Vaccination Coverage by Race/Ethnicity and Poverty Level Among Children Aged 19-35 Months -- United States, 1996

The Childhood Immunization Initiative (CII), implemented in 1993, is an intensive program to increase vaccination coverage among preschool-aged children and to reduce or eliminate vaccine-preventable diseases (1). In 1996, national coverage goals were achieved for 2-year-old children for the most critical doses of each routinely recommended vaccine (2). Disparities in vaccination coverage have been documented previously among different racial/ethnic groups. This report presents findings from CDC's National Immunization Survey (NIS), which document progress toward achieving the 1996 CII vaccination coverage goals * by racial/ethnic group ** and by level of poverty. The findings indicate that, for each of five racial/ethnic groups, most of the national CII vaccination coverage goals were met and that, based on poverty level, all the goals were met for children living at or above the poverty level, and two of the five goals were met for children living below the poverty level.

The NIS was implemented in 1994 and measures vaccination coverage among children aged 19-35 months (3). Race/ethnicity and poverty-related information are reported by the parent or caregiver through a random-digit-dialed telephone survey conducted in English, Spanish, and other languages. The health-care providers of the children in the survey are contacted to verify and/or complete vaccination information. An adjustment is made for households without telephones. Poverty level (i.e., above, at, or below the poverty level) is based on U.S. Bureau of the Census thresholds (4) for respondent-reported family income, household size, and number of children aged less than 18 years living in the household. In 1996, interviews were completed with the parents and caregivers of 33,305 children aged 19-35 months (median age: 27 months). Of these children, 20,839 (63%) were non-Hispanic white; 5891 (18%), non-Hispanic black; 4852 (15%), Hispanic; 1172 (4%), Asian/Pacific Islander; 462 (1%), American Indian/Alaskan Native; and 89 (less than 1%), other races. Coverage by Race/Ethnicity

Most of the CII vaccination coverage goals for 1996 were met for individual vaccines for children in each of the five racial/ethnic groups (Table_1). The goals of 90% coverage with three or more doses of diphtheria and tetanus toxoids and pertussis vaccine (DTP) and of 70% coverage with three or more doses of hepatitis B vaccine were met or exceeded for all five groups. The goal of 90% coverage with three or more doses of poliovirus vaccine was met or exceeded in all groups except Hispanics (89%; 95% confidence interval {CI}=plus or minus 1.2%) and American Indians/Alaskan Natives (89%; 95% CI=plus or minus 3.8%). The goal of 90% coverage with three or more doses of Haemophilus influenzae type b vaccine (Hib) was met or exceeded for all groups except Hispanics (89%; 95% CI=plus or minus 1.2%). The goal of 90% coverage with one or more doses of measles- containing vaccine (MCV) was exceeded for non-Hispanic whites and Asians/Pacific Islanders; coverage levels for non-Hispanic blacks, Hispanics, and American Indians/Alaskan Natives were less than 90% but were within three percentage points of the goal. Coverage levels for all the individual vaccines except hepatitis B vaccine and for both the 4:3:1 and 4:3:1:3 series *** were significantly lower among non-Hispanic blacks and Hispanics than among non-Hispanic whites (Table_1). Coverage by Poverty Level

Of the five 1996 CII coverage goals, three were not met for children living below the poverty level (levels for poliovirus vaccine, Hib, and MCV were 2, 2, and 3 percentage points below their corresponding goals, respectively) (Table_2). In comparison, all 1996 CII coverage goals were met or exceeded for children living at or above the poverty level.

In 1996, coverage levels for all vaccines and series of vaccines were lower among children living below the poverty level than among children living at or above the poverty level (Table_2). For children living below the poverty level, levels ranged from 4 to 11 percentage points lower for individual vaccines than for children at or above the poverty level. For children living below the poverty level, the coverage levels for the 4:3:1 and 4:3:1:3 series were 10 and 11 percentage points lower, respectively. Coverage by Race/Ethnicity and Poverty Level

Among children living below the poverty level, only the goal for hepatitis B was met in all five racial/ethnic groups. The DTP goal was met for all groups except Asians/Pacific Islanders. In general, the goals for poliovirus, Hib, and MCV were not met; however, the poliovirus and Hib goals were met for American Indians/Alaskan Natives, and the MCV goal was met for Asians/Pacific Islanders. In comparison, all goals were met or exceeded for children living at or above the poverty level, except for MCV for Hispanics and poliovirus vaccine and MCV for American Indians/Alaskan Natives.

For individual vaccines and by racial/ethnic group, the vaccination coverage levels of children living below the poverty level ranged from 2 percentage points higher to 13 percentage points lower than for children living at or above the poverty level. Similarly, for both the 4:3:1 and 4:3:1:3 series in individual racial/ethnic groups, the proportion of children who were series-complete was from 1 percentage point higher to 13 percentage points lower for children living below the poverty level (Table_2).

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

Editorial Note

Editorial Note: The NIS is the first national vaccination survey measuring vaccination coverage for five racial/ethnic groups. Data from the NIS presented in this report indicate that the 1996 national CII vaccination coverage goals were met or exceeded for most or all of the targeted vaccines for each of five racial/ethnic groups. However, for children living below the poverty level, vaccination coverage was substantially lower than for those living at or above the poverty level and, in most racial/ethnic groups, three of the five CII goals were not met.

In general, the differences in vaccination coverage with individual vaccines among racial/ethnic groups found in the 1996 NIS (range: 0-6%) are smaller than those reported in earlier surveys. From 1970 to 1985, in the United States Immunization Survey of children aged 1-4 years, differences in individual vaccine coverage between white children and children of other races ranged from seven to 26 percentage points for three or more doses of DTP and poliovirus vaccine and for one or more doses of MCV (5). During 1992-1994, the National Health Interview Survey reported coverage differences between black and white children (aged 19-35 months) of three to 12 percentage points (6). Despite methodologic differences that limit comparisons of findings from the three surveys, it is unlikely that these methodologic differences alone account for the narrowing of the gap in coverage between non-Hispanic white children and children of the other racial/ethnic groups found in the data.

The narrowing of the small differences in coverage for the individual vaccines among the racial/ethnic groups may reflect nationwide efforts to increase vaccination levels, including activities following the resurgence of measles during 1988-1991 and those prompted by the CII since 1993 (1). State and local health departments and community and professional organizations have implemented multifaceted efforts in some major urban areas to improve vaccination levels among racial/ethnic minority populations. Strategies that avoid missed opportunities must be sustained and expanded (e.g., assessment of vaccination at service sites of the Special Supplemental Food Program for Women, Infants, and Children {WIC} {7}, measuring and ranking vaccination coverage levels with feedback and incentives for providers {8}, and reminder and recall). In particular, the WIC program serves approximately 44% of each annual birth cohort in the United States and is the single largest means of making contact with low-income preschool-aged children. Therefore, efforts to expand and strengthen the WIC/immunization linkage should be among the highest priority activities in improving coverage for children living below the poverty level.

The 1996 NIS findings suggest that socioeconomic differences account for a substantial proportion of the racial/ethnic group-specific differences in vaccination coverage. This conclusion is based especially on the similarities in vaccination coverage among children of different racial/ethnic groups living below the poverty level. However, the proportion of children aged less than 5 years living below the poverty level (with corresponding lower levels of coverage) varies widely by race (i.e., 13.8% for whites, 17.5% for Asians/Pacific Islanders, 33.4% for Hispanics, 44.0% for blacks, and 44.4% for American Indians/Eskimos/Aleutians) (9). Some race-specific differences in coverage persisted despite adjusting for poverty: for children living above the poverty level, some vaccine-specific coverage levels differed by racial/ethnic groups, and within the groups, the apparent effect of poverty varied.

The NIS findings described in this report indicate substantial progress toward achieving most of the 1996 CII goals for racial/ethnic groups. Despite this progress, efforts to increase vaccination coverage must be intensified to achieve coverage goals for all children, particularly children of racial/ethnic minority groups living in poverty. In particular, achievement of the year 2000 national health objective of 90% coverage of all U.S. children with the vaccines in the basic vaccination series (10) will require a fully functional vaccine-delivery system and sustained participation of communities, health-care providers, government officials, and private-sector partners (2). The elimination of vaccine-preventable diseases in the United States requires the achievement and maintenance of uniformly high vaccination coverage levels for preschool children in all communities. CDC will continue using the NIS to monitor progress toward meeting national health objectives for the year 2000 by race/ethnicity and by other factors associated with undervaccination.

References

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

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 1997;46:657-64.

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, Public Health Service, CDC, National Immunization Program, 1996.

4. Bureau of the Census. Poverty in the United States, 1996. Washington, DC: US Department of Commerce, Economics and Statistics Administration, Bureau of the Census, 1997. (Current population reports; series P60-198).

5. National Center for Health Statistics. Health, United States, 1988. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1989:80; DHHS publication no. (PHS)89-1232.

6. National Center for Health Statistics. Health, United States, 1995. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1996:163; DHHS publication no. (PHS)96-1232.

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

8. 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.

9. Bureau of the Census. Social and economic characteristics, 1990. Washington, DC: US Department of Commerce, Economics and Statistics Administration, Bureau of the Census, 1993; publication no. CP-2-1.

10. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:122; DHHS publication no. (PHS)91-50212.

* At least 90% coverage for one or more doses of measles-mumps-rubella vaccine and three doses each of diphtheria and tetanus toxoids and pertussis vaccine, oral poliovirus vaccine, and Haemophilus influenzae type b vaccine. For three or more doses of hepatitis B vaccine, the goals were set at 70% by 1996 and 90% by 1998. Children in this survey were born during February 1993-May 1995. 

** Five groups were used: respondents were self-classified as non-Hispanic white, non-Hispanic black, Hispanic, non-Hispanic American Indian/Alaskan Native, and non-Hispanic Asian/Pacific Islander. 

*** The 4:3:1 series is four or more doses of diphtheria and tetanus toxoids and pertussis vaccine/ diphtheria and tetanus toxoids, three or more doses of poliovirus vaccine, and one or more doses of MCV. The 4:3:1:3 series is the 4:3:1 series plus three or more doses of Hib.

TABLE 1. Vaccination coverage levels among children aged 19-35 months, by selected vaccines and race/ethnicity -- United States, National Immunization Survey, 1996 *
====================================================================================================================================================================================================================================
                                                                                                                                Race/Ethnicity +
                                                          --------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                                                                   American
                                                                                                                             Black                                             Indian/Alaskan                Asian/Pacific
                                 Childhood                    National Estimates              White, non-Hispanic        non-Hispanic                Hispanic                       Native                     Islander
                               Immunization               ---------------------------     ----------------------------  ----------------      ----------------------          ----------------        ---------------------------
Vaccine/Dose               Initiative 1996 goal             %             (95% CI &)         %               (95% CI)    %     (95% CI)         %          (95%  CI)             %   (95% CI)            %             (95% CI)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
DTP/DT@
>=3 Doses                           90%                     95             (+/-0.4)         96               (+/-0.3)   93   (+/-0.9)**        93          (+/-0.9)**           93   (+/-3.1)           96             (+/-1.6)
>=4 Doses                           --                      81             (+/-0.7)         83               (+/-0.6)   79   (+/-1.5)**        77          (+/-1.6)**           83   (+/-4.4)           84             (+/-2.8)

Poliovirus
>=3 Doses                           90%                     91             (+/-0.5)         92               (+/-0.5)   90   (+/-1.1)**        89          (+/-1.2)**           89   (+/-3.8)           90             (+/-2.3)

Measles-containing
vaccine (MCV)++
>=1 Doses                           90%                     91             (+/-0.5)         92               (+/-0.5)   89   (+/-1.1)**        88          (+/-1.2)**           87   (+/-4.0)           94             (+/-1.8)

Haemophilus influenzae
type b (Hib)
>=3 Doses                           90%                     92             (+/-0.5)         93               (+/-0.4)   90   (+/-1.1)**        89          (+/-1.2)**           90   (+/-3.6)           92             (+/-2.1)

Hepatitis B
>=3 Doses                           70%                     82             (+/-0.7)         82               (+/-0.6)   82     (+/-1.3)        80            (+/-1.5)           78   (+/-4.8)           84             (+/-2.8)

Combined series
4 DTP/3 Polio/ 1 MCV&&              --                      78             (+/-0.8)         80               (+/-0.7)   76   (+/-1.5)**        73          (+/-1.6)**           81   (+/-4.6)           81             (+/-3.0)
4 DTP/3 Polio/ 1 MCV/3              --                      77             (+/-0.8)         79               (+/-0.7)   74   (+/-1.6)**        71          (+/-1.7)**           80   (+/-4.8)           78             (+/-3.1)
Hib @@
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
*  Children in this survey were born during February 1993-May 1995.
+  Five groups were used: respondents were self-classified as non-Hispanic white, non-Hispanic black, Hispanic, non-Hispanic American Indian/Alaskan Native, and non-Hispanic Asian/ Pacific Islander.
&  Confidence interval.
@  Diphtheria and tetanus toxoids and pertussis vaccine/diphtheria and tetanus toxoids.
** Difference in coverage level compared with non-Hispanic white children is statistically significant at the 0.05 level.
++ Goals are for measles- mumps- rubella vaccine; estimates are for MCV.
&& Four of more doses of diphtheria and tetanus toxoids and pertussis vaccine (DTP), three or more doses of poliovirus vaccine, and one or more doses of MCV.
@@ Four or more doses of DTP, three or more doses of poliovirus vaccine, one or more doses of MCV, and three or more doses of Hib.
====================================================================================================================================================================================================================================

TABLE 2. Vaccination coverage levels among children aged 19-35 months, by selected vaccines, race/ethnicity, * and poverty
level + -- United States, National Immunization Survey, 1996 &
================================================================================================================================================================================================================================
                                                                                                                          Race/Ethnicity and poverty level
                                                      ------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                          National estimates                                                                                                                        American Indian/                       Asian/
                          and poverty level                 White, non-Hispanic               Black, non-Hispanic                    Hispanic                       Alaskan Native                    Pacific Islander
                  ---------------------------------   -------------------------------   -------------------------------   -------------------------------   -------------------------------   --------------------------------
                                         At or                             At or                             At or                             At or                             At or                              At or
                       Below             above            Below            above            Below            above            Below            above            Below            above            Below             above
Vaccine/          ----------------   --------------   --------------   --------------   --------------   --------------   --------------   --------------   --------------   --------------   --------------   ---------------
Dose               %    (95% CI @)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %    (95% CI)    %     (95% CI)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
DTP/DT **
  >=3 Doses       92      (+/-0.9)   96    (+/-0.3)   92    (+/-1.5)   97    (+/-0.4)   91    (+/-1.7)   95    (+/-1.2)   92    (+/-1.7)   94    (+/-1.4)   93    (+/-5.9)   94    (+/-4.1)   87    (+/-6.7)   97     (+/-1.6)
  >=4 Doses       73      (+/-1.4)   84    (+/-0.6)   72    (+/-2.4)   85    (+/-0.7)   75    (+/-2.5)   82    (+/-2.1)   73    (+/-2.8)   79    (+/-2.4)   84    (+/-8.2)   84    (+/-6.0)   77    (+/-8.6)   83     (+/-3.4)

Poliovirus
  >=3 Doses       88      (+/-1.1)   92    (+/-0.5)   88    (+/-1.8)   93    (+/-0.5)   88    (+/-2.0)   92    (+/-1.5)   88    (+/-2.0)   90    (+/-1.8)   90    (+/-6.4)   88    (+/-5.2)   85    (+/-7.1)   90     (+/-2.9)

Measles-
  containing
  vaccine
  (MCV)
  >=1 Doses       87      (+/-1.1)   92    (+/-0.5)   86    (+/-1.9)   93    (+/-0.5)   88    (+/-1.9)   91    (+/-1.6)   88    (+/-2.1)   89    (+/-1.8)   89    (+/-6.7)   87    (+/-5.6)   94    (+/-5.2)   93     (+/-2.4)

Haemophilus
  influenzae
  type b (Hib)
  >=3 Doses       88      (+/-1.1)   93    (+/-0.4)   87    (+/-1.8)   94    (+/-0.5)   87    (+/-2.0)   92    (+/-1.5)   88    (+/-2.0)   90    (+/-1.7)   92    (+/-5.7)   90    (+/-5.0)   85    (+/-7.0)   93     (+/-2.4)

Hepatitis B
  >=3 Doses       78      (+/-1.3)   83    (+/-0.6)   75    (+/-2.2)   83    (+/-0.7)   79    (+/-2.4)   86    (+/-1.9)   79    (+/-2.5)   82    (+/-2.2)   76    (+/-9.1)   80    (+/-6.4)   79    (+/-7.8)   87     (+/-3.2)

Combined
  series
  4 DTP/          71      (+/-1.5)   81    (+/-0.7)   70    (+/-2.4)   82    (+/-0.7)   73    (+/-2.6)   80    (+/-2.2)   70    (+/-2.9)   75    (+/-2.5)   82    (+/-8.5)   81    (+/-6.3)   75    (+/-8.8)   80     (+/-3.7)
    3 Polio/
    1 MCV ++
  4 DTP/          69      (+/-1.5)   80    (+/-0.7)   68    (+/-2.4)   81    (+/-0.8)   70    (+/-2.7)   78    (+/-2.3)   68    (+/-2.9)   74    (+/-2.6)   81    (+/-8.5)   80    (+/-6.4)   73    (+/-8.9)   77     (+/-3.9)
    3 Polio/
    1 MCV/
    3 Hib &&
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
 * Five groups were used: respondents were self-classified as non-Hispanic white, non-Hispanic black, Hispanic, non-Hispanic American Indian/Alaskan Native, and
   non-Hispanic Asian/Pacific Islander.
 + Poverty level is based on family income and household size using Bureau of the Census poverty thresholds for 1996. Children for whom poverty level was not
   determined are excluded from this analysis.
 & Children in this survey were born during February 1993-May 1995.
 @ Confidence interval.
** Diphtheria and tetanus toxoids and pertussis vaccine/ diphtheria and tetanus toxoids.
++ Four or more doses of diphtheria and tetanus toxoids and pertussis vaccine (DTP), three or more doses of poliovirus vaccine, and one or more doses of MCV.
&& Four or more doses of DTP, three or more doses of poliovirus vaccine, one or more doses of MCV, and three or more doses of Hib.
================================================================================================================================================================================================================================

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