GEORGIA IMMUNIZATION STUDY 2008 Final Report Georgia Department of Community Health | Division of Public Health Epidemiology Section | Healthy Behavior Epidemiology Unit Immunization Program Eighteen Public Health Districts Prepared by Carol A. Hoban, MPH, PhD, & Rebecca M. Willis, MHS, Co-Principal Investigators and Co-Project Coordinators Contributors LaTonya M. Thomas, MBA-HCM, Assessment Coordinator Michelle Conner, BSN, MS, MBA, Georgia Immunization Program Di t Acknowledgments The Georgia Department of Community Health, Division of Public Health, Epidemiology Section and the Immunization Program would like to thank the public health representatives that participated in this study for all of their hard work, support and dedication. This study could not have been completed successfully without the cooperation of health district staff throughout Georgia. A profound thank you and sincere appreciation is also given to the private and non-public health providers and the Vaccines for Children providers that participated in this collaborative effort. Their cooperation and assistance throughout the study is greatly appreciated. We would also like to thank the Rollins School of Public Health at Emory University for providing us with the study materials. Their generosity allowed us to continue repeated assessments each year and compare our efforts with theirs. A special note of thanks to Mrs. Michelle Conner, Georgia Immunization Program Director, for her support and leadership during this study. 2008 Executive Summary The 2008 Immunization Study was conducted by the Georgia Department of Community Health, Division of Public Health, Epidemiology Section, Immunization Program and Public Health Districts. However, this study could not have been conducted without the assistance of the private providers, public health providers and the Vaccines for Children providers that contributed in this collaborative effort. Their cooperation and assistance throughout the study is greatly appreciated. The Immunization Study employs a non-experimental retrospective cohort research design to ascertain the immunization coverage rate for children born in the State of Georgia. This study design allows for the calculation of immunization rates for children who turned two in January 2008. Identifying information about the children and their parents was obtained from birth certificates. The Immunization Study found that during 2008 most childhood immunizations (80.6%) were administered in the private sector, while County Health Departments immunized 11.6%, and the sources for 7.8% are unknown. The proportion of children in Georgia who have received all of the recommended vaccinations showed a steady increase from 16% in 1997 to 79% in 2002, a slight decrease in 2003 to 74%, but an increase in 2004 to 81%. The 2005 study results showed another slight decrease in the immunization rate at 77% which remained stable during the 2006 study, increasing slightly to 78% in 2007 and slightly declined to 77.8% in 2008. Acute infection with Hepatitis B causes severe disease in only a small proportion of those infected, but it can lead to chronic infection, cirrhosis, and cancer of the liver. In Georgia in 2008, 94.3% of infants had received two doses of hepatitis B vaccine by 12 months of age, and, at 24 months, 91.7% of children had received the recommended three doses. Vaccines have largely controlled diphtheria, measles, pertussis, and other scourges of the past. In 1923, with a population of less than three million, Georgia recorded 274 deaths from diphtheria, 347 deaths from measles, and 254 deaths from pertussis, while in 2003, just 80 years later, and with a population that has almost tripled, Georgia had no reported cases of tetanus or diphtheria, and just 36 cases of pertussis. In 2008, 85.9% of children 12 months of age were appropriately immunized against diphtheria, tetanus and pertussis, and 77.8% of Georgia's two-year-olds were adequately immunized against ten vaccine-preventable childhood diseases (diphtheria, tetanus, pertussis, hepatitis B, H. influenzae type B, mumps, measles, rubella, polio and varicella). There was considerable variation from district to district in the proportion of twoyear-olds reported to be fully immunized, ranging from 69% in the Clayton County district to 93.1% in the East Metro (Gwinnett) district. Four of the state's public health districts (Dalton, Gainesville, Augusta, and Gwinnett) succeeded in immunizing at least 85% of their two-year-olds against the 10 vaccinepreventable childhood diseases. Only two of the state's public health districts (Fulton and Clayton) had a rate less than 75%. Within Metropolitan Atlanta, the immunization rates varied from 69% in Clayton to 93% in Gwinnett. In Georgia outside Metropolitan Atlanta, the immunization rates ranged from 75% in LaGrange to 91% in the Augusta district. Table of Contents List of Tables ........................................................................................................iii List of Figures ....................................................................................................... x List of Appendices................................................................................................ xi SECTION I: PROJECT OVERVIEW and Introduction .................................................... 1 Project Activity Timeline ............................................................................ 3 SECTION II: METHODOLOGY .................................................................................... 5 Research Design ....................................................................................... 6 Target and Sample Populations ................................................................ 6 Preparation for Data Collection ................................................................ 7 Data Form Development ........................................................................... 7 Data Collection Protocol ............................................................................ 9 Data Entry ............................................................................................... 10 Analysis Plan ...........................................................................................11 SECTION III: RESULTS OF STATEWIDE ANALYSES .................................................... 12 Sampling ................................................................................................. 13 Response Rates ...................................................................................... 15 Parent Refusals by District ....................................................................... 18 Statewide Immunization Results .............................................................. 19 Summary of Statewide Analyses ............................................................. 31 SECTION IV: RESULTS OF DISTRICT LEVEL ANALYSES .............................................. 32 Overview of District Rates ........................................................................ 33 Individual Health District Reports of Rates and Crosstabulations ............ 34 District 1-1 Northwest Health District........................................................ 34 District 1-2 North Georgia Health District ................................................. 37 District 2-0 North Health District ............................................................... 40 District 3-1 Cobb/Douglas Health District ................................................. 43 District 3-2 Fulton Health District.............................................................. 46 District 3-3 Clayton County Health District ............................................... 49 District 3-4 East Metro Health District ...................................................... 52 District 3-5 Dekalb Health District............................................................. 55 District 4-0 LaGrange Health District........................................................ 58 District 5-1 South Central Health District .................................................. 61 District 5-2 North Central Health District .................................................. 64 District 6-0 East Central Health District .................................................... 67 District 7-0 West Central Health District ................................................... 70 District 8-1 South Health District .............................................................. 73 District 8-2 Southwest Health District ....................................................... 76 District 9-1 East Health District................................................................. 79 i District 9-2 Southeast Health District........................................................ 82 District 10-0 Northeast Health District ...................................................... 85 SECTION V: DISCUSSION........................................................................................ 90 Summary.................................................................................................. 91 Conclusions.............................................................................................. 92 Strengths.................................................................................................. 93 Limitations ................................................................................................ 94 APPENDICES..................................................................................................... 95 ii List of Tables Page 1. Project Activity Timeline ............................................................................. 3 2. Sample Description ...................................................................................14 3. 2008 Eligible Sample, Number Located, and Response Rate by District .. 16 4. Parent Refusals by Health District for the 2008 Study .............................. 18 5. 4:3:1:3:3:1 State Immunization Coverage by Study Year.......................... 20 6. 4:3:1:3 State Immunization Coverage by Study Year................................ 20 7. State Immunization Coverage by Vaccine Series Study Year................... 22 8. Statewide Immunization Status by Individual Vaccines at 12 Months of Age............................................................................................................ 23 9. State and District Immunization Rates for DTP/DTaP by Study Year ....... 24 10. State and District Immunization Rates for OPV/IPV by Study Year .......... 25 11. State and District Immunization Rates for MMR by Study Year ................ 26 12. State and District Immunization Rates for Hib by Study Year ................... 27 13. State and District Immunization Rates for Hep B by Study Year............... 28 14. State and District Immunization Rates for Varicella by Study Year ........... 29 15. State and District Immunization Rates for PCV by Study Year ................. 30 16. District Immunization Rates for Health District 1-1 by Study Year............. 35 17. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 1-1 ......................................................................... 36 18. District Immunization Rates for Health District 1-2 by Study Year............. 38 19. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 1-2 ......................................................................... 39 20. District Immunization Rates for Health District 2-0 by Study Year............. 41 21. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 2-0 ......................................................................... 42 22. District Immunization Rates for Health District 3-1 by Study Year ............. 44 23. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 3-1 ......................................................................... 45 iii 24. District Immunization Rates for Health District 3-2 by Study Year ............. 47 25. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 3-2 ......................................................................... 48 26. District Immunization Rates for Health District 3-3 by Study Year ............. 50 27. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 3-3 ......................................................................... 51 28. District Immunization Rates for Health District 3-4 by Study Year ............. 53 29. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 3-4 ......................................................................... 54 30. District Immunization Rates for Health District 3-5 by Study Year............. 56 31. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 3-5 ......................................................................... 57 32. District Immunization Rates for Health District 4-0 by Study Year............. 59 33. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 4-0 ......................................................................... 60 34. District Immunization Rates for Health District 5-1 by Study Year............. 62 35. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 5-1 ......................................................................... 63 36. District Immunization Rates for Health District 5-2 by Study Year............. 65 37. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 5-2 ......................................................................... 66 38. District Immunization Rates for Health District 6-0 by Study Year............ 68 39. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 6-0 ......................................................................... 69 40. District Immunization Rates for Health District 7-0 by Study Year............. 71 41. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 7-0 ......................................................................... 72 42. District Immunization Rates for Health District 8-1 by Study Year............. 74 43. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 8-1 ......................................................................... 75 44. District Immunization Rates for Health District 8-2 by Study Year............. 77 iv 45. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 8-2 ......................................................................... 78 46. District Immunization Rates for Health District 9-1 by Study Year............. 80 47. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 9-1 ......................................................................... 81 48. District Immunization Rates for Health District 9-2 by Study Year............. 83 49. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 9-2 ......................................................................... 84 50. District Immunization Rates for Health District 10-0 by Study Year........... 86 51. 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 10-0 ....................................................................... 87 52. 2008 District 4:3:1:3:3:1 Immunization Rates Ranked from Highest to Lowest and Percent Difference from State Average.................................. 88 53. Data Used for Sample Size Estimates for the 2008 Study ........................ 98 54. 2008 Varicella Rates and Cases of Chicken Pox by District ................... 107 55. Statewide Percentage of Shots by Provider: 2004, 2005, 2006, 2007 and 2008 ........................................................................................................ 110 56. District Specific Percentage of Shots by Provider 2008 .......................... 111 57. Location of Immunizations by District -Four Year Comparison 2005, 2006, 2007 and 2008 ........................................................................................ 113 58. Margins of Error for 2008 Statewide and District 4:3:1:3:3:1 Rates......... 117 v List of Figures Page 1. Sampling Procedure.................................................................................... 13 2. 2008 Response Rates by District ................................................................ 17 3. Statewide Coverage 4:3:1:3:3:1 and 4:3:1:3:3:1:3 ...................................... 21 4. 4:3:1:3:3:1 Coverage for State and District 1-1 ........................................... 34 5. 4:3:1:3:3:1 Coverage for State and District 1-2 ........................................... 37 6. 4:3:1:3:3:1 Coverage for State and District 2-0 ........................................... 40 7. 4:3:1:3:3:1 Coverage for State and District 3-1 ........................................... 43 8. 4:3:1:3:3:1 Coverage for State and District 3-2 ........................................... 46 9. 4:3:1:3:3:1 Coverage for State and District 3-3 ........................................... 49 10. 4:3:1:3:3:1 Coverage for State and District 3-4 ........................................... 52 11. 4:3:1:3:3:1 Coverage for State and District 3-5 ........................................... 55 12. 4:3:1:3:3:1 Coverage for State and District 4-0 ........................................... 58 13. 4:3:1:3:3:1 Coverage for State and District 5-1 ........................................... 61 14. 4:3:1:3:3:1 Coverage for State and District 5-2 ........................................... 64 15. 4:3:1:3:3:1 Coverage for State and District 6-0 ........................................... 67 16. 4:3:1:3:3:1 Coverage for State and District 7-0 ........................................... 70 17. 4:3:1:3:3:1 Coverage for State and District 8-1 ........................................... 73 18. 4:3:1:3:3:1 Coverage for State and District 8-2 ........................................... 76 19. 4:3:1:3:3:1 Coverage for State and District 9-1 ........................................... 79 20. 4:3:1:3:3:1 Coverage for State and District 9-2 ........................................... 82 21. 4:3:1:3:3:1 Coverage for State and District 10-0 ......................................... 85 22. Percent Difference in Coverage Rates from State by District 2008 ............. 89 23. Explanations of Table 52 Data Used for Sample Size Estimates for the 2008 Study ...........................................................................................................99 24. 2008 State Varicella Coverage Rates and Percentage of Sample with Chicken Pox Disease ................................................................................ 108 x List of Appendices Page Appendix A: Description of Sampling Plan and Statistical Note.............. ........... 95 Appendix B: List of 2008 Public Health Representatives ......................... ........ 100 Appendix C: Data Collection Form........................................................... ........ 102 Appendix D: Varicella Vaccine and Chicken Pox Data ............................ ........ 105 Appendix E: Provider of Immunizations ................................................... ........ 109 Appendix F: Margins of Error for Immunization Coverage Rates............. ........ 115 xi SECTION I: PROJECT OVERVIEW 1 SECTION I: PROJECT OVERVIEW AND INTRODUCTION The Division of Public Health, Epidemiology Section, Immunization Program and Health Districts collaborated on the 2008 Georgia Immunization Study. The purpose of the study was to assess the immunization coverage rates of two-year-old children in Georgia statewide and for each of the eighteen health districts. The Georgia Immunization Survey is now in its twelfth year. The Rollins School of Public Health, Emory University conducted the first three years of the study and the Georgia Division of Public Health has continued on with the survey for the remaining nine years. Immunization data for each year of the study evaluate rates for children born two years before the beginning of the study. In 2008, immunization rates for children born in January 2006 were examined. The current rates are compared throughout this report with data from the previous four years of the study. Public health representatives in each of the eighteen health districts collected immunization data from both public and private health care providers. The Co-Principal Investigators and Co-Project Coordinators were Carol A. Hoban, MPH, PhD, and Rebecca M. Willis, MHS, and the Assistant Project Coordinator was LaTonya Thomas, MBA-HCM. Staff at the Georgia Division of Public Health began work on the Georgia Immunization Project in November 2007. During December 2007, the sampling procedure was completed, and revisions were made to the data collection form and training manual. Letters were sent to each district health director informing them about the study. Each Vaccines For Children provider in Georgia (approximately 700) received a letter and supporting information about the study during the month of January 2008. Throughout this report, we refer to study years one, two, three, four, and five as, 2004, 2005, 2006, 2007 and 2008 respectively. The results from these five study years refer to rates for 2001, 2002, 2003, 2004, and 2005 respectively. 2 During January, a training session for the public health representatives was held via conference call. Data were collected from February 2008 through September 2008. The Project Coordinator and Assistant Project Coordinator served as the contact persons for the public health representatives during the data collection period. Conference calls were held as needed with the public health representatives to answer questions and address concerns regarding data collection. Table 1 describes project activities that took place throughout the project timeline. Table 1: Project Activity Timeline Project Activity Date Stratified sample drawn December, 2007 Initial notification of public health community Immunization Coordinators December, 2007 Health Directors Initial notification of private health January, 2008 community Conference call training for public health January, 2008 representatives Data collection period February September, 2008 Data entry period March, 2008 September, 2009* Double data entry of 5% of data forms September, 2009 Final data cleaning and analysis of data September, 2009 Final Report October, 2009 * Due to departmental restructuring, data entry and analysis were delayed for a period of approximately 12 months. This Final Report includes both statewide and health district level immunization analyses. It contains an overview of data collection, sampling 3 methodology, and a discussion of the study findings. Additional reports on related topics are discussed in Appendices D, E, and F. Findings specific to Varicella are discussed in Appendix D. A report on the immunization site (public or private provider) is included in Appendix E. Margins of error for immunization coverage rates are included in Appendix F. 4 SECTION II: METHODOLOGY 5 SECTION II: METHODOLOGY Research Design The twelfth year of the Georgia Immunization Study employed a non- experimental retrospective cohort research design in order to ascertain the immunization coverage rate for children born in the State of Georgia in January 2006. In this retrospective study, all of the immunizations should have occurred prior to the initiation of the project. However, during the data collection time period children that were not up-to-date on all immunizations were allowed to receive their shots. The study design allowed for the calculation of immunization rates for children who turned two in January 2008. Identifying information about the children and their parents was obtained from birth certificates. Target and Sample Populations The target population of the twelfth year of the Georgia Immunization Study included all two-year-old children born in the State of Georgia in 2006. A sample size of 2,557 children born in the month of January 2006 was selected for the study. The sample design allowed for independent estimates for each of the 18 health districts in the state. (See Appendix A for a description of the sampling plan.) The final estimate for the state is based on weighted data to account for differential probabilities of selection for each health district. Dr. John Carter, Epidemiologist and Assistant Professor at the Rollins School of Public Health, drew a stratified random sample (by health district) from the total births in the state for January 2006. Information for each child, including all birth certificate variables available, was downloaded into an ASCII file. Examples of the type of birth certificate information obtained for each child include: Health district of birth County of birth Infant's first, middle, and last name Infant's sex 6 Infant's date of birth Infant's address Medicaid status of mother at birth of child Mother's first, middle, and last name Father's first, middle, and last name (if available) Mother's race Mother's level of education Preparation for Data Collection Public health representatives in each health district completed the data collection procedures. Division of Public Health staff trained the representatives via a conference call during January 2008. During this training, the public health representatives: Received an overview of childhood immunizations Learned the data collection process and locating methods Were taught information on recording data on the data collection form Were instructed in confidentiality and professional etiquette This information as well as other pertinent details were defined in the Public Health Representative Training Manual presented to each representative at the training. This manual was developed by the staff at the Rollins School of Public Health in 1996-97, and has been revised and updated by the staff at the Georgia Division of Public Health for use in each subsequent study year. Data Form Development The Georgia Division of Public Health, Epidemiology Section, revised the standardized data collection form developed by the staff at the Rollins School of Public Health. (See Appendix C for a copy of the data collection form.) The form followed the recommended schedule of childhood immunizations jointly approved by the Advisory Committee on Immunization Practices (ACIP), the American 7 Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). The data collection form contained four distinct sections to be completed by the public health representatives, and included identifying information from the child's birth certificate. The section titled "Part A: Identifying Information" included the identifying information for each child as well as a code number to uniquely identify each record. This section also included an area for the representatives to record any changes to identifying information (i.e., change of address). The immunization dates for each particular vaccination were recorded in the section labeled "Part B: Immunization History." There were spaces available for five Diphtheria, Tetanus, Pertussis (DTP/DTaP) vaccines, four Polio (OPV/IPV) vaccines, two Measles, Mumps, Rubella (MMR) vaccines, five Haemophilus Influenza type B (Hib) vaccines, four Hepatitis B (Hep B) vaccines, two Varicella vaccines, and four Pneumococcal Conjugate (PCV) vaccines. The data collection form provided at least one extra space for each vaccine to accommodate instances where a child was over-immunized. In this section the representative also noted the location where each individual vaccine was given (Health Department, Private Physician, or Unknown). See Appendix E for a report of the "Provider of Immunizations" information. The next section, "Part C: Tracking Log", provided space for representatives to chronicle all activities performed for each record. This section aided the representatives in their work by documenting where they were in the abstraction process at any point in time. The section also enabled the State staff to understand the steps necessary to find each child's immunization history and to clarify notations made by the representative in Part D of the form. "Part D: Data Collection" is designed to track where the data were collected and the reason data abstraction ended for each individual record. This information was used to understand why the representative returned the record to the State and to determine if any evidence of the child was found. 8 Data Collection Protocol Step #1: Search for immunization records at local health departments. In this step, representatives reviewed computerized files or immunization cards for shot dates. Representatives also used these files to find updated contact information for families. Representatives were instructed to check with Women, Infants, and Children (WIC) offices, for updated contact information as well. Step #2: Search for immunization records through the parent(s). In this step, representatives used the contact information from the birth certificate or any updated contact information found at the health department to contact the parent. Representatives also used sources such as city phone directories, directory assistance, and the Internet to find current contact information for parents. Parents were then contacted by phone and letter and asked to provide an immunization history or the location of immunization information (i.e., the name of the doctor or clinic office). Representatives also sent consent forms to parents. Note about Field Visits: In some cases, representatives made home visits to collect data. This practice was encouraged if the representative was comfortable with it. Step #3: Search for immunization records through private physician(s). In this step, representatives contacted private physicians and requested the child's immunization history. Most physicians provided the information by phone or fax, once a copy of the parent's consent form was received. Some provided the information with a verbal parental consent. Others cooperated by checking a list of children from the sample against their patient list. Some 9 physicians preferred that representatives visit their offices in person to collect the data. Representatives were instructed to collect the information by the method (e.g., phone, fax, personal visit) most convenient to the doctor's office. In most cases, nurses, office managers, and records clerks were the main contacts for representatives collecting data in private physician offices. Representatives returned completed data collection forms to the Georgia Immunization Program on a weekly basis via United States (U.S.) mail. The returned forms were reviewed by staff for correctness and completeness. ("Completeness" here refers not to immunization status, but to completion of the abstraction process, i.e., that a representative did all he or she could do to document a child's entire immunization record.) If a form was incorrectly filled out or incomplete, the public health representative was contacted for clarification. The immunization dates and location for each record were then entered into an Epi Info Version 6.04 data file. This program was developed specifically for this study in Year Two, revised in Year Three by Ms. Alperin, Co-Principal Investigator and again in subsequent study years by Dr. Hoban. Data Entry The co-principal investigators and co-project assistants reviewed each record prior to entry into the Epi Info database. Attempts were made to resolve any unclear information with the public health representative before data entry. Data cleaning and double data entry were done in the month of September 2009. Ten percent of the data were re-entered and correlated with the original forms to look for data entry errors and estimate the error rate for the final sample. A data reliability rate of approximately 97% was found. 10 Analysis Plan The plan for the analysis was very similar to that used in the previous years. Additionally, trends from the previous five years of the study are shown in this Final Report. Epi Info was the main software program used to assess immunization coverage rates, and provide a measure of where the immunizations were given. The analyses include univariate, bivariate, and multivariate analyses to produce a clear description of the immunization status of two-year-old children in the State of Georgia. 11 SECTION III: RESULTS OF STATEWIDE ANALYSES 12 SECTION III: RESULTS OF STATEWIDE ANALYSES Sampling A sample of 2,557 children was drawn from 11,916 children born in Georgia in January 2006. A total of 148,403 children were born in Georgia during 2006. Children who were ineligible for participation in the study were extracted from the original sample, leaving an eligible sample of 2,475. Ineligible children were those who were deceased, adopted, moved out of state, or were known to be part of a military family. Figure 1 below depicts the stages of the sampling procedure. Figure 1: Sampling Procedure All children born in Georgia in 2006 (N = 148,403) All children born in Georgia in January 2006 (N = 11,916) Original sample of 2,557 children Eligible sample of 2,475 children Final sample of 2,369 children Of the 2,475 children in the eligible sample, 2,383 children were located, 92 children never were located and 14 parental refusals were removed. The resulting final sample consisted of 2,369 children. The final sample represents the children for whom parental consent was given to have their child's immunization record included in this study. The children who were never 13 located were those for whom no evidence beyond the birth certificate could be found to confirm that the child existed. The final sample of 2,369 children represented 92.6% of the original sample and more than 96% of the eligible sample. Sampling Step Original Sample Deceased Adopted Moved out of state Military Table 2: Sample Description Number 2,557 3 11 62 6 Percent of Sample 100.0% 0.1% 0.4% 2.4% 0.2% Eligible Sample 2,475 96.8% Eligible Sample Records Not Located /Eligibility Unknown * 2,475 106 100.0% 4.3% Final Sample (Located Records**) 2,369 96.8% * Records Not Located / Eligibility Unknown - This category refers to records where no evidence of a child's existence was found beyond birth certificate data (including those records where only one Hepatitis B shot was given at birth [n=45] or if a parent refused to participate in the study). ** Located Records This category refers to all records where evidence of a child's existence was found, regardless of the child's immunization status. The supposition here is that, if evidence of a child's existence was found, it is possible to also find documentation of that child's immunization status. This category includes records where: a) a provider refused to participate in the study; b) no immunization record was available due to documented religious objection; c) a provider could not be found (this implies contact with a parent, who would have provided evidence of the child's existence); d) no immunization record was available due to documented medical exemption; e) a parent could not be found, but shot dates were found elsewhere 14 Response Rates Table 3 and Figure 2 depict the district and state response rates for the 2008 study. The response rates are the number of records located divided by the total number of records in the sample. Response rates provide some indication of the ease or difficulty of accessing records of the children in the study as well as the quality of data collection. As noted in the last column of Table 3, response rates are reported as a percentage of the eligible sample. In reviewing the response rates based on the eligible sample, the district response rates range from a low of 91.9% to a high of 100%, with a statewide average response rate of 96.8%. 15 Table 3: 2008 Eligible Sample, Number Located and Response Rates by District Health District Eligible Sample Number Located* (Number) 1-1 170 1-2 59 2-0 50 3-1 187 3-2 290 3-3 205 3-4 74 3-5 173 4-0 186 5-1 62 5-2 139 6-0 45 7-0 156 8-1 122 8-2 141 9-1 115 9-2 166 10-0 135 State 2,475 *Parental refusals included **number located / eligible sample 157 59 50 183 269 198 73 159 184 62 132 45 151 116 139 112 164 130 2,396 Response Rate ** (% of Eligible Sample located) 92.4% 100.0% 100.0% 97.9% 92.8% 96.6% 98.6% 91.9% 98.9% 100.0% 95.0% 100.0% 96.8% 95.1% 98.6% 97.4% 98.8% 96.3% 96.8% 16 Response Rate (%) Figure 2: 2008 Response Rates by District 120 100 80 60 40 20 0 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 10 Health Districts 17 Parent Refusals by District: Table 4 shows the number of parents who refused to participate in the study. Table 4: Parent Refusals by Health District for the 2008 Study District 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 10-0 Total Number of Records Found 157 59 50 183 269 198 73 159 184 62 132 45 151 116 139 112 164 130 2,396 Parent Refusals Number 0 1 0 4 2 0 1 2 0 1 1 0 0 0 2 0 0 0 14 Percent (%) 0.0 1.7 0.0 2.2 0.7 0.0 1.4 1.3 0.0 1.6 0.8 0.0 0.0 0.0 1.4 0.0 0.0 0.0 0.6 Parent refusals are defined as situations where the parent told the public health representative that he/she did not want to participate in the study. 18 Statewide Immunization Results The immunization rates that were calculated for this report included only the final sample of 2,369 children. All reported immunization rates include information from both public and private providers. Since "adequate immunization status" is defined differently by different authorities, the Georgia Immunization Study has evaluated immunization status in different ways: "4:3:1:3:3:1:3" status: a child has received four DTP/DaTP, three OPV/IPV, one MMR, three Hib, three Hep B, one Varicella at anytime, and three doses of PCV "4:3:1:3:3:1" status a child has received four DTP/DaTP, three OPV/IPV, one MMR, three Hib, three Hep B, and one Varicella at anytime Table 5 illustrates the percent of the children in the final samples in the last five years of this study who were adequately immunized with the 4:3:1:3:3:1 series compared to the children in the final sample who were not adequately immunized with this series. Of the 2,369 children who were located in 2008, 77.8% were adequately immunized at the 4:3:1:3:3:1 level. This percent of adequately immunized children was similar to the 78% reported in 2007. 19 Table 5: 4:3:1:3:3:1 State Immunization Coverage by Study Year Status 2004 Adequately Immunized Number % 2,150 81.3 2005 2,015 76.5 2006 1,790 76.8 2007 1,919 78.0 2008 1,844 77.8 Note: State rates based on data weighted by health district. Inadequately Immunized Number % 495 18.7 619 23.5 541 23.2 542 22.0 525 22.2 Table 6 illustrates the percent of the children in the final sample who were adequately immunized with the 4:3:1:3 series compared to the children in the final sample who were not adequately immunized with this series. This is a newer assessment of immunization coverage and will continue to be used in future study years. Table 6: 4:3:1:3:3:1:3 State Immunization Coverage by Study Year Status 2007 Adequately Immunized Number % 1,885 76.6 2008 1,836 77.5 Note: State rates based on data weighted by health district. Inadequately Immunized Number % 576 23.4 533 22.5 20 Figure 3: 2006-2008 Statewide Coverage 4:3:1:3:3:1 and 4:3:1:3:3:1:3 Percent Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2006 2007 2008 Year* 4:3:1:3:3:1 Level 4:3:1:3:3:1:3 Level Figure 3 shows the statewide 4:3:1:3:3:1 coverage rates for the 2006, 2007 and 2008 studies. The figure also shows statewide 4:3:1:3:3:1:3 vaccination coverage rates for the 2007 and 2008 studies. The statewide immunization status for each individual vaccine series is presented in Table 7. This table illustrates the number and percent of children who were adequately immunized with each of the recommended vaccines. Vaccines which are part of the 4:3:1:3:3:1 shot series are shown here. In 2004, all but one of the vaccine series met the coverage rate of 90%. Coverage levels for 2005 and 2006 decreased slightly, but still showed most of the vaccines near the 90% coverage rate with the 3 DTP/DtaP above 90%. In 2007, coverage for the 3 Hep B series was also above 90%. The 2008 statewide coverage rates range from 78% for the 4+ doses of the pneumococcal conjugate vaccine to 93% for the 3+ doses of DTP/DTaP. Although relatively low when compared to the other coverage rates, the 4+ doses of PCV has increased by 100% since 2005 and by 325% since 2004. In addition, the 3+ dose PCV coverage has increased 21 by 15% since 2005 and by 90% since 2004. (Note: The Hib vaccine status can be considered adequate with three or four shots, depending on the manufacturer of the vaccine. For this study, adequate immunization status for the Hib vaccines was calculated considering three Hib shots as "adequate"). Table 7: State Immunization Status by Vaccine Series by Study Year Vaccine 3 DTP/DTaP 2004 Number % 2,459 93.0 2005 Number % 2,428 92.2 2006 Number % 2,147 92.1 4 DTP/DTaP 2,268 85.7 2,169 82.3 1,907 81.8 3 OPV/IPV 2,401 90.8 2,315 87.9 2,076 89.1 1 MMR 2,405 90.9 2,296 87.2 2,070 88.8 3 Hib 2,387 90.2 2,306 87.5 2,062 88.5 3 Hep B 2,400 90.7 2,337 88.7 2,081 89.3 1 Varicella 2,378 89.9 2,302 87.4 2,070 88.8 3 PCV 1,262 47.7 2,080 79.0 1,970 84.5 4 PCV 485 18.3 1,024 38.9 1,453 62.3 Note: State rates based on data weighted by health district. 2007 Number % 2,261 91.9 2,034 82.6 2,209 89.8 2,185 88.8 2,145 87.2 2,223 90.3 2,169 88.1 2,189 88.9 1,799 73.1 2008 Number % 2,203 93.0 2,002 84.5 2,164 91.3 2,142 90.4 2,037 86.0 2,173 91.7 2,135 90.1 2,151 90.8 1,846 77.9 In addition to examining at the immunization status of the children in the sample at two years of age, the study also reviewed data on the immunization status of the children at one year of age. Table 8 provides an overview of the immunization status of the children in the final sample of the 2004, 2005, 2006, 2007, and 2008 studies at one year of age, looking at coverage status by individual doses of vaccine. 22 Table 8: Statewide Immunization Status by Individual Vaccines at 12 Months of Age Number Percent* Number Percent* Number Percent* Number Percent* Number Percent* Vaccine 2004 2004 2005 2005 2006 2006 2007 2007 2008 2008 DTP/DTaP1 2,554 96.6% 2,545 96.6% 2,269 97.3% 2,349 95.4% 2,274 96.0% DTP/DTaP2 2,472 93.5% 2,451 93.1% 2,193 94.1% 2,280 92.6% 2,205 93.1% DTP/DTaP3 2,255 85.3% 2,253 85.5% 1,992 85.5% 2,117 86.0% 2.035 85.9% DTP/DTaP4 26 1.0% 25 0.9% 9 0.4% 8 0.3% 11 0.5% DTP/DTaP5 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 2,553 2,458 1,132 5 96.5% 92.9% 42.8% 0.2% 2,541 2,433 1,275 9 96.5% 92.4% 48.4% 0.3% 2,262 2,181 1,339 9 97.0% 93.6% 57.4% 0.4% 2,357 2,286 1,542 4 95.8% 92.9% 62.7% 0.2% 2,272 2,197 1,494 6 95.9% 92.7% 63.1% 0.3% MMR1** MMR2 110 4.2% 96 3.6% 24 1.0% 93 3.8% 87 3.7% 0 0.0% 1 0.0% 0 0.0% 0 0.0% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 2,541 2,446 1,063 25 0 96.1% 92.5% 40.2% 0.9% 0.0% 2,531 2,407 955 32 1 96.1% 91.4% 36.3% 1.2% 0.0% 2,262 2,156 789 9 0 97.0% 92.5% 33.8% 0.4% 0.0% 2,353 2,263 687 8 0 95.6% 92.0% 27.9% 0.3% 0.0% 2,260 2,163 663 9 2 95.4% 91.3% 28.0% 0.4% 0.1% HEPB1 HEPB2 HEPB3 HEPB4 2,551 2,478 1,229 26 96.4% 93.7% 46.5% 1.0% 2,549 2,463 1,342 92 96.8% 93.5% 50.9% 3.5% 2,273 2,199 1,442 193 97.5% 94.3% 61.9% 8.3% 2,368 2,307 1,593 239 96.2% 93.7% 64.7% 9.7% 2,283 2,234 1,556 235 96.4% 94.3% 65.7% 9.9% VAR1** VAR2 136 5.1% 115 4.4% 27 1.2% 97 3.9% 96 4.1% 0 0.0% 1 0.0% 0 0.0% 0 0.0% 0 0.0% PCV1 --- --- 2,359 89.6% 2,167 93.0% 2,314 94.0% 2,248 94.9% PCV2 --- --- 2,209 83.9% 2,041 87.6% 2,223 90.3% 2,158 91.1% PCV3 --- --- 1,796 68.2% 1,570 67.4% 1,984 80.6% 1,914 80.8% PCV4 --- --- 25 2.1% 23 1.0% 59 2.4% 66 2.8% *Percents are calculated as (number immunized/sample size). **The Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday. Sample Sizes: 2004 study = 2, 645; 2005 study = 2,634; 2006 study = 2,331; 2007 study = 2,461; 2008 study = 2,369. 23 Tables 9-15 present the state and district rates for each individual vaccine during the 2004, 2005, 2006, 2007, and 2008 data collection periods. As shown in Table 9, 2008 district immunization rates for the DTP/DTaP vaccines ranged from 75.3% to 97.8%, with a statewide rate of 84.5% receiving all four doses. The 2008 statewide DTP/DTaP rate is 2.3 percent higher than the rate from the 2007 study year. Table 9: State and District Immunization Rates for DTP/DTaP by Study Year District 1-1 2004 Rates 4 DTP/DTaP 85.3% 2005 Rates 4 DTP/DTaP 82.3% 2006 Rates 4 DTP/DTaP 82.2% 1-2 88.2% 97.8% 100.0% 2-0 100% 97.8% 92.6% 3-1 78.8% 79.0% 75.2% 3-2 78.8% 73.8% 68.6% 3-3 67.4% 58.6% 78.0% 3-4 94.1% 92.4% 94.9% 3-5 82.4% 74.0% 76.5% 4-0 79.1% 83.9% 75.0% 5-1 85.5% 94.7% 89.6% 5-2 87.1% 88.5% 94.7% 6-0 90.5% 94.8% 98.6% 7-0 88.4% 90.3% 90.0% 8-1 89.5% 94.3% 89.7% 8-2 94.9% 87.1% 77.2% 9-1 97.5% 87.0% 85.1% 9-2 83.0% 86.0% 83.7% 9-3 83.1% 82.6% --- 10-0 94.3% 93.5% 94.4% State 85.7% 82.3% 81.8% Note: State rates based on data weighted by health district. 2007 Rates 4 DTP/DTaP 84.6% 95.5% 97.6% 83.6% 63.1% 75.0% 96.3% 84.2% 83.1% 93.9% 88.5% 97.9% 79.0% 87.4% 83.0% 82.9% 89.1% --87.5% 82.6% 2008 Rates 4 DTP/DTaP 83.4% 86.2% 92.0% 86.0% 75.3% 76.3% 95.8% 84.1% 81.5% 88.5% 86.3% 97.8% 84.8% 91.4% 88.3% 83.9% 89.0% --86.2% 84.5% 24 Table 10 shows the 2004, 2005, 2006, 2007, and 2008 state and district rates for the OPV/IPV vaccines. The 2008 district coverage rates for these vaccines varied between 84.3% and 100.0%. The 2008 statewide immunization rate for OPV/IPV was 91.3%, which is 1.6 percent higher than the previous year's study rate. Table 10: State and District Immunization Rates for OPV/IPV by Study Year District 2004 Rates 3 OPV/IPV 2005 Rates 3 OPV/IPV 2006 Rates 3 OPV/IPV 2007 Rates 3 OPV/IPV 1-1 89.9% 89.0% 91.4% 1-2 92.2% 98.5% 100.0% 2-0 100.0% 97.8% 96.3% 3-1 83.5% 86.2% 83.5% 3-2 85.0% 81.1% 80.9% 3-3 74.4% 68.4% 85.4% 3-4 96.1% 90.2% 97.4% 3-5 89.5% 83.1% 81.1% 4-0 85.6% 87.1% 88.6% 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 9-3 10-0 State 92.7% 93.2% 94.8% 93.5% 96.1% 97.7% 98.8% 90.4% 88.0% 98.9% 90.8% 96.0% 94.2% 97.4% 92.9% 97.7% 91.9% 94.4% 93.3% 88.7% 98.4% 87.9% 95.8% 96.9% 100.0% 96.0% 91.4% 85.8% 93.5% 92.7% --94.4% 89.1% Note: State rates based on data weighted by health district. 94.0% 97.7% 98.8% 90.7% 72.6% 90.1% 96.3% 88.2% 93.3% 97.0% 93.6% 100.0% 88.6% 95.8% 89.7% 90.0% 93.0% --91.3% 89.8% 2008 Rates 3 OPV/IPV 94.9% 91.4% 92.0% 93.9% 84.6% 84.3% 97.2% 88.5% 87.0% 96.7% 93.9% 100.0% 93.4% 96.6% 93.4% 92.9% 95.1% --90.8% 91.3% 25 Table 11 shows the 2004, 2005, 2006, 2007, and 2008 state and district rates for MMR. The 2008 district rates for MMR ranged from a low of 82.3% to a high of 97.8%, with a statewide rate of 90.4% coverage. The 2008 statewide rate for the MMR vaccine has risen by 1.8 percent since 2007. Table 11: State and District Immunization Rates for MMR by Study Year District 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 2004 Rates 1 MMR 91.3% 94.1% 100.0% 86.3% 82.7% 75.6% 96.1% 90.8% 85.0% 90.9% 2005 Rates 1 MMR 87.8% 97.8% 97.8% 82.1% 80.4% 65.6% 91.3% 84.8% 89.3% 96.0% 2006 Rates 1 MMR 92.0% 100.0% 92.6% 87.2% 81.6% 86.0% 95.7% 84.4% 83.2% 100.0% 5-2 93.2% 92.1% 95.4% 6-0 95.7% 94.8% 98.6% 7-0 8-1 8-2 9-1 9-2 9-3 10-0 93.0% 92.1% 97.7% 98.8% 89.6% 89.2% 97.7% 93.8% 97.7% 93.5% 92.6% 92.1% 87.0% 98.4% 95.0% 89.7% 87.4% 91.1% 86.2% --94.4% State 90.9% 87.2% 88.8% Note: State rates based on data weighted by health district. 2007 Rates 1 MMR 90.7% 97.7% 98.8% 88.5% 72.2% 82.9% 95.1% 90.0% 88.9% 98.5% 92.3% 100.0% 90.5% 94.7% 90.9% 90.7% 93.8% --92.3% 88.8% 2008 Rates 1 MMR 94.3% 91.4% 96.0% 91.1% 83.5% 82.3% 95.8% 89.2% 88.6% 93.4% 96.2% 97.8% 91.4% 94.8% 94.2% 86.6% 93.9% --90.0% 90.4% 26 As shown in Table 12, 2008 district immunization rates for the Hib vaccine varied between 75.3% and 100.0%. The statewide Hib coverage rate in 2008 was 86.0%, a decrease of 1.4 percent from the 2007 statewide rate of 87.2%. Table 12: State and District Immunization Rates for Hib by Study Year District 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 2004 Rates 3 Hib 90.8% 94.1% 100.0% 82.1% 84.1% 76.7% 96.7% 88.3% 86.6% 2005 Rates 3 Hib 87.2% 97.8% 95.7% 84.1% 81.4% 71.7% 92.4% 82.3% 88.8% 2006 Rates 3 Hib 89.0% 100.0% 96.3% 87.2% 81.6% 86.0% 95.7% 84.4% 83.2% 5-1 87.3% 96.0% 93.8% 5-2 91.2% 90.6% 97.7% 6-0 7-0 8-1 8-2 9-1 9-2 9-3 10-0 State 92.2% 93.0% 94.7% 98.3% 98.8% 91.1% 84.3% 95.5% 90.2% 94.8% 91.2% 96.6% 93.5% 94.4% 91.5% 88.7% 98.4% 87.5% 98.6% 92.0% 93.1% 91.3% 93.5% 86.2% --97.2% 88.5% Note: State rates based on data weighted by health district. 2007 Rates 3 Hib 91.2% 97.7% 96.4% 86.7% 69.1% 83.6% 95.1% 86.4% 89.8% 92.4% 87.2% 97.9% 86.7% 97.9% 90.3% 88.6% 91.5% --89.4% 87.2% 2008 Rates 3 Hib 89.8% 89.7% 88.0% 86.0% 77.9% 75.3% 95.8% 84.7% 84.2% 86.9% 87.0% 100.0% 87.4% 94.0% 85.4% 91.1% 88.4% --88.5% 86.0% The slight decrease in Hib coverage from 2006 to 2008 could partially be due to the nationwide Hib shortage that began in December 2007. The decline resulted in a temporary ACIP recommendation to defer the Hib booster dose (dose #4), given at age 12-15 months. However, it is conceivable that the shortage could have affected coverage even at the 3-dose level. 27 Table 13 reports the statewide and district immunization coverage rates for the Hepatitis B vaccine. In 2008, the district coverage rates varied from a low of 83.9% to 100.0%. The 2008 statewide rate of 91.7% for the Hepatitis B vaccine was 1.6 percent higher than the 2007 statewide rate of 90.3%. Table 13: State and District Immunization Rates for Hep B by Study Year District 1-1 2004 Rates 3 Hep B 90.8% 2005 Rates 3 Hep B 89.0% 2006 Rates 3 Hep B 92.0% 1-2 94.1% 98.5% 100.0% 2-0 98.5% 93.5% 96.3% 3-1 83.0% 83.6% 86.7% 3-2 85.4% 81.1% 78.0% 3-3 77.9% 75.0% 86.6% 3-4 96.7% 91.3% 95.7% 3-5 89.1% 82.3% 80.2% 4-0 86.1% 90.2% 89.7% 5-1 90.9% 96.0% 97.9% 5-2 91.8% 92.1% 96.9% 6-0 94.0% 95.7% 100.0% 7-0 93.5% 93.8% 97.0% 8-1 96.1% 97.7% 94.8% 8-2 97.7% 98.4% 89.8% 9-1 100.0% 96.3% 92.9% 9-2 90.4% 95.7% 90.2% 9-3 86.7% 90.4% --- 10-0 94.3% 98.4% 94.4% State 90.7% 88.7% 89.3% Note: State rates based on data weighted by health district. 2007 Rates 3 Hep B 94.0% 97.7% 98.8% 90.7% 72.6% 91.4% 96.3% 89.1% 92.9% 93.9% 92.3% 100.0% 91.4% 97.9% 93.9% 89.3% 94.6% --92.3% 90.3% 2008 Rates 3 Hep B 96.2% 93.1% 96.0% 91.6% 83.9% 86.4% 95.8% 89.2% 88.0% 98.4% 94.7% 100.0% 90.1% 94.8% 97.1% 92.9% 97.0% --91.5% 91.7% 28 Table 14 reports Varicella coverage rates among the health districts and statewide by study year. Children reported to have had Varicella disease are not considered in the results below. For a more detailed description of Varicella rates including prior history of disease, see Appendix D. The district coverage rates ranged from 82.8% to 97.8%, with a statewide coverage rate of 90.1% forthe Varicella vaccine. This is a 2.3 percent increase from the 2007 Varicella rate of 88.1%. Table 14: State and District Immunization Rates for Varicella by Study Year District 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 5-2 2004 Rates 1 Varicella 89.0% 95.1% 98.5% 83.5% 81.4% 74.4% 94.1% 89.5% 85.0% 90.9% 91.2% 2005 Rates 1 Varicella 87.2% 97.8% 97.8% 82.6% 78.5% 67.2% 92.4% 85.7% 89.7% 97.3% 92.8% 2006 Rates 1 Varicella 92.0% 100.0% 92.6% 84.9% 81.2% 86.0% 95.7% 84.8% 83.7% 97.9% 96.9% 2007 Rates 1 Varicella 90.1% 97.7% 98.8% 86.7% 70.3% 82.9% 96.3% 89.1% 88.9% 97.0% 92.3% 6-0 94.8% 93.9% 98.6% 100.0% 7-0 93.5% 93.8% 96.0% 89.5% 8-1 8-2 9-1 9-2 9-3 10-0 State 92.1% 97.7% 98.8% 90.4% 88.0% 94.3% 89.9% 96.6% 93.5% 94.4% 93.3% 87.8% 98.4% 87.4% 91.4% 85.0% 92.9% 87.8% --93.1% 88.8% 94.7% 90.3% 88.6% 94.6% --93.3% 88.1% Notes: State rates based on data weighted by health district. 2008 Rates 1 Varicella 94.3% 89.7% 96.0% 89.9% 83.5% 82.8% 94.4% 88.5% 86.4% 93.4% 93.9% 97.8% 91.4% 95.7% 93.4% 89.3% 94.5% --86.9% 90.1% 29 Table 15 reports the statewide and district immunization coverage rates for the PCV vaccine. In 2008, the district coverage rates varied from a low of 83.5% to 98.4%. The statewide rate of 90.8% in 2008 is 2.1 percent higher than the rate of 88.9% in 2007 and nearly 15 percent higher than the rate of 79% in 2005. Table 15: State and District Immunization Rates for PCV by Study Year District 2005 Rates 3 PCV 2006 Rates 3 PCV 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 9-3 10-0 State 81.1% 95.5% 95.7% 82.1% 79.8% 62.7% 90.2% 73.2% 78.1% 82.7% 69.1% 90.4% 67.3% 88.6% 85.5% 75.9% 79.3% 73.9% 91.9% 79.0% 82.2% 100.0% 96.3% 87.6% 79.4% 78.7% 95.7% 77.8% 81.5% 87.5% 90.1% 97.3% 82.0% 87.9% 81.1% 82.7% 89.4% --90.3% 84.5% Notes: State rates based on data weighted by health district. 2007 Rates 3 PCV 92.3% 95.5% 96.4% 92.0% 73.2% 88.2% 95.1% 90.0% 89.8% 95.5% 91.0% 93.6% 89.5% 94.7% 90.9% 85.7% 92.2% --91.3% 88.9% 2008 Rates 3 PCV 94.9% 91.4% 94.0% 93.3% 83.5% 85.4% 97.2% 90.4% 89.1% 98.4% 93.1% 97.8% 89.4% 94.0% 89.8% 89.0% 95.7% --92.3% 90.8% 30 Summary of Statewide Analyses The statewide analyses reviewed both the study's process of measuring immunization rates and the rates themselves. In measuring immunization rates, the study assessed rates on two levels: 4:3:1:3:3:1 and 4:3:1:3:3:1:3 coverage. In reviewing rates at the most commonly used level of coverage, 4:3:1:3:3:1 coverage, all but one of the immunization rates during the 2008 study year were higher than the rates measured by this study during 2007. Coverage increases ranged from 1.6% for the OPV/IPV and Hepatitis B series to 2.3% for both the DTP/DTaP and Varicella series. Coverage for the Hib vaccine was the exception, decreasing by 1.4 percent since 2007. 31 SECTION IV: RESULTS OF DISTRICT LEVEL ANALYSES 32 Section IV: Results of District Level Analyses Overview of District Rates The immunization rates for this twelfth year report were calculated based on final samples. The final sample sizes in each health district varied by district. The number of children in the final sample in each district is reported in each Individual Health District Report in this section, as well as in Table 3: 2008 Eligible Sample, Number Located and Response Rates by District. The rates reported are based on information collected from both public and private providers. Summaries of all district rates are included in Section III: Statewide Rates, specifically Tables 9-15. The Individual District Reports include immunization rates for each recommended vaccine as well as, 4:3:1:3:3:1 and 4:3:1:3:3:1:3 rates. Although statistical analyses would be informative for each of the districts, sub-category sample sizes in the cross tabulation tables were too small for such analyses to be interpreted and generalized to the target population. 33 Individual Health District Report: District 1-1 The eligible sample from this district included 170 children born in January 2006. From the 170 children, 157 records were located (Response Rate=92.4%). Of the 157 located records, there were no parental refusals leaving a final sample of 157 records. The 4:3:1:3:3:1 immunization coverage estimate is 75.8% (119/157). This rate is 2.6% lower than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Coverage (%) Figure 4: Coverage for State and District 1-1 2007 & 2008 - 4:3:1:3:3:1-level 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 1-1 State The 4:3:1:3:3:1:3 immunization coverage estimate is 75.2% (147/182). This rate is 3% lower than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 34 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 16: District Immunization Rates for Health District 1-1 by Study Year 2004 Adequate Rates 85.3% 89.9% 91.3% 90.8% 90.8% 89.0% 51.4% 15.6% 2005 Adequate Rates 79.5% 88.8% 87.6% 87.0% 88.8% 87.0% 82.0% 44.1% 2006 Adequate Rates 82.2% 91.4% 92.0% 89.0% 92.0% 92.0% 82.2% 69.9% 2007 Adequate Rates 84.6% 94.0% 90.7% 91.2% 94.0% 90.1% 92.3% 78.0% 2008 Adequate Rates 83.4% 94.9% 94.3% 89.8% 96.2% 94.3% 94.9% 79.6% Table 16 reveals the coverage rates of each vaccine series. Coverage rates ranged from 79.6 to 96.2% for the 2008 study data. Table 17 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 35 Table 17: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 1-1 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 154 98.1% 150 95.5% 139 88.5% 1 0.6% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 154 98.1% 150 95.5% 110 70.1% 1 0.6% MMR1 MMR2 5 3.2% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 153 97.5% 149 94.9% 40 25.5% 2 1.3% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 154 98.1% 152 96.8% 130 82.8% 48 30.6% VAR1 VAR2 3 1.9% 0 0.0% PCV1 153 PCV2 148 PCV3 132 PCV4 6 PCV5 1 *Percent = number immunized / sample size sample size = 157 97.5% 94.3% 84.1% 3.8% 0.6% 36 Individual Health District Report: District 1-2 The eligible sample from this district included 59 children born in January 2006. From these children, 59 records were located (Response Rate=100.0%). Of the 59 located records, there was 1 parental refusal leaving a final sample of 58 records. 4:3:1:3:3:1 immunization coverage estimate 84.5% (49/58). This rate is 8.6% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 5: Coverage for State and District 1-2 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 1-2 State 4:3:1:3:3:1:3 immunization coverage estimate 84.5% (49/58). This rate is 1.4% higher than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 37 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 18: District Immunization Rates Health District 1-2 by Study Year 2004 Adequate Rates 88.2% 92.2% 94.1% 94.1% 94.1% 95.1% 56.9% 14.7% 2005 Adequate Rates 97.8% 98.5% 97.8% 97.8% 98.5% 97.8% 95.5% 52.2% 2006 Adequate Rates 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 81.1% 2007 Adequate Rates 95.5% 97.7% 97.7% 97.7% 97.7% 97.7% 95.5% 86.4% 2008 Adequate Rates 86.2% 91.4% 91.4% 89.7% 93.1% 89.7% 91.4% 87.9% Table 18 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 86.2% to 93.1% for the 2008 study data. Table 19 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 38 Table 19: 2008 District Immunization Rates by Individual Vaccine at 12 months of age for Health District 1-2 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 54 93.1% 53 91.4% 47 81.0% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 53 91.4% 53 91.4% 43 74.1% 1 1.7% MMR1 MMR2 1 1.7% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 54 93.1% 52 89.7% 11 19.0% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 55 94.8% 53 91.4% 35 60.3% 4 6.9% VAR1 VAR2 1 1.7% 0 0.0% PCV1 54 PCV2 53 PCV3 45 PCV4 2 PCV5 0 *Percent = number immunized / sample size Sample size = 58 93.1% 91.4% 77.6% 3.4% 0.0% 39 Individual Health District Report: District 2-0 The eligible sample from this district included 50 children born in January 2006. From the 50 children, 50 records were located (Response rate = 100%). Of the 50 located records, there were no parental refusals leaving a final sample of 50 records. 4:3:1:3:3:1 immunization coverage estimate is 88.0% (44/50). This rate is 13% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 6: Coverage for State and District 2-0 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 2-0 State 4:3:1:3:3:1:3 immunization coverage estimate is 88.0% (44/50). This rate is 13.5% higher than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 40 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 20: District Immunization Rates for Health District 2-0 by Study Year 2004 Adequate Rates 100% 100% 100% 100% 100% 98.5% 77.6% 28.4% 2005 Adequate Rates 97.8% 97.8% 97.8% 95.7% 93.5% 97.8% 95.7% 65.2% 2006 Adequate Rates 92.6% 96.3% 92.6% 96.3% 96.3% 92.6% 96.3% 74.1% 2007 Adequate Rates 97.6% 98.8% 98.8% 96.4% 98.8% 98.8% 96.4% 89.3% 2008 Adequate Rates 92.0% 92.0% 96.0% 88.0% 96.0% 96.0% 94.0% 92.0% Table 20 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 88.0% to 96.0% for the 2008 study data. Table 21 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 41 Table 21: 2008 District Immunization Rates by Individual Vaccine at 12 months of age for Health District 2-0 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 48 48 47 0 0 96.0% 96.0% 94.0% 0.0% 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 48 96.0% 47 94.0% 20 40.0% 0 0.0% MMR1 MMR2 1 2.0% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 48 96.0% 47 94.0% 9 18.0% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 48 96.0% 48 96.0% 20 40.0% 2 4.0% VAR1 VAR2 1 2.0% 0 0.0% PCV1 48 PCV2 48 PCV3 47 PCV4 0 PCV5 0 *Percent = number immunized / sample size Sample size = 50 96.0% 96.0% 94.0% 0.0% 0.0% 42 Individual Health District Report: District 3-1 The eligible sample from this district included 187 children born in January 2006. From the 187 children, 183 records were located (Response Rate=97.9%). Of the 183 located records, there were 4 parental refusals leaving a final sample of 179 records. The 4:3:1:3:3:1 immunization coverage estimate is 76.0% (136/179). This rate is 2.3% lower than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 7: Coverage for State and District 3-1 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 3-1 State The 4:3:1:3:3:1:3 immunization coverage estimate is 75.4% (135/179). This rate is 2.7% lower than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 43 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 22: District Immunization Rates for Health District 3-1 by Study Year 2004 Adequate Rates 78.8% 83.5% 86.3% 82.1% 83.0% 83.5% 46.7% 23.1% 2005 Adequate Rates 79.0% 86.2% 82.1% 84.1% 83.6% 82.6% 82.1% 45.6% 2006 Adequate Rates 75.2% 83.5% 87.2% 86.2% 86.7% 84.9% 87.6% 68.8% 2007 Adequate Rates 83.6% 90.7% 88.5% 86.7% 90.7% 86.7% 92.0% 81.0% 2008 Adequate Rates 86.0% 93.9% 91.1% 86.0% 91.6% 89.9% 93.3% 79.9% Table 22 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 79.9% to 93.9% for the 2008 study data. Table 23 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 44 Table 23: 2008 District Immunization Rates by Individual Vaccine at 12 months of age for Health District 3-1 Vaccine Dose Number Immunized DTP1/DTaP1 174 DTP2/DTaP2 172 DTP3/DTaP3 165 DTP4/DTaP4 3 DTP5/DTaP5 0 OPV/IPV1 174 OPV/IPV2 172 OPV/IPV3 117 OPV/IPV4 1 MMR1 10 MMR2 0 HIB1 173 HIB2 167 HIB3 55 HIB4 0 HIB5 0 HEPB1 174 HEPB2 171 HEPB3 108 HEPB4 5 VAR1 9 VAR2 0 PCV1 172 PCV2 169 PCV3 157 PCV4 9 PCV5 0 *Percent = number immunized / sample size Sample size = 179 Percent* 97.2% 96.1% 92.2% 1.7% 0.0% 97.2% 96.1% 65.4% 0.6% 5.6% 0.0% 96.6% 93.3% 30.7% 0.0% 0.0% 97.2% 95.5% 60.3% 2.8% 5.0% 0.0% 96.1% 94.4% 87.7% 5.0% 0.0% 45 Individual Health District Report: District 3-2 The eligible sample from this district included 290 children born in January 2006. From the 290 children, 269 records were located (Response Rate=92.8%). Of the 269 located records, there were 2 parental refusals leaving a final sample of 267 records. The 4:3:1:3:3:1 immunization coverage estimate is 70.4% (188/267). This rate is 9.5% lower than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 8: Coverage for State and District 3-2 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 3-2 State The 4:3:1:3:3:1:3 immunization coverage estimate is 70.4% (188/267). This rate is 9.2% lower than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 46 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 24: District Immunization Rates for Health District 3-2 by Study Year 2004 Adequate Rates 78.8% 85.0% 82.7% 84.1% 85.4% 81.4% 66.8% 35.8% 2005 Adequate Rates 73.8% 81.1% 80.4% 81.4% 81.1% 78.5% 79.8% 47.6% 2006 Adequate Rates 68.6% 80.9% 81.6% 80.9% 78.0% 81.2% 79.4% 58.8% 2007 Adequate Rates 63.1% 72.6% 72.2% 69.1% 72.6% 70.3% 73.2% 56.5% 2008 Adequate Rates 75.3% 84.6% 83.5% 77.9% 83.9% 83.5% 83.5% 70.0% Table 24 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 70.0% to 84.6% for the 2008 study data. Table 25 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 47 Table 25: 2008 District Immunization Rates by Individual Vaccine at 12 months of age for Health District 3-2 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 246 92.1% 230 86.1% 211 79.0% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 244 91.4% 227 85.0% 162 60.7% 0 0.0% MMR1 MMR2 10 3.7% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 242 90.6% 221 82.8% 79 29.6% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 247 92.5% 235 88.0% 151 56.6% 7 2.6% VAR1 VAR2 10 3.7% 0 0.0% PCV1 244 PCV2 225 PCV3 202 PCV4 6 PCV5 0 *Percent = number immunized / sample size Sample size = 267 91.4% 84.3% 75.7% 2.2% 0.0% 48 Individual Health District Report: District 3-3 The eligible sample from this district included 205 children born in January 2006. From the 205 children, 198 records were located (Response Rate=96.6%). Of the 198 located records, there were no parental refusals leaving a final sample of 198 records. The 4:3:1:3:3:1 immunization coverage estimate is 69.2% (137/198). This rate is 11% lower than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 9: Coverage for State and District 3-3 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 3-3 State The 4:3:1:3:3:1:3 immunization coverage estimate is 68.7% (136/198). This rate is 11% lower than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 49 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 26: District Immunization Rates for Health District 3-3 by Study Year 2004 Adequate Rates 67.4% 74.4% 75.6% 76.7% 77.9% 74.4% 30.2% 11.6% 2005 Adequate Rates 58.6% 68.4% 65.6% 71.7% 75.0% 67.2% 62.7% 22.5% 2006 Adequate Rates 78.0% 85.4% 86.0% 84.8% 86.6% 86.0% 78.7% 52.4% 2007 Adequate Rates 75.0% 90.1% 82.9% 83.6% 91.4% 82.9% 88.2% 54.6% 2008 Adequate Rates 76.3% 84.3% 82.3% 75.3% 86.4% 82.8% 85.4% 68.2% Table 26 reveals the coverage rates of each vaccine series. Coverage rates ranged from 68.2% to 86.4% for the 2008 study data. Table 27 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 50 Table 27: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 3-3 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 180 90.9% 174 87.9% 157 79.3% 1 0.5% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 180 90.9% 173 87.4% 130 65.7% 0 0.0% MMR1 MMR2 9 4.5% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 181 91.4% 172 86.9% 57 28.8% 2 1.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 180 90.9% 176 88.9% 144 72.7% 19 9.6% VAR1 VAR2 7 3.5% 0 0.0% PCV1 180 PCV2 173 PCV3 148 PCV4 5 PCV5 0 *Percent = number immunized / sample size Sample size = 198 90.9% 87.4% 74.7% 2.5% 0.0% 51 Individual Health District Report: District 3-4 The eligible sample from this district included 74 children born in January 2006. From the 74 children, 73 records were located (Response Rate=98.6%). Of the 73 located records, there was 1 parental refusal leaving a final sample of 72 records. The 4:3:1:3:3:1 immunization coverage estimate is 93.1% (67/72). This rate is 19.7% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 10: Coverage for State and District 3-4 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 3-4 State The 4:3:1:3:3:1:3 immunization coverage estimate is 93.1% (67/72). This rate is 20.1% higher than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 52 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 28: District Immunization Rates for Health District 3-4 by Study Year 2004 Adequate Rates 94.1% 96.1% 96.1% 96.7% 96.7% 94.1% 76.5% 40.5% 2005 Adequate Rates 92.4% 90.2% 91.3% 92.4% 91.3% 92.4% 90.2% 53.3% 2006 Adequate Rates 94.9% 97.4% 95.7% 96.6% 95.7% 95.7% 95.7% 81.2% 2007 Adequate Rates 96.3% 96.3% 95.1% 95.1% 96.3% 96.3% 95.1% 88.9% 2008 Adequate Rates 95.8% 97.2% 95.8% 95.8% 95.8% 94.4% 97.2% 91.7% Table 28 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 91.7% to 97.2% for the 2008 study data. Table 29 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 53 Table 29: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 3-4 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 71 98.6% 71 98.6% 66 91.7% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 71 98.6% 71 98.6% 49 68.1% 0 0.0% MMR1 MMR2 1 1.4% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 70 97.2% 70 97.2% 29 40.3% 1 1.4% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 72 100.0% 71 98.6% 54 75.0% 7 9.7% VAR1 VAR2 2 2.8% 0 0.0% PCV1 71 PCV2 71 PCV3 64 PCV4 1 PCV5 0 *Percent = number immunized / sample size Sample size = 72 98.6% 98.6% 88.9% 1.4% 0.0% 54 Individual Health District Report: District 3-5 The eligible sample from this district included 173 children born in January 2006. From the 173 children, 159 records were located (Response Rate=91.9%). Of the 159 located records, there were 2 parental refusals leaving a final sample of 157 records. The 4:3:1:3:3:1 immunization coverage estimate is 79.0% (124/157). This rate is 1.5% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 11: Coverage for State and District 3-5 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 3-5 State The 4:3:1:3:3:1:3 immunization coverage estimate is 79.0% (124/157). This rate is 1.9% higher than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 55 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 30: District Immunization Rates for Health District 3-5 by Study Year 2004 Adequate Rates 82.4% 89.5% 90.8% 88.3% 89.1% 89.5% 43.5% 19.7% 2005 Adequate Rates 74.0% 83.1% 84.8% 82.3% 82.3% 85.7% 73.2% 38.5% 2006 Adequate Rates 76.5% 81.1% 84.4% 79.4% 80.2% 84.8% 77.8% 51.4% 2007 Adequate Rates 84.2% 88.2% 90.0% 86.4% 89.1% 89.1% 90.0% 73.8% 2008 Adequate Rates 84.1% 88.5% 89.2% 84.7% 89.2% 88.5% 90.4% 78.3% Table 30 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 78.3% to 90.4% for the 2008 study data. Table 31 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 56 Table 31: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 3-5 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3DTaP3 DTP4/DTaP4 DTP5/DTaP5 149 94.9% 144 91.7% 134 85.4% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 151 96.2% 143 91.1% 98 62.4% 1 0.6% MMR1 MMR2 7 4.5% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 149 94.9% 139 88.5% 42 26.8% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 151 96.2% 149 94.9% 110 70.1% 3 1.9% VAR1 VAR2 11 7.0% 0 0.0% PCV1 157 PCV2 149 PCV3 126 PCV4 4 PCV5 0 *Percent = number immunized / sample size Sample size = 157 100.0% 94.9% 80.3% 2.5% 0.0% 57 Individual Health District Report: District 4-0 The eligible sample from this district included 186 children born in January 2006. From the 186 children, 184 records were located (Response Rate=98.9%). Of the 184 located records, there were no parental refusals leaving a final sample of 184 records. The 4:3:1:3:3:1 immunization coverage estimate is 74.5% (137/184). This rate is 4.2% lower than the statewide 4:3:1:3:3:1 immunization rate of 77.8% Figure 12: Coverage for State and District 4-0 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 4-0 State The 4:3:1:3:3:1:3 immunization coverage estimate is 74.5% (137/184). This rate is 3.9% lower than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5% 58 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 32: District Immunization Rates for Health District 4-0 by Study Year 2004 Adequate Rates 79.1% 85.6% 85.0% 86.6% 86.1% 85.0% 32.1% 9.1% 2005 Adequate Rates 83.9% 87.0% 89.2% 88.8% 90.1% 89.7% 78.0% 26.9% 2006 Adequate Rates 75.0% 88.6% 83.2% 84.8% 89.7% 83.7% 81.5% 58.2% 2007 Adequate Rates 83.1% 93.3% 88.9% 89.8% 92.9% 88.9% 89.8% 71.1% 2008 Adequate Rates 81.5% 87.0% 88.6% 84.2% 88.0% 86.4% 89.1% 75.0% Table 32 reveals the coverage rates of each vaccine series. Coverage rates ranged from 75.0% to 89.1% for the 2008 study data. Table 33 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 59 Table 33: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 4-0 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 173 94.0% 164 89.1% 151 82.1% 1 0.5% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 172 93.5% 163 88.6% 117 63.6% 0 0.0% MMR1 MMR2 9 4.9% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 174 94.6% 163 88.6% 33 17.9% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 173 94.0% 170 92.4% 116 63.0% 15 8.2% VAR1 VAR2 9 4.9% 0 0.0% PCV1 174 PCV2 163 PCV3 145 PCV4 6 PCV5 0 *Percent = number immunized / sample size Sample size = 184 94.6% 88.6% 78.8% 3.3% 0.0% 60 Individual Health District Report: District 5-1 The eligible sample from this district included 62 children born in January 2006. From the 62 children, 62 records were located (Response Rate=100.0%). Of the 62 located records, there was 1 parental refusal leaving a final sample of 61 records. The 4:3:1:3:3:1 immunization coverage estimate 80.3% (49/61). This rate is 3.2% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 13: Coverage for State and District 5-1 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 5-1 State The 4:3:1:3:3:1:3 immunization coverage estimate 80.3% (49/61). This rate is 3.6% higher than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 61 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 34: District Immunization Rates for Health District 5-1 by Study Year 2004 Adequate Rates 85.5% 92.7% 90.9% 87.3% 90.9% 90.9% 23.6% 3.6% 2005 Adequate Rates 94.7% 96.0% 96.0% 96.0% 96.0% 97.3% 82.7% 32.0% 2006 Adequate Rates 89.6% 95.8% 100.0% 93.8% 97.8% 97.9% 87.5% 72.9% 2007 Adequate Rates 93.9% 97.0% 98.5% 92.4% 93.9% 97.0% 95.5% 78.8% 2008 Adequate Rates 88.5% 96.7% 93.4% 86.9% 98.4% 93.4% 98.4% 86.9% Table 34 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 86.9% to 98.4% for the 2008 study data. Table 35 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 62 Table 35: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 5-1 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 61 100.0% 59 96.7% 56 91.8% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 61 100.0% 59 96.7% 39 63.9% 0 0.0% MMR1 MMR2 1 1.6% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 61 100.0% 58 95.1% 9 14.8% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 61 100.0% 59 96.7% 51 83.6% 17 27.9% VAR1 VAR2 1 1.6% 0 0.0% PCV1 61 PCV2 59 PCV3 56 PCV4 2 PCV5 0 *Percent = number immunized / sample size Sample size = 61 100.0% 96.7% 91.8% 3.3% 0.0% 63 Individual Health District Report: District 5-2 The eligible sample from this district included 139 children born in January 2006. From the 139 children, 132 records were located (Response Rate=95.0%). Of the 132 located records, there was 1 parental refusal leaving a final sample of 131 records. The 4:3:1:3:3:1 immunization coverage estimate is 79.4% (104/131). This rate is 2.1% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 14: Coverage for State and District 5-2 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 5-2 State The 4:3:1:3:3:1:3 immunization coverage estimate is 77.1% (101/131). This rate is 0.5% lower than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 64 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 36: District Immunization Rates for Health District 5-2 by Study Year 2004 Adequate Rates 87.1% 93.2% 93.2% 91.2% 91.8% 91.2% 39.5% 15.0% 2005 Adequate Rates 88.5% 94.2% 92.1% 90.6% 92.1% 92.8% 69.1% 36.0% 2006 Adequate Rates 94.7% 96.9% 95.4% 97.7% 96.9% 96.9% 90.1% 68.7% 2007 Adequate Rates 88.5% 93.6% 92.3% 87.2% 92.3% 92.3% 91.0% 84.6% 2008 Adequate Rates 86.3% 93.9% 96.2% 87.0% 94.7% 93.9% 93.1% 74.0% Table 36 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 74.0% to 96.2% for the 2008 study data. Table 37 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. The Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 65 Table 37: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 5-2 Vaccine Dose Number Immunized DTP1/DTaP1 128 DTP2/DTaP2 121 DTP3/DTaP3 112 DTP4/DTaP4 1 DTP5/DTaP5 0 OPV/IPV1 129 OPV/IPV2 122 OPV/IPV3 81 OPV/IPV4 0 MMR1 2 MMR2 0 HIB1 124 HIB2 118 HIB3 30 HIB4 0 HIB5 0 HEPB1 130 HEPB2 127 HEPB3 76 HEPB4 10 VAR1 4 VAR2 0 PCV1 128 PCV2 118 PCV3 99 PCV4 0 PCV5 0 *Percent = number immunized / sample size Sample size = 131 Percent* 97.7% 92.4% 85.5% 0.8% 0.0% 98.5% 93.1% 61.8% 0.0% 1.5% 0.0% 94.7% 90.1% 22.9% 0.0% 0.0% 99.2% 96.9% 58.0% 7.6% 3.1% 0.0% 97.7% 90.1% 75.6% 0.0% 0.0% 66 Individual Health District Report: District 6-0 The eligible sample from this district included 45 children born in January 2006. From the 45 children, 45 records were located (Response Rate=100.0%). Of the 45 located records, there were no parental refusals leaving a final sample of 45 records. The 4:3:1:3:3:1 immunization coverage estimate is 91.1% (41/45). This rate is 17.1% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 15: Coverage for State and District 6-0 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 6-0 State The 4:3:1:3:3:1:3 immunization coverage estimate is 91.1% (41/45). This rate is 17.5% higher than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 67 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 38: District Immunization Rates for Health District 6-0 by Study Year 2004 Adequate Rates 90.5% 94.8% 95.7% 92.2% 94.0% 94.8% 54.3% 23.3% 2005 Adequate Rates 94.8% 97.4% 94.8% 94.8% 95.7% 93.9% 90.4% 52.2% 2006 Adequate Rates 98.6% 100.0% 98.6% 98.6% 100.0% 98.6% 97.3% 82.4% 2007 Adequate Rates 97.9% 100.0% 100.0% 97.9% 100.0% 100.0% 93.6% 89.4% 2008 Adequate Rates 97.8% 100.0% 97.8% 100.0% 100.0% 97.8% 97.8% 86.7% Table 38 reveals the coverage rates of each vaccine series. Coverage rates ranged from 86.7% to 100.0% for the 2008 study data. Table 39 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 68 Table 39: 2008 District Immunization Rates by Individual Vaccine at 12 months of age for Health District 6-0 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 45 100.0% 45 100.0% 41 91.1% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 45 100.0% 45 100.0% 31 68.9% 0 0.0% MMR1 MMR2 4 8.9% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 45 100.0% 45 100.0% 21 46.7% 1 2.2% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 45 100.0% 44 97.8% 40 88.9% 17 37.8% VAR1 VAR2 3 6.7% 0 0.0% PCV1 45 PCV2 44 PCV3 37 PCV4 3 PCV5 0 *Percent = number immunized / sample size Sample size = 45 100.0% 97.8% 82.2% 6.7% 0.0% 69 Individual Health District Report: District 7-0 The eligible sample from this district included 156 children born in January 2006. From the 156 children, 151 records were located (Response Rate=96.8%). Of the 151 located records, there were no parental refusals leaving a final sample of 151 records. The 4:3:1:3:3:1 immunization coverage estimate is 77.5% (117/151). This rate is 0.4% lower than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 16: Coverage for State and District 7-0 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 7-0 State The 4:3:1:3:3:1:3 immunization coverage estimate is 76.8% (116/151). This rate is 0.9% lower than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 70 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 40: District Immunization Rates for Health District 7-0 by Study Year 2004 Adequate Rates 88.4% 93.5% 93.0% 93.0% 93.5% 93.5% 34.2% 10.1% 2005 Adequate Rates 90.3% 92.9% 93.8% 91.2% 93.8% 93.8% 67.3% 35.4% 2006 Adequate Rates 90.0% 96.0% 95.0% 92.0% 97.0% 96.0% 82.0% 52.0% 2007 Adequate Rates 79.0% 88.6% 90.5% 86.7% 91.4% 89.5% 89.5% 68.6% 2008 Adequate Rates 84.8% 93.4% 91.4% 87.4% 90.1% 91.4% 89.4% 78.1% Table 40 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 78.1% to 93.4% for the 2008 study data. Table 41 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 71 Table 41: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 7-0 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 145 96.0% 140 92.7% 128 84.8% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 144 95.4% 140 92.7% 75 49.7% 1 0.7% MMR1 MMR2 4 2.6% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 144 95.4% 140 92.7% 52 34.4% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 142 94.0% 139 92.1% 99 65.6% 3 2.0% VAR1 VAR2 5 3.3% 0 0.0% PCV1 141 PCV2 134 PCV3 123 PCV4 3 PCV5 0 *Percent = number immunized / sample size Sample size = 151 93.4% 88.7% 81.5% 2.0% 0.0% 72 Individual Health District Report: District 8-1 The eligible sample from this district included 122 children born in January 2006. From the 122 children, 116 records were located (Response Rate=95.1%). Of the 116 located records, there were no parental refusals leaving a final sample of 116 records. The 4:3:1:3:3:1 immunization coverage estimate is 83.6% (97/116). This rate is 7.5% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 17: Coverage for State and District 8-1 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 8-1 State The 4:3:1:3:3:1:3 immunization coverage estimate is 82.8% (96/116). This rate is 6.8% higher than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 73 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 42: District Immunization Rates for Health District 8-1 by Study Year 2004 Adequate Rates 89.5% 96.1% 92.1% 94.7% 96.1% 92.1% 39.5% 13.2% 2005 Adequate Rates 94.3% 97.7% 97.7% 96.6% 97.7% 96.6% 88.6% 31.8% 2006 Adequate Rates 89.7% 91.4% 89.7% 93.1% 94.8% 91.4% 87.9% 53.4% 2007 Adequate Rates 87.4% 95.8% 94.7% 97.9% 97.9% 94.7% 94.7% 80.0% 2008 Adequate Rates 91.4% 96.6% 94.8% 94.0% 94.8% 95.7% 94.0% 83.6% Table 42 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 83.6% to 96.6% for the 2008 study data. Table 43 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 74 Table 43: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 8-1 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 114 98.3% 112 96.6% 105 90.5% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 114 98.3% 112 96.6% 69 59.5% 0 0.0% MMR1 MMR2 3 2.6% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 114 98.3% 112 96.6% 36 31.0% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 116 100.0% 113 97.4% 54 46.6% 1 0.9% VAR1 VAR2 4 3.4% 0 0.0% PCV1 111 PCV2 109 PCV3 99 PCV4 4 PCV5 0 *Percent = number immunized / sample size Sample size = 116 95.7% 94.0% 85.3% 3.4% 0.0% 75 Individual Health District Report: District 8-2 The eligible sample from this district included 141 children born in January 2006. From the 141 children, 139 records were located (Response Rate=98.6%). Of the 139 located records, there were 2 parental refusals leaving a final sample of 137 records. The 4:3:1:3:3:1 immunization coverage estimate rate is 78.8% (108/137). This rate is 1.3% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 18: Coverage for State and District 8-2 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 8-2 State The 4:3:1:3:3:1:3 immunization coverage estimate rate is 77.4% (106/137). This rate is 0.1% lower than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 76 Table 44: District Immunization Rates for Health District 8-2 by Study Year Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV 2004 Adequate Rates 94.9% 97.7% 97.7% 98.3% 97.7% 97.7% 38.9% 8.0% 2005 Adequate Rates 87.1% 91.9% 93.5% 93.5% 98.4% 93.5% 85.5% 27.4% 2006 Adequate Rates 77.2% 85.8% 87.4% 91.3% 89.8% 85.0% 81.1% 62.2% 2007 Adequate Rates 83.0% 89.7% 90.9% 90.3% 93.9% 90.3% 90.9% 70.9% 2008 Adequate Rates 88.3% 93.4% 94.2% 85.4% 97.1% 93.4% 89.8% 67.9% Table 44 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 67.9% to 97.1% for the 2008 study data. Table 45 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 77 Table 45: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 8-2 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 136 99.3% 134 97.8% 121 88.3% 1 0.7% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 136 99.3% 133 97.1% 90 65.7% 0 0.0% MMR1 MMR2 3 2.2% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 133 97.1% 127 92.7% 42 30.7% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 137 100.0% 136 99.3% 108 78.8% 2 1.5% VAR1 VAR2 3 2.2% 0 0.0% PCV1 129 PCV2 126 PCV3 100 PCV4 2 PCV5 0 *Percent = number immunized / sample size Sample size = 137 94.2% 92.0% 73.0% 1.5% 0.0% 78 Individual Health District Report: District 9-1 The eligible sample from this district included 115 children born in January 2006. From the 115 children, 112 records were located (Response Rate=97.4%). Of the 112 located records, there were no parental refusals leaving a final sample of 112 records. The 4:3:1:3:3:1 immunization coverage estimate is 77.7% (87/112). This rate is 0.1% lower than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 19: Coverage for State and District 9-1 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 9-1 State The 4:3:1:3:3:1:3 immunization coverage estimate is 77.7% (87/112). This rate is 0.3% higher than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 79 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 46: District Immunization Rates for Health District 9-1 by Study Year 2004 Adequate Rates 97.5% 98.8% 98.8% 98.8% 100% 98.8% 53.1% 17.3% 2005 Adequate Rates 87.0% 94.4% 92.6% 94.4% 96.3% 94.4% 75.9% 33.3% 2006 Adequate Rates 85.1% 93.5% 91.1% 93.5% 92.9% 92.9% 82.7% 61.9% 2007 Adequate Rates 82.9% 90.0% 90.7% 88.6% 89.3% 88.6% 85.7% 73.6% 2008 Adequate Rates 83.9% 92.9% 86.6% 91.1% 92.9% 89.3% 86.6% 75.9% Table 46 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 75.9% to 92.9% for the 2008 study data. Table 47 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 80 Table 47: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 9-1 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 107 95.5% 104 92.9% 93 83.0% 1 0.9% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 107 95.5% 104 92.9% 71 63.4% 0 0.0% MMR1 MMR2 3 2.7% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 107 95.5% 104 92.9% 39 34.8% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 108 96.4% 105 93.8% 62 55.4% 6 5.4% VAR1 VAR2 3 2.7% 0 0.0% PCV1 101 PCV2 97 PCV3 81 PCV4 4 PCV5 0 *Percent = number immunized / sample size Sample size = 112 90.2% 86.6% 72.3% 3.6% 0.0% 81 Individual Health District Report: District 9-2 The eligible sample from this district included 166 children born in January 2006. From the 166 children, 164 records were located (Response Rate=98.8%). Of the 164 located records, there were no parental refusals leaving a final sample of 164 records. The 4:3:1:3:3:1 immunization coverage estimate is 83.5% (137/164). This rate is 7.3% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 20: Coverage for State and District 9-2 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 9-2 State The 4:3:1:3:3:1:3 immunization coverage estimate is 83.5% (137/164). This rate is 7.7% higher than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 82 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 48: District Immunization Rates for Health District 9-2 by Study Year 2004 Adequate Rates 83.0% 90.4% 89.6% 91.1% 90.4% 90.4% 39.3% 5.2% 2005 Adequate Rates 86.0% 93.3% 92.1% 91.5% 95.7% 93.3% 79.3% 28.7% 2006 Adequate Rates 83.7% 92.7% 86.2% 86.2% 90.2% 87.8% 89.4% 54.5% 2007 Adequate Rates 89.1% 93.0% 93.8% 91.5% 94.6% 94.6% 92.2% 75.2% 2008 Adequate Rates 89.0% 95.1% 93.9% 88.4% 97.0% 94.5% 95.7% 85.4% Table 48 reveals the coverage rates of each vaccine series. Coverage rates ranged from 85.4% to 97.0% for the 2008 study data. Table 49 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. As shown in the following table, the percentage of children vaccinated for DTP/DTaP decreases by dose. Similarly, the Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 83 Table 49: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 9-2 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 161 98.2% 158 96.3% 145 88.4% 2 1.2% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 161 98.2% 158 96.3% 112 68.3% 1 0.6% MMR1 MMR2 9 5.5% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 161 98.2% 155 94.5% 34 20.7% 2 1.2% 1 0.6% HEPB1 HEPB2 HEPB3 HEPB4 163 99.4% 161 98.2% 138 84.1% 68 41.5% VAR1 VAR2 10 6.1% 0 0.0% PCV1 159 PCV2 154 PCV3 138 PCV4 5 PCV5 0 *Percent = number immunized / sample size Sample size = 164 97.0% 93.9% 84.1% 3.0% 0.0% 84 Individual Health District Report: District 10-0 The eligible sample from this district included 135 children born in January 2006. From the 135 children, 130 records were located (Response Rate=96.3%). Of the 130 located records, there were no parental refusals leaving a final sample of 130 records. The 4:3:1:3:3:1 immunization coverage estimate is 79.2% (103/130). This rate is 1.8% higher than the statewide 4:3:1:3:3:1 immunization rate of 77.8%. Figure 21: Coverage for State and District 10-0 2007 & 2008 - 4:3:1:3:3:1-level Coverage (%) 100 90 80 70 60 50 40 30 20 10 0 2007 2008 District 10-0 State The 4:3:1:3:3:1:3 immunization coverage estimate is 80.8% (105/130). This rate is 4.3% higher than the statewide 4:3:1:3:3:1:3 immunization rate of 77.5%. 85 Vaccine 4 DTP/DTaP 3 OPV/IPV 1 MMR 3 Hib 3 HepB 1 Varicella 3 PCV 4 PCV Table 50: District Immunization Rates for Health District 10-0 by Study Year 2004 Adequate Rates 94.3% 98.9% 97.7% 95.5% 94.3% 94.3% 60.2% 25.0% 2005 Adequate Rates 93.5% 98.4% 98.4% 98.4% 98.4% 98.4% 91.9% 35.5% 2006 Adequate Rates 94.4% 94.4% 94.4% 97.2% 94.4% 93.1% 90.3% 61.1% 2007 Adequate Rates 87.5% 91.3% 92.3% 89.4% 92.3% 93.3% 91.3% 76.0% 2008 Adequate Rates 86.2% 90.8% 90.0% 88.5% 91.5% 90.0% 92.3% 84.6% Table 50 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 84.6% to 92.3% for the 2008 study data. Table 51 shows the immunization rates for each individual vaccine at twelve months of age. Not all shots are recommended prior to the first birthday; therefore, certain immunization rates within each series are expected to be low. For example, the DTP/DTaP vaccine series includes 4 doses before the second birthday; however, only three of the four shots are recommended within the first year of life. The Advisory Committee on Immunization Practices (ACIP) does not recommend the initiation of the MMR and Varicella vaccine series until after the first birthday, so these rates should be close to 0% at 12 months. 86 Table 51: 2008 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 10-0 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 DTP2/DTaP2 DTP3/DTaP3 DTP4/DTaP4 DTP5/DTaP5 128 98.5% 126 96.9% 117 90.0% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 128 98.5% 125 96.2% 80 61.5% 0 0.0% MMR1 MMR2 5 3.8% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 127 97.7% 124 95.4% 45 34.6% 1 0.8% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 128 98.5% 125 96.2% 60 46.2% 1 0.8% VAR1 VAR2 10 7.7% 0 0.0% PCV1 128 PCV2 126 PCV3 115 PCV4 4 PCV5 0 *Percent = number immunized / sample size Sample size = 130 98.5% 96.9% 88.5% 3.1% 0.0% 87 In addition to the individual comparisons between the state rate and each district rate, the districts were examined together and ranked by highest to lowest levels of 4:3:1:3:3:1 coverage. These comparisons were made to illustrate which districts are adequately immunizing the most children and also which districts show the most room for improvement. Table 52: 2008 District 4:3:1:3:3:1 Immunization Rates Ranked from Highest to Lowest and Percent Difference from State Average Health Districts (Ranked from highest 4:3:1:3:3:1 coverage to lowest) 4:3:1:3:3:1 Coverage (%) 1 3-4; East Metro (Lawrenceville) 2 6-0; East Central (Augusta) 3 2-0; North (Gainesville) 4 1-2: North Georgia (Dalton) 5 8-1; South (Valdosta) 6 9-2; Southeast (Waycross) 7 5-1; South Central (Dublin) 8 5-2; North Central (Macon) 9 10-0; Northeast (Athens) 10 3-5; DeKalb 11 8-2; Southwest (Albany) 12 9-1; Coastal (Savannah) 13 7-0; West Central (Columbus) 14 3-1; Cobb-Douglas 15 1-1; Northwest (Rome) 16 4-0; LaGrange 17 3-2; Fulton 18 3-3; Clayton (Jonesboro) State 93.1 91.1 88.0 84.5 83.6 83.5 80.3 79.4 79.2 79.0 78.8 77.7 77.5 76.0 75.8 74.5 70.4 69.2 77.8 Difference in 4:3:1:3:3:1 Coverage from State (%) 19.7 17.1 13.0 8.6 7.5 7.3 3.2 2.1 1.6 1.5 1.3 -0.1 -0.4 -2.3 -2.6 -4.2 -9.5 -11 0 For this comparison, each district was evaluated by the percent deviation of the 4:3:1:3:3:1-level coverage from the state's average rate of 77.8%. The East-Metro (Lawrenceville) district showed the highest coverage of 93.1%, which is 19.7 percent higher than the state average. The Clayton (Jonesboro) district showed the lowest coverage rate at 69.2%, 11 percent lower than the state average. 88 Figure 22 offers a graphical representation of the district-level coverage rates in relation to the state averages. Figure 22: Percent Difference in Coverage Rates from State by District 2008 10-0 9-2 9-1 8-2 8-1 7-0 6-0 5-2 5-1 4-0 3-5 3-4 3-3 3-2 3-1 2-0 1-2 1-1 -15 -10 -5 0 5 10 15 20 25 Percent Difference (%) 4:3:1:3:3:1 4:3:1:3:3:1:3 89 Section V: Discussion 90 Section V: Discussion Summary The purpose of the twelfth year of the Georgia Immunization Study (GIS) was to assess the statewide and district-specific immunization coverage rates of two-year-old children who received immunizations from both public and private providers in Georgia in 2008. To assess these rates, the study drew an original sample of 2,557 children born in January 2006. After removal of ineligible children (those deceased, adopted, moved out of state, born in military hospitals) the eligible sample was 2,475. Of these, 2,369 records were located and make up the final sample. The twelfth year of the GIS, 2008, measured immunization coverage for children born in 2006 at three levels: 4:3:1:3:3:1:3 coverage, defined as 4 DTaP, 3 OPV/IPV, 1 MMR, 3 Hib, 3 Hep B, 1 Varicella and 3 PCV 4:3:1:3:3:1 coverage, defined as 4 DTaP, 3 OPV/IPV, 1 MMR, 3 Hib, 3 Hep B and 1 Varicella Of these two coverage levels, 4:3:1:3:3:1:3 rates were generally the lower but close to the 4:3:1:3:3:1 rates. The 4:3:1:3:3:1 measure was used most frequently throughout the study. The 4:3:1:3:3:1 measure of coverage was added in 1997-98. Therefore, 4:3:1:3:3:1 rates can be compared using study data from the 1997-98 on. The 2008 results reflect immunization rates for children born in 2006. The results of the study indicate that, of the 2,369 children whose immunization records were located during data collection: *It must be remembered that the 2008 study is estimating 2006 rates. The 2007 study is estimating 2005 rates, 2006 study estimated 2004 rates, 2005 study estimated 2003 rates and the 2004 study estimated rates for 2002. 91 77.8% of children born in January of 2006 in Georgia were adequately immunized with the 4:3:1:3:3:1 vaccine series. 77.5% of children born in January of 2006 in Georgia were adequately immunized with the 4:3:1:3:3:1:3 vaccine series. The study investigated where the immunizations are being administered in Georgia (See Appendix E). In the twelfth study year, 80.6% of the shots found were given by private providers. Furthermore, the findings may serve to guide future immunization assessments, as well as to highlight areas for additional research. Conclusions Immunization rates for the 4:3:1:3:3:1 vaccine series decreased by less than 1% in the 2008 study (78.0% to 77.8%). The 2008 Georgia Immunization Study measured Varicella rates for the eleventh year. From one perspective, the rates represent a success for the Georgia Immunization Program and the Health Districts. Measurement of rates for a new vaccine series has to begin at some time. The collection of data on 4:3:1:3:3:1 rates from the first point at which these rates became available (i.e. the 1997-98 Georgia Immunization Study) will allow public health staff to examine trends and monitor rates. In reviewing the 4:3:1:3:3:1 vaccine series, rates appeared stable statewide from the 2005 study (76.5%) to the 2006 study (76.8%), increasing slightly in the 2007 study (78.0%) and remaining close to that rate in 2008 (77.8%), as mentioned above. The results of the previous four years of the study (2004, 2005, 2006 and 2007) show that immunization-specific coverage rates for the state have remained relatively similar. 92 Strengths 1. This study represents Georgia's twelfth successful statewide, population- based assessment of immunization coverage rates. Dr. Joan Herold, Demographer/Survey Specialist at Emory University, originally developed the sampling methodology for the study. The sample sizes fulfill the power and accuracy requirements for the data analyses. 2. The stratification of the sample by health district, allows for the calculation of district level immunization rates. 3. The methodology allowed for analysis of these useful data: Determination of where the shots are given, either public or private provider. (See Appendix E: Provider of Immunizations). Former immunization audits in Georgia have looked at rates of public providers alone. Assessment of immunization status based on the most recent recommended 4:3:1:3:3:1:3 vaccine series. Comparison of rates for children born in 2004, 2005, 2006, 2007 and 2008 in Georgia. 4. As a measure of reliability for the data entry process, double data entry was conducted on 10% of all records entered. The data entry error rate is approximately 3% for the 2008 study. 5. The implementation of the Georgia Registry of Immunizations and Transaction Services (GRITS) has assisted with locating immunization records. The response rate for 2008 was 96.8%, which is 3.4% increase from the 2007 study's response rate. 93 Limitations The following describe important limitations of the study that should be considered when interpreting study results. 1. There were three limitations related to sampling. First, although the study included a random sample of children born in January 2006 and, thus, represented a generalizable estimate of coverage rates for all two-year-olds born in 2006, it could not account for variations that may routinely occur in other months of the year. Second, limiting the sample to children born in one month does not form the basis of a surveillance system capable of detecting changes in the health care system. Third, there may be children in the eligible sample who were erroneously included in the eligible sample and listed as not located. Examples of this type of error would be cases where a child died, was adopted, or was part of a military family, but the child's ineligibility related to these circumstances never became known to the public health representatives because the child could not be found. Although public health representatives were trained to follow the same protocol, each worked independently with limited supervision and may have deviated from the stated protocol in order to obtain all of the information. 2. Each year of the study parents in the Metro Atlanta District more often refused to participate (District 3-2 and 3-5). Response rates also tend to be lower in the Metro area (Districts 3-2, 3-3, 3-4 and 3-5). 94 APPENDIX A: DESCRIPTION OF SAMPLING PLAN AND STATISTICAL NOTE 95 APPENDIX A: DESCRIPTION OF SAMPLING PLAN AND STATISTICAL NOTE The target population for this study was children born in the state of Georgia in 2006 who were residing in the state in 2008. Children who were born in Georgia to mothers who were not Georgia residents were excluded, since Georgia was not responsible for the health care of these children. Children born on military bases were excluded because they fall under their own health care system and their immunization records were not obtainable. Those who died or moved out of state before their second birthday were also excluded because Georgia was no longer responsible for their immunization status. Adopted children were excluded because they were untraceable. The sampling frame for the study was all infants born in January 2006 in the state of Georgia who were born to Georgia residents, not in military hospitals, and who survived until their first birthday. This choice of sampling frame assumes no seasonality in birth coverage or exposure to immunizations in the state in 2006. From this sampling frame, independent random samples of birth certificate data were drawn for each health district in Georgia, in accordance with the required sample sizes. At the time of sample selection, children born in military hospitals and children known to have died within the first year of life were eliminated from the sampling frame. However, it was impossible to eliminate from the sampling frame children born to military families who were not born in a military hospital, children who were adopted, and children who died after the first year of life, or who moved out of state during 2008. Thus, these exclusions were made after sample selection. It can be assumed that the elimination of these records after sample selection did not have a significant effect on the random nature of the sampling because of the very small percentage they represented of the total population. For a description of sample sizes, see Table 53: Data Used for Sample Size Estimates for the 2008 Study. Response rates and immunization coverage levels from the 2007 study were used in the sample size calculation for the 2008 study. The sample sizes were adjusted for small population size. The desired 96 sample size was then increased by a factor equivalent to the non-response rate (non-locatable immunization records) for each district from the 2007 study. The final calculated sample size is shown in the last column (Column H) of Table 53. This is the number of birth records statewide and per health district used as a result of this calculation for the study. At the end of the study, response rates (located immunization records) varied from a low of 91.9% to a high of 100.0%, with the average response rate for the state at 96.8%. The state level data are based on a sample stratified by health district, with differing probabilities of selection. Therefore, the district data were weighted in order to provide more accurate, weighted estimates for the state level coverage rates. 97 Table 53: Data Used for 2008 Study Sample Size Estimates A B C D E F G H Health District Jan 2006 Total Births Jan 2006 Eligible Births 2007 4:3:1 Immunization Rates 2008 2008 First Second Sample Sample Estimate Estimate Return Rate based on 2007 Eligible Sample 2008 Adjusted Sample Size 1-1 745 729 0.846 200 157 0.924 170 1-2 546 535 0.955 66 59 0.978 60 2-0 717 705 0.976 36 34 0.999 50 3-1 1,059 1,033 0.819 228 187 0.958 195 3-2 1,076 1,051 0.625 360 268 0.944 284 3-3 443 434 0.737 298 177 0.817 216 3-4 1,358 1,327 0.951 72 68 0.943 72 3-5 929 904 0.833 214 173 0.922 188 4-0 861 843 0.822 225 177 0.922 193 5-1 160 154 0.924 108 63 0.985 64 5-2 613 593 0.859 186 142 0.942 150 6-0 567 554 0.979 32 30 0.999 50 7-0 438 384 0.79 255 153 0.938 163 8-1 344 334 0.874 169 112 0.913 123 8-2 453 443 0.83 217 146 0.976 149 9-1 674 616 0.821 226 165 0.959 172 9-2 435 424 0.891 149 110 0.917 120 10-0 498 485 0.865 179 131 0.946 138 State 11,916 11,548 0.819 228 223 0.935 2,559 98 Figure 23: Explanations of Table 52 Data Used for Sample Size Estimates For the 2008 Study Column A: Health District Column B: January 2007 Total Births Column C: January 2007 Eligible Births Column D: 2007 4:3:1 Immunization Rates Column E: First Sample Estimate 2008 Study Column F: Second Sample Estimate 2008 Study Column G: Estimated Return Rate (Based on 2007 Study) District number. Source: DHR Vital Records Office. Source: Georgia Birth Cohort Follow-up Study (2005). Formula Used: 3.8416 x (D) (1 D) / .0025 Adjustment for small size district populations. Formula Used: E / (1 + E/C). Given. Source: Georgia Birth Cohort Follow-up Study (2005). Column H: Adjusted Sample Size 2008 Study Formula Used: (Column F) / (Column G) 99 APPENDIX B: LIST OF 2008 PUBLIC HEALTH REPRESENTATIVES FOR THE GEORGIA IMMUNIZATION STUDY 100 APPENDIX B: LIST OF 2008 PUBLIC HEALTH REPRESENTATIVES FOR THE GEORGIA IMMUNIZATION STUDY Health District 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 10-0 Public Health Representative Marie Smith, B.S.N. Marian Babb, R.N. Ann Vossen, R.N. Sandy Moore, LPN Janie Dalton, R.N. Karen Thomas, R.N., B.S.N. Sylvia Frausto Georgia Goseer, R.N. Jessica Harris Freda Sheppard, L.P.N. Brenda Crowe Gloria Melvin Joyce Hess, R.N. Darlene Sheets Deborah Cox, L.P.N. Amy Fenn, RN Donna Forth, R.N. Kelly Knight Sherry Cook Melba McNorrill, R.N. Clois Witt, R.N., B.S.N. Beverly Roberson, R.N., B.S.N. Debra Adams Sue Dale Marianne Pappas, R.N. Cathy Schmid, R.N. Joanne Burnsed, B.S.N Mary Fleming Kim Carter Mona Smith Kathleen Knight, RN. Michelle Eitel Carol Lightsey Kathy Rowell Cindy Grovenstein Annie Washington, R.N. Debbie Melton, R.N. Karen Mikell, R.N. Diane Watson Betty Miller Jessie Jones, L.P.N. Doris Wilbon, B.S., M.A. Virginia Bellamy, B.S.N. Kimberly Brown, B.S.N. Pat Thomas, R.N. Hollard Phillips, M.S., M.P.H. Dionne Hansey 101 APPENDIX C: DATA COLLECTION FORM 102 APPENDIX D: VARICELLA VACCINE AND CHICKEN POX DATA 105 APPENDIX D: Varicella Vaccine and Chicken Pox Data Table 54 presents information on the Varicella vaccine as well as information on chicken pox. The results of this study have considered a child immunized for Varicella if the vaccine was administered anytime before or during the data collection period. The table below demonstrates the utilization of the Varicella vaccine results in two ways. The first column describes the Varicella results had the twoyear cut off been applicable. The second column depicts the Varicella results without the two-year restriction. The Varicella vaccination rates that report vaccination within the first two years of a child's life are lower than the Varicella vaccination rates that report vaccination at any point in time during the data collection period. These rates have not been adjusted for children who had natural Varicella immunity due to the chicken pox. The final column describes the frequency of cases of chicken pox by district. A child's chicken pox status was provided by health department records, parents, or physicians. The % column is equal to the number of children who had chicken pox divided by the district's final sample size. 106 Table 54: 2008 Varicella Rates and Cases of Chicken Pox by District Health District Varicella shot by age 2 Varicella shot Had chicken pox at anytime (by end of anytime (by end of data collection) data collection) 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 10-0 Number 138 51 47 154 213 160 68 136 155 55 116 41 133 102 120 94 151 113 Statewide 2,047 % 87.9 87.9 94.0 86.0 79.8 80.8 94.4 86.6 84.2 90.2 88.5 91.1 88.1 87.9 87.6 83.9 92.1 86.9 86.4 Number 148 52 48 161 223 164 68 139 159 57 123 44 138 111 128 100 155 117 2,135 % 94.3 89.7 96.0 89.9 83.5 82.8 94.4 88.5 86.4 93.4 93.9 97.8 91.4 95.7 93.4 89.3 94.5 90.0 90.1 Number 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 % 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.5 0.08 107 Figure 24: 2008 State Varicella Vaccine Coverage Rates and Percentage of Sample With Disease 100 80 60 40 20 0 STATE Vaccine by Age 2 Vaccine Anytime With Disease Figure 24 depicts the Varicella rate by the age of two years and the Varicella rate without the two-year cut-off (received Varicella shot at any time during the data collection period). The last bar indicates the percentage of children with documented chicken pox disease at any point in time. 108 Table 58: Margins of Error for 2008 Statewide and District 4:3:1:3:3:1 Rates Health District 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 10-0 Sizes of Final Sample (Records Located) 157 58 50 179 267 198 72 157 184 61 131 45 151 116 137 112 164 130 Statewide Rate (weighted) 2,369 4:3:1:3:3:1 Immunization Coverage Rates (percent) 75.8 84.5 88.0 76.0 70.4 69.2 93.1 79.0 74.5 80.3 79.4 91.1 77.5 83.6 78.8 77.7 83.5 79.2 Margins of Error (percent) +/- 6.7 +/- 9.3 +/- 9.0 +/- 6.3 +/- 5.5 +/- 6.4 +/- 5.9 +/- 6.4 +/- 6.3 +/- 10.0 +/- 6.9 +/- 8.3 +/- 6.7 +/- 6.7 +/- 6.8 +/- 7.7 +/- 5.7 +/- 7.0 95% Confidence Intervals (percent) 69.1 82.5 75.2 93.8 79.0 97.0 69.7 82.3 64.9 75.9 62.8 75.6 87.2 99.0 72.6 85.4 68.2 80.8 70.3 90.3 72.5 86.3 82.8 99.4 70.8 84.2 76.9 90.3 72.0 85.6 70.0 85.4 77.8 89.2 72.2 86.2 77.8 +/- 1.7 76.1 79.5 117 Appendix E: Provider of Immunizations 109 Appendix E: Provider of Immunizations Information about the provider of the immunizations was collected by noting where the shots were given (Public Health, Private Health, or Both) and who provided the information (Health Department, Private Provider, or Parent). If there was no indication of who gave the individual shot, the location for that shot was classified as unknown. The total number and percentage of shots given at each of the provider categories is shown in Table 55. Table 55: Statewide Percentage of Shots by Provider: 2004, 2005, 2006, 2007, and 2008 Provider 2004 Total % # Public 5,449 14.3 Health Dept Private 26,73 70.1 Physician 4 Unknown 5,966 15.6 2005 Total % # 6,013 13.2 35,06 77.1 5 4,407 9.7 2006 Total % # 4,793 11.6 33,26 80.5 8 3,256 7.9 2007 Total % # 4,307 9.8 35,51 81.2 8 3,916 9.0 2008 Total # 5,014 % 11.6 35,02 80.6 2 3,395 7.8 Total 38,14 100.0 45,48 100.0 41,31 100.0 43,741 100.0 43,431 100.0 9 5 7 As shown in Table 55, in 2008, over 80% of the shots recorded for the sampled children were administered by a private provider. 110 Location of Immunizations by District Table 56 illustrates the distribution of immunizations among public and private providers for each health district. These data were generated by counting the total number of shots given in each health district by provider location. Table 56: District Specific Percentage of Shots by Provider 2008 District Public Health Department Private Physician Unknown 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 10-0 State # Shots Given % 160 5.4 116 11.2 7 0.8 215 6.6 68 1.5 347 10.3 0 0.0 226 8.7 470 14.7 179 15.4 178 7.4 145 16.2 316 11.6 356 16.4 370 14.9 209 10.5 857 27.3 83 3.5 4,302 10.1 # Shots Given % 2,749 92.5 899 86.4 889 97.2 2,031 62.4 4,361 96.4 2,683 79.6 1,360 98.6 1,780 68.2 2,672 83.8 749 64.3 2,171 90.5 736 82.1 2,388 87.7 1,678 77.3 1,622 65.5 1,686 84.6 2,184 69.6 2,281 96.3 34,919 82.0 # Shots Given % 64 2.2 25 2.4 19 2.1 1,007 31.0 95 2.1 340 10.1 19 1.4 604 23.1 47 1.5 236 20.3 50 2.1 15 1.7 19 0.7 138 6.4 484 19.5 97 4.9 95 3.0 5 0.2 3,359 7.9 Total Shots Given 2,973 1,040 915 3,253 4,524 3,370 1,379 2,610 3,189 1,164 2,399 896 2,723 2,172 2,476 1,992 3,136 2,369 42,580 111 In Year Ten: In seventeen health districts more than 50% of the shots were administered in the Private sector. Results by region: North (Districts 1-1, 1-2, 2-0, and 10-0) In all of these districts private physicians gave the majority of the immunizations. Metro Atlanta (Districts 3-1, 3-2, 3-3, 3-4, and 3-5) In most of the metro-Atlanta area more of the immunizations were administered in the private sector rather than in the public sector. District 31, Cobb County, had a high number of unknown shot locations (31.0%). Central (Districts 4-0, 5-1, 5-2, 6-0, 7-0) Children in all of the central districts received the majority of their shots at a private provider. South (Districts 8-1, 8-2, 9-1, 9-2, 9-3) Private providers provided the majority of vaccinations in all health districts. District 9-2 also had a significant proportion of their shots given in the public sector (27.3%). 112 Four Year Comparison of Provider Information The following table shows a comparison of results from the current year and the three previous years of the study. The comparisons reflect a movement of immunization services into the private sector in Georgia. Table 57: Location of Immunizations by District Four Year Comparison 2005, 2006, 2007, and 2008 District Public Health Department Private Physician 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 9-3 10-0 State Totals 2005 9.8 4.1 6.5 13.1 8.3 8.7 4.4 21.4 15.0 13.8 15.4 8.2 11.7 13.7 26.4 14.6 30.2 8.7 20.7 13.2 2006 6.3 5.6 15.2 5.9 6.8 10.9 2.2 10.5 18.5 16.9 15.7 11.0 5.4 7.9 3.2 14.7 49.2 --7.1 11.6 2007 9.9 9.0 9.8 9.0 3.6 7.6 4.1 3.0 10.2 13.6 16.6 11.1 14.4 15.1 2.7 14.2 31.4 --10.0 9.8 2008 5.4 11.2 0.8 6.6 1.5 10.3 0.0 8.7 14.7 15.4 7.4 16.2 11.6 16.4 14.9 10.5 27.3 3.5 5.4 10.1 2005 82.3 92.7 82.8 22.5 87.3 75.9 94.2 75.1 80.2 79.1 70.2 89.0 86.7 86.3 73.6 85.4 65.9 89.3 78.0 77.1 2006 84.9 92.8 84.8 46.4 87.2 78.2 97.8 87.2 80.5 83.1 76.3 87.2 94.6 92.1 96.8 80.1 47.9 --92.9 80.5 2007 87.5 83.6 89.4 44.5 93.9 73.9 95.9 92.9 82.5 73.4 76.4 86.6 83.4 84.9 95.1 79.4 60.1 --89.7 81.2 2008 92.5 86.4 97.2 62.4 96.4 79.6 98.6 68.2 83.8 64.3 90.5 82.1 87.7 77.3 65.5 84.6 69.6 96.3 92.5 82.0 113 Four-Year Comparison: Summary of Table 57: In 2005 In 2006 In 2007 In 2008 13.2% of the shots were received at the public health department 77.1% of the shots were given in the private sector 9.7% of the shot locations were unknown 11.6% of the shots were received at the public health department 80.5% of the shots were given in the private sector 7.9% of the shot locations were unknown 9.8% of the shots were received at the public health department 81.2% of the shots were given in the private sector 9.0% of the shot locations were unknown 10.1% of the shots were received at the public health department 82.0% of the shots were given in the private sector 7.9% of the shot locations were unknown 114 APPENDIX F: MARGINS OF ERROR FOR IMMUNIZATION COVERAGE RATES 115 APPENDIX F: MARGINS OF ERROR FOR IMMUNIZATION COVERAGE RATES Margins of error were calculated for the 4:3:1:3:3:1 rate. This margin of error can be found in Tables 114. The formula used to calculate this margin of error in this table is: Margin of error = square root of: (3.8416)(imm rate)(1 - imm rate) Final sample size Confidence intervals can be calculated using the margins of error. The constant 3.8416 is the chi-square value representing an error probability of less than 5%. Using the above formula for margin of error yields a 95% confidence interval for immunization rates. The interpretation of the 95% confidence interval for the state 4:3:1:3:3:1 immunization rate is as follows: With 95% confidence, the true statewide 4:3:1:3:3:1 immunization rate for infants born in 2006 is between 76.1% and 79.5%. Due to the extensive analyses conducted for this report and the large number of rates reported, margins of error for specific rates were only calculated for the following: Statewide 4:3:1:3:3:1 immunization coverage rates These margins of error and confidence intervals are noted in this appendix. 116 Table 58: Margins of Error for 2008 Statewide and District 4:3:1:3:3:1 Rates Health District 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 10-0 Sizes of Final Sample (Records Located) 157 58 50 179 267 198 72 157 184 61 131 45 151 116 137 112 164 130 Statewide Rate (weighted) 2,369 4:3:1:3:3:1 Immunization Coverage Rates (percent) 75.8 84.5 88.0 76.0 70.4 69.2 93.1 79.0 74.5 80.3 79.4 91.1 77.5 83.6 78.8 77.7 83.5 79.2 Margins of Error (percent) +/- 6.7 +/- 9.3 +/- 9.0 +/- 6.3 +/- 5.5 +/- 6.4 +/- 5.9 +/- 6.4 +/- 6.3 +/- 10.0 +/- 6.9 +/- 8.3 +/- 6.7 +/- 6.7 +/- 6.8 +/- 7.7 +/- 5.7 +/- 7.0 95% Confidence Intervals (percent) 69.1 82.5 75.2 93.8 79.0 97.0 69.7 82.3 64.9 75.9 62.8 75.6 87.2 99.0 72.6 85.4 68.2 80.8 70.3 90.3 72.5 86.3 82.8 99.4 70.8 84.2 76.9 90.3 72.0 85.6 70.0 85.4 77.8 89.2 72.2 86.2 77.8 +/- 1.7 76.1 79.5 117