Angel Rivera, MD (Puerto Rico Immunization Program) Childhood Vaccination Coverage and Household Telephone Service in Puerto Rico Jennifer Stanley, MPH candidate (Emory, CDC), Ranee Seither, MPH (CDC), Angel Rivera, MD (Puerto Rico Immunization Program)

Objectives Assess vaccination coverage in 19–35 month-olds in Puerto Rico Assess feasibility of inclusion of Puerto Rico in the NIS by examining vaccination coverage in 19–35 month-olds by type of phone service

Source: CIA World Fact Book

Puerto Rico Census 2008 population estimate - 3.9 M 9 Health Districts Eligible for Government Health Insurance Program (GHIP): 70% Receive VFC and 317 funding Almost all children vaccinated at public health clinics

Immunization Assessment in the States National Immunization Survey Telephone survey of all 50 states Children aged 19–35 months Provider-reported vaccination dates Sampling frame for other CDC surveys

Puerto Rico Immunization Survey Local annual birth certificate based survey Sample of children 35 months old drawn annually from birth certificates Very few lost to follow-up Estimates by 9 regions Unweighted overall estimate for Puerto Rico

Household Immunization Survey 2006 Collaboration with University of Puerto Rico and Puerto Rico Immunization Program Multistage cluster survey Systematic random sample of households from 60 clusters Interviews conducted for all children 1, 2 or 6 years-old in selected households Consent for review of medical records

Key Variables Date of birth Provider-reported vaccination dates Medical chart and/or immunization registry Telephone service (landline/cell phone) Household income

Methods Weighted analysis Provider-reported vaccination of 315 children 19-35 months old from 286 households Antigen-specific coverage 4:3:1:3:3 series Up-to-date status By type of phone service By household income

Demographics

Provider-Reported Single Antigen and Series Coverage Among 19–35 Month-Olds Puerto Rico, 2006

Provider-Reported Vaccine Series Coverage by Household Telephone Service Among 19–35 Month-Olds Puerto Rico, 2006

Provider-Reported Vaccine Series Coverage by Household Income Among 19–35 Month-Olds Puerto Rico, 2006

Results Lower coverage among children in households with Half of households have no landline No phone in >10% of households 75% of 19-35 month-olds are up-to-date Lower coverage among children in households with Landline telephones Higher income

Barrier to Immunizing Higher Income Children: 2003 Vaccine Storage Law Requires providers to apply for certification to store vaccines – expensive and slow process Private providers stopped administering vaccines Special vaccination days and new public health facilities to serve insured children In 2007, drop in 317 funds used for these special activities

Limitations Missing data from four of the 60 clusters Unable to determine eligibility and refusal rates No access to some gated communities and apartment buildings – may overestimate coverage Possible incomplete documentation in the medical record Data from 2006

Conclusions DTaP, Hib, Varicella, <90% 4:3:1:3:3 – 75% 4:3:1:3:3 – 75% Lower vaccination coverage in higher income, landline households consistent with observations following the new law Likely overestimated coverage due to inability to reach some higher income households Current coverage possibly even lower

Recommendations To increase coverage… Reduce barriers to private providers’ storage and administration of vaccines To improve local assessment capacity… Strengthen the immunization registry A record for every child A record of every vaccine administered Adjust the annual birth certificate survey methodology for weighted estimates

Next Steps Complete analyses of the data Compare coverage of 6 year-olds at 35 months to 19–35 month-olds (before & after the 2003 law) Repeat household survey of Puerto Rico Telephone survey problematic due to low landline coverage Need greater access to affluent households Increase data quality & program relevance

Thank You CDC Puerto Rico Immunization Program Elizabeth Luman Gabriel Anaya Anne Lutz Mayra Lacén Natalie Darling Mark Freedman Edith Gary James Singleton Abigail Shefer Emory University Saad B. Omer Puerto Rico Immunization Program Veronica Rodríguez Iris Cardona Madelyn del Toro Miriam Gonzalez Manuel Vargas University of Puerto Rico Gilberto Ramos All of the interviewers and the respondents