Racial/Ethnic Disparities in Preschool Immunization, United States, Am J Public Health June 2004; 94:

Objective To examine current racial/ethnic differences in immunization coverage among US preschool children

Table 1: Coverage with the 4:3:1:3:3* series by race/ethnicity YearCoverage for non-Hispanic whites(%) (95% confidence limits) Coverage for Hispanics (%) (95% confidence limits) Coverage for non-Hispanic blacks (%) (95% confidence limits) Coverage for Asians (%) (95% confidence limits) ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 4.7 * 4:3:1:3:3 series (­> 4 doses of diphtheria and tetanus toxoids and (acellular) pertussis vaccine (DTP/DTaP) and > 3 doses of poliovirus vaccine (IPV/OPV) and > 1 dose of measles-containing vaccine (MCV) and > 3 doses of Haemophilus influenzae type b (Hib) vaccine and > 3 doses of hepatitis B (HepB) vaccine)

Figure 1. 4:3:1:3:3 coverage* for non-Hispanic whites minus that of non-Hispanic blacks Dashed lines are 95% confidence limits for the regression line. (β=1.14; 95% confidence limits ; p-value = 0.01); gap widened an average 1.1% each year * 4:3:1:3:3 series (>= 4 doses of diphtheria and tetanus toxoids and (acellular) pertussis vaccine (DTP/DTaP) and >= 3 doses of poliovirus vaccine (IPV/OPV) and >= 1 dose of measles-containing vaccine (MCV) and >= 3 doses of Haemophilus influenzae type b (Hib) vaccine and >= 3 doses of hepatitis B (HepB) vaccine)

Figure 2. 4:3:1:3:3 coverage* for non-Hispanic whites minus that of Hispanics Dashed lines are 95% confidence limits for the regression line. (β=0.59; 95% confidence limits ; p-value = 0.14); gap widened an average 0.5% each year * 4:3:1:3:3 series (>= 4 doses of diphtheria and tetanus toxoids and (acellular) pertussis vaccine (DTP/DTaP) and >= 3 doses of poliovirus vaccine (IPV/OPV) and >= 1 dose of measles-containing vaccine (MCV) and >= 3 doses of Haemophilus influenzae type b (Hib) vaccine and >= 3 doses of hepatitis B (HepB) vaccine)

Figure 3. 4:3:1:3:3 coverage* for non-Hispanic whites minus that of Asians Dashed lines are 95% confidence limits for the regression line. ( β=-0.80; 95% confidence limits ; p-value = 0.06); gap narrowed an average 0.8% each year * 4:3:1:3:3 series (>= 4 doses of diphtheria and tetanus toxoids and (acellular) pertussis vaccine (DTP/DTaP) and >= 3 doses of poliovirus vaccine (IPV/OPV) and >= 1 dose of measles-containing vaccine (MCV) and >= 3 doses of Haemophilus influenzae type b (Hib) vaccine and >= 3 doses of hepatitis B (HepB) vaccine)

Summary National childhood immunization coverage levels have increased substantially over the past decade Disparities by race and ethnicity, which were relatively small during the mid-90’s, have been increasing, especially between white and black children

Potential reasons for growing disparity -- 1 Limited minority access to primary care White children see physicians at twice the rate of minority children Black and Hispanic children more frequently seek care in emergency rooms and hospital outpatient clinics Differences in quality of care Physicians who treated more black patients were less likely to be board certified and less connected with subspecialists

Potential reasons for growing disparity -- 2 Increase guardedness among minority parents towards vaccine safety or health care system Misconceptions about risks/benefits of vaccination –NIS data module found minority parents more likely to believe children will become ill after vaccination Diminished effectiveness of known interventions –Reminder-recall dependent on stable provider-patient relationships

NIP Childhood Disparities Workgroup Formed August 2004 Objective: To address growth in racial and ethnic disparities in immunization coverage among US preschool children found in National Immunization Survey (NIS). Multidisciplinary group –Epidemiologists –Behavioral scientists –Statisticians –Health communications specialists

Goals Develop a plan to increase NIP’s understanding of racial\ethnic immunization disparities Identify or develop interventions that can be implemented or tested for effectiveness in addressing racial\ethnic immunization disparities.

Objectives, I Near term –Identify and review existing information on racial/ethnic disparities in immunization, including strategies that have been effective in reducing racial/ethnic disparities –Identify gaps in our current understanding about the nature and causes of racial and ethnic disparities –Develop plans to collect new data to address these gaps

Objectives, II Longer term –Develop, implement, and evaluate strategies to reduce or eliminate racial/ethnic disparities in immunization - Continue monitoring through the NIS and other surveillance instruments

2003 NIS - 1 Record high coverage levels nationally for the series and each individual vaccine –Increased coverage for the two newest vaccines (varicella and pneumococcal conjugate vaccines) Continued wide variability among states and urban areas

2003 NIS - 2 A number of factors continue to be associated with underimmunization –Non-Hispanic black race/ethnicity –Low maternal education –Low household income –Young mothers –Residence in a central city Trends in disparities found in NIS continue with 2003 NIS data