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National, State, and Urban Area Vaccination Coverage Levels Among Children Aged 19-35 Months -- United States, July 1994-June 1995

The National Immunization Survey (NIS) is an ongoing survey to provide estimates of vaccination coverage levels among children aged 19-35 months in the United States, all 50 states, and selected urban areas. CDC implemented NIS in April 1994 as one element of the five-part Childhood Immunization Initiative (CII), a national strategy to achieve and maintain high vaccination levels among children during the first 2 years of life (1). NIS collects quarterly data from all 50 states, the District of Columbia, and 27 urban areas considered to be at high risk for undervaccination (2,3). This report provides NIS findings for July 1994-June 1995, which indicate that coverage levels for diphtheria and tetanus toxoids and pertussis vaccine (DTP), Haemophilus influenzae type b vaccine (Hib), poliovirus vaccine, and hepatitis B vaccine have met or exceeded the 1995 interim goals of the CII and that coverage for measles-mumps-rubella vaccine (MMR) is within 1 percentage point of the objective.

NIS uses a two-phase sample design: the first phase employs a quarterly random sample of telephone numbers for each survey area and includes administration of a screening questionnaire to respondents aged greater than or equal to 18 years to locate households with one or more children aged 19-35 months *. Vaccination information is collected for all age-eligible children. All respondents are asked to refer to written records; however, reports from recall also are accepted. During July 1994-June 1995, approximately 1.6 million telephone numbers were called, and 35,440 interviews were completed (an average of 454 interviews per survey area). The overall response rate for eligible households was 71% (range: 57%-86% among the 78 survey sites).

In the second phase, vaccination information is requested from health-care providers for children in surveyed households. During 1994, households were excluded that used records indicating their children received all recommended doses of four specific vaccines. ** All households identified in the first and second quarters of 1995 were included in the second phase. Based on exclusions, 30,543 (86%) children were eligible for the second phase; of these, vaccination information was obtained from providers for 13,755 (45%) children. The demographic characteristics and the reported vaccination histories were similar for children with and without provider information. Overall, for 59% of the children in the survey, either written records of having received all of the required doses for the four vaccines were available (29%) or vaccination information based on provider records was available (30%). As previously described, these provider data were used to adjust responses for the entire group of children surveyed (2-5). Data from four consecutive quarters yielded 12-month estimates for the United States, the 50 states, the District of Columbia, and the 27 urban areas.

Compared with the previous reporting period (April 1994-March 1995), there were statistically significant increases in national vaccination coverage with three or more doses of poliovirus vaccine (from 84% {95% confidence interval (CI)=plus or minus 0.9%} to 86% {95% CI=plus or minus 0.8%}) and with three or more doses of hepatitis b vaccine (from 42% {95% CI=plus or minus 1.2%} to 51% {95% CI=plus or minus 1.1%}) (Table_1) ***. The series-complete coverage estimates for 4:3:1 (i.e., four doses of DTP, three doses of poliovirus vaccine, and one dose of MMR) and 4:3:1:3 (i.e., four doses of DTP, three doses of poliovirus vaccine, one dose of MMR, and three doses of Hib) remained stable.

For every vaccine or series of vaccines, estimated vaccination coverage for the most recent quarter (April-June 1995) was equal to or higher than that for the most recent 12 months. Coverage increased the most for hepatitis B vaccine (62% {95% CI=plus or minus 1.5%} versus 51% {95% CI=plus or minus 1.1%}) (Table_1).

During July 1994-June 1995, state-specific estimated coverage levels for the 4:3:1:3 series ranged from 61% to 87% (median: 75%), and for the 4:3:1 series ranged from 64% to 88% (median: 77%) (Table_2). Estimated coverage levels among selected urban areas ranged from 51% to 86% for the 4:3:1:3 series (median: 72%), and for the 4:3:1 series ranged from 55% to 86% (median: 76%) (Table_3). Compared with April 1994-March 1995 (3), changes for the 4:3:1:3 series were greatest in Illinois (from 64% {95% CI=plus or minus 5.2%} to 72% {95% CI=plus or minus 4.5%}); coverage in Chicago increased from 55% (95% CI=plus or minus 8.7%) to 65% (95% CI=plus or minus 7.4%) (3).

The 1995 CII interim goal for coverage with three or more doses of DTP was achieved by all states, the District of Columbia, and by all except one of the 27 urban areas; the goal for coverage with three or more doses of Hib vaccine was achieved by 49 states and 24 urban areas. For coverage with three or more doses of poliovirus vaccine, the 1995 interim goal was achieved by 31 states and 16 urban areas; for coverage with one or more dose of MMR vaccine, by 25 states and 16 urban areas; and for coverage with three or more doses of hepatitis B vaccine, by 20 states and 16 urban areas.

Reported by: National Center for Health Statistics; Assessment Br, Data Management Div, National Immunization Program, CDC.

Editorial Note

Editorial Note: The findings from the NIS indicate that the 1995 CII interim coverage goals have been met or exceeded for DTP, Hib, poliovirus vaccine, and hepatitis B vaccine (1); the coverage estimate for MMR is within 1 percentage point of the goal. This report presents for the first time national quarterly estimates. However, because these estimates reflect changes in coverage in a more timely manner than 12-month estimates, increased variability must be considered when interpreting these quarterly data.

Compared with the previous 12-month estimates, increases in vaccination coverage were greatest for hepatitis B vaccine, probably reflecting substantial progress in the implementation of the infant hepatitis B Advisory Committee on Immunization Practices (ACIP) recommendations (6). In addition, coverage for three doses of poliovirus vaccine exceeded the 1995 goal for the first time, and the results for the second quarter of 1995 suggest a continuation of this upward trend. This increase preceded recommendations by the ACIP to encourage administration of the third dose of oral polio vaccine at age 6 months rather than in the second year of life (7). National vaccination coverage for 4:3:1 series completion did not change for the 12-month period. Thus, approximately 1 million children still need one or more of the recommended doses of vaccine.

NIS enables identification of differences in coverage levels among states and urban areas and development of area-specific interventions (3). States and urban areas that did not meet the 1995 interim goals will need to intensify efforts to meet the 1995 and 1996 goals. Strategies for improving coverage include avoiding missed opportunities for vaccinations by increasing health care providers' awareness of the need to check the vaccination status of children evaluated for other reasons (8,9) and linking vaccination to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (10). CDC and other public health agencies will continue to use NIS to monitor and target efforts to improve vaccination coverage levels.

References

  1. CDC. Reported vaccine-preventable diseases -- United States, 1993, and the Childhood Immunization Initiative. MMWR 1994;43:57-60.

  2. CDC. State and national vaccination coverage levels among children aged 19-35 months -- United States, April-December 1994. MMWR 1995;44:613, 619-23.

  3. CDC. National, state, and urban area vaccination coverage levels among children aged 19-35 months -- United States, April 1994-March 1995. MMWR 1996;45:145-50.

  4. Massey JT, Botman SL. Weighting adjustments for random digit dialed surveys. In: Groves RM, Biemer PP, Lyberg LE, Massey JT, Nicholls WL, Waksberg J, eds. Telephone survey methodology. New York: John Wiley & Sons, Inc, 1988:143-60.

  5. Cochran WG. Sampling techniques. 3rd ed. New York: John Wiley & Sons, Inc, 1977:327-57.

  6. CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;49(RR-13).

  7. CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1994;43 (RR-1):1-11.

  8. CDC. Impact of missed opportunities to vaccinate preschool-aged children on vaccination coverage levels -- selected U.S. sites, 1991-1992. MMWR 1994;43:709-11,717-8.

  9. Szilagyi PG, Rodewald LE. Missed opportunities for immunizations: a review of the evidence. J Public Health Management Practice 1996;2: 18-25.

  10. Birkhead GS, LeBaron CW, Parsons P, et al. The immunization of children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): the impact of different strategies. JAMA 1995;274:312-6.

* For this reporting period, included children born during August 1991- November 1993 (median: age 27 months).

** Four doses of DTP, three doses of poliovirus vaccine, one dose of MMR, and three doses of Hib.

*** The overlap of three quarters between the current reporting period and the previous reporting period requires a special procedure for calculating the standard error of the difference. Taking the overlap into account leads to a smaller standard error than if the reporting periods were regarded as independent.
Table_1
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Table 1. Vaccination coverage levels among children aged 19-35 months, by selected
vaccines -- National Immunization Survey (NIS), United States, July 1994-June 1995
==============================================================================================
                                                    National Immunization Survey
                                         --------------------------------------------------
                                          April 1994 -       July 1994-       April 1995-
                                           March 1995        June 1995        June 1995 +
                           1995   1996   ---------------   --------------    --------------
Vaccine/Dose               Goal   Goal   %    (95% CI *)   %    (95% CI)     %    (95% CI)
-------------------------------------------------------------------------------------------
DTP/DT &
  >=3 Doses                87%    90%    94   (+/-0.6%)    94   (+/-0.5%)    95   (+/-0.8%)
  >=4 Doses                --     --     77   (+/-1.0%)    78   (+/-1.0%)    78   (+/-1.3%)

Poliovirus
  >=3 Doses                85%    90%    84   (+/-0.9%)    86   (+/-0.8%)    88   (+/-1.1%)

Hib @
  >=3 Doses                85%    90%    90   (+/-0.7%)    91   (+/-0.7%)    92   (+/-0.9%)

MMR **
  >=1 Dose                 90%    90%    89   (+/-0.8%)    89   (+/-0.7%)    89   (+/-1.0%)

Hepatitis B
  >=3 Doses                50%    70%    42   (+/-1.2%)    51   (+/-1.1%)    62   (+/-1.5%)
    19-24 Months           --     --     58   (+/-1.4%)    64   (+/-1.3%)    70   (+/-2.4%)
    25-30 Months           --     --     41   (+/-1.4%)    51   (+/-1.3%)    67   (+/-2.5%)
    31-35 Months           --     --     24   (+/-1.3%)    34   (+/-1.3%)    49   (+/-2.6%)

Combined Series
  4 DTP/3 Polio/1 MMR ++   --     --     75   (+/-1.0%)    75   (+/-1.0%)    76   (+/-1.4%)
  4 DTP/3 Polio/1 MMR/     --     --     72   (+/-1.1%)    73   (+/-1.0%)    75   (+/-1.4%)
    3 Hib &&
-------------------------------------------------------------------------------------------
 * Confidence interval.
 + For this reporting period, included children born during May 1992-November 1993.
 & Diphtheria and tetanus toxoids and pertussis vaccine/Diphtheria and tetanus toxoids.
 @ Haemophilus influenzae type b vaccine.
** Measles-mumps-rubella vaccine.
++ Four doses of DTP/DT, three doses of poliovirus vaccine, and one dose of MMR.
&& Four doses of DTP/DT, three doses of poliovirus vaccine, one dose of MMR, and three doses
   of Hib.
==============================================================================================

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Table_2
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TABLE 2. Estimated vaccination coverage levels with the 4:3:1 series * and the 4:3:1:3
series +, by coverage level and state -- National Immunization Survey, United States,
July 1994-June 1995
=============================================================================================================
                     4:3:1 Series coverage                         4:3:1:3 Series coverage
Coverage Level/      ---------------------      Coverage level/    -----------------------
  State                 %    (95% CI &)           State                 %    (95% CI)
-------------------------------------------+-----------------------------------------------
>=85%                                           >=85%
 Connecticut @          86   (+/-4.7%)           New Hampshire          85   (+/-4.3%)
 Massachusetts @        85   (+/-4.0%)           Vermont                87   (+/-3.8%)
 New Hampshire @        87   (+/-4.0%)          75%-84%
 Vermont **             88   (+/-3.7%)           Alabama                76   (+/-4.7%)
75%-84%                                          Connecticut            84   (+/-5.0%)
 Alabama ++             77   (+/-4.7%)           Delaware               77   (+/-5.7%)
 Delaware @             79   (+/-5.5%)           Florida                78   (+/-4.7%)
 Florida @              78   (+/-4.7%)           Hawaii                 78   (+/-5.7%)
 Georgia @              75   (+/-5.1%)           Iowa                   81   (+/-4.5%)
 Hawaii @               82   (+/-5.3%)           Kansas                 75   (+/-5.0%)
 Illinois ++            75   (+/-4.4%)           Kentucky               83   (+/-4.8%)
 Iowa++                 82   (+/-4.4%)           Maine                  82   (+/-4.5%)
 Kansas++               78   (+/-4.8%)           Massachusetts          83   (+/-4.2%)
 Kentucky **            84   (+/-4.7%)           Minnesota              78   (+/-5.2%)
 Maine **               84   (+/-4.3%)           Mississippi            81   (+/-5.0%)
 Maryland @             78   (+/-4.6%)           New York               77   (+/-4.2%)
 Minnesota **           79   (+/-5.2%)           North Carolina         79   (+/-5.2%)
 Mississippi **         82   (+/-4.9%)           North Dakota           81   (+/-4.4%)
 New Jersey @           76   (+/-5.0%)           Ohio                   75   (+/-4.2%)
 New Mexico ++          75   (+/-5.8%)           Pennsylvania           77   (+/-4.5%)
 New York @             78   (+/-4.1%)           Rhode Island           82   (+/-4.8%)
 North Carolina **      82   (+/-5.0%)           South Carolina         80   (+/-5.1%)
 North Dakota ++        82   (+/-4.3%)           South Dakota           78   (+/-5.2%)
 Ohio ++                77   (+/-4.2%)           Virginia               78   (+/-5.4%)
 Pennsylvania @         80   (+/-4.2%)           Wisconsin              75   (+/-4.0%)
 Rhode Island @         83   (+/-4.7%)           Wyoming                77   (+/-5.2%)
 South Carolina @       81   (+/-5.0%)          65%-74%
 South Dakota ++        79   (+/-5.1%)           Alaska                 68   (+/-6.1%)
 Virginia **            79   (+/-5.4%)           Arizona                71   (+/-4.3%)
 Washington ++          75   (+/-4.2%)           Arkansas               68   (+/-5.8%)
 Wisconsin **           78   (+/-3.9%)           California             69   (+/-4.4%)
 Wyoming **             79   (+/-5.1%)           Colorado               70   (+/-5.8%)
65%-74%                                          Georgia                74   (+/-5.2%)
 Alaska &&              72   (+/-6.0%)           Idaho                  67   (+/-6.0%)
 Arizona ++             74   (+/-4.2%)           Illinois               72   (+/-4.5%)
 Arkansas ++            71   (+/-5.8%)           Indiana                71   (+/-5.1%)
 California &&          72   (+/-4.3%)           Louisiana              70   (+/-5.4%)
 Colorado ++            74   (+/-5.6%)           Maryland               74   (+/-4.8%)
 Idaho ++               68   (+/-6.0%)           Missouri               70   (+/-6.0%)
 Indiana ++             73   (+/-5.0%)           Montana                68   (+/-5.9%)
 Louisiana &&           72   (+/-5.3%)           Nebraska               71   (+/-5.4%)
 Missouri ++            71   (+/-6.0%)           New Jersey             73   (+/-5.2%)
 Montana ++             70   (+/-5.8%)           New Mexico             71   (+/-6.0%)
 Nebraska ++            73   (+/-5.3%)           Oklahoma               69   (+/-6.5%)
 Nevada &&              66   (+/-6.1%)           Oregon                 68   (+/-5.9%)
 Oklahoma ++            72   (+/-6.4%)           Tennessee              72   (+/-4.0%)
 Oregon &&              71   (+/-5.8%)           Texas                  69   (+/-3.7%)
 Tennessee &&           73   (+/-4.0%)           Utah                   69   (+/-4.4%)
 Texas ++               71   (+/-3.6%)           Washington             73   (+/-4.3%)
 Utah ++                72   (+/-4.3%)           West Virginia          67   (+/-6.2%)
 West Virginia ++       68   (+/-6.2%)          <65%
<65%                                             Michigan               61   (+/-5.3%)
 Michigan ++            64   (+/-5.2%)           Nevada                 64   (+/-6.1%)
                                           
Total                   75   (+/-1.0%)           Total                  73   (+/-1.0%)
-------------------------------------------+-----------------------------------------------
 * Four doses of diphtheria and tetanus toxoids and pertussis vaccine/diphtheria and tetanus toxoids
   (DTP/DT), three doses of poliovirus vaccine, and one dose of measles-mumps-rubella vaccine (MMR).
 + Four doses of DTP/DT, three doses of poliovirus vaccine, and one dose of MMR, and three doses of
   Haemophilus influenzae type b vaccine (Hib).
 & Confidence interval.
 @ Met the 1995 Childhood Immunization Initiative (CII) goals for three or more doses of DTP, three or more
   doses of poliovirus, one or more dose of MMR, three or more doses of Hib, and three or more doses
   doses of hepatitis B vaccine.
** Met the 1995 CII goals for three or more doses of DTP, three or more doses of poliovirus, one or more
   dose of MMR, three or more doses of Hib, but not for three or more doses of hepatitis B vaccine.
++ Did not meet the 1995 CII goals for at least one of three or more doses of DTP, three or more doses of
   poliovirus, one or more dose of MMR, or three or more doses of Hib, or the 1995 goal for three or more
   doses of hepatitis B vaccine.
&& Did not meet the 1995 CII goals for at least one of three or more doses of DTP, three or more doses of
   poliovirus, one or more dose of MMR, or three or more doses of Hib, but did meet the 1995 goal for
   three or more doses of hepatitis B vaccine.
=============================================================================================================

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Table_3
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TABLE 3. Estimated vaccination coverage levels with the 4:3:1 series * and the 4:3:1:3
series +, by coverage level and selected urban area -- National Immunization Survey,
United States, July 1994-June 1995
=================================================================================================
                              4:3:1 Series                                      4:3:1:3 Series
                                coverage                                           coverage
Coverage level/              ---------------         Coverage level/            --------------
  Area                       %    (95% CI &)          Area                      %    (95% CI)
------------------------------------------------+----------------------------------------------
>=85%                                                >=85%
 Boston @                    86   (+/-5.1%)           Boston                    86   (+/-5.1%)
75%-84%                                              75%-84%
 Baltimore **                79   (+/-6.0%)           Cuyahoga Co., Ohio        76   (+/-5.9%)
 Cuyahoga Co., Ohio **       79   (+/-5.7%)           El Paso Co., Tex.         80   (+/-4.7%)
 Dade Co., Fla. ++           76   (+/-5.3%)           Fulton/Dekalb Co., Ga.    75   (+/-6.5%)
 El Paso Co., Tex. @         81   (+/-4.6%)           Jefferson Co., Ala.       79   (+/-5.7%)
 Fulton/Dekalb Co., Ga. @    78   (+/-6.3%)           King Co., Wash.           77   (+/-5.2%)
 Jefferson Co., Ala. **      80   (+/-5.6%)           Marion Co., Ind.          77   (+/-5.9%)
 King Co., Wash. @           80   (+/-4.9%)           New York City             76   (+/-6.2%)
 Maricopa Co., Ariz. &&      75   (+/-5.8%)           Santa Clara Co., Calif.   77   (+/-5.8%)
 Marion Co., Ind. ++         78   (+/-5.8%)          65%-74%
 Milwaukee Co., Wis. **      76   (+/-5.8%)           Baltimore                 74   (+/-6.5%)
 New York City @             78   (+/-6.1%)           Chicago                   65   (+/-7.4%)
 San Diego Co., Calif. @     76   (+/-5.5%)           Dallas Co., Tex.          67   (+/-6.6%)
 Santa Clara Co., Calif. @   81   (+/-5.3%)           Dade Co., Fla.            74   (+/-6.4%)
 Shelby Co., Tenn. @         76   (+/-6.4%)           Davidson Co., Tenn.       67   (+/-6.2%)
65%-74%                                               Duval Co., Fla.           70   (+/-6.0%)
 Bexar Co., Tex. &&          68   (+/-6.4%)           Franklin Co., Ohio        71   (+/-6.5%)
 Chicago &&                  69   (+/-7.2%)           Los Angeles Co., Calif.   66   (+/-7.1%)
 Dallas Co., Tex. ++         67   (+/-6.6%)           Maricopa Co., Ariz.       71   (+/-6.0%)
 Davidson Co., Tenn. ++      69   (+/-6.1%)           Milwaukee Co., Wis.       73   (+/-6.0%)
 District of Columbia &&     68   (+/-6.7%)           Philadelphia Co., Pa.     67   (+/-7.5%)
 Duval Co., Fla. ++          73   (+/-6.4%)           San Diego Co., Calif.     74   (+/-5.6%)
 Franklin Co., Ohio &&       72   (+/-6.4%)           Shelby Co., Tenn.         74   (+/-6.4%)
 Los Angeles Co. Calif. @    68   (+/-7.0%)          <65%
 Orleans Parish, La. ++      66   (+/-7.4%)           Bexar Co., Tex.           63   (+/-6.5%)
 Philadelphia Co., Pa. ++    69   (+/-7.4%)           Detroit                   51   (+/-7.7%)
<65%                                                  District of Columbia      62   (+/-6.9%)
 Detroit &&                  55   (+/-7.9%)           Houston                   62   (+/-7.7%)
 Houston &&                  64   (+/-7.7%)           Newark, N.J.              57   (+/-9.1%)
 Newark, N.J. &&             60   (+/-9.0%)           Orleans Parish, La.       64   (+/-7.5%)
------------------------------------------------+----------------------------------------------
 * Four doses of diphtheria and tetanus toxoids and pertussis vaccine/diphtheria and tetanus
   toxoids (DTP/DT), three doses of  poliovirus vaccine, and one dose of measles-mumps-
   rubella vaccine (MMR).
 + Four doses of DTP/DT, three doses of poliovirus vaccine, one dose of MMR, and three doses
   of Haemophilus influenzae type b vaccine (Hib).
 & Confidence interval.
 @ Met the 1995 Childhood Immunization Initiative (CII) goals for three or more doses of DTP,
   three or more doses of poliovirus, one or more dose of MMR, three or more doses of Hib,
   and three or more doses of hepatitis B vaccine.
** Met the 1995 CII goals for three or more doses of DTP, three or more doses of poliovirus,
   one or more dose of MMR, three or more doses of Hib, but not for three or more doses of
   hepatitis B vaccine.
++ Did not meet the 1995 CII goals for at least one of three or more doses of DTP, three or
   more doses of poliovirus, one or more dose of MMR, or three or more doses of Hib, but
   did meet the 1995 goal for three or more doses of hepatitis B vaccine.
&& Did not meet the 1995 CII goals for at least one of three or more doses of DTP, three or
   more doses of poliovirus, one or more dose of MMR, or three or more doses of Hib, or the
   1995 goal for three or more doses of hepatitis B vaccine.
=================================================================================================


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