Advertisement

Beyond Vaccination Coverage: Population-Based Measurement of Early Childhood Immunization Schedule Adherence

  • Sophia R. Newcomer
    Correspondence
    Address correspondence to Sophia R Newcomer, PhD, MPH, University of Montana School of Public and Community Health Sciences, 32 Campus Drive, Skaggs Bldg. 177, Missoula, MT 59812
    Affiliations
    University of Montana School of Public and Community Health Sciences (SR Newcomer), Missoula, Mont

    University of Montana Center for Population Health Research (SR Newcomer), Missoula, Mont
    Search for articles by this author
  • Jason M. Glanz
    Affiliations
    Kaiser Permanente Colorado, Institute for Health Research (JM Glanz, MF Daley), Aurora, Colo

    University of Colorado, Colorado School of Public Health, Department of Epidemiology (JM Glanz), Aurora, Colo
    Search for articles by this author
  • Matthew F. Daley
    Affiliations
    Kaiser Permanente Colorado, Institute for Health Research (JM Glanz, MF Daley), Aurora, Colo

    University of Colorado, School of Medicine, Department of Pediatrics (MF Daley), Aurora, Colo
    Search for articles by this author
Published:August 19, 2022DOI:https://doi.org/10.1016/j.acap.2022.08.003

      Abstract

      The immunization schedule recommended by the U.S. Advisory Committee on Immunization Practices (ACIP) provides a structure for how 10 different vaccine series should be administered to children in the first 18 months of life. Progress toward US early childhood immunization goals has largely focused on measuring vaccination coverage at age 24 months. However, standard vaccination coverage measures do not reflect whether children received vaccine doses by recommended ages, or whether vaccines were given concomitantly, per the schedule. In this paper, we describe innovations in population-level measurement of immunization schedule adherence through quantifying vaccination timeliness and undervaccination patterns. Measuring vaccination timeliness involves comparing when children received vaccine doses relative to ACIP age recommendations. To assess undervaccination patterns, children's vaccination histories are analyzed to determine whether they were vaccinated consistent with the ACIP schedule. Some patterns, such as spreading out vaccines across visits, are indicative of parental hesitancy. Other patterns, such as starting all recommended series but missing doses, are largely indicative of other immunization services delivery challenges. Since 2003, at least 12 studies have used National Immunization Survey-Child, immunization information system, or integrated health plan data to measure vaccination timeliness or undervaccination patterns at national or state levels. Moving forward, these novel measures can be leveraged for population-based surveillance of vaccine confidence, and for distinguishing undervaccination due to parental vaccine hesitancy from undervaccination due to other causes. Broader adoption of these measures can facilitate identification of targeted strategies for improving timely and routine early childhood vaccination uptake across the United States.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Academic Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Wodi AP
        • Murthy N
        • Bernstein H
        • et al.
        Advisory Committee on Immunization Practices recommended immunization schedule for children and adolescents aged 18 years or younger—United States, 2022.
        Morb Mortal Wkly Rep. 2022; 71: 234
        • Institute of Medicine
        The Childhood Immunization Schedule and Safety: Stakeholder Concerns, Scientific Evidence, and Future Studies.
        The National Academies Press, Washington, DC2013https://doi.org/10.17226/13563
        • Hill HA
        • Yankey D
        • Elam-Evans LD
        • et al.
        Vaccination coverage by age 24 months among children born in 2016 and 2017—National Immunization Survey-Child, United States, 2017–2019.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 1505
        • Hill HA
        • Elam-Evans LD
        • Yankey D
        • et al.
        Vaccination coverage among children aged 19–35 months—United States, 2017.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 1123
        • Luman ET
        • Barker LE
        • Shaw KM
        • et al.
        Timeliness of childhood vaccinations in the United States: days undervaccinated and number of vaccines delayed.
        JAMA. 2005; 293: 1204-1211
        • Glanz JM
        • Newcomer SR
        • Narwaney KJ
        • et al.
        A population-based cohort study of undervaccination in 8 managed care organizations across the United States.
        JAMA Pediatr. 2013; 167: 274-281
        • Robison SG
        • Groom H
        • Young C.
        Frequency of alternative immunization schedule use in a metropolitan area.
        Pediatrics. 2012; 130: 32-38
        • Newcomer SR
        • Freeman RE
        • Wehner BK
        • et al.
        Timeliness of early childhood vaccinations and undervaccination patterns in Montana.
        Am J Prev Med. 2021; 61: e21-e29
        • Phadke VK
        • Bednarczyk RA
        • Salmon DA
        • et al.
        Association between vaccine refusal and vaccine-preventable diseases in the United States: a review of measles and pertussis.
        JAMA. 2016; 315: 1149-1158
        • Rane MS
        • Rohani P
        • Halloran ME.
        Association of diphtheria-tetanus–acellular pertussis vaccine timeliness and number of doses with age-specific pertussis risk in infants and young children.
        JAMA Ntwk Open. 2021; 4 (e2119118)
        • Zhao Z
        • Smith PJ
        • Hill HA.
        Missed opportunities for simultaneous administration of the fourth dose of DTaP among children in the United States.
        Vaccine. 2017; 35: 3191-3195
        • National Vaccine Advisory Committee
        Assessing the state of vaccine confidence in the United States: recommendations from the National Vaccine Advisory Committee: approved by the National Vaccine Advisory Committee on June 9, 2015 [corrected].
        Public Health Rep. 2015; 130: 573-595
        • Rodewald L
        • Maes E
        • Stevenson J
        • et al.
        Immunization performance measurement in a changing immunization environment.
        Pediatrics. 1999; 103: 889-897
        • Glanz JM
        • Newcomer SR
        • Jackson ML
        • et al.
        White paper on studying the safety of the childhood immunization schedule in the Vaccine Safety Datalink.
        Vaccine. 2016; 34: A1-A29
        • Opel DJ
        • Taylor JA
        • Mangione-Smith R
        • et al.
        Validity and reliability of a survey to identify vaccine-hesitant parents.
        Vaccine. 2011; 29: 6598-6605
        • Luman ET
        • Chu SY.
        When and why children fall behind with vaccinations: missed visits and missed opportunities at milestone ages.
        Amer J Prev Med. 2009; 36: 105-111
        • Maglione MA
        • Das L
        • Raaen L
        • et al.
        Safety of vaccines used for routine immunization of US children: a systematic review.
        Pediatrics. 2014; 134: 325-337
        • Kennedy A
        • Basket M
        • Sheedy K
        • et al.
        Vaccine attitudes, concerns, and information sources reported by parents of young children: results from the 2009 HealthStyles survey.
        Pediatrics. 2011; 127: S92-S99
        • Kempe A
        • O'Leary ST
        • Kennedy A
        • et al.
        Physician response to parental requests to spread out the recommended vaccine schedule.
        Pediatrics. 2015; 135: 666-677
        • Dempsey AF
        • Schaffer S
        • Singer D
        • et al.
        Alternative vaccination schedule preferences among parents of young children.
        Pediatrics. 2011; 128: 848-856
        • Saada A
        • Lieu TA
        • Morain SR
        • et al.
        Parents’ choices and rationales for alternative vaccination schedules: a qualitative study.
        Clin Pediatr. 2015; 54: 236-243
        • Hargreaves AL
        • Nowak G
        • Frew P
        • et al.
        Adherence to timely vaccinations in the United States.
        Pediatrics. 2020; 145e20190783
        • Nadeau JA
        • Bednarczyk RA
        • Masawi MR
        • et al.
        Vaccinating my way—use of alternative vaccination schedules in New York state.
        J Pediatr. 2015; 166 (e151): 151-156
        • Daley MF
        • Reifler LM
        • Shoup JA
        • et al.
        Temporal trends in undervaccination: a population-based cohort study.
        Am J Prev Med. 2021; 61: 64-72
        • Daley MF
        • Shoup JA
        • Newcomer SR
        • et al.
        Assessing potential confounding and misclassification bias when studying the safety of the childhood immunization schedule.
        Acad Pediatr. 2018; 18: 754-762
        • Shipman SA
        • Lan J,
        • Chang C-h.
        • et al.
        Geographic maldistribution of primary care for children.
        Pediatrics. 2011; 127: 19-27
        • Wagner NM
        • Dempsey AF
        • Narwaney KJ
        • et al.
        Addressing logistical barriers to childhood vaccination using an automated reminder system and online resource intervention: a randomized controlled trial.
        Vaccine. 2021; 39: 3983-3990
        • Grant R
        • Gracy D
        • Goldsmith G
        • et al.
        Transportation barriers to child health care access remain after health reform.
        JAMA Pediatr. 2014; 168: 385-386
        • Vann JCJ
        • Jacobson RM
        • Coyne-Beasley T
        • et al.
        Patient reminder and recall interventions to improve immunization rates.
        Cochrane Database Syst Rev. 2018; 1CD003941
        • Stokley S
        • Maurice E
        • Smith PJ
        • et al.
        Evaluation of invalid vaccine doses.
        Am J Prev Med. 2004; 26: 34-40
        • Luman ET
        • Barker LE
        • McCauley MM
        • et al.
        Timeliness of childhood immunizations: a state-specific analysis.
        Am J Public Health. 2005; 95: 1367-1374
        • Kurosky SK
        • Davis KL
        • Krishnarajah G.
        Completion and compliance of childhood vaccinations in the United States.
        Vaccine. 2016; 34: 387-394
        • Zell ER
        • Ezzati-Rice TM
        • Battaglia MP
        • et al.
        National Immunization Survey: the methodology of a vaccination surveillance system.
        Public Health Rep. 2000; 115: 65
        • U.S. Department of Health and Human Services (DHHS). National Center for Immunization and Respiratory Diseases
        National Immunization Survey-Child: A User's Guide for the 2019 Public-Use Data File.
        Centers for Disease Control and Prevention, Atlanta, GA2020 (Available at:) (Accessed June 12, 2022)
        • Wolter KM
        • Smith PJ
        • Khare M
        • et al.
        Statistical methodology of the National Immunization Survey, 2005–2014.
        Series 1, Program and Collection Procedures; no. 61. National Center for Health Statistics, Vital and Health Statistics, 2017 (Available at) (Accessed June 12, 2022)
        • Smith PJ
        • Simpson D
        • Battaglia MP
        • et al.
        Split sampling design for topical modules in the National Immunization Survey.
        in: Proceedings of the American Statistical Association Survey Research Methods Section. 2000 (Available at) (Accessed June 12, 2022)
        • Gilkey MB
        • McRee A-L
        • Magnus BE
        • et al.
        Vaccination confidence and parental refusal/delay of early childhood vaccines.
        PloS One. 2016; 11e0159087
        • Scharf LG
        • Coyle R
        • Adeniyi K
        • et al.
        Current challenges and future possibilities for immunization information systems.
        Acad Pediatr. 2021; 21: S57-S64
      1. Centers for Disease Control and Prevention. Immunization information systems annual report data participation rates and maps. 2020. Available at: https://www.cdc.gov/vaccines/programs/iis/annual-report-iisar/rates-maps-table.html. Accessed June 12, 2022.

        • McNeil MM
        • Gee J
        • Weintraub ES
        • et al.
        The Vaccine Safety Datalink: successes and challenges monitoring vaccine safety.
        Vaccine. 2014; 32: 5390-5398
        • Hambidge SJ
        • Ross C
        • Shoup JA
        • et al.
        Integration of data from a safety net health care system into the Vaccine Safety Datalink.
        Vaccine. 2017; 35: 1329-1334
        • Murthy N
        • Rodgers L
        • Pabst L
        • et al.
        Progress in childhood vaccination data in immunization information systems—United States, 2013–2016.
        MMWR Morb Mortal Wkly Rep. 2017; 66: 1178
        • Cataldi JR
        • Kerns ME
        • O'Leary ST
        Evidence-based strategies to increase vaccination uptake: a review.
        Curr Opin Pediatr. 2020; 32: 151-159
        • Lieu TA
        • Ray GT
        • Klein NP
        • et al.
        Geographic clusters in underimmunization and vaccine refusal.
        Pediatrics. 2015; 135: 280-289
        • Newcomer SR
        • Freeman RE
        • Graham J
        • et al.
        Spatial analyses of undervaccination patterns in early childhood in Montana.
        in: Abstract. American Immunization Registry Association 2021 Annual Meeting; August 3, Portland, OR2021
        • Mbaeyi S
        • Cohn A
        • Messonnier N.
        A call to action: strengthening vaccine confidence in the United States.
        Pediatrics. 2020; 145e20200390
        • Wagner AL
        • Eccleston AM
        • Potter RC
        • et al.
        Vaccination timeliness at age 24 months in Michigan children born 2006–2010.
        Am J Prev Med. 2018; 54: 96-102
        • Robison SG
        • Kurosky SK
        • Young CM
        • et al.
        Immunization milestones: a more comprehensive picture of age-appropriate vaccination.
        J Biomed Biotechnol. 2010; 2010916525
        • Santoli JM
        • SziIagyi PG
        • Rodewald LE.
        Barriers to immunization and missed opportunities.
        Pediatr Ann. 1998; 27: 366-374
        • Smith PJ
        • Lindley MC
        • Rodewald LE.
        Vaccination coverage among US children aged 19–35 months entitled by the Vaccines for Children program, 2009.
        Public Health Rep. 2011; 126: 109-123
        • Centers for Disease Control and Prevention
        Retrospective assessment of vaccination coverage among school-aged children–selected US cities, 1991.
        MMWR Morb Mortal Wkly Rep. 1992; 41: 103-107
        • Whitney CG
        • Zhou F
        • Singleton J
        • et al.
        Benefits from immunization during the Vaccines for Children Program era-United States, 1994-2013.
        MMWR Morb Mortal Wkly Rep. 2014; 63: 352-355
        • Siddiqui M
        • Salmon DA
        • Omer SB.
        Epidemiology of vaccine hesitancy in the United States.
        Hum Vaccin Immunother. 2013; 9: 2643-2648
        • Bednarczyk RA
        • King AR
        • Lahijani A
        • et al.
        Current landscape of nonmedical vaccination exemptions in the United States: impact of policy changes.
        Expert Rev Vaccines. 2019; 18: 175-190
        • Kennedy A
        • LaVail K
        • Nowak G
        • et al.
        Confidence about vaccines in the United States: understanding parents’ perceptions.
        Health Aff. 30. 2011: 1151-1159
        • Brewer NT.
        What works to increase vaccination uptake.
        Acad Pediatr. 2021; 21: S9-S16
        • Opel DJ
        • Heritage J
        • Taylor JA
        • et al.
        The architecture of provider-parent vaccine discussions at health supervision visits.
        Pediatrics. 2013; 132: 1037-1046
        • Glanz JM
        • Wagner NM
        • Narwaney KJ
        • et al.
        Web-based social media intervention to increase vaccine acceptance: a randomized controlled trial.
        Pediatrics. 2017; 140e20171117
        • Hofstetter AM
        • Schaffer S.
        Childhood and adolescent vaccination in alternative settings.
        Acad Pediatr. 2021; 21: S50-S56
        • Mooney SJ
        • Pejaver V.
        Big data in public health: terminology, machine learning, and privacy.
        Annu Rev Public Health. 2018; 39: 95-112