conducted with the women in order to gain an understanding of their experiences of antenatal care and to identify missed opportunities for participation in PMTCT.
15 women actually missed their nevirapine not because of stigma and ignorance but because of health systems failures. Six were not tested for HIV during antenatal care. Two were tested but did not receive their results. Seven were tested and received their results, but did not receive nevirapine. Health Systems failure for these programme leakages ranged from non-availability of counselors, supplies such as HIV test kits, consent forms, health staff giving the women incorrect instructions about when to take the tablet and health staff not supplying the women with the tablet to take.
HIV testing enables access to PMTCT interventions and should therefore be strengthened. The single dose nevirapine regimen is simple to implement but the all or nothing nature of the regimen may result in many missed opportunities. A short course dual or triple drug regimen could increase the effectiveness of PMTCT programmes.
We described the uptake and coverage rates of meningococcal conjugate vaccine (MCV4); tetanus-diphtheria-acellular pertussis vaccine (Tdap); and quadrivalent human papillomavirus vaccine (HPV4) in North Dakota using the North Dakota Immunization Information System (NDIIS).
We analyzed all available MCV4, Tdap, and HPV4 doses given after vaccine licensure and through December 31, 2009, obtained from the NDIIS to identify trends and patterns in vaccine administration. We analyzed all data by administration date, age group, and health-care provider type. We also calculated missed opportunities to complete all recommended vaccines among vaccinated adolescents.
For adolescents aged 13–17 years, 69.2% had ≥1 dose of Tdap and 62.8% had ≥1 dose of MCV4. Of females aged 13–17 years, 42.8% initiated the HPV4 vaccination series and 24.9% received ≥3 HPV4 doses. Only 48.7% of males aged 13–17 years received both Tdap and MCV4 at the same visit, and only 11.5% of females aged 13–17 years received Tdap, MCV4, and HPV4 doses at the first visit.
The NDIIS is useful in tracking adolescent vaccine uptake. The immunization rates for all three routinely recommended adolescent vaccines are rising in North Dakota, although at different paces. Providers should be educated about the importance of not missing opportunities to vaccinate, and school-based vaccination clinics should be used to reach adolescents who are less likely to have preventive care visits.
AIM—To assess the
potential for administering catch up and scheduled immunisations during
status according to the child's principal carer was checked against
official records for 1000 consecutively admitted preschool age
children. Junior doctors were instructed to offer appropriate
vaccination before discharge, and consultants were asked to reinforce
this proactive policy on ward rounds.
those children who were not fully immunised against pertussis through
parental choice, 142 children (14.2%) had missed an age appropriate
immunisation and 41 were due a scheduled immunisation. None had a valid
contraindication. Only 43 children were offered vaccination on the ward
but uptake was 65% in this group.
to hospital provides opportunities for catch up and routine
immunisations and can contribute to the health care of an often
disadvantaged group of children. These opportunities are frequently
missed. Junior doctors must be encouraged to see opportunistic
immunisation as an important part of their routine work.
Current levels of influenza vaccine uptake in patients considered to be at high risk have been determined by means of a questionnaire survey. During March-April 1992, information was sought from 624 patients in Leicestershire, UK with either chronic cardiovascular or respiratory disease, or diabetes; questions related to current health status and the request, offer and receipt of influenza vaccine in the current and three previous seasons. Ninety-eight percent of all offers of immunization were made in the primary care setting, and vaccine was well tolerated as judged by the fact that 86% of vaccinees between 1988/9-1990/1 returned for immunization in the following year. However in the 1991/2 season the overall level of vaccine uptake was only about 41% which is at variance with the stated policies and practices of general practitioners. Opportunities were missed, in both hospitals and general practices, to publicise and offer immunization to individuals with vaccine indications. Future attempts to improve vaccine uptake should focus on increasing the role of hospital staff in influenza prevention, in addition to promoting better vaccine delivery through primary care.
Members of the Collaborative Immunization Initiatives determined the immunization coverage rates for two groups of children in our clinic: those 7 to 12 months old and those 18 to 23 months old. The Clinic Assessment Software Application from the Centers for Disease Control and Prevention was used. The immunization rates determined by this method appeared to significantly underestimate the vaccination coverage rates in our clinic. A review of available charts included in the original sample was done excluding patients no longer attending our clinic. We found a higher rate of coverage in the same sample and a low rate of missed opportunities for administering immunizations. The major reason for this discrepancy is overly stringent Clinic Assessment Software Application inclusion criteria. Additional factors include failure to take into account the wide range of acceptable ages for administering immunizations and different dosages for different brands of vaccines. Different methods of calculation may cause as much as a 20% difference in immunization rates for the same or similar population groups. Such large differences may lead to vastly different responses and interventions. We believe that a central registry is the most accurate method of determining immunization rates. Until this is widely available and applied, a more accurate measure of a facility’s immunization effectiveness is the number of missed opportunities for administering immunizations.
Immunization; Immunization Programs; Immunization Rates; Patient Participation Rates; Registries; Vaccination
HIV remains responsible for an estimated 40% of mortality in South African pregnant women and their children. To address these avoidable deaths, eligibility criteria for antiretroviral therapy (ART) in pregnant women were revised in 2010 to enhance ART coverage. With greater availability of HIV services in public health settings and increasing government attention to poor maternal-child health outcomes, this study used the patient's journey through the continuum of maternal and child care as a framework to track and document women's experiences of accessing ART and prevention of mother-to-child HIV transmission (PMTCT) programmes in the Eastern Cape (three peri-urban facilities) and Gauteng provinces (one academic hospital).
In-depth interviews identified considerable weaknesses within operational HIV service delivery. These manifested as missed opportunities for HIV testing in antenatal care due to shortages of test kits; insufficient staff assigned to HIV services; late payment of lay counsellors, with consequent absenteeism; and delayed transcription of CD4 cell count results into patient files (required for ART initiation). By contrast, individual factors undermining access encompassed psychosocial concerns, such as fear of a positive test result or a partner's reaction; and stigma. Data and information systems for monitoring in the three peri-urban facilities were markedly inadequate.
A single system- or individual-level delay reduced the likelihood of women accessing ART or PMTCT interventions. These delays, when concurrent, often signalled wholesale denial of prevention and treatment. There is great scope for health systems' reforms to address constraints and weaknesses within PMTCT and ART services in South Africa. Recommendations from this study include: ensuring autonomy over resources at lower levels; linking performance management to facility-wide human resources interventions; developing accountability systems; improving HIV services in labour wards; ensuring quality HIV and infant feeding counselling; and improved monitoring for performance management using robust systems for data collection and utilisation.
Low childhood immunization rates have been a challenge in Colorado, an issue that was exacerbated by a diphtheria-tetanus-acellular pertussis (DTaP) vaccine shortage that began in 2001. To combat this shortage, the locally based Tri-County Health Department conducted a study to assess immunization-related barriers among children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a population at risk for undervaccination.
This study assessed characteristics and perceptions of WIC mothers in conjunction with their children's immunization status in four clinics.
Results indicated poor immunization rates, which improved with assessment and referral. The uninsured were at higher risk for undervaccination. DTaP was the most commonly missing vaccine, and discrepancies existed between the children's perceived and actual immunization status, particularly regarding DTaP. Targeted interventions were initiated as a result of this study.
Local health departments should target immunization-related interventions by assessing their own WIC populations to identify unique vaccine-related deficiencies, misperceptions, and high-risk subpopulations.
A substantial dropout from the first dose of diphtheria-tetanus-pertussis (DTP1) to the 3rd dose of DTP (DTP3) immunization has been recorded in Pakistan. We conducted a randomized controlled trial to assess the effects of providing substantially redesigned immunization card, center-based education, or both interventions together on DTP3 completion at six rural Expanded Programme on Immunization (EPI) centers in Pakistan.
Mother-child units were enrolled at DTP1 and randomized to four study groups: redesigned card, center-based education, combined intervention, and standard care. Each child was followed-up for 90 days to record the dates of DTP2 and DTP3 visits. The study outcome was DTP3 completion by the end of follow-up period in each study group.
We enrolled 378 mother-child units in redesigned card group, 376 in center-based education group, 374 in combined intervention group, and 378 in standard care group. By the end of follow-up, 39% of children in standard care group completed DTP3. Compared to this, a significantly higher proportion of children completed DTP3 in redesigned card group (66%) (crude Risk Ratio [RR] = 1.7; 95% CI = 1.5, 2.0), center-based education group (61%) (RR = 1.5; 95% CI = 1.3, 1.8), and combined intervention group (67%) (RR = 1.7; 95% CI = 1.4, 2.0).
Improved immunization card alone, education to mothers alone, or both together were all effective in increasing follow-up immunization visits. The study underscores the potential of study interventions’ public health impact and necessitates their evaluation for complete EPI schedule at a large scale in the EPI system.
OBJECTIVE: To compare estimates based on vaccination cards, parental recall, and medical records of the percentages of children up-to-date on vaccinations for diphtheria, tetanus, and pertussis; polio; and measles, mumps, and rubella. METHOD: The authors analyzed parent interview and medical records data from the Baltimore Immunization Study for 525 2-year-olds born from August 1988 through March 1989 to mothers living in low-income Census tracts of the city of Baltimore. RESULTS: Only one-third of children had vaccination cards; based on medical records, these children had higher up-to-date coverage at 24 months of age than did children without cards. For individual vaccines, only two-thirds of parents could provide information to calculate coverage rates; however, almost all provided enough information to estimate coverage for the primary series. For each vaccine and the series, parental recall estimates were at least 17 percentage points higher than estimates from medical records. For children without vaccination cards whose parents could not provide coverage information, up-to-date rates based on medical records were consistently lower than for children with cards or with parents who provided coverage information. CONCLUSIONS: Population-based vaccine coverage surveys that rely on vaccination cards or parental recall or both may overestimate vaccination coverage.
Delayed diagnosis of colorectal cancer (CRC) is among the most common reasons for ambulatory diagnostic malpractice claims in the United States. Our objective was to describe missed opportunities to diagnose CRC before endoscopic referral, in terms of patient characteristics, nature of clinical clues, and types of diagnostic-process breakdowns involved.
We conducted a retrospective cohort study of consecutive, newly diagnosed cases of CRC between February 1999 and June 2007 at a tertiary health-care system in Texas. Two reviewers independently evaluated the electronic record of each patient using a standardized pretested data collection instrument. Missed opportunities were defined as care episodes in which endoscopic evaluation was not initiated despite the presence of one or more clues that warrant a diagnostic workup for CRC. Predictors of missed opportunities were evaluated in logistic regression. The types of breakdowns involved in the diagnostic process were also determined and described.
Of the 513 patients with CRC who met the inclusion criteria, both reviewers agreed on the presence of at least one missed opportunity in 161 patients. Among these patients there was a mean of 4.2 missed opportunities and 5.3 clues. The most common clues were suspected or confirmed iron deficiency anemia, positive fecal occult blood test, and hematochezia. The odds of a missed opportunity were increased in patients older than 75 years (odds ratio (OR) = 2.3; 95% confidence interval (CI) 1.3–4.1) or with iron deficiency anemia (OR = 2.2; 95% CI 1.3–3.6), whereas the odds of a missed opportunity were lower in patients with abnormal flexible sigmoidoscopy (OR = 0.06; 95% CI 0.01–0.51), or imaging suspicious for CRC (OR = 0.3; 95% CI 0.1–0.9). Anemia was the clue associated with the longest time to endoscopic referral (median = 393 days). Most process breakdowns occurred in the provider–patient clinical encounter and in the follow-up of patients or abnormal diagnostic test results.
Missed opportunities to initiate workup for CRC are common despite the presence of many clues suggestive of CRC diagnosis. Future interventions are needed to reduce the process breakdowns identified.
This analysis draws on longitudinal, qualitative interviews with disadvantaged mothers and fathers who participated in the Fragile Families Study (a U.S. birth cohort study) to examine how issues related to men's employment, social support, skills, and motivation facilitated their care of young children in different relationship contexts. Interviews with parents indicate that while some motivated and skilled men actively chose to become caregivers with the support of mothers, others developed new motivations, skills, and parenting supports in response to situations in which they were out of work or the mother was experiencing challenges. These findings suggest that disadvantaged men who assume caregiving responsibilities take different paths to involvement in the early years after their child's birth. Policies that overlook paternal caregivers may not only miss the opportunity to support relationships that benefit at-risk children but also unintentionally undermine this involvement.
caregiving; fathers; custodial fathers; fragile families; low-income fathers; primary caregivers; public policy; shared parenting
Early diagnosis of children living with HIV is a prerequisite for accessing timely paediatric HIV care and treatment services and for optimizing treatment outcomes. Testing of HIV-exposed infants at 6 weeks and later is part of the national prevention of mother to child transmission (PMTCT) of HIV programme in Zimbabwe, but many opportunities to test infants and children are being missed. Early childhood development (ECD) playcentres can act as an entry point providing multiple health and social services for orphans and vulnerable children (OVC) under 5 years, including facilitating access to HIV treatment and care.
Sixteen rural community-based, community-run ECD playcentres were established to provide health, nutritional and psychosocial support for OVC aged 5 years and younger exposed to or living with HIV, coupled with family support groups (FSGs) for their families/caregivers. These centres were located in close proximity to health centres giving access to nurse-led monitoring of 697 OVC and their caregivers. Community mobilisers identified OVC within the community, supported their registration process and followed up defaulters. Records profiling each child's attendance, development and health status (including illness episodes), vaccinations and HIV status were compiled at the playcentres and regularly reviewed, updated and acted upon by nurse supervisors. Through FSGs, community cadres and a range of officers from local services established linkages and built the capacity of parents/caregivers and communities to provide protection, aid psychosocial development and facilitate referral for treatment and support.
Available data as of September 2011 for 16 rural centres indicate that 58.8% (n=410) of the 697 children attending the centres were tested for HIV; 18% (n=74) tested positive and were initiated on antibiotic prophylaxis. All those deemed eligible for antiretroviral therapy were commenced on treatment and adherence was monitored.
This community-based playcentre model strengthens comprehensive care (improving emotional, cognitive and physical development) for OVC younger than 5 years and provides opportunities for caregivers to access testing, care and treatment for children exposed to, affected by and infected with HIV in a secure and supportive environment. More research is required to evaluate barriers to counselling and testing of young children and the long-term impact of playcentres upon specific health and developmental outcomes.
HIV and AIDS; orphans and vulnerable children; community based interventions; paediatric HIV; care and support; PMTCT; capacity building; early childhood development; participatory methods
Missed radio-capitellar joint dislocation is one of the feared complications of Monteggia fractures, especially when associated with subtle fractures of the ulna bone. Many treatment strategies have been described to manage the chronic Monteggia fracture and the need for annular ligament reconstruction is not always clear. This study is an attempt to address the issue of annular ligament reconstruction in the surgical management of missed Monteggia fracture.
Materials and methods
A retrospective study was performed in 12 patients who presented with missed Monteggia fracture. All children underwent open reduction of the radio-capitellar joint. Five children (Group A) were treated with ulna angulation–distraction osteotomy and annular ligament reconstruction, and six cases required only an ulna angulation–distraction osteotomy without ligament reconstruction. The duration of missed dislocation was from 3 to 18 months (mean 9 months). Ten patients were classified as Bado I, and one each as Bado II and III, respectively.
The mean follow up period was 22 months. All ulna osteotomies healed uneventfully. The mean loss of pronation was 15° in Group A and 10° in Group B. Elbow flexion improved from the preoperative range and no child complained of pain, deformity and restriction of activity. In one case (Group A), there was 3 mm of radiographic subluxation of the radial head, but this child was clinically asymptomatic. The elbow score was excellent in ten cases and good in two cases.
Distraction–angulation osteotomy of the ulna suffices in most cases of missed Monteggia fracture and the need for annular ligament reconstruction is based on the intra-operative findings of radial head instability.
Missed Monteggia; Annular ligament reconstruction; Ulna osteotomy
By sequential random numbering 10 schools in greater Winnipeg were selected for a nutrition survey. Interviews were conducted with 201 grade 3 children and 182 grade 6 children for whom parental consent was obtained. Of these, 48 in grade 3 and 51 in grade 6 were studied in further detail. There were no differences in descriptive data between the general and detailed groups or among the 10 schools. Most fathers were skilled or unskilled labourers and about 50% of the mothers were homemakers without outside employment; parental occupation did not influence eating patterns. Breakfast was the meal most often missed; 8% of the 383 children had come to school without breakfast. Since many children in grade 3 had prepared their own breakfast and since there was a relative lack of physical activity, school health programs should incorporate more than nutritional supplements and nutrition education. On the basis of body weight and height the nutritional status of the 99 children studied in detail was judged to be generally satisfactory; according to the Boston standards the boys were heavy and tall, and the girls were normal in weight but short.
We evaluated the validity of CD4 count against CD4 percentage criteria of 2008 World Health Organization guideline for initiating antiretroviral therapy using the data of 446 Asian HIV - infected children aged 1 to 12 years who were screened to the PREDICT study. The overall sensitivity and specificity were 34% and 98%, respectively. Using the current CD4 count criteria would globally result in 66% missed opportunity to initiate treatment in a timely fashion. Raising CD4 count thresholds should be considered to increases its sensitivity and reduces missed opportunity.
HIV; CD4; antiretroviral treatment; ART initiation; WHO; children; Asia
Understanding delays in cancer diagnosis requires detailed information about timely recognition and follow-up of signs and symptoms. This information has been difficult to ascertain from paper-based records. We used an integrated electronic health record (EHR) to identify characteristics and predictors of missed opportunities for earlier diagnosis of lung cancer.
Using a retrospective cohort design, we evaluated 587 patients of primary lung cancer at two tertiary care facilities. Two physicians independently reviewed each case, and disagreements were resolved by consensus. Type I missed opportunities were defined as failure to recognize predefined clinical clues (ie, no documented follow-up) within 7 days. Type II missed opportunities were defined as failure to complete a requested follow-up action within 30 days.
Reviewers identified missed opportunities in 222 (37.8%) of 587 patients. Median time to diagnosis in cases with and without missed opportunities was 132 days and 19 days, respectively (P < .001). Abnormal chest x-ray was the clue most frequently associated with type I missed opportunities (62%). Follow-up on abnormal chest x-ray (odds ratio [OR], 2.07; 95% CI, 1.04 to 4.13) and completion of first needle biopsy (OR, 3.02; 95% CI, 1.76 to 5.18) were associated with type II missed opportunities. Patient adherence contributed to 44% of patients with missed opportunities.
Preventable delays in lung cancer diagnosis arose mostly from failure to recognize documented abnormal imaging results and failure to complete key diagnostic procedures in a timely manner. Potential solutions include EHR-based strategies to improve recognition of abnormal imaging and track patients with suspected cancers.
For patients in all health-care settings HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines. The nation's physicians and other health care providers should assume a much more active role in promoting HIV testing. The aim of this study was to investigate the extent to which missed opportunities for earlier HIV testing and diagnosis occur in the health facilities of north east Ethiopia.
A confidential client exit interview and medical record review was made on 427 clients who attended health facilities of Dessie town between November-December 2008. Data collection was done by counselors trained on Provider Initiated Counseling and Testing (PICT) and data collection tool included demographics, reason for visit to health facilities, HIV test initiation by service providers, clients self risk perception, clients willingness and acceptance of HIV test, HIV test result and review of client medical records.
Among 427 clients, missed opportunities for HIV testing were found in 76.1% (325) of clients. HIV test initiation was made by data collecting counselors during interview period and 80.0% (260) of clients not initiated by service providers were found to be willing to have HIV test. Large number, 43.0% (112), of the willing clients actually tested for HIV. Of the tested clients, 13.4% (15) were found to be HIV positive. Most, 60% (9), of HIV positive clients who lost the opportunities of diagnosis felt themselves as having no risk for HIV infection. Missed opportunities for HIV diagnosis of 51.7% (15), overall HIV test acceptance rate of 36.5% (154) and positivity rate of 6.9% (29) were found.
The missed opportunities for earlier HIV test and diagnosis of patients attending health facilities were found to be high and frequent. Testing only clients with HIV risk misses large number of HIV positive patients. Asking clients' willingness for HIV testing should be conducted by all service providers irrespective of the clients' risk behaviors for HIV infection or the type of services they need.
With the use of Centers for Disease Control and Prevention (CDC) immunization recommendations as the gold standard, our objectives were to measure the accuracy (“is this child up-to-date on immunizations?”) and usefulness (“is this child due for catch-up immunizations?”) of the Healthcare Effectiveness Data and Information Set (HEDIS) childhood immunization measures.
For children aged 24 to 35 months from the 2009 National Immunization Survey, we assessed the accuracy and usefulness of the HEDIS childhood immunization measures for 6 individual immunizations and a composite.
A total of 12 096 children met all inclusion criteria and composed the study sample. The HEDIS measures had >90% accuracy when compared with the CDC gold standard for each of the 6 immunizations (range, 94.3%–99.7%) and the composite (93.8%). The HEDIS measure was least accurate for hepatitis B and pneumococcal conjugate immunizations. The proportion of children for which the HEDIS measure yielded a nonuseful result (ie, an incorrect answer to the question, “is this child due for catch-up immunization?”) ranged from 0.33% (varicella) to 5.96% (pneumococcal conjugate). The most important predictor of HEDIS measure accuracy and usefulness was the CDC-recommended number of immunizations due at age 2 years; children with zero or all immunizations due were the most likely to be correctly classified.
HEDIS childhood immunization measures are, on the whole, accurate and useful. Certain immunizations (eg, hepatitis B, pneumococcal conjugate) and children (eg, those with a single overdue immunization), however, are more prone to HEDIS misclassification.
immunizations; quality indicators; health care surveys
Reasons for the low coverage of immunization vary from logistic ones to those dependent on human behaviour. The study was planned to find out: (a) the immunization status of children admitted to a paediatric ward of tertiary-care hospital in Delhi, India and (b) reasons for partial immunization and non-immunization. Parents of 325 consecutively-admitted children aged 12–60 months were interviewed using a semi-structured questionnaire. A child who had missed any of the vaccines given under the national immunization programme till one year of age was classified as partially-immunized while those who had not received any vaccine up to 12 months of age or received only pulse polio vaccine were classified as non-immunized. Reasons for partial/non-immunization were recorded using open-ended questions. Of the 325 children (148 males, 177 females), 58 (17.84%) were completely immunized, 156 (48%) were partially immunized, and 111 (34.15%) were non-immunized. Mothers were the primary respondents in 84% of the cases. The immunization card was available with 31.3% of the patients. All 214 partially- or completely-immunized children received BCG, 207 received OPV/DPT1, 182 received OPV/DPT2, 180 received OPV/DPT3, and 115 received measles vaccines. Most (96%) received pulse polio immunization, including 98 of the 111 non-immunized children. The immunization status varied significantly (p<0.05) with sex, education of parents, urban/rural background, route and place of delivery. On logistic regression, place of delivery [odds ratio (OR): 2.3, 95% confidence interval (CI) 1.3–4.1], maternal education (OR=6.94, 95% CI 3.1–15.1), and religion (OR=1.75, 95% CI 1.2–3.1) were significant (p<0.05). The most common reasons for partial or non-immunization were: inadequate knowledge about immunization or subsequent dose (n=140, 52.4%); belief that vaccine has side-effects (n=77, 28.8%); lack of faith in immunization (n=58, 21.7%); or oral polio vaccine is the only vaccine required (n=56, 20.9%. Most (82.5%) children admitted to a tertiary-care hospital were partially immunized or non-immunized. The immunization status needs to be improved by education, increasing awareness, and counselling of parents and caregivers regarding immunizations and associated misconceptions as observed in the study.
Child; Immunization; Vaccination; India
The introduction of pneumococcal conjugate vaccine (PCV) to the U.S. recommended childhood immunization schedule in the year 2000 added three injections to the number of vaccinations a child is expected to receive during the first year of life. Surveys have suggested that the addition of PCV has led some immunization providers to move other routine childhood vaccinations to later ages, which could increase the possibility of missing these vaccines. The purpose of this study was to evaluate whether introduction of PCV affected immunization coverage for recommended childhood vaccinations among 13-month olds in four large provider groups.
In this retrospective cohort study, we analyzed computerized data on vaccinations for 33,319 children in four large provider groups before and after the introduction of PCV. The primary outcome was whether the child was up to date for all non-PCV recommended vaccinations at 13 months of age. Logistic regression was used to evaluate the association between PCV introduction and the primary outcome. The secondary outcome was the number of days spent underimmunized by 13 months. The association between PCV introduction and the secondary outcome was evaluated using a two-part modelling approach using logistic and negative binomial regression.
Overall, 93% of children were up-to-date at 13 months, and 70% received all non-PCV vaccinations without any delay. Among the entire study population, immunization coverage was maintained or slightly increased from the pre-PCV to post-PCV periods. After multivariate adjustment, children born after PCV entered routine use were less likely to be up-to-date at 13 months in one provider group (Group C: OR = 0.5; 95% CI: 0.3 – 0.8) and were less likely to have received all vaccine doses without any delay in two Groups (Group B: OR = 0.4, 95% CI: 0.3 – 0.6; Group C: OR = 0.5, 95% CI: 0.4 – 0.7). This represented 3% fewer children in Group C who were up-to-date and 14% (Group C) to 16% (Group B) fewer children who spent no time underimmunized at 13 months after PCV entered routine use compared to the pre-PCV baseline. Some disruptions in immunization delivery were also observed concurrent with temporary recommendations to suspend the birth dose of hepatitis B vaccine, preceding the introduction of PCV.
These findings suggest that the introduction of PCV did not harm overall immunization coverage rates in populations with good access to primary care. However, we did observe some disruptions in the timely delivery of other vaccines coincident with the introduction of PCV and the suspension of the birth dose of hepatitis B vaccine. This study highlights the need for continued vigilance in coming years as the U.S. introduces new childhood vaccines and policies that may change the timing of existing vaccines.
Identifying and counseling individuals with Acute HIV Infection (AHI) offers a critical opportunity to avert preventable HIV transmission, however opportunities to recognize these individuals may be missed. We surveyed 32 adults diagnosed with AHI during voluntary HIV testing from 1/1/03 to 2/28/05 in publicly funded testing sites in NC to describe their clinical, social, and behavioral characteristics. Eighty-one percent of participants were men; 59% were African American. Seventy-five percent experienced symptoms consistent with acute retroviral syndrome; although 83% sought medical care for these symptoms, only 15% were appropriately diagnosed at that initial medical visit, suggesting opportunities to diagnose these individuals earlier were missed. Eighty-five percent of the men engaged in sex with men. More than 50% of the participants thought they were infected with HIV by a steady partner. This study yields important information to assist in identifying populations at risk for or infected with AHI and designing both primary and secondary prevention interventions.
Acute HIV Infection (AHI); North Carolina (NC); HIV/AHI screening; AHI Epidemiology; HIV Risk Factors