Assessing Immunization Coverage Among Children Attending Licensed Child Care Centers, New York City New York City Department of Health and Mental Hygiene (NYC DOHMH) Bureau of Immunization Ayaan Gedi, MPH Sharon Spence, MPH, EdD, CHES Christopher Zimmerman, MD, MPH

New York City Background Population of 8.3 million* Annual birth cohort ~127,000* 238,911 children in child care programs ** Accounts for 37% of all children < 6 years of age *Source: U.S. Census Bureau, Population Division U.S. Census 2008 Population Estimates * * New York City Administration for Children’s Services, June 2008

Two Types of Centers Assessed Home-based centers 4,500 private centers 23,565 children enrolled Maximum of 16 children per site Children aged six weeks to 12 years Commercial centers 1,600 private/public centers 101,000 children enrolled Includes Universal Pre-Kindergarten and Head Start programs Ages of children vary by license type

Child Care Centers NYC Bureau of Child Care (BCC) Provides oversight, licensing and registration Conduct inspections for new/renewal permits Issues violations for non-compliance NYC Bureau of Immunization (BOI) Responsible for monitoring compliance with state immunization law in child care settings Tools used to assess coverage An annual mandated state survey Limited audits conducted at centers BCC Permit requirements include minimum standards for health examinations and immunizations for the staff and children. inspectors are unannounced. Violations cited during an inspection must be corrected either immediately or between two and four weeks, depending on the type of violation. A child care service cannot obtain a new or renewed permit until all violations have been corrected. The Bureau assigns an Early Childhood Education Consultant to each child care service to assist with with issues or concerns that may arise during these inspections.

New York State (NYS) Public Health Law (PHL) §2164 Defines immunization requirements for schools and child care programs Requires age-appropriate immunizations for children in child care including: 4 DTaP,3 Polio,1MMR,3 HepB,3 Hib,1 Var ,4 PCV* (4:3:1:3:3:1:4) Requires child care programs to submit an annual self-reported immunization coverage survey to the state Required immunization for children in Day dare and pre-schools include: PCV for children born on or after 1/1/2008 Forgiven at age-appropriate times and intervals Additionally all preschool programs are Pre-school defined as any private or public child care centers which include: Nurseries Head Start, UPK Daycares, Group family child cares (GFC) - Licensed home-based centers *Requirement starting 2006

Pre-school Age Immunization Coverage in NYC 2009 NIS coverage for the 4:3:1:3:3:1 series among children 19-35 months in NYC was 74.2% ±6.8* NYC BOI has been exploring ways to improve coverage among pre-school age children *2009 National Immunization Survey, CDC

Previous Analysis of Pre-school Age Coverage Assess geographic differences in coverage Identify neighborhoods for targeted outreach Used NYC Department of Education immunization data Assessed students entering kindergarten during the 2009-2010 SY Retrospectively determined their DTaP4 coverage at 2 years of age In 2010 last year the NYC BOI conducted a geographic analysis of to identify low coverage areas. The goal of assessment was to identity and target neighborhoods for assessment. To identify areas with the highest number of children not up-to-date, coverage was weighted by number of children born in each zip code in 2008 using CIR birth record data. *Immunization data from Automate the Schools, a computerized system maintained by the NYC Department of Education

Identified 10 zip codes with highest number of children missing DTaP4 6 in Brooklyn 4 in Bronx Bronx Zip codes with highest number of children missing DTap4

Goal Assess immunization coverage of children attending licensed child care centers located in 10 targeted zip codes To determine whether enhanced enforcement of state immunization requirements in child care settings can be used to improve vaccination coverage among pre-school children

Methods Obtained list from BCC for centers located in the targeted zip codes Excluded centers that: Did not respond to NYS survey during the 2009-2010 SY Had only one child attending Visited sites during summer and fall 2010 Collected all immunization records on file For home-based centers we knew that there were many sites that did not report children or just had one child. We also knew from experience that sites that report at least 2 children generally enroll more children during the course of the year. So we included in the study centers that reported and had 2 or more children.

Methods Entered data into CoCASA* v.5.1 Searched NYC’s Immunization Information System (IIS), the Citywide Immunization Registry (CIR)** Missing records/doses Invalid doses Used CoCASA to calculate up-to-date (UTD) status Only valid doses used for analysis PCV coverage not assessed The CIR was which is populations based immunization registry PCV Born on or after 1/1/08 4 doses by 15 months of age (verbalize it) *Comprehensive Clinic Assessment Software Application (CDC) ** The CIR is a mature population based immunization registry

Analysis Evaluated age-appropriate UTD coverage at the time of assessment Assessed 4:3:1:3:3:1 for those19-35 months of age Retrospective coverage for two vaccine series at specific age milestones 3:3:1:3:3:1 at 13 months for those >13 months 4:3:1:3:3:1 at 19, 24 & 35 months Assess to compliance with state laws Compare with NIS Timeliness of vaccination. Assessed retrospective retrospectively. So for all children assessed 13 months and older know how well immunized children were at 13. For all children in these respective age groups and older. Compare to our previous analysis

Results

Commercial Centers Home-based Centers 613 99 94 397 Visited 155 120 Excluded Excluded 613 sites identified 216 Not responded NYS survey 99 sites identified 5 closed/moved 94 Visited 397 Responded to NYS survey 242 <2 children 155 w/>2 children 35 closed/moved 120 Visited

Average # children/site Summary of Centers 214 centers visited 7,751 children <6 years of age identified Type of centers Total centers visited Children # (%) Average # children/site Home-based 120 956 (12%) 8 (range 4-12) Commercial 94 6,795 (88%) 92 (range 38-230)

Age Distribution of Children Assessed Median age= 37 months (range=2-71 months) Age Group # (%) 0-12 months 71 (1) 13-19 months 114(1) 20-23 months 92 (1) 24-35 months 1,369 (18) 36-71 months (3-<6 yrs) 6,105 (79) Narrative: 3% of children identified were less than 24 months of age. 18% of the children were between 2-3 years of age and 79% of children in child care were between 3 yrs and 5 yrs.

UTD Status at Time of Assessment (n=7,751) Received immunization by assessment date 86% (6,642) Of those NOT UTD and eligible to receive a vaccination on their last visit 11%(770) Need 1 dose 85% (657) Need 2 doses 1% (83) Needed 3+ doses <1%(30) 86% pf children of children assessed were UTD for age appropriate vaccines at time of assessment. Of the 11% of the were eligible but not UTD, 85% needed just one additional dose to become UTD UTD for age-appropriate for DTaP, Polio, MMR, HepB, Hib, Var

UTD Status at Time of Assessment by Type of Center UTD for age-appropriate for DTaP, Polio, MMR, HepB, Hib, Var

Single Antigen Coverage of Children 19-35 months of age (n=1,102) We also looked at the UTD of children who were 19-35 months of age. For the this age cohort, the expectation is that they would have completed all due recommended vaccines. For 431331, 79 % of children in this cohort has completed the series. When we compare to NIS data you can see that the covergae is slighly higher but when you account for the confidence interval the difference disappreas. By Antegin, you can see that the lowest coverage is for 4th Dtap and 3rd HepB.

Timeliness of Vaccination Retrospective UTD Status at Specific Age Milestones 3:3:1:3:3:1 4:3:1:3:3:1

Summary of Findings Majority of children were 3 yrs and older 14% of all children assessed were not in compliance with immunization requirements at the time of assessment Of these, the majority were just one dose away from being UTD Delays in completing vaccine series Coverage increased at 24-35 months of age which is when children appear to be entering day care in the targeted areas Coverage was lower in home-based centers Each bullet point what we thought and what we got

Challenges/Limitations Specific challenges with home-based centers Numerous centers More resources required for assessments Fewer number of children enrolled Incomplete immunization records on site Necessary to conduct CIR (IIS) look-ups Data was manually entered into CoCASA Time consuming effort

Conclusions Day care immunization requirements are important to ensure children are UTD Increased compliance activities are needed Commercial centers have the most children and are the most efficient place to target activities Challenges in conducting assessments in home-based centers where coverage is lower

Next Steps Coordinate with BCC to identify ways to better enforce immunization requirements in licensed child care centers Develop better monitoring tools to assess coverage Examine the role of using the CIR (IIS) for compliance activities

Acknowledgements Bureau of Immunization Bureau of Child Care Program Support Staff Grecia Caines, PHA Mirleine Joseph, PHA Emily Le, PHA Osayuki Oshodin, PHA Jane Tubridy, SPHA Nancy Villanueva, PHA Sharon Spence, PHE Betty Sanchez, PAA Medical Director Christopher Zimmerman, MD, MPH Bureau of Child Care Ann Nazitto, HSM