Impact of Outreach Activities on Childhood Immunization Coverage in Philadelphia, PA Philadelphia Department of Public Health Abbey Mahady, Andrew Chilkatowsky, Michael Eberhart, Bruce Barlow National Immunization Program Maureen Kolasa, Yuan Kong, Katie Endress, Lindsay Newcomb

Background Many infants don’t receive vaccinations on time during their first year. Increased susceptibility to disease Impacts coverage rates at 19-35 months Outreach targets children at 9 months, not up-to-date (NUTD) for age-appropriate immunizations according to the KIDS Immunization Registry.

Setting 20,000 - annual birth cohort in Philadelphia 98.7% in registry 82% of children <1 are VFC eligible Philadelphia Department Public Health (PDPH) contracts with two community-based outreach organizations: Supportive Child Adult Network (SCAN) Council of Spanish-Speaking Organizations, Inc. (CONCILIO) 65% of Philadelphia children live in areas served by outreach organizations.

Outreach Methods Every month, PDPH uses the KIDS Immunization Registry to identify children, 9 months, NUTD, and living in an “outreachable zipcode”. Outreachable zipcodes: Lower socio-economic status High density of minority populations

Outreach Interventions Outreach workers Check KIDS Registry for updates. Contact last immunization provider listed in registry for child’s history. Enter missing immunizations into KIDS Registry. If the child is UTD, the case is closed.

Outreach Interventions For children still NUTD Outreach worker contacts parents by telephone and/or home visit. Encourages vaccination at the medical home. Makes the appointment. Assists with transportation, if needed. Outreach activities include locating a new or alternate address.

Objectives Determine the impact of outreach on increasing immunization coverage by 13 and 19 months of age. Assess the impact of outreach across different racial and ethnic groups. Assess the impact by outreach organization.

Up-to-Date Definitions UTD 9 months: 3 DTaP, 2 Polio, 2 Hib, 2 HepB UTD 13 months: UTD 19 months: 4 DTaP, 3 Polio, 3 Hib, 2 HepB, 1 MMR, 1 Varicella 2 HepB – accounts for missing birth dose

Inclusion Criteria Children born April 1, 2003 - Feb 28, 2004 All 19 months by Sept 30, 2005 Received outreach from SCAN\Concilio =6854 Removed from analysis because no outreach completed = 918 Moved from Philadelphia (85) Died (0) Unable to locate (833)

Children referred to outreach because NUTD at 9 months according to Registry N = 5936 Received additional outreach through another PDPH initiative N=1444 (24%) UTD at 9 months after chart review N = 1458 (25%) NUTD at 9 months N = 3034 (51%) Chart reviews: Concilio 871 SCAN 587 Outreach done: Concilio 2,131 SCAN 903

Race of Outreached Children White Black API O\U Total Concilio 215 16% 757 56% 222 17% 152 11% 1346 64% SCAN 60 8% 642 84% 42 6% 16 2% 760 36% 275 13% 1399 66% 264 168 2106 API = Asian\ Pacific Islander; O\U = Other\Unknown

Ethnicity of Outreached Children Hispanic Non-Hispanic Unknown Total Concilio 222 21% 664 64% 152 15% 1038 69% SCAN 23 5% 419 88% 32 7% 474 31% 245 16% 1083 72% 184 12% 1512

2004 CONCILIO SCAN

Black and Hispanic Population Philadelphia 2000

Asian and White Population Philadelphia 2000

Among children NUTD at 9 months, UTD coverage at 13 & 19 months, 86% 35%

Among children NUTD at 9 months, UTD coverage at 13 & 19 months by outreach organization, N = 3034 %

Comparison of NIS Immunization coverage of children 19 months (2004) to Coverage among children receiving outreach Jan 1, 2004 – Sept 30, 2005 at 19 months %

Philadelphia NIS Immunization coverage for 4:3:1:3:3:1 among children 19-35 months in 2004 by Race/Ethnicity %

Among children NUTD at 9 months, UTD coverage at 13 & 19 months by race, N = 2106 % API = Asian\ Pacific Islander; O\U = Other\Unknown

Among children NUTD at 9 months, UTD coverage at 13 & 19 months by ethnicity, N = 1512 %

Conclusions Outreach is effective at bringing NUTD children UTD by 19 months. 86% UTD by 19 months (2609 children) Outreach is effective at bringing NUTD children UTD by 13 months. 35% brought UTD between 9 and 13 months (1062 children) Many others likely needed more than one immunization visit to get them UTD.

Conclusions UTD coverage at 19 months similar among all races\ethnicities. UTD coverage at 13 months lower among API (Asian-Pacific Islanders) than other races\ethnicities. Outreach efforts initiated for children already UTD. 1,458 children (25% of those thought NUTD at 9 months) truly were UTD. Referred to outreach because NUTD in registry (registry data incomplete). Review of charts is helpful to complete registry data.

Recommendations Improve quality of registry data to decrease staff time conducing outreach on UTD children. Provider-based outreach initiative. Prevent immunization delay in the first year to achieve a larger impact at 13 months. Address late starters. Consider initiating recall intervention or outreach at an earlier age.

Recommendations Low coverage among API at 13 months suggests need to engage API population. Seek opportunities to collaborate with other city agencies to locate children. Transient children may be more likely to be NUTD.