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National, State, and Local Area Vaccination Coverage Among Children Aged 19--35 Months --- United States, 2009

Since 1994, the National Immunization Survey (NIS) has been collecting data to monitor childhood immunization coverage. This report describes the 2009 NIS coverage estimates for children born during January 2006--July 2008 and focuses on the more recently recommended vaccines (i.e., hepatitis B [HepB] vaccine birth dose, hepatitis A vaccine [HepA], pneumococcal conjugate vaccine [PCV], and rotavirus vaccine) for children aged 19--35 months. The most recent NIS data indicate that vaccination coverage increased in 2009 compared with 2008 for HepB birth dose (from 55.3% to 60.8%) and HepA (from 40.4% to 46.6%), but coverage for PCV (≥4 doses) remained stable (80.4%). Full coverage for rotavirus vaccine was 43.9% among children born within 2 years of licensure (1). Coverage for poliovirus (92.8%), measles, mumps, and rubella (MMR) (90.0%), hepatitis B (HepB) (92.4%), and varicella (VAR) (89.6%) vaccines continued to be at or near the national health objective of 90%, although coverage for MMR and HepB vaccines decreased slightly in 2009. The percentage of children who have not received any vaccines remained low (<1%). Parents and primary-care providers continued to ensure that children were vaccinated, in spite of interim recommendations to suspend the booster dose of Haemophilus influenzae type b vaccine (Hib) because of a national shortage, and heightened public awareness of controversies in vaccine safety (2,3).

To estimate coverage for all age-eligible children, NIS uses a quarterly, random-digit--dialed sample of telephone numbers for the 50 states and selected urban areas and territories,* followed by a mail survey of the children's vaccination providers to collect vaccination information. Data were weighted to represent the population of children aged 19--35 months, with adjustments for households with multiple telephone lines, household nonresponse, and exclusion of households without landline telephones. During 2009, the household response rate§ was 63.9%; a total of 17,313 children with provider-reported vaccination records were included in this report, representing 70.7% of all children with completed household interviews. Because the number of Hib and rotavirus** vaccine doses required differs according to manufacturer, coverage estimates for these vaccines now take into account the brand of vaccine used. Logistic regression was used to examine differences among racial/ethnic groups, controlling for poverty status. Statistical analyses were conducted using t-tests based on weighted data and accounting for the complex survey design. All tests with p<0.05 were regarded as statistically significant.

During 2009, national coverage with the first dose of HepB within 3 days of birth (birth dose) increased to 60.8% from 55.3% in 2008, the largest increase observed for the birth dose in the past 5 years (Table 1); by state, coverage ranged from 22.8% in Vermont to 80.7% in Michigan (Table 2). Coverage with ≥2 doses of HepA vaccine increased from 40.4% in 2008 to 46.6% in 2009. Coverage ranged from 19.3% in Maine to 63.2% in North Dakota. Coverage with ≥4 doses PCV at the national level changed little (from 80.1% to 80.4%), but increased significantly in Illinois (from 76.2% to 82.9%), Mississippi (from 74.7% to 85.0%), Nevada (from 63.6% to 75.1%), and Wyoming (from 69.2% to 82.3%). Across all states, PCV coverage ranged from 67.5% in Missouri to 90.7% in Connecticut. Coverage for rotavirus vaccine was 43.9% nationally, similar to previous coverage reports for newly recommended vaccines, and varied widely by state, from 20.9% in Washington to 71.2% in Rhode Island. Rotavirus vaccine coverage increased from 8.0% among children born during January--June 2006 to 60.0% among children born January--June 2008. For children born between those periods, estimated coverage ranged from 34.8% for children born July--December 2006, to 49.0% for children born January--June 2007, to 53.4% for children born July--December 2007.

The seven-vaccine series (i.e., 4:3:1:3:3:1:4) reported in the 2009 NIS added ≥4 doses of PCV to the combined 4:3:1:3:3:1†† series reported in previous years. Because of changes in measurement of the Hib vaccine and the vaccine shortage that occurred from December 2007 to September 2009 (2), state coverage estimates included in this report were based on the series that excludes Hib. Using this modified seven-vaccine series (minus Hib), coverage remained stable in 2009 (70.5%) compared with 2008 (70.6%) (Table 1). In 2009, modified series coverage ranged from 56.2% in Missouri to 78.1% in Iowa (Table 2). Significant increases were observed in Wyoming (69.6% versus 58.9%), Idaho (70.5% versus 60.4%), Oklahoma (66.3% versus 57.4%), Nevada (62.6% versus 55.2%), and North Dakota (77.0% versus 69.1%). Among the 13 local areas, coverage ranged from 61.4% in the eastern/western counties of Washington to 73.5% in Los Angeles, California. The percentage of children aged 19--35 months receiving no vaccinations remained at 0.6%.

Coverage differed by race/ethnicity.§§ Among the more recently recommended vaccines, PCV and rotavirus coverage was lower among black and multiracial children than among white children (Table 3). Coverage for PCV also was lower among Asian children. Coverage for HepA was lower among black children and American Indian/Alaska Native children than among white children. Except for rotavirus coverage among black children, these differences persisted after controlling for poverty status. HepB birth dose coverage was higher among Hispanic children than among white children. For vaccines with longer-standing recommendations, differences were observed for diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine. Compared with coverage among white children, coverage was lower for black children for ≥3 and ≥4 DTaP doses and lower for Hispanic children for ≥4 doses only. The difference in coverage between white and black children for ≥4 doses remained statistically significant after controlling for poverty status.

Coverage also differed by poverty status.¶¶ Coverage for HepB birth dose was higher among children living below poverty level than for those living at or above poverty level (by 3.8 percentage points). Among children living below poverty level, coverage was lower for ≥4 doses of PCV (by 8.4 percentage points) and rotavirus vaccine (by 9.4 percentage points) than for other children. Among the longer-standing recommendations, coverage for ≥4 doses of DTaP also was lower (by 5.6 percentage points).

Reported by

KG Wooten, MA, M Kolasa, MPH, JA Singleton MS, A Shefer, MD, Immunization Svcs Div, National Center for Immunization and Respiratory Diseases, CDC.

Editorial Note

NIS is the only population-based survey to provide national, state, local area, and territorial estimates of provider-reported vaccination coverage among children aged 19--35 months in the United States. Coverage levels for poliovirus, MMR, HepB, and VAR continued to hold at or above 90%, the national health objective for specific vaccines. PCV, first recommended in 2000, has now reached coverage levels comparable to those for DTaP, a vaccine also requiring 4 doses but with longer-standing recommendations. For the more recently recommended vaccines, coverage for the birth dose of the HepB series and the full series of HepA increased. These findings demonstrate the ability of immunization programs at state and local levels to incorporate newly recommended vaccines while sustaining coverage at or above national target levels for most longer-standing recommended vaccines. Careful monitoring of uptake of new vaccines overall and in subpopulations (e.g., by race/ethnicity and geographically) will be important to ensure that all children are protected adequately against vaccine-preventable diseases.

The Hib shortage and interim recommendation to suspend the booster dose for healthy children (2) occurred during a period when 70% of the children in the 2009 NIS would have been eligible for the booster dose of Hib vaccine. Not surprisingly, Hib vaccine coverage measured by receipt of ≥3 doses dropped from 90.9% in 2008 to 83.6% in 2009, in part because of the shortage and interim recommendation. Starting in 2009, coverage estimates are reported based on a more accurate measurement of Hib vaccination status that takes into account vaccine product type (Hib vaccine products vary in the number of recommended doses) (2). Concerns that providers were not vaccinating children adequately with the primary series during the shortage and temporary suspension of the booster vaccine proved unfounded; nationally, 92.1% of eligible children completed the primary series for Hib.

Since the 2006 introduction of live rotavirus vaccine, hospitalizations for gastroenteritis during the rotavirus season have declined markedly, beginning in 2007, as have emergency department and physician office visits for gastroenteritis (4). NIS estimates of rotavirus coverage in this report reflect early vaccinations, primarily among children born during the first 2 years of licensure of rotavirus vaccine. Analysis by birth cohort of the 2009 NIS showed rotavirus vaccination for the full vaccine series has increased steadily and reached 60.0% among children born during January--June 2008; overall vaccination coverage for rotavirus likely will continue to increase.

The Vaccines for Children program,*** a federal entitlement program that provides vaccine at no cost for eligible children, has been effective in reducing potential gaps in coverage levels resulting from poverty status; however, some gaps persist that reflect other barriers that must be addressed. Race/ethnicity was associated with vaccination status in the 2009 NIS data, independent of poverty status, for HepA, 4 doses of PCV, and 4 doses of DTaP. In the 2008 NIS data, racial/ethnic disparities for 4 doses of PCV and 4 doses of DTaP were observed but did not persist after controlling for poverty status (5). Associations of race/ethnicity and poverty with vaccination status will continue to be monitored, and further research will explore reasons for disparities.

State variation in vaccine coverage persists year to year. Many factors that potentially could affect vaccination coverage rates vary across states. Such factors include population characteristics, health system characteristics, state policies (e.g., child care vaccination requirements), vaccine financing policies that might affect speed with which new vaccine recommendations can be adopted and the degree to which underinsured children can receive publicly purchased vaccine, reimbursement of providers for immunization services, and immunization program activities (6--8). How these various factors interact to influence observed differences in vaccination coverage is unclear. Further work is needed to understand factors that most strongly influence vaccination coverage and to identify best practices among states.

The findings in this report are subject to at least three limitations. First, NIS is a landline-based telephone survey, and statistical adjustments might not fully compensate for nonresponse and households without landline or only cellular telephones. Vaccination coverage estimates that include nonlandline households might be lower than NIS estimates (9). Second, underestimates of vaccination coverage might have resulted from the exclusive use of provider-reported vaccination histories because completeness of these records is unknown. Finally, although national coverage estimates are precise, annual estimates and trends for state and local areas should be interpreted with caution because of smaller sample sizes and wider confidence intervals.

Achieving and maintaining high vaccination coverage levels is important to reduce the burden of vaccine-preventable diseases and prevent a resurgence of these diseases in the United States, particularly in undervaccinated populations. Continued partnerships among national, state, local, private, and public entities are needed to sustain vaccination coverage levels and ensure that coverage levels for the more recently recommended vaccines continue to increase. CDC encourages the use of evidence-based methods of improving coverage, which include parent and provider reminders, reducing out-of-pocket costs, increasing access to vaccination, and multicomponent interventions that include education (10). Research is under way to understand barriers to implementing proven methods of improving coverage and identify approaches to promoting more widespread implementation.

References

  1. CDC. Reduction in rotavirus after vaccine introduction---United States, 2000--2009. MMWR 2009;48:1146--9.
  2. CDC. Changes in measurement of Haemophilus influenzae serotype b (Hib) vaccination coverage---National Immunization Survey, United States, 2009. MMWR 2010;59:1069--72.
  3. Chatterjee A, O'Keefe C. Current controversies in the USA regarding vaccine safety. Expert Rev Vaccines 2010;9:497--502.
  4. Curns AT, Steiner CA, Barrett M, Hunter K, Wilson E, Parashar UD. Reduction in acute gastroenteritis hospitalizations among US children after introduction of rotavirus vaccine: analysis of hospital discharge data from 18 US states. J Infect Dis 2010;201:1607--10.
  5. CDC. National, state, and local area vaccination coverage among children aged 19--35 months---United States, 2008. MMWR 2009;58:921--6.
  6. Groom H, Kennedy A, Evans V, Fasano N. Qualitative analysis of immunization programs with most improved childhood vaccination coverage from 2001 to 2004. J Public Health Manag Pract 2010;16:E1--8.
  7. Lee GM, Santoli JM, Hannan C, et al. Gaps in vaccine financing for underinsured children in the United States. JAMA 2007;298:638--43.
  8. Coleman MS, Lindley MC, Ekong J, Rodewald L. Net financial gain or loss from vaccination in pediatric medical practices. Pediatrics 2009;124:S472--91.
  9. Barron M, Wooten K, Taylor B. Comparing vaccination estimates from four survey designs: vaccination estimates from RDD, RDD+Cell, ABS, and area probability sampling. Presented at the 2010 Joint Statistical Meetings; July 31--August 5, 2010; Vancouver, British Columbia, Canada.
  10. Task Force on Community Preventive Services. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med 2000;18(1S):92--6.

* The 13 local areas separately sampled for the 2009 NIS included six areas that receive federal immunization grant funds and are included in the NIS sample every year (District of Columbia; Chicago, Illinois; New York, New York; Philadelphia County, Pennsylvania; Bexar County, Texas; and Houston, Texas); six previously sampled areas (Los Angeles County, California; Marion County, Indiana; Baltimore, Maryland; Dallas County, Texas; El Paso County, Texas; and eastern/western counties, Washington); and one area sampled for the first time (Lake County, Indiana). Local areas sampled in the NIS might change yearly as state immunization programs target local assessments where they are most needed. For the first time, the U.S. Virgin Islands (including St. Croix, St. Thomas, St. John, and Water Island) was included in the NIS sample.

Since the inception of NIS in 1994, its methodology has undergone several revisions. A report of revisions implemented during 1994--2002 that includes a description of the sampling design, response rates, and the precision of key monitoring statistics is available at http://www.cdc.gov/nchs/data/series/sr_02/sr02_138.pdf. NIS conducts quarterly surveys in each state and local area to produce annual estimates within each area. For 2009, the U.S. Virgin Islands survey was conducted only for the second quarter for annual estimates. National estimates exclude the territory of the U.S. Virgin Islands.

§ The Council of American Survey Research Organization (CASRO)household response rate, calculated as the product of the resolution rate (percentage of the total telephone numbers called that were classified as either nonworking, nonresidential, or residential), screening completion rate (percentage of known households that were successfully screened for the presence of age-eligible children), and the interview completion rate (percentage of households with one or more age-eligible children that completed the household survey). Additional information is available at http://www.casro.org/codeofstandards.cfm.

Coverage for Hib vaccine for the primary series was based on receipt of ≥2 or ≥3 doses, depending on product type received. The Merck Hib vaccines require a 2-dose primary series with doses at ages 2 months and 4 months, and the Sanofi Pasteur Hib vaccines require a 3-dose primary series with doses at ages 2, 4, and 6 months. Coverage for the full series, which includes the primary series and a booster dose, was based on receipt of ≥3 or ≥4 doses, depending on product type received. Both Merck and Sanofi Pasteur Hib vaccines require a booster dose at age 12--15 months.

** Coverage for rotavirus vaccine was based on ≥2 or ≥3 doses, depending on product type received (≥2 doses for Rotarix [RV1], licensed in April 2008, and ≥3 doses for RotaTeq [RV5], licensed in February 2006).

†† The combined 4:3:1:3:3:1 series includes ≥4 doses of diphtheria, tetanus toxoid, and cellular pertussis vaccine, which can include diphtheria and tetanus toxoid vaccine or diphtheria, tetanus toxoid, and pertussis vaccine (DTaP), ≥3 doses of poliovirus vaccine; ≥1 doses of MMR vaccine; ≥3 doses of Hib vaccine; ≥3 doses of HepB vaccine; and ≥1 doses of VAR vaccine.

§§ Race was self-reported. Persons identified as white, black, Asian, or American Indian/Alaska Native are all non-Hispanic. Persons identified as Hispanic might be of any race. Children identified as multiracial selected more than one race category.

¶¶ Poverty status categorizes income into 1) at or above the poverty level and 2) below the poverty level. Poverty level was based on 2008 U.S. Census poverty thresholds, available at http://www.census.gov/hhes/www/poverty.html.

*** Additional information on the Vaccines for Children program is available at http://www.cdc.gov/vaccines/programs/vfc/default.htm.


What is already known on this topic?

By estimating vaccination coverage among U.S. children aged 19--35 months, the National Immunization Survey (NIS) is used to monitor efforts to reduce the burden and prevent a resurgence of vaccine-preventable diseases.

What is added by this report?

The 2009 NIS findings demonstrate 1) the ability of state and local immunization programs to incorporate newly recommended vaccines while sustaining coverage at or above national target levels for most longer-standing recommended vaccines, and 2) the existence of racial/ethnic disparities in coverage for some vaccines, independent of poverty status.

What are the implications for public health practice?

Continued partnerships among national, state, local, private, and public entities are needed to sustain coverage levels, increase coverage with the more recently recommended vaccines, implement targeted vaccination programs to address disparities in coverage, and support research to explore reasons for disparities and understand barriers to implementing proven methods to improve coverage.


TABLE 1. Estimated vaccination coverage among children aged 19--35 months, by selected vaccines and dosages --- National Immunization Survey, United States, 2005--2009*

2005

2006

2007

2008

2009

Vaccine

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

DTP/DT/DTaP

≥3 doses

96.1

(±0.5)

95.8

(±0.5)

95.5

(±0.5)

96.2

(±0.5)

95.0

(±0.6)

≥4 doses

85.7

(±0.9)

85.2

(±0.9)

84.5

(±0.9)

84.6

(±1.0)

83.9

(±1.0)

Poliovirus

91.7

(±0.7)

92.8

(±0.6)

92.6

(±0.7)

93.6

(±0.6)

92.8

(±0.7)

MMR ≥1 doses

91.5

(±0.7)

92.3

(±0.6)

92.3

(±0.7)

92.1

(±0.7)

90.0

(±0.8)

Hib

≥3 doses

93.9

(±0.6)

93.4

(±0.6)

92.9

(±0.7)

90.9

(±0.7)

83.6

(±1.0)

Primary series

N/A

N/A

N/A

N/A

92.1

(±0.8)

Full series

N/A

N/A

N/A

N/A

54.8

(±1.4)

Hepatitis B

≥3 doses

92.9

(±0.6)

93.3

(±0.6)

92.7

(±0.7)

93.5

(±0.7)

92.4

(±0.7)

1 dose by 3 days (birth)§

49.6

(±1.2)

50.1

(±1.1)

53.2

(±1.3)

55.3

(±1.3)

60.8

(±1.3)

Varicella ≥1 doses

87.9

(±0.8)

89.2

(±0.7)

90.0

(±0.7)

90.7

(±0.7)

89.6

(±0.8)

PCV

≥3 doses

82.8

(±1.0)

86.9

(±0.8)

90.0

(±1.0)

92.8

(±0.6)

92.6

(±0.7)

≥4 doses

53.7

(±1.3)

68.4

(±1.1)

75.3

(±1.3)

80.1

(±1.1)

80.4

(±1.2)

Hepatitis A (≥2 doses)

N/A

N/A

N/A

40.4

(±1.2)

46.6

(±1.4)

Rotavirus**

N/A

N/A

N/A

N/A

43.9

(±1.4)

Combined series

4:3:1:3:3:1††

76.1

(±1.1)

76.9

(±1.0)

77.4

(±1.1)

76.1

(±1.1)

69.9

(±1.2)

4:3:1:3:3:1 with Hib excluded

76.6

(±1.1)

77.6

(±1.0)

78.3

(±1.1)

78.7

(±1.1)

77.5

(±1.1)

4:3:1:3:3:1:4§§

47.2

(±1.3)

60.1

(±1.2)

66.5

(±1.3)

68.4

(±1.2)

63.6

(±1.2)

4:3:1:3:3:1:4 with Hib excluded

47.3

(±1.3)

60.4

(±1.2)

67.0

(±1.3)

70.6

(±1.2)

70.5

(±1.2)

Children who received no vaccinations

0.4

(±0.1)

0.4

(±0.1)

0.6

(±0.1)

0.6

(±0.2)

0.6

(±0.1)

Abbreviations: CI = confidence interval; DTP/DT/DTaP = diphtheria, tetanus toxoids and pertussis vaccines, diphtheria and tetanus toxoids, and diphtheria, tetanus toxoids and acellular pertussis vaccine; Hib = Haemophilus influenzae type b vaccine; MMR = measles, mumps, and rubella vaccine; N/A = not available; PCV = pneumococcal conjugate vaccine.

* For 2005, includes children born during February 2002--July 2004; for 2006, children born during January 2003--June 2005; for 2007, children born during January 2004--July 2006; for 2008, children born during January 2005--June 2007; and for 2009, children born during January 2006--July 2008.

Primary series: receipt of ≥2 or ≥3 doses, depending on product type received. Full series: receipt of ≥3 or ≥4 doses, depending on product type received (primary series and booster dose). Hib coverage for primary or full series not available until 2009.

§ Hepatitis B vaccine administered between birth and age 3 days.

Hepatitis A vaccine coverage not available before 2008.

** Rotavirus vaccine includes ≥2 or ≥3 doses, depending on product type received (≥2 doses for Rotarix [RV1] and ≥3 doses for RotaTeq [RV5]). Estimates of rotavirus vaccine coverage not available before 2009.

†† 4:3:1:3:3:1 Series, referred to as routine, includes ≥4 doses of DTP/DT/DTaP, ≥3 doses of poliovirus vaccine, ≥1 doses of measles-containing vaccine, ≥3 doses of Hib vaccine, ≥3 doses of hepatitis B vaccine, and ≥1 doses of varicella vaccine.

§§ 4:3:1:3:3:1:4 Series, referred to as routine, includes ≥4 doses of DTP/DT/DTaP, ≥3 doses of poliovirus vaccine, and ≥1 doses of measles-containing vaccine, ≥3 doses of Hib vaccine, ≥3 doses of hepatitis B vaccine, ≥1 doses of varicella vaccine, and ≥4 doses of PCV.


TABLE 2. Estimated vaccination coverage for vaccination series (modified)* and selected individual vaccines among children aged 19--35 months, by state and local area --- National Immunization Survey, United States, 2009

MMR (≥1 doses)

PCV (≥4 doses)

Hep B (birth)§

HepA (≥2 doses)

Rotavirus**

Vaccine series (modified)

State/Area

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

United States

90.0

(±0.8)

80.4

(±1.1)

60.8

(±1.3)

46.6

(±1.4)

43.9

(±1.4)

70.5

(±1.2)

Alabama

95.4

(±2.9)

73.3

(±9.2)

68.1

(±7.0)

43.6

(±8.0)

50.8

(±8.4)

63.9

(±8.9)

Alaska

85.2

(±5.8)

73.2

(±7.3)

65.4

(±7.6)

45.9

(±8.2)

32.3

(±7.4)

56.6

(±8.3)

Arizona

90.8

(±3.6)

77.8

(±5.6)

77.6

(±5.7)

51.9

(±6.8)

39.8

(±6.5)

66.4

(±6.5)

Arkansas

81.8

(±6.0)

69.2

(±6.8)

70.7

(±6.7)

25.1

(±5.7)

27.3

(±5.8)

61.5

(±6.9)

California

89.8

(±3.7)

79.8

(±5.1)

49.8

(±6.3)

51.5

(±6.3)

43.9

(±6.1)

72.2

(±5.5)

Los Angeles County

88.9

(±5.4)

79.4

(±6.7)

51.5

(±8.1)

51.7

(±8.0)

51.5

(±8.1)

73.5

(±7.2)

Rest of state

90.1

(±4.7)

79.9

(±6.5)

49.1

(±8.1)

51.5

(±8.0)

41.1

(±7.8)

71.7

(±7.1)

Colorado

83.6

(±7.0)

77.5

(±7.6)

52.5

(±8.8)

38.9

(±8.5)

44.8

(±8.8)

66.1

(±8.4)

Connecticut

93.7

(±3.3)

90.7

(±5.4)

46.8

(±9.6)

46.9

(±9.8)

46.4

(±9.6)

76.0

(±7.7)

Delaware

90.2

(±4.2)

81.6

(±5.9)

62.8

(±7.4)

52.3

(±7.3)

56.4

(±7.4)

69.2

(±6.8)

District of Columbia

91.2

(±4.5)

77.6

(±7.1)

67.9

(±6.8)

54.1

(±7.2)

39.3

(±7.1)

63.8

(±7.5)

Florida

91.2

(±3.8)

79.5

(±5.5)

47.8

(±6.8)

44.6

(±6.6)

36.4

(±6.5)

68.7

(±6.1)

Georgia

91.3

(±4.2)

79.4

(±5.9)

71.2

(±6.6)

58.1

(±7.1)

48.5

(±7.1)

73.1

(±6.5)

Hawaii

86.7

(±5.3)

80.7

(±5.9)

65.4

(±7.3)

47.1

(±7.7)

39.4

(±7.5)

71.0

(±6.9)

Idaho

88.1

(±4.8)

82.5

(±6.0)

70.3

(±7.1)

37.3

(±7.5)

30.3

(±7.2)

70.5

(±7.0)

Illinois

88.2

(±3.9)

82.9

(±4.6)

58.6

(±5.7)

38.0

(±5.5)

37.9

(±5.4)

72.8

(±5.2)

City of Chicago

90.4

(±4.0)

84.7

(±5.0)

69.8

(±7.1)

47.2

(±7.5)

39.9

(±7.1)

71.4

(±6.9)

Rest of state

87.5

(±5.1)

82.3

(±5.9)

54.7

(±7.3)

34.8

(±6.8)

37.2

(±6.8)

73.2

(±6.6)

Indiana

86.6

(±4.6)

78.6

(±5.6)

74.8

(±5.4)

46.1

(±6.5)

50.8

(±6.5)

67.3

(±6.3)

Lake County

82.7

(±6.4)

75.5

(±7.3)

69.9

(±7.6)

22.6

(±6.8)

33.4

(±7.4)

61.5

(±8.0)

Marion County

87.4

(±5.0)

81.0

(±6.0)

77.4

(±6.0)

45.1

(±7.3)

44.3

(±7.3)

69.5

(±6.9)

Rest of state

86.8

(±6.1)

78.4

(±7.4)

74.8

(±7.0)

48.8

(±8.5)

54.2

(±8.5)

67.4

(±8.2)

Iowa

93.2

(±3.8)

83.8

(±5.3)

46.7

(±7.2)

47.8

(±7.0)

51.1

(±7.1)

78.1

(±6.0)

Kansas

92.5

(±4.6)

78.6

(±7.4)

72.6

(±7.7)

43.8

(±8.5)

39.7

(±8.1)

71.7

(±8.0)

Kentucky

88.9

(±3.8)

75.2

(±5.4)

76.6

(±5.0)

37.9

(±5.7)

45.3

(±5.8)

67.5

(±5.7)

Louisiana

94.4

(±3.0)

81.6

(±5.9)

63.0

(±6.9)

52.2

(±7.4)

50.9

(±7.4)

74.9

(±6.5)

Maine

91.4

(±3.9)

82.5

(±5.2)

68.6

(±6.2)

19.3

(±5.2)

28.5

(±6.3)

72.3

(±6.1)

Maryland

89.7

(±5.2)

83.4

(±6.7)

67.6

(±7.8)

44.9

(±8.1)

44.5

(±7.9)

77.9

(±7.0)

City of Baltimore

91.0

(±4.4)

80.1

(±6.5)

67.8

(±7.0)

46.1

(±7.3)

37.5

(±6.7)

70.4

(±7.0)

Rest of state

89.5

(±5.9)

83.9

(±7.6)

67.6

(±8.9)

44.7

(±9.1)

45.5

(±9.0)

79.0

(±7.9)

Massachusetts

93.7

(±3.2)

86.0

(±5.3)

62.5

(±6.8)

47.1

(±7.1)

45.2

(±7.0)

76.0

(±6.3)

Michigan

90.9

(±5.1)

87.0

(±4.3)

80.7

(±6.1)

43.2

(±7.4)

46.0

(±7.4)

76.5

(±6.4)

Minnesota

93.6

(±3.0)

83.8

(±5.7)

34.1

(±6.2)

49.4

(±6.6)

50.1

(±6.6)

71.6

(±6.3)

Mississippi

91.6

(±3.3)

85.0

(±4.3)

68.0

(±6.2)

41.3

(±6.6)

43.4

(±6.5)

75.2

(±5.4)

Missouri

88.8

(±5.0)

67.5

(±6.9)

59.9

(±6.7)

33.6

(±6.5)

46.9

(±7.1)

56.2

(±7.0)

Montana

87.2

(±5.0)

74.6

(±6.7)

65.2

(±7.2)

31.1

(±7.0)

30.7

(±6.8)

61.7

(±7.5)

Nebraska

93.6

(±3.1)

79.2

(±6.5)

45.4

(±7.4)

52.7

(±7.3)

62.3

(±7.4)

65.4

(±7.3)

Nevada

86.3

(±4.6)

75.1

(±5.7)

72.3

(±5.8)

49.1

(±6.8)

34.4

(±6.4)

62.6

(±6.5)

New Hampshire

92.0

(±3.8)

85.8

(±5.2)

63.7

(±7.1)

49.7

(±7.4)

54.8

(±7.5)

73.3

(±6.5)

New Jersey

86.9

(±4.3)

79.6

(±6.0)

39.0

(±6.1)

34.5

(±6.0)

42.4

(±6.3)

67.2

(±6.4)

New Mexico

89.1

(±4.1)

79.9

(±5.4)

51.2

(±6.8)

40.8

(±6.5)

43.6

(±6.6)

70.2

(±6.4)

New York

90.3

(±3.2)

80.1

(±4.3)

48.6

(±5.4)

34.6

(±5.2)

39.5

(±5.3)

67.2

(±5.0)

City of New York

91.9

(±4.4)

77.2

(±6.5)

41.1

(±7.8)

35.0

(±7.4)

38.6

(±7.7)

67.5

(±7.2)

Rest of state

88.7

(±4.5)

82.9

(±5.5)

55.8

(±7.4)

34.2

(±7.3)

40.4

(±7.3)

67.0

(±6.8)

North Carolina

92.9

(±4.0)

84.0

(±5.8)

76.6

(±6.7)

47.5

(±7.7)

41.1

(±7.4)

76.7

(±6.5)

North Dakota

94.4

(±3.2)

84.0

(±5.5)

78.3

(±6.0)

63.2

(±7.0)

62.6

(±7.1)

77.0

(±6.2)

Ohio

89.4

(±4.2)

82.1

(±5.3)

63.6

(±7.5)

46.7

(±7.4)

48.9

(±7.4)

72.4

(±6.2)

Oklahoma

94.2

(±2.7)

74.0

(±6.1)

66.0

(±6.3)

59.0

(±6.5)

33.4

(±6.3)

66.3

(±6.5)

Oregon

88.1

(±4.3)

81.9

(±5.3)

59.4

(±6.7)

49.5

(±6.6)

31.6

(±6.0)

69.9

(±6.2)

Pennsylvania

89.3

(±4.4)

82.6

(±4.7)

69.1

(±5.8)

52.0

(±6.1)

59.0

(±6.1)

69.4

(±5.9)

Philadelphia County

90.7

(±4.0)

77.6

(±6.0)

72.2

(±6.6)

50.0

(±6.8)

52.6

(±7.2)

68.5

(±6.7)

Rest of state

89.1

(±5.1)

83.6

(±5.5)

68.5

(±6.7)

52.4

(±7.1)

60.2

(±7.1)

69.6

(±6.9)

Rhode Island

90.8

(±4.2)

83.6

(±6.5)

69.5

(±7.3)

55.5

(±7.8)

71.2

(±7.3)

69.7

(±7.5)

South Carolina

86.9

(±4.9)

79.7

(±5.9)

62.5

(±6.8)

43.9

(±6.8)

42.5

(±6.7)

70.9

(±6.4)

South Dakota

92.8

(±3.5)

80.6

(±5.9)

53.0

(±7.2)

43.0

(±7.2)

38.6

(±7.0)

69.6

(±6.7)

Tennessee

94.7

(±2.7)

81.2

(±5.3)

49.7

(±6.7)

47.3

(±6.7)

53.1

(±6.8)

72.5

(±5.9)

See Table 2 footnotes on next page.


TABLE 2. (Continued) Estimated vaccination coverage for vaccination series (modified)* and selected individual vaccines among children aged 19--35 months, by state and local area --- National Immunization Survey, United States, 2009

MMR (≥1 doses)

PCV (≥4 doses)

Hep B (birth)§

HepA (≥2 doses)

Rotavirus**

Vaccine series (modified)

State/Area

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

Texas

88.5

(±3.2)

80.8

(±4.2)

69.8

(±4.8)

55.0

(±5.5)

45.8

(±5.4)

71.3

(±5.0)

Bexar County

87.6

(±5.6)

76.3

(±7.4)

58.3

(±7.5)

51.2

(±8.0)

49.9

(±8.0)

65.4

(±7.8)

City of Houston

86.9

(±4.9)

75.7

(±6.8)

62.3

(±7.9)

57.3

(±7.9)

46.6

(±8.4)

67.9

(±7.4)

Dallas County

84.9

(±6.1)

78.0

(±7.1)

70.5

(±7.0)

46.4

(±8.2)

47.4

(±8.1)

69.7

(±7.8)

El Paso County

87.1

(±4.4)

72.7

(±5.7)

71.5

(±5.8)

56.6

(±6.2)

56.5

(±6.3)

63.9

(±6.1)

Rest of state

89.5

(±4.6)

83.1

(±6.0)

72.1

(±7.0)

56.5

(±8.1)

44.5

(±7.9)

73.3

(±7.2)

Utah

91.3

(±4.1)

79.2

(±5.9)

77.8

(±6.1)

51.3

(±7.2)

43.6

(±7.4)

69.3

(±6.9)

Vermont

91.9

(±3.2)

80.9

(±5.0)

22.8

(±5.1)

43.4

(±6.2)

34.5

(±5.8)

59.9

(±6.1)

Virginia

85.8

(±6.8)

76.4

(±7.9)

60.8

(±7.9)

37.8

(±7.5)

53.1

(±8.1)

68.6

(±8.0)

Washington

90.8

(±3.0)

82.2

(±4.1)

70.1

(±5.4)

52.3

(±5.9)

20.9

(±4.7)

64.9

(±5.7)

Eastern/Western Washington

87.8

(±4.4)

72.9

(±6.0)

73.0

(±6.1)

41.1

(±6.4)

25.5

(±5.5)

61.4

(±6.5)

Rest of state

92.1

(±3.8)

86.2

(±5.2)

68.8

(±7.3)

57.1

(±7.8)

18.9

(±6.3)

66.4

(±7.6)

West Virginia

89.2

(±5.7)

74.4

(±7.5)

53.7

(±8.2)

51.7

(±8.1)

40.9

(±7.9)

60.9

(±8.0)

Wisconsin

94.4

(±2.7)

86.9

(±4.7)

63.1

(±6.6)

52.5

(±6.6)

46.7

(±6.8)

75.9

(±6.0)

Wyoming

91.3

(±3.6)

82.3

(±5.1)

61.2

(±6.8)

32.2

(±6.3)

34.7

(±6.3)

69.6

(±6.5)

U.S. Virgin Islands

71.2

(±6.4)

46.5

(±7.1)

81.8

(±5.5)

15.9

(±5.5)

5.6

---††

37.0

(±6.8)

Abbreviations: CI = confidence interval; DTP/DT/DTaP = diphtheria, tetanus toxoids and pertussis vaccines, diphtheria and tetanus toxoids, and diphtheria, tetanus toxoids, and acellular pertussis vaccine; HepB = hepatitis B vaccine; Hib = Haemophilus influenzae type b vaccine; MMR = measles, mumps, and rubella vaccine; PCV = pneumococcal conjugate vaccine.

* Includes ≥4 doses of DTP/DT/DTaP, ≥3 doses of poliovirus vaccine, ≥1 doses of any measles-containing vaccine, ≥3 doses of HepB, ≥1 doses of varicella vaccine, and ≥4 doses of PCV; Hib vaccine is excluded.

Children in the 2009 National Immunization Survey were born during January 2006--July 2008.

§ ≥1 doses of HepB vaccine administered between birth and age 3 days.

≥2 doses hepatitis A vaccine and measured among children aged 19--35 months.

** ≥2 or ≥3 doses of rotavirus vaccine, depending on product type received (≥2 doses for Rotarix [RV1] and ≥3 doses for RotaTeq [RV5]).

†† The asymmetric CI of 3.1--10.0 is reported instead of the confidence width.


TABLE 3. Estimated vaccination coverage among children aged 19--35 months, by selected vaccines and dosages by race/ethnicity* and poverty level --- National Immunization Survey, United States, 2009§

Race/Ethnicity

Poverty level

White,

non-Hispanic

Black,

non-Hispanic

Hispanic

American Indian/ Alaska Native

Asian

Multiracial, non-Hispanic

Below

At or above

Vaccine

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

%

(95% CI)

DTP/DT/DTaP

≥3 doses

95.6

(±0.6)

93.3

(±2.0)

94.6

(±1.6)

94.5

(±4.8)

95.9

(±2.4)

95.9

(±2.4)

94.1

(±1.2)

95.6

(±0.7)

≥4 doses

85.8

(±1.1)

78.6

(±3.1)

82.9

(±2.5)

82.1

(±8.1)

86.6

(±5.5)

81.8

(±4.1)

80.1

(±2.3)**

85.7

(±1.1)

Poliovirus

93.3

(±0.8)

90.9

(±2.3)

92.5

(±1.8)

92.2

(±5.5)

94.0

(±3.4)

92.8

(±3.0)

92.0

(±1.5)

93.3

(±0.8)

MMR ≥1 doses

90.8

(±0.9)

88.3

(±2.7)

89.3

(±2.0)

94.9

(±3.1)

90.7

(±4.3)

88.5

(±3.8)

88.8

(±1.8)

90.6

(±0.9)

Hib††

≥3 doses

82.9

(±1.2)

80.4

(±3.1)

86.4

(±2.2)

88.3

(±5.9)

81.4

(±6.4)

83.7

(±4.0)

82.0

(±2.1)

84.3

(±1.1)

Primary series

92.6

(±0.8)

91.0

(±2.2)

92.3

(±1.8)

91.8

(±5.2)

86.5

(±5.6)

91.9

(±2.6)

90.1

(±1.7)**

93.1

(±0.8)

Full series

55.3

(±1.6)

51.2

(±3.7)

55.4

(±3.3)

62.5

(±3.1)

54.6

(±8.8)

53.7

(±5.9)

51.4

(±3.0)**

56.5

(±1.5)

Hepatitis B

≥3 doses

92.3

(±0.9)

91.6

(±2.2)

92.6

(±1.7)

92.5

(±5.2)

93.1

(±3.2)

93.3

(±2.6)

92.3

(±1.4)

92.7

(±0.9)

1 dose by 3 days (birth)§§

58.8

(±1.6)

61.7

(±3.7)

64.7

(±3.1)

N/A¶¶

53.3

(±9.2)

60.7

(±5.9)

63.2

(±2.9)**

59.4

(±1.5)

Varicella ≥1 doses

89.2

(±1.0)

88.2

(±2.7)

90.7

(±1.9)

89.2

(±6.3)

89.5

(±5.3)

90.6

(±3.1)

89.0

(±1.8)

90.2

(±0.9)

PCV

≥3 doses

93.2

(±0.8)

91.5

(±2.2)

92.7

(±1.7)

94.4

(±4.3)

88.5

(±5.0)

91.1

(±3.0)

91.2

(±1.5)

93.5

(±0.8)

≥4 doses

83.4

(±1.2)

73.2

(±3.4)

80.6

(±2.5)

76.2

(±9.2)

72.5

(±9.5)

73.1

(±5.7)

74.8

(±2.6)**

83.2

(±1.1)

Hepatitis A (≥2 doses)

46.2

(±1.6)

41.3

(±3.7)

49.3

(±3.3)

33.2

(±9.8)

50.9

(±9.1)

47.8

(±5.9)

47.3

(±3.0)

46.2

(±1.5)

Rotavirus***

46.4

(±1.6)

38.0

(±3.6)

43.7

(±3.2)

N/A¶¶

41.7

(±8.6)

38.4

(±5.6)

37.7

(±2.8)**

47.1

(±1.5)

Combined series

4:3:1:3:3:1†††

69.2

(±1.5)

66.6

(±3.5)

72.8

(±2.8)

73.4

(±9.4)

69.9

(±7.4)

67.1

(±5.2)

68.4

(±2.6)

70.4

(±1.3)

4:3:1:3:3:1 with Hib excluded

78.1

(±1.3)

73.7

(±3.3)

78.2

(±2.7)

76.6

(±9.0)

80.3

(±6.2)

74.8

(±4.8)

75.5

(±2.4)

78.5

(±1.2)

4:3:1:3:3:1:4§§§

64.1

(±1.5)

58.2

(±3.7)

67.1

(±3.0)

N/A¶¶

55.0

(±8.9)

57.2

(±5.8)

60.7

(±2.8)**

64.8

(±1.4)

4:3:1:3:3:1:4 with Hib excluded

72.4

(±1.4)

64.3

(±3.6)

72.0

(±2.9)

N/A¶¶

62.5

(±9.1)

63.4

(±5.8)

66.9

(±2.7)**

72.1

(±1.4)

Abbreviations: CI = confidence interval; DTP/DT/DTaP = diphtheria, tetanus toxoids and pertussis vaccines, diphtheria and tetanus toxoids, and diphtheria, tetanus toxoids and acellular pertussis vaccine; Hib = Haemophilus influenzae type b vaccine; MMR = measles, mumps, and rubella vaccine; N/A = not available; PCV = pneumococcal conjugate vaccine.

* Native Hawaiian or other Pacific Islanders were not included in the table because of small sample sizes.

Poverty level was determined for all children. Children were classified as below poverty if their total family income was less than the poverty threshold specified for the applicable family size, and number of children aged <18 years. All others were classified as at or above poverty. Poverty thresholds reflect yearly changes in the Consumer Price Index. Thresholds and guidelines available at http://www.census.gov/hhes/www/poverty.html.

§ Children in the 2009 National Immunization Survey were born during January 2006--July 2008.

Estimates are statistically significant at p<0.05. White, non-Hispanic children were the reference group.

** Estimates are statistically significant at p<0.05. Children living at or above poverty were the reference group.

†† Primary series: receipt of ≥2 or ≥3 doses, depending on product type received; full series: primary series and booster dose includes receipt of ≥3 or ≥4 doses depending on product type received.

§§ Hepatitis B vaccine administered between birth and age 3 days.

¶¶ Estimate not available if the unweighted sample size for the numerator was <30 or CI half width / estimate >0.5 of CI half width >10.

*** Includes ≥2 or ≥3 doses, depending on product type received (≥2 doses for Rotarix [RV1], ≥3 doses for RotaTeq [RV5]).

††† 4:3:1:3:3:1 series includes ≥4 doses of DTP/DT/DTaP, ≥3 doses of poliovirus vaccine, ≥1 doses of any measles-containing vaccine, ≥3 doses of Hib vaccine, ≥3 doses of hepatitis B vaccine, and ≥1 doses of varicella vaccine.

§§§ 4:3:1:3:3:1:4 series includes ≥4 doses of DTP/DT/DTaP, ≥3 doses of poliovirus vaccine, ≥1 doses of any measles-containing vaccine, ≥3 doses of Hib vaccine, ≥3 doses of hepatitis B vaccine, ≥1 doses of varicella vaccine, and ≥4 doses of PCV.



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