Volume 17, No.1, March 2007

Childhood Immunization

Contributors:
Debra Gayer, Ph.D. Professor MU Sinclair School of Nursing
Tanna L. Klein, Research Associate MU Extension, Office of Social & Economic Data Analysis

Vaccine preventable diseases are rare, but they do occur. The consequences of vaccine preventable childhood diseases can be quite serious and include liver damage, hearing loss, blindness, coma and death. Childhood immunization rates are fairly high for Missouri yet approximately 6 to 27 percent are not adequately immunized against certain diseases. Childhood immunizations are safe with only minimal side effects of pain, redness and swelling at the injection site, compared to the horrible consequences of the diseases themselves.

Importance
Diseases that once spread quickly and killed thousands are now largely controlled by vaccines. Vaccines are given early in life because many vaccine-preventable diseases are more common and more deadly among infants and small children. Additionally, childhood immunization is an important step in maintaining high vaccination levels, which prevent outbreaks of such diseases. It is unlikely that an individual who is immune to a disease will transmit it to someone else. In this way, vaccination protects not only the child receiving the vaccine, but also those in the child's community. For this reason, most schools require that children be fully immunized when enrolling. Protecting children against severe illnesses also results in positive outcomes other than improved physical health, including the ability to attend school more regularly and the absence of increased family stress.

Because children are highly susceptible to disease, the Centers for Disease Control and Prevention (CDC) recommends vaccinating children against most vaccine-preventable diseases by the time they are two years old. The CDC's immunization schedule for children recommends four doses of the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine, three or more doses of polio vaccine, one or more doses of the measles-mumps-rubella (MMR) vaccine and varicella (chickenpox) vaccine, three or more doses of the Haemophilus influenzae type b (Hib) vaccine and the hepatitis B vaccine. The DTaP, polio, MMR, and Hib vaccines are collectively referred to as the combination series or 4:3:1:3 vaccine. Since 2002, the CDC has tracked a new combination series that includes all of these vaccines (called the 4:3:1:3:3:1 series).

Definitions and importance by vaccine
DTaP – includes vaccines against diphtheria, tetanus and acellular pertussis (whooping cough). This vaccine is given as a series of four shots before the age of two: at 2 months, 4 months, 6 months, and 15 to 18 months. It is also given before entry to kindergarten, 4-6 years of age. It may be administered alone or in a combination “Pediarix” (includes vaccines diphtheria, tetanus, pertussis, hepatitis B virus and polio). The combination decreases the number of injections an infant would receive.

Polio (IPV) – inactivated polio vaccine is given to prevent polio. This vaccine is given as a series of three shots before the age of two: at 2 months, 4 months, 6 months to 18 months. It is also given before entry to kindergarten, 4-6 years of age.

Hepatitis B (HepB) is a virus that may cause severe liver disease. The hepatitis B vaccine is given to prevent this virus from affecting our children. It is given as a series of three shots. The first dose is given between birth and 2 months of age. The second dose is given one to two months after the first dose. The third dose is given between 6 months and 18 months of age.

Haemophilus influenzae type b (Hib) is a bacterium that infects the lining of the brain, causing meningitis. This vaccine is given as a series of either three to four shots depending on the brand used: 2 months, 4 months, 6 months* and 12 – 15 months. *(may not be given depending on vaccine brand).

Streptococcus Pneumoniae (Prevnar or pneumococcal conjugate vaccine – PVC ) is indicated for children to prevent the common infections of pneumonia and bacterial meningitis. The routine schedule is 2 months, 4 months, 6 months, and 12 to 15 months of age.

Measles, Mumps and Rubella (MMR) Vaccine
This vaccine contains a combination of vaccines called MMR (measles, mumps and rubella, also known as German measles). MMR is given as a series of two doses at 12 to 15 months of age and at 4 to 6 years of age.

Chicken Pox (Varicella) and MMR (ProQuad) is the combination of both. It is given at 12 to 15 month of age and again at 4 to 6 years of age. It is fine to use with children who have egg allergies.

Hepatitis A is a virus and its most common mode of transmission is person-to-person resulting from the fecal-oral route of contamination. It is an acute self-limiting illness associated with fever, malaise, and jaundice. Hepatitis A vaccine is now recommended for children at least one year of age. The second booster is recommended six to 12 months after the first.

Combined Series (4:3:1:3) Vaccine- includes 4 or more doses of diphtheria and tetanus toxoids and the pertussis vaccine (DTP), 3 or more doses of an oral polio vaccine, 1 or more doses of a measles-containing vaccine, and 3 or more doses of Haemophilus influenzae type b vaccine (Hib).

Combined Series (4:3:1:3:3:1) Vaccine- includes 4 or more doses of diphtheria, tetanus, and pertussis vaccine (DTP), 3 or more doses of polio vaccine, 1 or more doses of a measles-containing vaccine, 3 or more doses of Haemophilus influenzae type b vaccine (Hib), three or more doses of hepatitis B vaccine (HepB), and one or more doses of varicella.

Differences by Type of Immunization
In 2005, the immunization rates in Missouri lagged behind both those of the nation and the neighboring states of Iowa, Illinois, Nebraska and Tennessee (see Map 1) . Rates for MMR, polio, hepatitis B and Hib vaccines each met or exceeded 90 percent, the Healthy People 2010 target levels. However, only 85 percent – 86 percent nationally – had received the DTP vaccine and 88 percent had received the chickenpox vaccine (see Table 1).

Challenges for Immunizing Missouri’s Children
Despite 27 percent of Missouri’s children not having the recommended immunizations by their second birthday, there are several challenges for improvement. One is availability of the vaccines for ALL Missouri children. For the primary care physician, providing the full gamut of vaccines for young children is a very expensive undertaking for the private paying patient. It requires purchasing a set amount depending on the vaccine and payment upfront. However, for the children on the Vaccine for Children’s (VFC) program, there is no cost to the primary care physician – it is just ordered from the State’s VFC’s program office. So the challenge comes for families when the primary care physician chooses not to carry certain immunizations, as illustrated in a case example:

A Missouri family who had insurance was able to immunize their 2-month old with Pediarix (DTaP, HepB, and IPV) and HiB. However, they wanted their child to have Prevnar and RotaTeq. The mother was an Emergency Room nurse and feared she might bring the Rota virus (a virus that infects the lining of the intestines) home to her infant and wanted him immunized. The primary care practice where she took her child was out of Prevnar and was not going to carry RotaTeq. In the same practice children on Medicaid were able to receive RotaTeq. This mother was told to go to the local health department to get these immunizations for her infant. She was able to get the Prevnar for $78. However, again she was told that Rotateq was only available for children on Medicaid. Since this mother was resourceful, she was able to get the immunizations she wanted for her infant by going to an Illinois county health department. Her quote was “The best part was, they didn't care that I lived in Missouri! In Missouri I had to be a resident of the county I was talking to! I paid $10 a vaccine and got all that I wanted…” She is having all of her infant’s shots done at the Illinois health department rather than the clinic. This health department in Illinois also gives families a computer printout showing every immunization to date. After hearing this family’s story and looking at Missouri’s immunization rate, it is understandable why the Prevnar rates are only 55 percent.

A second challenge is developing a user-friendly system for recording and providing documentation for Missouri children’s immunization status. In a web-based society having easy access to a child’s immunization status is of great importance. Maintaining an up-to-date immunization record is a challenge if a family moves or receives their child’s vaccines from different providers. This may result in a child having to be revaccinated if the series is viewed as incomplete when beginning school. Currently, children who are receiving their immunization through the local health departments are being recorded consistently via a program called MOSIAC that could be accessed from another health department.

A third challenge for some small private offices in offering vaccines for children on the VFC program (children on Medicaid) are the new VFC recommendations that came about January 2007. The new recommendations require having a dually controlled refrigerator and freezer, specific approved thermometers for both the refrigerator and freezer and an alarm system and plan for impending bad weather. These requirements are the new best practices in the storage and delivery of these very expensive and sensitive vaccines. However, some private practice offices may not have the space or resources to meet these new requirements and choose not to administer vaccines to this population of children as a result of the new requirements.

Concluding Remarks
The goal of routine immunization of our children is protecting them from preventable illnesses and this goal has made a significant impact on childhood diseases in the United States. However, we still have not attained our target goal set by Healthy People 2010 of 90 percent. In Missouri we are at 73 percent for the 4:3:1:3:3:1 series which is considerably less than the 95 percent required to achieve “community immunity”. This is of concern as immunizations protect the public as well as the child who is immunized.

So what are some recommendations to improve our status in Missouri with regard to immunizations?

• Adhere as much as possible to the schedule of immunizations.
• Support development and implementation of a statewide immunization registry that is user- friendly.
• Advocate for government sponsored programs that guarantee supplies of vaccines for all children.
• Use current multi-antigen and combination vaccines to decrease the “poke” effect.
• Promote effective parent and provider education about the benefits of vaccination.
• Discourage sensationalism by the media of adverse effects of vaccines.

Map 1

Vaccine Information Resources:

The 2007 Immunization schedule: http://www.cdc.gov/nip/recs/child-schedule.htm

Centers for Disease Control and Prevention, National Immunization Program: http://www.cdc.gov/nip

Childhood Immunization Support Program: www.cispimmunize.org

Child Trends Databank: http://www.childtrendsdatabank.org/indicators/17Immunization.cfm

Department of Health and Human Services, Vaccine Adverse Event Reporting System: http://www.vaers.hhs.gov

Health People 2010: http://www.healthypeople.gov/Document/HTML/Volume1/14Immunization.htm

See the 2006 Missouri Kids Count Data Book for the most recent reliable county-level data: http://oseda.missouri.edu/kidscount

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