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National, State, and Urban Area Vaccination Coverage Levels Among Children Aged 19-35 Months -- United States, July 1996-June 1997

The National Immunization Survey (NIS) is an ongoing survey that provides national estimates of vaccination coverage among children aged 19-35 months * based on data for the most recent 12 months for each of the 50 states, the District of Columbia, and 27 other selected urban areas (1,2). CDC initiated the NIS in April 1994 to monitor vaccination coverage levels as part of the Childhood Immunization Initiative (CII), a national strategy to ensure high vaccination coverage of children during the first 2 years of life (3). This report presents NIS findings for July 1996-June 1997, which indicate that vaccination levels among U.S. children aged 19-35 months remain the highest ever recorded. This report also includes the first annualized estimates for varicella vaccine coverage.

NIS uses a quarterly random-digit-dialed sample of telephone numbers for each survey area to collect vaccination information for all eligible children. During July 1996-June 1997, a total of 32,652 household interviews were completed, representing 33,064 children (mean: 424 children per survey area). The overall response rate for eligible households was 67% for all 78 survey areas (range: 55%-83%). For completeness and verification, vaccination data also are requested from vaccination providers. Provider data are weighted to represent the entire group of children surveyed and to account for household nonresponse, natality data, and the lower vaccination coverage levels among children in households without telephones (1,2,4).

Compared with 1996, national vaccination coverage with all individual vaccines and the 4:3:1 ** and 4:3:1:3 *** series during July 1996-June 1997 remained stable at high levels, except that coverage with hepatitis B vaccine showed a small, but statistically significant, increase of 1.5% (from 81.8% to 83.3%) (Table_1).

The national coverage level for varicella vaccine during July 1996-June 1997 was 19% (Table_1). During the last quarter of this reporting period (April-June 1997), national varicella vaccine coverage was 25% (Table_1). For July 1996-June 1997, varicella coverage levels ranged from 3% to 33% (median: 17%) among states and from 7% to 33% (median: 16%) among selected urban areas (Table_2).

During July 1996-June 1997, estimated state-specific coverage levels for the 4:3:1 series ranged from 69% to 91% (median: 79%), and for the 4:3:1:3 series, from 67% to 88% (median: 77%) (Table_3). Estimated coverage levels among selected urban areas ranged from 63% to 86% (median: 77%) for the 4:3:1 series and from 61% to 85% (median: 74%) for the 4:3:1:3 series (Table_4). Compared with 1996, there were statistically significant changes in state-specific coverage with the 4:3:1:3 series in West Virginia (from 71% to 80%) and New York (from 79% to 74%); among selected urban areas, changes were statistically significant in Marion County, Indiana (from 72% to 78%), and the District of Columbia (from 78% to 72%). During July 1996-June 1997, the coverage range for 4:3:1:3 among the states narrowed compared with 1996 (range: 67%-88% versus 63%-87%, respectively). For urban areas, the 4:3:1:3 coverage range remained virtually unchanged (61%-85% in July 1996-June 1997 versus 62%-84% in 1996) (2).

Compared with 1996, the number of states and selected urban areas that met the 1996 CII coverage goal for three or more doses of hepatitis B vaccine increased from 48 to 50 and from 27 to 28, respectively. The number that met the goal for three or more doses of DTP increased from 48 to 50 states and decreased from 26 to 25 urban areas; urban areas that did not meet the goal were within 2% below the goal. The number that met the goal for three or more doses of poliovirus vaccine increased from 38 to 40 states and decreased from 17 to 13 urban areas; all remaining states and 13 of the remaining 15 urban areas had coverage levels of 85%-89%. For one or more doses of MCV, the number reaching the 1996 interim coverage goal for measles-mumps-rubella vaccine (MMR) increased from 32 to 37 states, but decreased from 19 to 18 urban areas; all the remaining states and eight of the 10 remaining urban areas had coverage levels of 85%-89%. The number that met the goal for three or more doses of Hib vaccine increased from 41 to 45 states but decreased from 19 to 18 urban areas; all remaining states and nine of the remaining 10 urban areas had coverage levels of 85%-89%. Overall, the number that met all CII vaccination coverage goals, including the goal for hepatitis B vaccine, increased from 30 to 33 states, but decreased from 14 to 11 urban areas (2).

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

Editorial Note

Editorial Note: The NIS data in this report indicate that all national coverage goals established by CII for 1996 have been met or exceeded for the vaccines routinely recommended for children. Attainment of these goals reflects the widespread implementation of the comprehensive CII strategy by public- and private-sector organizations and health-care providers at the national, state, and local levels (3).

Coverage with hepatitis B vaccine for July 1996-June 1997 increased slightly over 1996 levels, whereas sizable increases occurred from 1994 to 1995 (from 37% to 68%) and from 1995 to 1996 (from 68% to 82%). These findings indicate that substantial effort will be required to attain the 1998 interim national goal of 90% for hepatitis B vaccine (2,3,5).

Before the availability of varicella vaccine, approximately 4 million cases occurred each year in the United States, resulting in an annual average of 105 deaths and 4000-9000 hospitalizations. Most cases occur among children and are preventable by vaccination. In 1997, several deaths attributed to varicella among adults were associated with transmission from unvaccinated preschool-aged family members; these deaths underscore the importance of universal childhood vaccination for varicella (6).

This reporting period coincided with the first 12 months since the inclusion of varicella vaccine in the recommended childhood immunization schedule in July 1996. The national coverage estimate for varicella vaccine was the lowest of all the recommended vaccines, partially because most children surveyed during this reporting period were aged greater than 18 months before the vaccine was first recommended (2). The wide variation of varicella vaccine coverage by state (from 3% to 33%; median: 16%) indicates a need for special efforts in states with lower coverage levels. The national estimates for the last quarter of this reporting period suggest an upward trend in varicella vaccination coverage. Additional increases are expected with the implementation of the extended financing of varicella vaccination by the Vaccines for Children Program (VFC), which makes available all recommended vaccines to public- and private-sector health-care providers for children who qualify (7). State and local public health officials should encourage more public- and private-sector providers to participate in VFC, which should be especially beneficial for uninsured children and children living below the poverty level.

In this reporting period, the 4:3:1 and 4:3:1:3 series coverage remained relatively unchanged. These findings primarily reflect relatively low coverage with the fourth dose of DTP (81%) (Table_1). On the basis of these data, approximately 1 million children still need one or more of the recommended doses of vaccine to be fully protected.

Although national 1996 CII coverage goals have been attained for all individual vaccines, coverage differed substantially by state and urban area, and many states and urban areas did not meet the 1996 CII goals for the individual vaccines. Moreover, 13 states and 10 urban areas have not achieved the 1995 interim goal for MCV (90%); two urban areas have not achieved the 1995 goal for poliovirus vaccine (85%); and one urban area has not achieved the 1995 goal for Hib vaccine (85%) (2). Vaccination providers in these areas should intensify their efforts, so that children are equally well protected throughout the United States.

The addition of new vaccines (e.g., varicella vaccine) to the existing vaccination schedule presents a challenge to the vaccine-delivery system that must be met before the full benefits of new vaccine technology can be realized. The achievement of the 1996 goals during July 1996-June 1997 was a major milestone in the effort to control vaccine-preventable diseases; however, this reporting period indicated only one net gain compared with 1996: a modest increase in hepatitis B vaccine coverage. Furthermore, except for varicella vaccine, no other meaningful increases were detected for the last quarter of this reporting period, which may suggest a leveling off in vaccination coverage. To overcome this apparent leveling in coverage, and to attain the year 2000 objective of 90% coverage with a complete series, vaccination providers must become even more efficient and effective in ensuring full protection of children. Each day, an estimated 11,000 children are born in the United States, and all must receive 12-16 doses of vaccine before the second birthday to be fully vaccinated.

Achievement of the 1996 goals demonstrates that reaching high coverage levels is possible but does not ensure such coverage in the future. Meeting these and other goals at the national, state, and local levels requires a fully functional vaccination delivery system, which remains incomplete in 1998. Important components of this system are state- and community-based computerized vaccination registries, which include all children from birth and can identify children in need of vaccines and recall them for missed vaccinations (8); ongoing quality assurance and information feedback activities; continuous education programs for parents and health-care providers, which remain to be fully created and implemented (9); and expanding and strengthening the links to the Special Supplemental Nutrition Program for Women, Infants, and Children (10). CDC will continue to use NIS to monitor and target efforts to improve vaccination coverage levels in the United States.

References

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

  2. CDC. Status report on the Childhood Immunization Initiative: national, state, and urban area vaccination coverage levels among children aged 19-35 months -- United States, 1996. MMWR 1996;46:657-65.

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

  4. CDC. Sample design and procedures to produce estimates of vaccination coverage in the National Immunization Survey. Atlanta: US Department of Health and Human Services, CDC, 1996.

  5. CDC. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination. MMWR 1991;40(no. RR-13).

  6. CDC. Varicella-related deaths among adults -- United States, 1997. MMWR 1997;46:409-12.

  7. CDC. Vaccines for Children Program, 1994. MMWR 1994;43:705.

  8. Cordero JF, Orenstein WA. The future of immunization registries. Am J Prev Med 1997;13(suppl 1):122-4.

  9. LeBaron CW, Chaney M, Baughman AL, et al. Impact of measurement and feedback on vaccination coverage in public clinics, 1988-1994. JAMA 1997;277:631-5.

  10. Shefer A, Maes E, Brink E, Mize J, Passino JP. Assessment and related immunization issues in the special supplemental nutrition program for women, infants, and children: a status report. J Public Health Management Practice 1996;2:34-44.

* For this reporting period (July 1996-June 1997), the NIS included children born during August 1993-November 1995 (median age: 27 months).

** Four or more doses of diphtheria and tetanus toxoids and pertussis vaccine/diphtheria and tetanus toxoids (DTP/DT), three or more doses of poliovirus vaccine, and one or more doses of measles-containing vaccine (MCV). *** Four or more doses of DTP/DT, three or more doses of poliovirus vaccine, one or more doses of MCV, and three or more doses of Haemophilus influenzae type b vaccine (Hib).

Table_1
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TABLE 1. Childhood Immunization Initiative (CII) goals for 1996 and vaccination coverage levels among children aged 19-35 months,
by selected vaccines -- United States,* National Immunization Survey, July 1996-June 1997
==================================================================================================================================
                                                     12-Month estimate
                                        ----------------------------------------------------
  3-Month
  estimate
                                                                                                  ------------------------
                                          January- December                 July 1996-                  April-June
                                                1996&                       June 1997                      1997
                                        --------------------------    ---------------------       ------------------------
Vaccine/Dose          CII 1996 goals      %            (95% CI@)        %          (95% CI)         %           (95% CI)
----------------------------------------------------------------------------------------------------------------------------------
DTP/DT**
 >=3 Doses               90%             95%           (+/-0.4%)       95%        (+/-0.4%)        95%         (+/-0.6%)
 >=4 Doses               --              81%           (+/-0.7%)       81%        (+/-0.7%)        82%         (+/-1.0%)

Poliovirus
 >=3 Doses               90%             91%           (+/-0.5%)       91%        (+/-0.5%)        90%         (+/-0.8%)

Hib++
 >=3 Doses               90%             92%           (+/-0.5%)       92%        (+/-0.5%)        93%         (+/-0.7%)

MCV&&
 >=1 Dose                90%             91%           (+/-0.5%)       90%        (+/-0.5%)        91%         (+/-0.8%)

Hepatitis B
 >=3 Doses               70%             82%           (+/-0.7%)       83%        (+/-0.6%)        84%         (+/-1.0%)

Varicella@@
 1 Dose                  --              NA***                --       19%        (+/-0.6%)        25%         (+/-1.1%)

Combined series
 4 DTP/3 Polio/1         --              78%           (+/-0.8%)       78%        (+/-0.7%)        78%         (+/-1.1%)
MCV+++
 4 DTP/3 Polio/1         --              77%           (+/-0.8%)       76%        (+/-0.8%)        77%         (+/-1.1%)
MCV/ 3 Hib&&&
----------------------------------------------------------------------------------------------------------------------------------
*   One of the national health objectives for the year 2000 is to achieve series-complete coverage for the recommended vaccines
    among 390% of children aged 2 years.
+   Children in this survey period were born during August 1993-November 1995.
&   Children in this survey period were born during February 1993-May 1995.
@   Confidence interval.
**  Diphtheria and tetanus toxoids and pertussis vaccine/diphtheria and tetanus toxoids.
++  Haemophilus influenzae type b vaccine.
&&  Any measles-containing vaccine; vaccination coverage goals are for measles-mumps-rubella (MMR) vaccine.
@@  One dose administered on or after the first birthday.
*** Not available for this reporting period. Data collection began in July 1996.
+++ Four or more doses of DTP/DT, three or more doses of poliovirus vaccine, and one or more doses of MCV.
&&& Four or more doses of DTP/DT, three or more doses of poliovirus vaccine, one or more doses of MCV, and three or more doses
    of Hib.
==================================================================================================================================

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Table_2
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TABLE 2. Estimated vaccination coverage with individual vaccines routinely recommended for children aged 19-35 months, by state and selected urban area -- United States, National Immunization Survey, July  1996-June 1997*
==============================================================================================================================================================================================================================
                                        >=3 DTP+                     >=4  DTP&                 >=3 Polio@                 >=1 MCV**                >=3 Hib++                    >=3                        >=1
                                                                                                                                                                              Hepatitis                Varicella@@
                                                                                                                                                                                 B&&
                                   ----------------------       ----------------------   -----------------------     -----------------------   --------------------   ------------------------    -----------------------
State/ Urban area                    %        (95% CI***)         %        (95% CI)         %         (95% CI)         %        (95% CI)        %        (95% CI)         %        (95% CI)          %         (95% CI)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama+++                          95          (+/-2.2)         83        (+/-3.6)         90        (+/-2.7)        90        (+/-2.8)       92        (+/-2.6)        85        (+/-3.2)         15         (+/-2.8)
Jefferson Co.&&&                    97          (+/-1.8)         84        (+/-4.2)         89        (+/-3.6)        93        (+/-2.9)       94        (+/-2.7)        89        (+/-3.6)         24         (+/-4.7)
Alaska &&&                          94          (+/-2.9)         78        (+/-4.8)         90        (+/-3.4)        87        (+/-4.0)       87        (+/-4.0)        86        (+/-3.5)          9         (+/-3.1)
Arizona &&&                         91          (+/-2.5)         74        (+/-3.6)         87        (+/-2.8)        86        (+/-2.9)       89        (+/-2.6)        81        (+/-2.9)         17         (+/-2.8)
Maricopa Co.&&&                     90          (+/-3.5)         72        (+/-5.0)         86        (+/-3.9)        87        (+/-3.8)       88        (+/-3.8)        80        (+/-4.1)         19         (+/-4.1)
Arkansas &&&                        94          (+/-2.7)         81        (+/-4.3)         91        (+/-3.1)        90        (+/-3.2)       89        (+/-3.5)        88        (+/-3.2)         11         (+/-3.2)
California&&&                       93          (+/-1.9)         79        (+/-3.0)         89        (+/-2.3)        89        (+/-2.3)       89        (+/-2.3)        81        (+/-2.7)         26         (+/-2.6)
Los Angeles Co.&&&                  93          (+/-3.1)         80        (+/-4.9)         88        (+/-3.9)        90        (+/-3.3)       92        (+/-3.2)        80        (+/-4.9)         27         (+/-5.0)
Santa Clara Co.+++                  96          (+/-2.2)         85        (+/-3.9)         92        (+/-3.0)        93        (+/-2.8)       91        (+/-3.3)        87        (+/-3.4)         33         (+/-5.0)
San Diego Co.+++                    94          (+/-2.9)         81        (+/-4.4)         90        (+/-3.4)        93        (+/-2.8)       90        (+/-3.4)        83        (+/-4.1)         24         (+/-4.2)
Colorado&&&                         93          (+/-3.1)         78        (+/-4.9)         87        (+/-4.1)        92        (+/-3.1)       90        (+/-3.6)        74        (+/-5.1)         16         (+/-3.9)
Connecticut+++                      99          (+/-0.8)         93        (+/-2.7)         96        (+/-1.9)        95        (+/-2.3)       97        (+/-1.8)        87        (+/-3.5)         23         (+/-4.4)
Delaware+++                         98          (+/-1.8)         84        (+/-4.3)         94        (+/-2.7)        91        (+/-3.4)       96        (+/-2.2)        88        (+/-3.5)         18         (+/-4.0)
District of Columbia&&&             95          (+/-2.6)         80        (+/-4.8)         89        (+/-3.8)        91        (+/-3.4)       90        (+/-3.7)        80        (+/-4.7)         22         (+/-4.5)
Florida+++                          95          (+/-2.0)         81        (+/-3.5)         90        (+/-2.7)        90        (+/-2.8)       91        (+/-2.7)        82        (+/-3.2)         22         (+/-3.2)
Duval Co.+++                        95          (+/-2.6)         76        (+/-4.9)         90        (+/-3.4)        90        (+/-3.4)       93        (+/-3.0)        87        (+/-3.6)         25         (+/-4.6)
Dade Co.+++                         95          (+/-2.5)         82        (+/-4.5)         91        (+/-3.4)        91        (+/-3.4)       92        (+/-3.2)        78        (+/-4.7)         16         (+/-4.1)
Georgia+++                          98          (+/-1.2)         85        (+/-3.1)         95        (+/-1.9)        92        (+/-2.4)       95        (+/-1.8)        89        (+/-2.5)         16         (+/-3.0)
Fulton/DeKalb Cos.+++               96          (+/-2.2)         81        (+/-4.7)         91        (+/-3.4)        93        (+/-3.1)       92        (+/-3.2)        81        (+/-4.5)         24         (+/-4.7)
Hawaii+++                           96          (+/-2.2)         84        (+/-4.1)         92        (+/-3.0)        95        (+/-2.4)       94        (+/-2.5)        87        (+/-3.6)         22         (+/-4.5)
Idaho&&&                            91          (+/-3.3)         72        (+/-4.9)         88        (+/-3.6)        86        (+/-3.8)       87        (+/-3.7)        77        (+/-4.2)          3         (+/-1.4)
Illinois&&&                         95          (+/-1.9)         82        (+/-3.4)         89        (+/-2.8)        90        (+/-2.7)       91        (+/-2.5)        81        (+/-3.3)         13         (+/-2.8)
City of Chicago&&&                  95          (+/-2.9)         78        (+/-5.0)         88        (+/-4.1)        89        (+/-3.6)       88        (+/-4.1)        77        (+/-5.0)          7         (+/-2.9)
Indiana&&&                          94          (+/-1.9)         77        (+/-3.5)         89        (+/-2.7)        87        (+/-2.9)       92        (+/-2.2)        80        (+/-3.1)         13         (+/-2.6)
Marion Co.&&&                       93          (+/-3.0)         80        (+/-4.7)         90        (+/-3.6)        89        (+/-3.6)       91        (+/-3.4)        79        (+/-4.6)         17         (+/-4.1)
Iowa+++                             98          (+/-1.4)         85        (+/-3.5)         94        (+/-2.2)        90        (+/-3.0)       96        (+/-1.8)        85        (+/-3.4)         13         (+/-3.2)
Kansas+++                           94          (+/-2.9)         81        (+/-4.4)         90        (+/-3.5)        90        (+/-3.4)       91        (+/-3.2)        78        (+/-4.5)         18         (+/-3.8)
Kentucky+++                         95          (+/-2.4)         81        (+/-4.3)         92        (+/-3.0)        90        (+/-3.4)       93        (+/-2.8)        85        (+/-3.9)         17         (+/-4.0)
Louisiana+++                        97          (+/-1.3)         86        (+/-3.3)         93        (+/-2.3)        93        (+/-2.3)       96        (+/-1.6)        85        (+/-3.3)         10         (+/-2.7)
Orleans Parish&&&                   94          (+/-3.1)         76        (+/-5.8)         85        (+/-4.9)        87        (+/-4.6)       92        (+/-3.7)        78        (+/-5.5)         10         (+/-3.8)
Maine+++                            98          (+/-1.1)         93        (+/-2.4)         94        (+/-2.4)        95        (+/-2.0)       95        (+/-2.1)        82        (+/-3.6)          8         (+/-2.6)
Maryland+++                         97          (+/-1.5)         86        (+/-3.2)         93        (+/-2.3)        93        (+/-2.3)       94        (+/-2.2)        83        (+/-3.2)         27         (+/-3.8)
City of Baltimore+++                98          (+/-1.7)         90        (+/-3.5)         92        (+/-3.1)        94        (+/-2.7)       96        (+/-2.4)        81        (+/-4.6)         15         (+/-4.0)
Massachusetts+++                    98          (+/-1.0)         91        (+/-2.4)         95        (+/-1.9)        96        (+/-1.6)       96        (+/-1.8)        89        (+/-2.6)         13         (+/-2.5)
City of Boston+++                   98          (+/-1.6)         89        (+/-3.4)         94        (+/-2.8)        94        (+/-2.6)       96        (+/-2.3)        89        (+/-3.4)          9         (+/-3.2)
Michigan+++                         94          (+/-2.0)         78        (+/-3.6)         91        (+/-2.4)        91        (+/-2.4)       90        (+/-2.5)        81        (+/-3.2)         14         (+/-2.8)
City of Detroit&&&                  88          (+/-3.8)         70        (+/-5.3)         81        (+/-4.6)        84        (+/-4.3)       79        (+/-4.8)        70        (+/-5.2)         12         (+/-3.6)
Minnesota+++                        97          (+/-1.6)         89        (+/-3.1)         93        (+/-2.5)        94        (+/-2.5)       96        (+/-2.1)        78        (+/-4.2)         33         (+/-4.5)
Mississippi+++                      96          (+/-1.8)         83        (+/-4.0)         93        (+/-2.6)        91        (+/-3.0)       94        (+/-2.4)        84        (+/-3.8)          6         (+/-2.4)
Missouri&&&                         94          (+/-2.8)         78        (+/-4.5)         90        (+/-3.4)        89        (+/-3.5)       93        (+/-2.8)        82        (+/-4.2)         21         (+/-4.1)
Montana&&&                          96          (+/-2.2)         83        (+/-3.9)         91        (+/-2.9)        89        (+/-3.3)       93        (+/-2.6)        81        (+/-4.0)         14         (+/-3.3)
Nebraska+++                         96          (+/-2.0)         83        (+/-3.8)         93        (+/-2.7)        90        (+/-3.2)       93        (+/-2.7)        81        (+/-3.8)         17         (+/-3.8)
Nevada&&&                           93          (+/-2.9)         75        (+/-4.9)         90        (+/-3.4)        87        (+/-3.9)       91        (+/-3.3)        84        (+/-3.8)          6         (+/-2.3)
New Hampshire+++                    98          (+/-1.2)         87        (+/-3.6)         93        (+/-2.7)        94        (+/-2.5)       96        (+/-2.0)        86        (+/-3.4)         15         (+/-3.5)
New Jersey+++                       98          (+/-1.6)         78        (+/-4.6)         92        (+/-3.0)        91        (+/-3.3)       95        (+/-2.4)        89        (+/-2.9)         20         (+/-3.8)
City of Newark&&&                   94          (+/-3.1)         68        (+/-5.9)         82        (+/-5.0)        87        (+/-4.3)       89        (+/-4.0)        78        (+/-5.3)          8         (+/-3.0)
New Mexico&&&                       94          (+/-2.7)         81        (+/-4.4)         90        (+/-3.4)        89        (+/-3.6)       91        (+/-3.4)        81        (+/-4.1)         15         (+/-3.6)
New York+++                         96          (+/-1.6)         82        (+/-3.2)         90        (+/-2.6)        91        (+/-2.3)       91        (+/-2.4)        83        (+/-2.9)         20         (+/-2.9)
New York City&&&                    95          (+/-2.9)         81        (+/-4.6)         89        (+/-3.9)        92        (+/-3.3)       89        (+/-3.9)        81        (+/-4.4)         15         (+/-4.0)
North Carolina+++                   98          (+/-1.6)         85        (+/-3.8)         96        (+/-1.9)        91        (+/-3.0)       94        (+/-2.6)        90        (+/-3.0)         18         (+/-4.0)
North Dakota+++                     95          (+/-2.3)         85        (+/-3.7)         91        (+/-3.1)        90        (+/-3.1)       93        (+/-2.6)        84        (+/-3.6)         13         (+/-3.2)
Ohio+++                             96          (+/-1.6)         81        (+/-3.2)         91        (+/-2.4)        92        (+/-2.2)       94        (+/-2.0)        84        (+/-2.8)         17         (+/-2.8)
Cuyahoga Co.+++                     97          (+/-2.1)         80        (+/-4.6)         92        (+/-3.2)        92        (+/-3.0)       94        (+/-2.6)        84        (+/-4.0)         16         (+/-3.8)
Franklin Co.&&&                     97          (+/-2.2)         79        (+/-4.9)         88        (+/-4.0)        92        (+/-3.3)       93        (+/-3.1)        79        (+/-4.7)         22         (+/-4.5)
Oklahoma&&&                         95          (+/-2.6)         76        (+/-4.9)         89        (+/-3.6)        88        (+/-3.8)       93        (+/-2.9)        81        (+/-4.2)         18         (+/-4.0)
Oregon&&&                           92          (+/-3.0)         77        (+/-4.4)         86        (+/-3.7)        88        (+/-3.4)       90        (+/-3.2)        78        (+/-4.2)         20         (+/-3.8)
Pennsylvania+++                     97          (+/-1.6)         85        (+/-3.4)         93        (+/-2.3)        92        (+/-2.5)       93        (+/-2.4)        85        (+/-3.1)         33         (+/-3.8)
Philadelphia Co.+++                 96          (+/-2.3)         84        (+/-4.5)         94        (+/-3.0)        90        (+/-3.7)       92        (+/-3.3)        86        (+/-4.2)         32         (+/-5.5)
Rhode Island+++                     99          (+/-0.8)         88        (+/-3.5)         94        (+/-2.5)        95        (+/-2.2)       95        (+/-2.4)        88        (+/-3.3)         26         (+/-4.5)
South Carolina+++                   97          (+/-1.8)         86        (+/-3.6)         94        (+/-2.5)        93        (+/-2.7)       96        (+/-2.0)        89        (+/-2.9)         18         (+/-3.8)
South Dakota+++                     96          (+/-1.8)         83        (+/-3.8)         91        (+/-2.9)        92        (+/-2.5)       95        (+/-2.2)        79        (+/-4.1)          5         (+/-2.1)
Tennessee+++                        96          (+/-1.4)         82        (+/-2.8)         93        (+/-1.7)        91        (+/-2.1)       94        (+/-1.7)        84        (+/-2.5)         15         (+/-2.4)
Shelby Co.&&&                       93          (+/-2.9)         75        (+/-4.9)         87        (+/-3.9)        86        (+/-4.0)       89        (+/-3.6)        86        (+/-3.4)         18         (+/-4.1)
Davidson Co.&&&                     94          (+/-2.5)         83        (+/-4.0)         89        (+/-3.3)        91        (+/-3.0)       92        (+/-2.8)        81        (+/-4.1)         25         (+/-4.4)
Texas&&&                            94          (+/-1.7)         77        (+/-3.1)         89        (+/-2.3)        90        (+/-2.2)       91        (+/-2.0)        84        (+/-2.3)         15         (+/-2.3)
Dallas Co.&&&                       93          (+/-3.3)         77        (+/-5.4)         88        (+/-4.3)        89        (+/-4.1)       88        (+/-4.2)        85        (+/-4.0)         20         (+/-4.7)
El Paso Co.&&&                      88          (+/-3.8)         70        (+/-5.3)         86        (+/-4.0)        84        (+/-4.2)       85        (+/-4.2)        79        (+/-4.2)         11         (+/-3.1)
City of Houston&&&                  89          (+/-4.0)         68        (+/-5.9)         86        (+/-4.5)        85        (+/-4.6)       86        (+/-4.5)        79        (+/-4.8)         14         (+/-4.1)
Bexar Co.+++                        96          (+/-2.2)         81        (+/-4.4)         93        (+/-2.8)        91        (+/-3.2)       93        (+/-2.7)        88        (+/-3.1)         15         (+/-3.9)
Utah&&&                             92          (+/-3.0)         72        (+/-4.8)         89        (+/-3.4)        86        (+/-3.8)       90        (+/-3.3)        75        (+/-4.4)         10         (+/-2.9)
Vermont+++                          98          (+/-1.0)         89        (+/-3.0)         95        (+/-1.9)        93        (+/-2.5)       96        (+/-1.8)        82        (+/-3.5)         15         (+/-3.4)
Virginia+++                         96          (+/-2.0)         80        (+/-4.5)         91        (+/-3.1)        90        (+/-3.4)       95        (+/-2.4)        86        (+/-3.6)         24         (+/-4.4)
Washington+++                       97          (+/-1.4)         84        (+/-2.9)         94        (+/-1.8)        91        (+/-2.2)       95        (+/-1.6)        83        (+/-2.8)          9         (+/-2.0)
King Co.+++                         97          (+/-1.7)         88        (+/-3.4)         94        (+/-2.3)        95        (+/-2.2)       96        (+/-1.9)        84        (+/-3.8)          9         (+/-2.9)
West Virginia+++                    98          (+/-1.4)         85        (+/-3.8)         94        (+/-2.6)        91        (+/-3.0)       95        (+/-2.4)        82        (+/-3.9)         13         (+/-3.4)
Wisconsin+++                        96          (+/-1.6)         85        (+/-2.8)         92        (+/-2.2)        92        (+/-2.2)       93        (+/-1.9)        83        (+/-2.8)         16         (+/-2.6)
Milwaukee Co.&&&                    96          (+/-2.1)         78        (+/-4.4)         90        (+/-3.2)        93        (+/-2.7)       89        (+/-3.5)        79        (+/-4.3)         16         (+/-3.8)
Wyoming&&&                          94          (+/-2.5)         80        (+/-4.2)         90        (+/-3.1)        87        (+/-3.5)       92        (+/-2.8)        74        (+/-4.3)          9         (+/-2.9)
U.S. total                          95          (+/-0.4)         81        (+/-0.7)         91        (+/-0.5)        90        (+/-0.5)       92        (+/-0.5)        83        (+/-0.6)         19         (+/-0.6)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
*    Children in this period were born during August 1993-November 1995.
+    Three or more doses of diphtheria and tetanus toxoids and pertussis vaccine/diphtheria and tetanus toxoids.
&    Four or more doses of DTP/DT.
@    Three or more doses of poliovirus vaccine.
**   One or more doses of measles-containing vaccine.
++   Three or more doses of Haemophilus influenzae type b vaccine.
&&   Three or more doses of hepatitis B vaccine.
@@   One dose of varicella vaccine on or after the first birthday. Data collection began in July 1996.
***  Confidence interval.
+++  Achieved the 1996 Childhood Immunization Initiative (CII) goals for three or more doses of DTP, three or
     more doses of poliovirus vaccine, one or more doses of MCV, three or more doses of Hib, and three or more doses of hepatitis B vaccine.
&&&  Achieved the 1996 CII goal for three or more doses of hepatitis B vaccine, but did not achieve the goals
     for at least one of the following: three or more doses of DTP, three or more doses of poliovirus vaccine,
     one or more doses of MCV, or three or more doses of Hib.
==============================================================================================================================================================================================================================

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Table_3
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TABLE 3. Estimated vaccination coverage with the 4:3:1 series * and the
4:3:1:3 series + among children aged 19-35 months, by coverage level and
state -- United States, National Immunizaation Survey, July 1996-June 1997 &
=============================================================================
                              4:3:1 Series
                                coverage
                           -----------------------
Coverage level/State         %         (95% CI@)
--------------------------------------------------
>=85%
Connecticut                  91        (+/-3.0%)
Maine                        88        (+/-3.2%)
Massachusetts                88        (+/-2.7%)
Minnesota                    85        (+/-3.6%)
Vermont                      86        (+/-3.3%)
75%-84%
Alabama                      80        (+/-3.7%)
Alaska                       76        (+/-4.8%)
Arkansas                     77        (+/-4.5%)
California                   77        (+/-3.0%)
Delaware                     81        (+/-4.6%)
Florida                      78        (+/-3.6%)
Georgia                      81        (+/-3.4%)
Hawaii                       81        (+/-4.4%)
Illinois                     79        (+/-3.5%)
Iowa                         81        (+/-3.9%)
Kansas                       79        (+/-4.4%)
Kentucky                     79        (+/-4.5%)
Louisiana                    83        (+/-3.6%)
Maryland                     81        (+/-3.6%)
Michigan                     76        (+/-3.6%)
Mississippi                  82        (+/-4.1%)
Missouri                     75        (+/-4.7%)
Montana                      79        (+/-4.2%)
Nebraska                     81        (+/-3.9%)
New Hampshire                83        (+/-4.0%)
New Jersey                   75        (+/-4.7%)
New Mexico                   77        (+/-4.7%)
New York                     77        (+/-3.5%)
North Carolina               81        (+/-4.1%)
North Dakota                 82        (+/-4.0%)
Ohio                         77        (+/-3.4%)
Pennsylvania                 83        (+/-3.5%)
Rhode Island                 84        (+/-4.0%)
South Carolina               84        (+/-3.8%)
South Dakota                 79        (+/-4.1%)
Tennessee                    79        (+/-3.0%)
Virginia                     76        (+/-4.7%)
Washington                   82        (+/-3.0%)
West Virginia                81        (+/-4.0%)
Wisconsin                    81        (+/-3.0%)
Wyoming                      76        (+/-4.4%)
65%-74%
Arizona                      71        (+/-3.7%)
Colorado                     74        (+/-5.2%)
Idaho                        69        (+/-5.0%)
Indiana                      73        (+/-3.7%)
Nevada                       72        (+/-5.0%)
Oklahoma                     70        (+/-5.2%)
Oregon                       73        (+/-4.6%)
Texas                        73        (+/-3.2%)
Utah                         69        (+/-4.8%)
U.S. total                   78        (+/-0.7%)
-----------------------------------------------------------------------------

                                         4:3:1:3 Series coverage
                                         -----------------------
Coverage level/State                          %    (95% CI)
----------------------------------------------------------------
>=85%
Connecticut                                  88   (+/-3.3%)
Maine                                        85   (+/-3.5%)
Massachusetts                                86   (+/-3.0%)
75%-84%
Alabama                                      78   (+/-3.9%)
Arkansas                                     75   (+/-4.6%)
California                                   75   (+/-3.1%)
Delaware                                     79   (+/-4.7%)
Florida                                      77   (+/-3.7%)
Georgia                                      80   (+/-3.5%)
Hawaii                                       80   (+/-4.4%)
Illinois                                     76   (+/-3.6%)
Iowa                                         80   (+/-4.0%)
Kansas                                       77   (+/-4.5%)
Kentucky                                     77   (+/-4.6%)
Louisiana                                    82   (+/-3.7%)
Maryland                                     78   (+/-3.7%)
Minnesota                                    83   (+/-3.7%)
Mississippi                                  81   (+/-4.1%)
Montana                                      78   (+/-4.2%)
Nebraska                                     78   (+/-4.1%)
New Hampshire                                82   (+/-4.0%)
New Mexico                                   75   (+/-4.8%)
North Carolina                               80   (+/-4.2%)
North Dakota                                 80   (+/-4.1%)
Ohio                                         75   (+/-3.5%)
Pennsylvania                                 82   (+/-3.5%)
Rhode Island                                 81   (+/-4.3%)
South Carolina                               82   (+/-3.9%)
South Dakota                                 77   (+/-4.2%)
Tennessee                                    78   (+/-3.0%)
Vermont                                      84   (+/-3.5%)
Virginia                                     75   (+/-4.7%)
Washington                                   81   (+/-3.0%)
West Virginia                                80   (+/-4.2%)
Wisconsin                                    79   (+/-3.1%)
65%-74%
Alaska                                       72   (+/-5.0%)
Arizona                                      69   (+/-3.7%)
Colorado                                     73   (+/-5.3%)
Idaho                                        67   (+/-5.0%)
Indiana                                      71   (+/-3.7%)
Michigan                                     73   (+/-3.8%)
Missouri                                     74   (+/-4.7%)
Nevada                                       70   (+/-5.1%)
New Jersey                                   73   (+/-4.8%)
New York                                     74   (+/-3.6%)
Oklahoma                                     69   (+/-5.2%)
Oregon                                       72   (+/-4.6%)
Texas                                        72   (+/-3.3%)
Utah                                         68   (+/-4.8%)
Wyoming                                      74   (+/-4.5%)
U.S. total                                   76   (+/-0.8%)
-----------------------------------------------------------------------------
* Four or more doses of diphtheria and tetanus toxoids and pertussis
  accine/diphtheria and tetanus toxoids (DTP/DT), three or more doses of
  poliovirus vaccine, and one or more doses of measles-containing vaccine
  (MCV).
+ Four or more doses of DTP/DT, three or more doses of poliovirus vaccine,
  one or more doses of MCV, and three or more doses of Haemophilus
  influenzae type b vaccine (Hib).
& Children in this period were born during August 1993-November 1995.
@ Confidence interval.
=============================================================================

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Table_4
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TABLE 4. Estimated vaccination coverage with the 4:3:1 series * and the
4:3:1:3 series + among children aged 19-35 months, by coverage level and
selected urban area -- United States, National Immunization Survey,
July 1996-June 1997 &
=============================================================================
                                      4:3:1 Series
                                        coverage
                                  ------------------------
Coverage level/ Urban area         %           (95% CI@)
----------------------------------------------------------
>=85%
 Baltimore,Md.                      85          (+/-4.1%)
 Boston,Mass.                       85          (+/-4.1%)
 King County,Wash.                  86          (+/-3.6%)
75%-84%
 Bexar County,Tex.                  79          (+/-4.5%)
 Chicago,Ill.                       75          (+/-5.2%)
 Cuyahoga County,Ohio               78          (+/-4.7%)
 Dade County,Fla.                   77          (+/-4.9%)
 Davidson County,Tenn.              78          (+/-4.4%)
 District of Columbia               75          (+/-5.1%)
 Franklin County,Ohio               77          (+/-5.1%)
 Fulton/DeKalb Counties,Ga.         77          (+/-5.0%)
 Jefferson County,Ala.              79          (+/-4.6%)
 Los Angeles County,Calif.          78          (+/-5.0%)
 Marion County,Ind.                 79          (+/-4.7%)
 New York City,N.Y.                 76          (+/-5.0%)
 Philadelphia County,Pa.            81          (+/-4.7%)
 San Diego County,Calif.            78          (+/-4.5%)
 Santa Clara County,Calif.          79          (+/-4.4%)
65%-74%
 Dallas County,Tex.                 74          (+/-5.5%)
 Detroit,Mich.                      67          (+/-5.3%)
 Duval County,Fla.                  73          (+/-5.0%)
 El Paso County,Tex.                67          (+/-5.3%)
 Houston,Tex.                       65          (+/-6.0%)
 Maricopa County,Ariz.              69          (+/-5.1%)
 Milwaukee County,Wis.              74          (+/-4.6%)
 Orleans Parish,La.                 71          (+/-6.0%)
 Shelby County,Tenn.                69          (+/-5.2%)
<65%
 Newark,N.J.                        63          (+/-6.0%)
 U.S total                          78          (+/-0.7%)
-------------------------------------------------------------------------
                                                4:3:1:3 Series coverage
                                                -----------------------
Coverage level/ Urban area                             %    (95% CI)
------------------------------------------------------------------------
>=85%
 King County,Wash.                                     85   (+/-3.6%)
75%-84%
 Baltimore,Md.                                         83   (+/-4.3%)
 Bexar County,Tex.                                     78   (+/-4.5%)
 Boston,Mass.                                          83   (+/-4.3%)
 Cuyahoga County,Ohio                                  77   (+/-4.8%)
 Dade County,Fla.                                      75   (+/-5.1%)
 Davidson County,Tenn.                                 77   (+/-4.4%)
 Jefferson County,Ala.                                 76   (+/-4.8%)
 Los Angeles County,Calif.                             77   (+/-5.0%)
 Marion County,Ind.                                    78   (+/-4.8%)
 Philadelphia County,Pa.                               79   (+/-5.0%)
 San Diego County,Calif.                               77   (+/-4.6%)
 Santa Clara County,Calif.                             76   (+/-4.6%)
65%-74%
 Chicago,Ill.                                          71   (+/-5.4%)
 Dallas County,Tex.                                    71   (+/-5.6%)
 District of Columbia                                  72   (+/-5.3%)
 Duval County,Fla.                                     73   (+/-5.1%)
 Franklin County,Ohio                                  74   (+/-5.2%)
 Fulton/DeKalb Counties,Ga.                            74   (+/-5.2%)
 Maricopa County,Ariz.                                 68   (+/-5.1%)
 Milwaukee County,Wis.                                 70   (+/-4.8%)
 New York City,N.Y.                                    72   (+/-5.3%)
 Orleans Parish,La.                                    70   (+/-6.1%)
 Shelby County,Tenn.                                   67   (+/-5.3%)
<65%
 Detroit,Mich.                                         63   (+/-5.4%)
 El Paso County,Tex.                                   64   (+/-5.4%)
 Houston,Tex.                                          63   (+/-6.0%)
 Newark,N.J.                                           61   (+/-6.0%)
U.S. total                                             76   (+/-0.8%)
-----------------------------------------------------------------------------
* Four or more doses of diphtheria and tetanus toxoids and pertussis
  vaccine/diphtheria and tetanus toxoids (DTP/DT), three or more doses of
  poliovirus vaccine, and one or more doses of measles-containing vaccine
  (MCV).
+ Four or more doses of DTP/DT, three or more doses of poliovirus vaccine,
  one or more doses of MCV, and three or more doses of Haemophilus influenzae
  type b vaccine (Hib).
& Children in this period were born during August 1993-November 1995.
@ Confidence interval.
=============================================================================

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