1. 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)

2. 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

3. Source: CIA World Fact Book

4. 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

5. 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

6. 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

7. 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

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

9. Methods Weighted analysis
Provider-reported vaccination of 315 children 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

10. Demographics

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

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

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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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