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

CDC's National Immunization Survey (NIS) provides ongoing national estimates of vaccination coverage among children aged 19-35 months, based on the data for the most recent 12 months, for each of the 50 states and for 28 selected urban areas (1). The NIS was implemented 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 (2). This report presents the findings of the 1997 NIS *, which indicate that vaccination coverage among U.S. children aged 19-35 months remains at the highest levels ever, but that some new vaccines or recommended vaccine doses are below 90% coverage levels.

NIS uses a quarterly random-digit-dialing sample of telephone numbers for each survey area to collect vaccination information for all age-eligible children. During 1997, a total of 32,433 household interviews were completed, representing 32,742 children (mean: 420 children per survey area). The overall response rate for households with children aged 19-35 months for all 78 survey areas was 69% (range: 56%-89%). For completeness and verification, vaccination data are requested from vaccination providers with consent of parents. 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 among children in households without telephones (1,3). The demographic characteristics and reported vaccination histories were similar for children with and without provider information.

Compared with 1996, national vaccination coverage during 1997 increased slightly for three or more doses of Haemophilus influenzae type b vaccine (Hib3) (from 92% to 93%) and for three or more doses of hepatitis B vaccine (HepB3) (from 82% to 84%) (Table_1). Coverage with varicella vaccine (VAR) increased from 16% in 1996 to 26% in 1997. During 1997, VAR coverage increased from 18% in the first quarter to 33% in the last quarter. As in 1996, coverage with three or more doses of diphtheria and tetanus toxoids and pertussis vaccine/diphtheria and tetanus toxoids (DTP3), three or more doses of poliovirus vaccine (Polio3), one or more doses of measles-containing vaccine (MCV), and Hib3 exceeded 90% in 1997; coverage with four or more doses of DTP (DTP4) remained at 81%.

For the 4:3:1 ** and 4:3:1:3 *** series, national coverage remained stable (78% and 76%, respectively). The range of state-specific coverage for the 4:3:1 series narrowed from 64% to 88% (median: 79%) in 1996 to 71% to 87% (median: 78%) in 1997 (Table_2). For selected urban areas, coverage for the 4:3:1 series ranged from 63% to 84% (median: 79%) in 1996 to 66% to 88% (median: 76%) in 1997. Although the median coverge levels remained stable, the low end of the ranges increased.

Coverage levels for Polio3, MCV, and Hib3 ranged from 84% to 97% among states and from 81% to 96% among urban areas (Table_3). For DTP4, coverage ranged from 75% to 91% among states and 69% to 91% among urban areas. For HepB3, coverage ranged from 73% to 91% among states and 76% to 90% among urban areas.

During 1997, all states and 27 of the 28 selected urban areas achieved 90% coverage with DTP3. Four states and one urban area achieved 90% coverage with DTP4, and eight of the 46 remaining states and two of the 27 remaining urban areas had coverage levels of 85% to 89% (Table_3).

Compared with 1996, 90% coverage with Polio3 during 1997 increased from 38 to 41 states and decreased from 17 to 12 urban areas; all remaining states and 12 of the remaining 16 urban areas had coverage of 85% to 89% (1). For MCV, 90% coverage decreased from 32 to 31 states and from 19 to 17 urban areas; 18 of the 19 remaining states and nine of the 11 remaining urban areas had coverage of 85% to 89%. For Hib3, 90% coverage increased from 41 to 48 states and from 19 to 20 urban areas; all remaining states and six of the remaining eight urban areas had coverage levels of 85% to 89%. In 1997, two states and one urban area achieved 90% coverage for HepB3; 17 of the remaining 48 states and seven of the remaining 27 urban areas had HepB3 coverage levels of 85% to 89%. Compared with July 1996-June 1997, the median VAR coverage during 1997 increased from 17% (range: 3%-33%) to 26% (range: 13%-43%) among urban areas (Table_3). Compared with 1996, the number that reached or exceeded 90% coverage goals (70% for HepB3) in 1997 remained unchanged at 30 states and decreased from 14 to 10 urban areas (1).

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

Editorial Note

Editorial Note: The findings in this report indicate that national coverage for the recommended vaccines remained the highest ever recorded, with four of the antigens at greater than 90% coverage levels. This accomplishment reflects improvements in the vaccination delivery system since the low coverage levels reported during the 1989-1991 measles epidemic. The findings also suggest that several challenges remain: coverage levels for DTP4 have not changed since 1996, HepB3 coverage increased only slightly in 1997, and VAR coverage levels are increasing but remain at relatively low levels.

The low coverage levels with DTP4 may reflect in part the difficulty of getting children to return to providers in the second year of life when receipt of DTP4 is recommended. Reminding parents or recalling children that are overdue by using reminder and recall systems may further increase coverage with the fourth dose of DTP. Acellular-based DTP4 also can be administered to children as early as age 12 months if providers believe that the child is unlikely to return for a vaccination visit at age 15-18 months and if at least 6 months has elapsed since the third dose (4). Coverage with DTP4 is particularly low among children living below the poverty level (5). Conducting vaccine assessment and referral in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is an effective strategy to address this gap in coverage (6).

Achieving high coverage with HepB3 vaccine since the 1991 ACIP recommendation for universal administration in infancy initially may have been hampered by provider resistance to vaccination of children at low immediate risk for disease (7) and the lack of adequate resources for vaccine purchase. During the mid-1990s, the federal government and several state governments enhanced the availability of HepB vaccine, and coverage with three or more doses increased from 37% in 1994 to 82% in 1996. Strategies that may further increase coverage with HepB3 include greater provider and parental education on the reasons for vaccination of infants, vaccination assessment and referral for needed vaccines at WIC sites (6), provider assessment and feedback (8), use of reminder and recall systems for vaccination administration (9 ), and state laws requiring vaccination for day care and school entry.

Although VAR coverage increased substantially in 1997, the wide variation among states and urban areas indicates a need for special efforts in most areas. Among children, varicella is the leading cause of vaccine-preventable deaths in the United States, resulting in approximately 1 death per week. Increased coverage with VAR will be enhanced by promotional and education programs to address the lack of knowledge of the health burden associated with varicella in the United States and lack of provider knowledge about vaccine safety, efficacy, and duration of immunity (10). The national estimate for the last quarter of this reporting period suggests a continuing upward trend in coverage with VAR.

Although national coverage levels of 90% have been attained for several individual vaccines, substantial variation remains at the state and urban area level, and many states have not achieved 90% coverage levels for specific vaccines. Achieving the national goal of 90% coverage by 2000 will require states to achieve and maintain high coverage levels for each vaccine. Public health efforts must focus on implementing effective strategies that achieve and sustain high vaccination coverage.

References

  1. 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 1997;46:657-64.

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

  3. CDC. Sample design and procedures to produce estimates of vaccination coverage in the National Immunization Survey. Atlanta, Georgia: US Department of Health and Human Ser-vices, CDC, National Immunization Program, April 18, 1996.

  4. CDC. Immunization schedule -- United States, 1998. MMWR 1998;47:8-12.

  5. CDC. Vaccination coverage by race/ethnicity and poverty level among children aged 19-35 months -- United States, 1996. MMWR 1997;46:963-9.

  6. 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. Journal of Public Health Management Practice 1996;2:34-44.

  7. Freed GL, Freeman VA, Clark SJ, Konrad TR, Pathman DE. Pediatrician and family physician agreement with and adoption of universal hepatitis B immunization. J Fam Pract 1996;42:587-92.

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

  9. Linkins RW, Dini EF, Watson G, Patriarca PA. A randomized trial of the effectiveness of computer-generated telephone messages in increasing immunization visits among preschool children. Archive of Pediatric and Adolescent Medicine 1994;148:908-14.

  10. CDC. Varicella-related deaths among children -- United States, 1997. MMWR 1998;47:365-8.

* For this reporting period (January-December 1997), NIS included children born during February 1994-May 1996 (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.



Table_1
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TABLE 1. Vaccination coverage levels among children aged 19-35 months, by selected
vaccines -- United States, National Immunizaton Survey, 1994-1997
===============================================================================================================
                                       April-         January-              January-         January-
                                   December 1994*    December 1995+     December 1996&      December 1997@
                                 ----------------    -------------    ------------------   ---------------
Vaccine/Dose                      %    (95% CI**)     %   (95% CI)     %      (95% CI)      %    (95% CI)
----------------------------------------------------------------------------------------------------------
DTP/DT++
>=3 Doses                        94      (+/-0.6)    95   (+/-0.6)    95      (+/-0.4)     95    (+/-0.4)
>=4 Doses                        76      (+/-1.1)    79   (+/-1.0)    81      (+/-0.7)     81    (+/-0.7)

Poliovirus
>=3 Doses                        83      (+/-1.0)    88   (+/-0.8)    91      (+/-0.5)     91    (+/-0.5)

Hib&&
>=3 Doses                        86      (+/-0.8)    92   (+/-0.6)    92      (+/-0.5)     93    (+/-0.5)

MCV@@
>=1 Doses                        89      (+/-0.8)    90   (+/-0.7)    91      (+/-0.5)     91    (+/-0.5)

Hepatitis B
>=3 Doses                        37      (+/-1.2)    68   (+/-1.0)    82      (+/-0.7)     84    (+/-0.6)

Varicella
>=1 Doses                           NA***               NA            16      (+/-0.7)+++  26    (+/-0.7)


Combined series
4 DTP/3 Polio/1 MCV&&&           74      (+/-1.1)    76   (+/-1.0)    78      (+/-0.8)     78    (+/-0.7)
4 DTP/3 Polio/1 MCV/3 Hib@@@     69      (+/-1.2)    74   (+/-1.0)    77      (+/-0.8)     76    (+/-0.8)
----------------------------------------------------------------------------------------------------------

*   Children in this survey period were born during May 1991-May 1993.
+   Children in this survey period were born during February 1992-May 1994.
&   Children in this survey period were born during February 1993-May 1995.
@   Children in this survey period were born during February 1994-May 1996.
**  Confidence interval.
++  Diphtheria and tetanus toxoids and pertussis vaccine/diphtheria and tetanus toxoids (DTP/DT).
&&  Haemophilus influenzae type b (Hib) vaccine.
@@  Includes any measles-containing vaccine (MCV).
*** Data not available in this reporting period. Data collection for varicella vaccine began in July 1996.
+++ Estimate based on data collected during July-December 1996 for children born during August 1993-
    May 1995.
&&& Four or more doses of DTP/DT, three or more doses of poliovirus vaccine, and one or more doses of
    MCV.
@@@ Four of 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 the 4:3:1 series* and 4:3:1:3 series +
among children aged 19-35 months, by coverage level and state and selected urban
area -- United States, National Immunization Survey, 1997 &
=============================================================================================================
                                 Series 4:3:1                                            Series 4:3:1:3
Coverage Level/              --------------------       Coverage Level/               --------------------
  State/Urban area           %          (95% CI)@         State/Urban area            %          (95% CI)@
----------------------------------------------------+------------------------------------------------------
>=85%                                                   >=85%
  Alabama                    86         (+/-3.2)          Alabama                     85         (+/-3.2)
    Jefferson Co.            84         (+/-4.2)            Jefferson Co.             82         (+/-4.3)
  Connecticut                87         (+/-3.6)          Connecticut                 85         (+/-3.8)
  Maine                      87         (+/-3.4)          Massachusetts               86         (+/-3.1)
  Massachusetts              87         (+/-2.9)            Boston                    86         (+/-3.6)
    Boston                   88         (+/-3.4)        75%-84%
  New Hampshire              85         (+/-3.8)          Alaska                      75         (+/-4.8)
  Vermont                    86         (+/-3.1)          Arkansas                    77         (+/-4.4)
75%-84%                                                   Delaware                    79         (+/-4.8)
  Alaska                     77         (+/-4.7)          Florida                     77         (+/-3.6)
  Arkansas                   77         (+/-4.4)            Dade Co.                  75         (+/-5.0)
  California                 76         (+/-3.0)            Duval Co.                 70         (+/-5.1)
    Los Angeles Co.          73         (+/-5.5)          Georgia                     79         (+/-3.6)
    San Diego Co.            80         (+/-4.3)            Fulton/DeKalb cos.        75         (+/-4.9)
    Santa Clara Co.          75         (+/-4.7)          Hawaii                      79         (+/-4.7)
  Delaware                   81         (+/-4.6)          Iowa                        76         (+/-4.3)
  District of Columbia       76         (+/-5.3)          Kansas                      82         (+/-3.8)
  Florida                    79         (+/-3.5)          Kentucky                    79         (+/-4.4)
    Dade Co.                 77         (+/-4.9)          Louisiana                   76         (+/-4.1)
    Duval Co.                71         (+/-5.1)            Orleans Parish            69         (+/-6.0)
  Georgia                    81         (+/-3.6)          Maine                       84         (+/-3.6)
    Fulton/DeKalb cos.       78         (+/-4.7)          Maryland                    80         (+/-3.6)
  Hawaii                     81         (+/-4.6)            Baltimore                 83         (+/-4.7)
  Illinois                   76         (+/-3.7)          Michigan                    75         (+/-3.7)
    Chicago                  71         (+/-5.3)            Detroit                   65         (+/-5.6)
  Iowa                       76         (+/-4.3)          Minnesota                   78         (+/-4.4)
  Kansas                     82         (+/-3.8)          Mississippi                 80         (+/-4.4)
  Kentucky                   81         (+/-4.3)          Missouri                    77         (+/-4.4)
  Louisiana                  77         (+/-4.1)          Nebraska                    75         (+/-4.3)
    Orleans Parish           71         (+/-5.9)          New Hampshire               84         (+/-3.8)
  Maryland                   82         (+/-3.5)          New Jersey                  76         (+/-4.2)
    Baltimore                85         (+/-4.5)            Newark                    66         (+/-6.3)
  Michigan                   77         (+/-3.6)          New Mexico                  75         (+/-4.8)
    Detroit                  70         (+/-5.4)          New York                    76         (+/-3.5)
  Minnesota                  81         (+/-4.2)            New York City             75         (+/-5.1)
  Mississippi                81         (+/-4.4)          North Carolina              80         (+/-4.2)
  Missouri                   78         (+/-4.4)          North Dakota                82         (+/-3.9)
  Montana                    75         (+/-4.3)          Pennsylvania                80         (+/-3.7)
  Nebraska                   77         (+/-4.2)            Philadelphia Co.          78         (+/-5.1)
  New Jersey                 78         (+/-4.1)          Rhode Island                81         (+/-4.1)
    Newark                   70         (+/-6.1)          South Carolina              79         (+/-4.2)
  New Mexico                 77         (+/-4.6)          South Dakota                76         (+/-4.3)
  New York                   79         (+/-3.3)          Tennessee                   77         (+/-3.1)
    New York City            79         (+/-4.8)            Davidson Co.              77         (+/-4.6)
  North Carolina             81         (+/-4.2)            Shelby Co.                70         (+/-5.3)
  North Dakota               83         (+/-3.8)          Vermont                     84         (+/-3.3)
  Ohio                       75         (+/-3.6)          Washington                  79         (+/-3.2)
    Franklin Co.             75         (+/-5.0)            King Co.                  77         (+/-4.6)
    Cuyahoga Co.             74         (+/-5.3)          West Virginia               80         (+/-4.1)
  Pennsylvania               82         (+/-3.6)          Wisconsin                   79         (+/-3.1)
    Philadelphia Co.         80         (+/-4.9)            Milwaukee Co.             70         (+/-4.9)
  Rhode Island               84         (+/-3.9)        65%-74%
  South Carolina             80         (+/-4.2)          Arizona                     73         (+/-3.4)
  South Dakota               78         (+/-4.3)            Maricopa Co.              72         (+/-4.8)
  Tennessee                  78         (+/-3.1)          California                  74         (+/-3.1)
    Davidson Co.             77         (+/-4.6)            Los Angeles Co.           71         (+/-5.5)
    Shelby Co.               73         (+/-5.1)            San Diego Co.             78         (+/-4.3)
  Texas                      75         (+/-3.1)            Santa Clara Co.           73         (+/-4.8)
    Bexar Co.                81         (+/-4.7)          Colorado                    72         (+/-5.0)
    Dallas Co.               77         (+/-5.2)          District of Columbia        73         (+/-5.4)
    El Paso Co.              67         (+/-5.2)          Idaho                       70         (+/-4.7)
    Houston                  66         (+/-6.1)          Illinois                    74         (+/-3.8)
  Washington                 80         (+/-3.1)            Chicago                   68         (+/-5.5)
    King Co.                 79         (+/-4.8)          Indiana                     72         (+/-3.7)
  West Virginia              82         (+/-4.0)            Marion Co.                81         (+/-4.5)
  Wisconsin                  80         (+/-3.0)          Montana                     74         (+/-4.4)
    Milwaukee Co.            73         (+/-4.8)          Nevada                      71         (+/-4.9)
65%-74%                                                   Ohio                        73         (+/-3.6)
  Arizona                    74         (+/-3.4)            Cuyahoga Co.              73         (+/-5.3)
    Maricopa Co.             74         (+/-4.7)            Franklin Co.              74         (+/-5.0)
  Colorado                   74         (+/-4.9)          Oklahoma                    71         (+/-4.9)
  Idaho                      72         (+/-4.6)          Oregon                      72         (+/-4.7)
  Indiana                    74         (+/-3.6)          Texas                       74         (+/-3.1)
    Marion Co.               82         (+/-4.4)            Bexar Co.                 79         (+/-4.8)
  Nevada                     73         (+/-4.8)            Dallas Co.                74         (+/-5.4)
  Oklahoma                   72         (+/-4.9)            El Paso Co.               65         (+/-5.3)
  Oregon                     73         (+/-4.6)            Houston                   64         (+/-6.1)
  Utah                       71         (+/-4.7)          Utah                        69         (+/-4.7)
  Virginia                   73         (+/-4.7)          Virginia                    72         (+/-4.8)
  Wyoming                    74         (+/-4.4)          Wyoming                     72         (+/-4.4)
                                                    
Total                        78         (+/-0.7)        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.
& Children in this survey period were born during February 1994-May 1996.
@ Confidence interval.
=============================================================================================================

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Table_3
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TABLE 3. Estimated vaccination coverage with individual vaccines among children aged 19-35 months, by state and selected
urban area -- United States, National Immunization Survey, 1997*
===============================================================================================================================================================
                           >=3 DTP/DT+      >=4 DTP/DT&     >=3 Poliovirus@    >=1 MCV**       >=3 Hib++       >=3 Hepatitis B  >=1 Varicella&&
                          --------------   --------------   ---------------  --------------   --------------   ---------------  ---------------
State/Urban area           %   (95%CI@@)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %    (95% CI)
-----------------------------------------------------------------------------------------------------------------------------------------------
Alabama***                98    (+/-1.2)   89    (+/-2.9)   95    (+/-1.8)   92    (+/-2.5)   97    (+/-1.5)   86    (+/-3.1)   27    (+/-3.5)
 Jefferson Co.***         98    (+/-1.8)   87    (+/-3.8)   93    (+/-2.9)   93    (+/-2.9)   96    (+/-2.2)   89    (+/-3.5)   34    (+/-5.3)
Alaska+++                 93    (+/-2.9)   80    (+/-4.5)   91    (+/-3.2)   87    (+/-3.9)   90    (+/-3.5)   87    (+/-3.3)   12    (+/-3.3)
Arizona+++                91    (+/-2.3)   79    (+/-3.3)   88    (+/-2.7)   88    (+/-2.6)   90    (+/-2.4)   79    (+/-3.1)   28    (+/-3.4)
 Maricopa Co.+++          91    (+/-3.2)   79    (+/-4.5)   87    (+/-3.8)   89    (+/-3.5)   89    (+/-3.4)   79    (+/-4.3)   29    (+/-4.8)
Arkansas***               95    (+/-2.4)   81    (+/-4.1)   91    (+/-3.0)   92    (+/-2.8)   93    (+/-2.7)   85    (+/-3.3)   16    (+/-3.7)
California+++             94    (+/-1.8)   79    (+/-3.0)   90    (+/-2.2)   89    (+/-2.4)   91    (+/-2.2)   83    (+/-2.4)   35    (+/-2.9)
 Los Angeles Co.+++       93    (+/-3.4)   76    (+/-5.4)   89    (+/-3.9)   90    (+/-3.7)   91    (+/-3.6)   82    (+/-4.6)   40    (+/-5.5)
 Santa Clara Co.+++       97    (+/-2.0)   83    (+/-4.1)   89    (+/-3.6)   91    (+/-3.0)   93    (+/-2.8)   87    (+/-3.2)   37    (+/-5.1)
 San Diego Co.***         96    (+/-2.2)   83    (+/-4.1)   91    (+/-3.1)   94    (+/-2.4)   93    (+/-2.7)   86    (+/-3.4)   33    (+/-4.6)
Colorado+++               94    (+/-2.7)   79    (+/-4.6)   88    (+/-3.7)   94    (+/-2.7)   91    (+/-3.4)   80    (+/-4.4)   20    (+/-4.2)
Connecticut***            98    (+/-1.3)   91    (+/-3.0)   94    (+/-2.6)   94    (+/-2.7)   95    (+/-2.2)   84    (+/-3.9)   27    (+/-4.6)
Delaware***               97    (+/-1.9)   84    (+/-4.4)   94    (+/-2.8)   91    (+/-3.5)   94    (+/-2.8)   83    (+/-4.1)   28    (+/-4.8)
District of Columbia+++   94    (+/-3.0)   80    (+/-5.0)   89    (+/-3.9)   91    (+/-3.6)   90    (+/-3.8)   79    (+/-4.8)   36    (+/-5.6)
Florida***                96    (+/-1.7)   82    (+/-3.3)   91    (+/-2.4)   91    (+/-2.4)   93    (+/-2.2)   85    (+/-3.0)   27    (+/-3.3)
 Duval Co.+++             95    (+/-2.4)   75    (+/-4.8)   90    (+/-3.4)   89    (+/-3.6)   93    (+/-3.0)   88    (+/-3.2)   34    (+/-5.0)
 Dade Co.+++              96    (+/-2.4)   81    (+/-4.6)   89    (+/-3.7)   91    (+/-3.4)   93    (+/-2.9)   82    (+/-4.3)   23    (+/-4.7)
Georgia***                98    (+/-1.2)   85    (+/-3.3)   94    (+/-1.9)   92    (+/-2.5)   95    (+/-1.8)   87    (+/-2.9)   25    (+/-3.4)
 Fulton/DeKalb cos.+++    95    (+/-2.5)   84    (+/-4.2)   88    (+/-3.8)   93    (+/-2.9)   92    (+/-3.2)   83    (+/-4.2)   35    (+/-5.3)
Hawaii***                 94    (+/-2.8)   84    (+/-4.3)   90    (+/-3.5)   93    (+/-3.0)   92    (+/-3.3)   88    (+/-3.4)   34    (+/-5.2)
Idaho+++                  92    (+/-2.9)   75    (+/-4.6)   89    (+/-3.2)   89    (+/-3.4)   88    (+/-3.5)   79    (+/-4.1)    6    (+/-2.4)
Illinois+++               95    (+/-1.9)   81    (+/-3.4)   89    (+/-2.8)   89    (+/-2.7)   92    (+/-2.3)   81    (+/-3.2)   20    (+/-3.2)
 Chicago+++               94    (+/-3.0)   75    (+/-5.2)   88    (+/-3.9)   87    (+/-4.0)   89    (+/-3.8)   80    (+/-4.7)   17    (+/-4.0)
Indiana+++                95    (+/-1.9)   77    (+/-3.5)   89    (+/-2.7)   89    (+/-2.7)   91    (+/-2.5)   80    (+/-3.1)   16    (+/-2.7)
 Marion Co.***            96    (+/-2.3)   84    (+/-4.3)   92    (+/-3.1)   91    (+/-3.4)   93    (+/-2.9)   82    (+/-4.4)   20    (+/-4.4)
Iowa+++                   96    (+/-1.9)   82    (+/-3.9)   91    (+/-2.9)   89    (+/-3.3)   95    (+/-2.2)   85    (+/-3.3)   18    (+/-3.8)
Kansas***                 96    (+/-2.1)   85    (+/-3.6)   93    (+/-2.6)   93    (+/-2.5)   94    (+/-2.4)   81    (+/-4.3)   25    (+/-4.5)
Kentucky***               95    (+/-2.3)   83    (+/-4.1)   92    (+/-2.9)   90    (+/-3.3)   94    (+/-2.6)   83    (+/-4.0)   28    (+/-4.6)
Louisiana+++              96    (+/-1.6)   81    (+/-3.8)   92    (+/-2.4)   88    (+/-3.2)   94    (+/-2.1)   86    (+/-3.1)   16    (+/-3.2)
 Orleans Parish+++        90    (+/-4.1)   75    (+/-5.8)   82    (+/-5.2)   86    (+/-4.7)   86    (+/-4.7)   77    (+/-5.4)   19    (+/-5.0)
Maine***                  98    (+/-1.3)   90    (+/-3.0)   95    (+/-2.1)   95    (+/-2.2)   96    (+/-1.8)   84    (+/-3.4)   13    (+/-3.2)
Maryland***               97    (+/-1.4)   86    (+/-3.2)   93    (+/-2.3)   94    (+/-2.0)   95    (+/-2.0)   85    (+/-3.1)   40    (+/-4.1)
 Baltimore***             97    (+/-2.2)   89    (+/-4.0)   93    (+/-3.1)   94    (+/-3.1)   95    (+/-2.7)   83    (+/-4.5)   26    (+/-5.3)
Massachusetts***          98    (+/-1.2)   91    (+/-2.4)   94    (+/-2.0)   95    (+/-1.8)   96    (+/-1.8)   88    (+/-2.8)   21    (+/-3.3)
 Boston***                98    (+/-1.5)   91    (+/-3.0)   96    (+/-2.0)   95    (+/-2.3)   96    (+/-2.2)   90    (+/-2.9)   20    (+/-4.4)
Michigan+++               95    (+/-1.9)   79    (+/-3.5)   91    (+/-2.4)   89    (+/-2.8)   91    (+/-2.4)   84    (+/-2.8)   17    (+/-3.1)
 Detroit+++               90    (+/-3.7)   73    (+/-5.3)   82    (+/-4.7)   84    (+/-4.4)   82    (+/-4.7)   76    (+/-4.9)   15    (+/-4.2)
Minnesota***              96    (+/-2.0)   84    (+/-4.0)   93    (+/-2.5)   92    (+/-2.9)   93    (+/-2.7)   77    (+/-4.3)   36    (+/-4.7)
Mississippi***            95    (+/-2.4)   83    (+/-4.2)   92    (+/-3.1)   90    (+/-3.4)   94    (+/-2.6)   86    (+/-3.7)   11    (+/-3.6)
Missouri***               97    (+/-1.9)   83    (+/-4.1)   90    (+/-3.2)   90    (+/-3.3)   95    (+/-2.2)   83    (+/-3.8)   25    (+/-4.4)
Montana+++                96    (+/-2.2)   80    (+/-4.1)   91    (+/-3.0)   87    (+/-3.5)   92    (+/-2.8)   80    (+/-3.9)   19    (+/-3.6)
Nebraska+++               95    (+/-2.2)   81    (+/-4.0)   90    (+/-3.0)   89    (+/-3.3)   92    (+/-2.7)   82    (+/-3.6)   22    (+/-3.9)
Nevada+++                 93    (+/-2.9)   78    (+/-4.6)   90    (+/-3.4)   89    (+/-3.6)   91    (+/-3.3)   84    (+/-3.5)   13    (+/-3.7)
New Hampshire***          99    (+/-1.0)   89    (+/-3.3)   95    (+/-2.3)   95    (+/-2.3)   97    (+/-1.7)   87    (+/-3.2)   27    (+/-4.3)
New Jersey***             98    (+/-1.3)   82    (+/-3.9)   93    (+/-2.6)   93    (+/-2.5)   94    (+/-2.2)   91    (+/-2.1)   29    (+/-4.3)
 Newark+++                92    (+/-4.0)   74    (+/-6.0)   81    (+/-5.4)   85    (+/-4.9)   84    (+/-5.1)   78    (+/-5.4)   15    (+/-4.4)
New Mexico+++             93    (+/-3.0)   81    (+/-4.4)   88    (+/-3.8)   87    (+/-3.9)   89    (+/-3.6)   82    (+/-4.2)   20    (+/-4.1)
New York***               98    (+/-1.2)   83    (+/-3.1)   91    (+/-2.3)   94    (+/-2.0)   93    (+/-2.2)   86    (+/-2.4)   26    (+/-3.3)
 New York City***         97    (+/-1.9)   83    (+/-4.5)   92    (+/-3.2)   93    (+/-2.9)   92    (+/-3.4)   85    (+/-3.6)   22    (+/-4.6)
North Carolina***         98    (+/-1.3)   84    (+/-4.0)   96    (+/-2.0)   94    (+/-2.4)   95    (+/-2.2)   90    (+/-2.8)   30    (+/-4.8)
North Dakota***           98    (+/-1.5)   87    (+/-3.4)   93    (+/-2.6)   91    (+/-3.0)   96    (+/-2.0)   87    (+/-3.0)   24    (+/-4.0)
Ohio+++                   97    (+/-1.4)   80    (+/-3.4)   90    (+/-2.6)   89    (+/-2.7)   95    (+/-1.8)   83    (+/-2.9)   23    (+/-3.0)
 Cuyahoga Co.***          95    (+/-2.7)   78    (+/-5.1)   90    (+/-3.7)   91    (+/-3.5)   93    (+/-3.2)   83    (+/-4.3)   26    (+/-4.9)
 Franklin Co.+++          96    (+/-2.4)   79    (+/-4.7)   88    (+/-3.8)   90    (+/-3.6)   94    (+/-2.8)   78    (+/-4.5)   30    (+/-5.0)
Oklahoma+++               95    (+/-2.5)   77    (+/-4.7)   90    (+/-3.3)   88    (+/-3.7)   93    (+/-2.8)   83    (+/-3.7)   26    (+/-4.4)
Oregon+++                 94    (+/-2.5)   78    (+/-4.4)   88    (+/-3.4)   88    (+/-3.4)   92    (+/-2.9)   83    (+/-3.7)   29    (+/-4.5)
Pennsylvania***           96    (+/-1.9)   84    (+/-3.5)   90    (+/-2.9)   91    (+/-2.7)   93    (+/-2.4)   83    (+/-3.3)   39    (+/-3.9)
 Philadelphia Co.***      95    (+/-2.8)   82    (+/-4.8)   91    (+/-3.5)   92    (+/-3.3)   93    (+/-3.2)   81    (+/-4.7)   43    (+/-5.9)
Rhode Island***           99    (+/-0.6)   89    (+/-3.2)   95    (+/-2.3)   95    (+/-2.3)   96    (+/-2.0)   87    (+/-3.3)   35    (+/-4.8)
South Carolina***         96    (+/-2.1)   83    (+/-4.0)   91    (+/-3.0)   91    (+/-3.2)   95    (+/-2.3)   86    (+/-3.4)   26    (+/-4.5)
South Dakota***           96    (+/-1.9)   81    (+/-4.1)   92    (+/-2.8)   91    (+/-3.0)   95    (+/-2.2)   79    (+/-4.0)    4    (+/-1.9)
Tennessee***              96    (+/-1.5)   83    (+/-2.9)   91    (+/-2.0)   90    (+/-2.3)   94    (+/-1.6)   84    (+/-2.5)   22    (+/-2.9)
 Shelby Co.+++            95    (+/-2.6)   79    (+/-4.7)   88    (+/-3.8)   89    (+/-3.7)   91    (+/-3.5)   84    (+/-4.0)   24    (+/-4.6)
 Davidson Co.+++          95    (+/-2.5)   83    (+/-4.1)   89    (+/-3.4)   89    (+/-3.5)   93    (+/-2.9)   79    (+/-4.1)   30    (+/-4.6)
Texas+++                  92    (+/-2.1)   78    (+/-3.0)   88    (+/-2.4)   89    (+/-2.3)   90    (+/-2.2)   82    (+/-2.5)   23    (+/-2.5)
 Bexar Co.***             95    (+/-2.7)   83    (+/-4.5)   94    (+/-2.8)   91    (+/-3.4)   94    (+/-2.9)   88    (+/-3.3)   25    (+/-4.6)
 Dallas Co.+++            95    (+/-2.5)   79    (+/-5.1)   91    (+/-3.4)   88    (+/-4.1)   91    (+/-3.4)   86    (+/-3.8)   27    (+/-5.1)
 El Paso Co.+++           89    (+/-3.5)   69    (+/-5.2)   87    (+/-3.7)   84    (+/-4.2)   87    (+/-3.8)   79    (+/-3.9)   18    (+/-3.9)
 Houston+++               90    (+/-4.1)   69    (+/-6.0)   84    (+/-4.8)   86    (+/-4.7)   85    (+/-4.8)   78    (+/-4.9)   21    (+/-4.5)
Utah+++                   93    (+/-2.7)   75    (+/-4.6)   90    (+/-3.2)   86    (+/-3.7)   90    (+/-3.2)   73    (+/-4.5)   14    (+/-3.6)
Vermont***                99    (+/-0.5)   91    (+/-2.6)   95    (+/-1.9)   94    (+/-2.1)   96    (+/-1.6)   83    (+/-3.2)   22    (+/-3.9)
Virginia***               94    (+/-2.5)   76    (+/-4.6)   90    (+/-3.2)   90    (+/-3.1)   92    (+/-2.9)   84    (+/-3.7)   32    (+/-4.7)
Washington***             97    (+/-1.3)   84    (+/-2.9)   93    (+/-1.9)   91    (+/-2.3)   93    (+/-1.9)   81    (+/-3.0)   13    (+/-2.5)
 King Co.***              94    (+/-2.7)   83    (+/-4.2)   90    (+/-3.3)   92    (+/-3.1)   90    (+/-3.4)   79    (+/-4.4)   13    (+/-3.6)
West Virginia***          98    (+/-1.2)   87    (+/-3.6)   95    (+/-2.2)   91    (+/-3.0)   97    (+/-1.7)   86    (+/-3.3)   19    (+/-3.9)
Wisconsin***              95    (+/-1.8)   83    (+/-2.9)   92    (+/-2.1)   91    (+/-2.4)   93    (+/-1.9)   82    (+/-2.8)   20    (+/-2.8)
 Milwaukee Co.+++         94    (+/-2.7)   77    (+/-4.6)   88    (+/-3.6)   93    (+/-2.7)   88    (+/-3.6)   77    (+/-4.5)   23    (+/-4.2)
Wyoming+++                93    (+/-2.6)   78    (+/-4.2)   89    (+/-3.1)   84    (+/-3.8)   91    (+/-2.9)   82    (+/-3.6)   10    (+/-3.0)

Total                     95    (+/-0.4)   81    (+/-0.7)   91    (+/-0.5)   91    (+/-0.5)   93    (+/-0.5)   84    (+/-0.6)   26    (+/-0.7)
-----------------------------------------------------------------------------------------------------------------------------------------------

*   Children in this survey period were born during February 1994- May 1996.
+   Three or more doses of diphtheria and tetanus toxoids and pertussis vaccine/diphtheria and tetanus toxoids (DTP/ DT).
&   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.
&&  One dose of varicella vaccine on or after the first birthday. Data collection for varicella vacine began in July 1996.
@@  Confidence interval.
*** Achieved the 1996 Childhood Immunization Initiative (CII) goals for three or more doses of DTP/ DT, 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.
+++ Did not achieve the 1996 CII goals for at least one of the following: three or more doses of DTP/ DT, three or more doses of poliovirus vaccine, one or
    more doses of MCV, or three or more doses of Hib, but achieved the 1996 goal for three or more doses of hepatitis B vaccine.
=============================================================================================================================================================

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