GEORGIA IMMUNIZATION STUDY 2007 Final Report Georgia Department of Human Resources | Division of Public Health Epidemiology Section |Healthy Behavior Epidemiology Unit Immunization Program Eighteen Public Health Districts Prepared by Carol A. Hoban, M.S., M.P.H., Principal Investigator and Project Coordinator Katherine Kahn, B.A., Project Assistant Contributors Latonya M. Thomas, Assessment Coordinator Michelle Conner, Georgia Immunization Program Director Acknowledgments The Georgia Department of Human Resources, 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. 2007 Executive Summary The 2007 Immunization Study was conducted by the Georgia Department of Human Resources, 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 2007. Identifying information about the children and their parents was obtained from birth certificates. The Immunization Study found that during 2007 most childhood immunizations (81.2%) were administered in the private sector, while County Health Departments immunized 9.8%, and the sources for 9% 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, but increased slightly to 78% during the 2007 study. 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 2007, 94% of infants had received two doses of hepatitis B vaccine by 12 months of age, and, at 24 months, 90% 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 2007, 86% of children 12 months of age were appropriately immunized against diphtheria, tetanus and pertussis, and 78% of Georgia's two-year-olds were adequately immunized against ten vaccinepreventable 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 two-yearolds reported to be fully immunized, ranging from 59% in the Fulton district to 98% in the East Central (Augusta) district. Six of the state's public health districts (Dalton, Gainesville, Gwinnett, Augusta, Valdosta, and Waycross) succeeded in immunizing at least 85% of their two-year-olds against the 10 vaccine-preventable 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 59% in Fulton to 93% in Gwinnett. In Georgia outside Metropolitan Atlanta, the immunization rates ranged from 76% in Macon and Columbus to 98% in the Augusta district (see Maps below). Georgia Vaccination Rates (4:3:1:3) by Public Health District 2007 Vaccination Rates * PUBLIC HEALTH DISTRICTS 1-1 Northwest (Rome) Dade Catoosa Fannin Murray Walker Whitfield 1-2 Gilmer Towns Union Rabun White Habersham Chattooga 1-1 Floyd Gordon Bartow Lumpkin Pickens Dawson 2 Hall Cherokee Forsyth Stephens Banks Franklin Hart 61.5 - 73.0 77.1 - 87.6 92.4 - 97.9 * State Overall Vaccination Rate: 80.8 Jackson Madison Elbert Polk Haralson Cobb 3-4 Paulding 3-1 Gwinnett 3-5 Douglas Fulton DeKalb Rock- Barrow Clarke Oglethorpe Oconee 10 Walton Wilkes Lincoln Carroll 3-2 3-3 dale Newton Morgan Greene Taliaferro Columbia Heard Troup Clayton McDuffie Fayette Coweta Henry Spalding Butts Jasper Putnam Warren Hancock Glascock 4 Meriwether Pike Lamar Monroe Jones Baldwin 5-2 Jefferson Washington Richmond 6 Burke Upson Harris Talbot Crawford Bibb Wilkinson Twiggs Johnson Jenkins 1-2 North Georgia (Dalton) 2 North (Gainesville) 3-1 Cobb-Douglas 3-2 Fulton 3-3 Clayton (Jonesboro) 3-4 East Metro (Lawrenceville) 3-5 DeKalb 4 LaGrange 5-1 South Central (Dublin) 5-2 North Central (Macon) 6 East Central (Augusta) 7 West Central (Columbus) 8-1 South (Valdosta) 8-2 Southwest (Albany) 9-1 Coastal (Savannah) 9-2 Southeast (Waycross) 10 Northeast (Athens) Screven Health Districts Counties Muscogee Taylor Peach Emanuel Chatta- Marion hoochee 7 Schley Macon Stewart Webster Sumter Houston Bleckley Laurens 5-1 Treutlen Candler Bulloch Dooly Pulaski Dodge Montgomery Wheeler Toombs Evans Tattnall Effingham Bryan Chatham Quitman Crisp Wilcox Telfair Liberty Terrell Lee Randolph Turner Ben Hill Jeff Davis Appling Long 9-1 Clay Calhoun Dougherty Early Baker Miller 8-2 Mitchell Worth Colquitt Irwin Tift 8-1 Berrien Cook Coffee Atkinson Seminole Decatur Grady Thomas Brooks Lanier Lowndes Clinch Bacon Wayne McIntosh Pierce 9-2 Brantley Ware Glynn Charlton Camden Echols 20 0 20 Georgia Department of Human Resources Division of Public Health Health Planning & Assessment Unit Miles Created: April 2008 Source: Division of Public Health Classification: Natural Breaks Projection: Georgia Statewide Lambert Conformal Conic Note: Map originally printed in color Georgia Vaccination Rates (4:3:1:3:3:1) by Public Health District 2007 Vaccination Rates * PUBLIC HEALTH DISTRICTS 1-1 Northwest (Rome) Dade Catoosa Fannin Murray Walker Whitfield 1-2 Gilmer Towns Union Rabun White Habersham Chattooga 1-1 Floyd Gordon Bartow Lumpkin Pickens Dawson 2 Hall Cherokee Forsyth Stephens Banks Franklin Hart 59.3 - 69.7 75.6 - 86.3 92.6 - 97.9 * State Overall Vaccination Rate: 78.0 Jackson Madison Elbert Polk Haralson Cobb 3-4 Paulding 3-1 Gwinnett 3-5 Douglas Fulton DeKalb Rock- Barrow Clarke Oglethorpe Oconee 10 Walton Wilkes Lincoln Carroll 3-2 3-3 dale Newton Morgan Greene Taliaferro Columbia Heard Troup Clayton McDuffie Fayette Coweta Henry Spalding Butts Jasper Putnam Warren Hancock Glascock 4 Meriwether Pike Lamar Monroe Jones Baldwin 5-2 Jefferson Washington Richmond 6 Burke Upson Harris Talbot Crawford Bibb Wilkinson Twiggs Johnson Jenkins 1-2 North Georgia (Dalton) 2 North (Gainesville) 3-1 Cobb-Douglas 3-2 Fulton 3-3 Clayton (Jonesboro) 3-4 East Metro (Lawrenceville) 3-5 DeKalb 4 LaGrange 5-1 South Central (Dublin) 5-2 North Central (Macon) 6 East Central (Augusta) 7 West Central (Columbus) 8-1 South (Valdosta) 8-2 Southwest (Albany) 9-1 Coastal (Savannah) 9-2 Southeast (Waycross) 10 Northeast (Athens) Screven Health Districts Counties Muscogee Taylor Peach Emanuel Chatta- Marion hoochee 7 Schley Macon Stewart Webster Sumter Houston Bleckley Laurens 5-1 Treutlen Candler Bulloch Dooly Pulaski Dodge Montgomery Wheeler Toombs Evans Tattnall Effingham Bryan Chatham Quitman Crisp Wilcox Telfair Liberty Terrell Lee Randolph Turner Ben Hill Jeff Davis Appling Long 9-1 Clay Calhoun Dougherty Early Baker Miller 8-2 Mitchell Worth Colquitt Irwin Tift 8-1 Berrien Cook Coffee Atkinson Seminole Decatur Grady Thomas Brooks Lanier Lowndes Clinch Bacon Wayne McIntosh Pierce 9-2 Brantley Ware Glynn Charlton Camden Echols 20 0 20 Georgia Department of Human Resources Division of Public Health Health Planning & Assessment Unit Miles Created: April 2008 Source: Division of Public Health Classification: Natural Breaks Projection: Georgia Statewide Lambert Conformal Conic Note: Map originally printed in color 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 S..u..m...m...a..r.y...o..f..S...t.a..t.e..w..i.d..e...A..n..a..l.y..s..e..s................................................................3..1. ..................................................................................................................... SECTIO1N8IV: 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........................................................................................ 88 Summary.................................................................................................. 89 Conclusions.............................................................................................. 90 Strengths.................................................................................................. 91 Limitations ................................................................................................ 92 APPENDICES..................................................................................................... 93 ii List of Tables Page 1. Project Activity Timeline ............................................................................. 3 2. Sample Description ...................................................................................14 3. 2007 Eligible Sample, Number Located, and Response Rate by District .. 16 4. Parent Refusals by Health District for the 2007 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 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 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. 2007 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 10-0 ....................................................................... 87 52. Data Used for Sample Size Estimates for the 2007 Study ........................ 96 53. 2007 Varicella Rates and Cases of Chicken Pox by District ................... 105 54. Statewide Percentage of Shots by Provider: 2003, 2004, 2005, 2006 and 2007 ........................................................................................................ 108 55. District Specific Percentage of Shots by Provider 2007 .......................... 109 56. Location of Immunizations by District -Four Year Comparison 2004, 2005, 2006 and 2007 ........................................................................................ 111 57. Margins of Error for 2007 Statewide and District 4:3:1:3:3:1 Rates......... 115 v List of Figures Page 1. Sampling Procedure.................................................................................... 13 2. 2007 Response Rates by District ................................................................ 17 3. Statewide Coverage 4:3:1:3 and 4:3:1:3:3:1 ............................................... 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. Explanations of Table 52 Data Used for Sample Size Estimates for the 2007 Study ...........................................................................................................97 23. 2007 State Varicella Coverage Rates and Percentage of Sample with Chicken Pox Disease ................................................................................ 106 x List of Appendices Page Appendix A: Description of Sampling Plan and Statistical Note.............. ........... 93 Appendix B: List of 2007 Public Health Representatives ......................... .......... 98 Appendix C: Data Collection Form........................................................... ........ 100 Appendix D: Varicella Vaccine and Chicken Pox Data ............................ ........ 103 Appendix E: Provider of Immunizations ................................................... ........ 107 Appendix F: Margins of Error for Immunization Coverage Rates ............. ........ 113 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 2007 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 eleventh 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 eight years. Immunization data for each year of the study evaluate rates for children born two years before the beginning of the study. In 2007, immunization rates for children born in January 2005 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 Principal Investigator and Project Coordinator was Carol A. Hoban, MS, MPH, the Assistant Project Coordinator was La Tonya Thomas, MBA-HCM, and the Project Assistant was Mrs. Katherine Kahn. Staff at the Georgia Division of Public Health began work on the Georgia Immunization Project in November 2006. During December 2006, 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 2007. Throughout this report, we refer to study years one, two, three, four, and five as, 2003, 2004, 2005, 2006 and 2007 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 2007 through September 2007. 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, 2006 Initial notification of public health community Immunization Coordinators December, 2006 Health Directors Initial notification of private health January, 2007 community Conference call training for public health January, 2007 representatives Data collection period February September, 2007 Data entry period March December, 2007 Double data entry of 5% of data forms December, 2007 Final data cleaning and analysis of data January-February, 2008 Final Report April, 2008 This Final Report includes both statewide and health district level immunization analyses. It contains an overview of data collection, sampling methodology, and a discussion of the study findings. Additional reports on 3 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 eleventh 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 2005. 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 2007. Identifying information about the children and their parents was obtained from birth certificates. Target and Sample Populations The target population of the eleventh year of the Georgia Immunization Study included all two-year-old children born in the State of Georgia in 2005. A sample size of 2,742 children born in the month of January 2005 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 2005. 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 2007. 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 further 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 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 Ms. Hoban. Data Entry The principal investigator and project assistant 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 December 2007. Five 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 2,742 children was drawn from 11,619 children born in Georgia in January 2005. A total of 140,903 children were born in Georgia during 2005. Children who were ineligible for participation in the study were extracted from the original sample, leaving an eligible sample of 2,658. 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 2005 (N = 140,903) All children born in Georgia in January 2005 (N = 11,619) Original sample of 2,742 children Eligible sample of 2,658 children Final sample of 2,461 children Of the 2,658 children in the eligible sample, 2,461 children were located, 170 children never were located and 27 parental refusals were removed. The resulting final sample consisted of 2,461 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 2,461 children represented over 92% of the eligible sample. Sampling Step Original Sample Deceased Adopted Moved out of state Military Table 2: Sample Description Number 2,742 8 4 56 16 Percent of Sample 100.0% 0.3% 0.1% 2.0% 0.6% Eligible Sample 2,658 97.0% Eligible Sample Records Not Located /Eligibility Unknown * 2,658 197 100.0% 7.4% Final Sample (Located Records**) 2,461 92.6% * 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=58] 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 2007 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 - using the eligible sample as the total. In reviewing the response rates based on the eligible sample, the district response rates range from a low of 81.7% to a high of 100%, with a statewide average response rate of 93.5%. 15 Table 3: 2007 Eligible Sample, Number Located and Response Rates by District Health District Eligible Sample Number Located* (Number) 1-1 197 1-2 46 2-0 87 3-1 236 3-2 342 3-3 186 3-4 87 3-5 243 4-0 245 5-1 68 5-2 86 6-0 47 7-0 112 8-1 104 8-2 169 9-1 147 9-2 145 10-0 111 State 2,658 *sample includes parental refusals **number located / eligible sample 182 45 87 226 323 152 82 224 226 67 81 47 105 95 165 141 133 105 2,486 Response Rate ** (% of Eligible Sample located) 92.4% 97.8% 100.0% 95.8% 94.4% 81.7% 94.3% 92.2% 92.2% 98.5% 94.2% 100.0% 93.8% 91.3% 97.6% 95.9% 91.7% 94.6% 93.5% 16 Figure 2 2007 Response Rates by District 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 Georgia 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 2007 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 182 45 87 226 323 152 82 224 226 67 81 47 105 95 165 141 133 105 2,486 Parent Refusals Number 0 1 3 0 6 0 1 3 1 1 3 0 0 0 0 1 5 2 27 Percent 0.00 0.02 0.03 0.00 0.02 0.00 0.01 0.01 0.00 0.01 0.04 0.00 0.00 0.00 0.00 0.01 0.04 0.02 0.01 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 2,461 children (children located). 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 several 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 "4:3:1:3" status a child has received four DTP/DaTP, three OPV/IPV, one MMR, and three Hib vaccinations Table 5 illustrates the% 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 2,461 children who were located in 2007, 78% were adequately immunized at the 4:3:1:3:3:1 level. This% of adequately immunized children was similar to the 76.8% reported in 2006. 19 Table 5: 4:3:1:3:3:1 State Immunization Coverage by Study Year Status 2003 Adequately Immunized Number % 1,906 74.3 2004 2,150 81.3 2005 2,015 76.5 2006 1,790 76.8 2007 1,919 78.0 Note: State rates based on data weighted by health district. Inadequately Immunized Number % 661 25.7 495 18.7 619 23.5 541 23.2 542 22.0 Table 6 illustrates the% 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 State Immunization Coverage by Study Year Status 2005 Adequately Immunized Number % 2,095 79.5 2006 1,863 79.9 2007 1,988 80.8 Note: State rates based on data weighted by health district. Inadequately Immunized Number % 539 20.5 468 20.1 473 19.2 20 Figure 3: Statewide Coverage 4:3:1:3 and 4:3:1:3:3:1 100 90 80 70 60 50 4:3:1:3 40 4:3:1:3:3:1 30 20 10 0 2005 2006 2007 Figure 3 shows the statewide 4:3:1:3 coverage rates for the 2005, 2006 and 2007 studies. The figure also shows statewide 4:3:1:3:3:1 vaccination coverage for the 2005, 2006 and 2007 studies. The statewide immunization status for each individual vaccine series is presented in Table 7. This table illustrates the number and% 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. During the 2003 assessment, nearly all vaccines were near the state goal of 90% coverage, with coverage for the 3 DTP/DtaP vaccine series over 90%. In 2004, all but one of the vaccine series met the coverage rate of 90%. Coverage levels for 2005 and 2006 have decreased slightly, but still show most of the vaccines are 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%. (Note: The Hib vaccine status can be considered adequate with three or four shots, depending on the manufacturer of 21 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 2003 Number % 2,340 91.2 2004 Number % 2,459 93.0 2005 Number % 2,428 92.2 4 DTP/DTaP 2,096 81.7 2,268 85.7 2,169 82.3 3 OPV/IPV 2,251 87.7 2,401 90.8 2,315 87.9 1 MMR 2,266 88.3 2,405 90.9 2,296 87.2 3 Hib 2,242 87.3 2,387 90.2 2,306 87.5 3 Hep B 2,255 87.8 2,400 90.7 2,337 88.7 1 Varicella 2,101 81.8 2,378 89.9 2,302 87.4 3 PCV --- --- 1,262 47.7 2,080 79.0 4 PCV --- --- 485 18.3 1,024 38.9 Note: State rates based on data weighted by health district. * PCV data not collected before 2004. 2006 Number % 2,147 92.1 1,907 81.8 2,076 89.1 2,070 88.8 2,062 88.5 2,081 89.3 2,070 88.8 1,970 84.5 1,453 62.3 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 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 2003, 2004, 2005, 2006, and 2007 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 2003 2003 2004 2004 2005 2005 2006 2006 2007 2007 DTP/DTaP1 2,447 95.3% 2,554 96.6% 2,545 96.6% 2,269 97.3% 2,349 95.4% DTP/DTaP2 2,367 92.2% 2,472 93.5% 2,451 93.1% 2,193 94.1% 2,280 92.6% DTP/DTaP3 2,176 84.8% 2,255 85.3% 2,253 85.5% 1,992 85.5% 2,117 86.0% DTP/DTaP4 8 0.3% 26 1.0% 25 0.9% 9 0.4% 8 0.3% 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 2,442 2,350 1,004 3 95.1% 91.5% 39.1% 0.1% 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% MMR1** MMR2 92 3.6% 110 4.2% 96 3.6% 24 1.0% 93 3.8% 1 0.0% 0 0.0% 1 0.0% 0 0.0% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 2,436 2,345 1,110 16 0 94.9% 91.4% 43.2% 0.6% 0.0% 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% HEPB1 HEPB2 HEPB3 HEPB4 2,440 2,346 1,264 19 95.1% 91.4% 49.2% 0.7% 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% VAR1** VAR2 125 4.9% 136 5.1% 115 4.4% 27 1.2% 97 3.9% 1 0.0% 0 0.0% 1 0.0% 0 0.0% 0 0.0% PCV1 --- --- --- --- 2,359 89.6% 2,167 93.0% 2,314 94.0% PCV2 --- --- --- --- 2,209 83.9% 2,041 87.6% 2,223 90.3% PCV3 --- --- --- --- 1,796 68.2% 1,570 67.4% 1,984 80.6% PCV4 --- --- --- --- 25 2.1% 23 1.0% 59 2.4% *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 Size for 2003 study = 2,567; 2004 study = 2, 645; 2005 study = 2,634; 2006 study = 2,331; 2007 study = 2,461. 23 Tables 9-15 present the state and district rates for each individual vaccine during the 2003, 2004, 2005, 2006, and 2007 data collection periods. As shown in Table 9, 2007 district immunization rates for the DTP/DTaP vaccines ranged from 63.1% to 97.9%, with a statewide rate of 82.6% receiving all four doses. The 2007 statewide DTP/DTaP rate is only slightly higher than the rate from the 2006 study year. Table 9: State and District Immunization Rates for DTP/DTaP by Study Year District 1-1 2003 Rates 4 DTP/DTaP 77.1% 2004 Rates 4 DTP/DTaP 85.3% 2005 Rates 4 DTP/DTaP 82.3% 1-2 86.3% 88.2% 97.8% 2-0 95.7% 100% 97.8% 3-1 76.6% 78.8% 79.0% 3-2 68.1% 78.8% 73.8% 3-3 79.1% 67.4% 58.6% 3-4 90.0% 94.1% 92.4% 3-5 66.0% 82.4% 74.0% 4-0 84.5% 79.1% 83.9% 5-1 93.3% 85.5% 94.7% 5-2 84.9% 87.1% 88.5% 6-0 87.8% 90.5% 94.8% 7-0 77.1% 88.4% 90.3% 8-1 91.9% 89.5% 94.3% 8-2 75.3% 94.9% 87.1% 9-1 77.3% 97.5% 87.0% 9-2 9-3 10-0 82.6% 83.0% 93.2% 83.0% 83.1% 94.3% 86.0% 82.6% 93.5% State 81.7% 85.7% 82.3% Note: State rates based on data weighted by health district. 2006 Rates 4 DTP/DTaP 82.2% 100.0% 92.6% 75.2% 68.6% 78.0% 94.9% 76.5% 75.0% 89.6% 94.7% 98.6% 90.0% 89.7% 77.2% 85.1% 83.7% --94.4% 81.8% 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% 24 Table 10 shows the 2003, 2004, 2005, 2006, and 2007 state and district rates for the OPV/IPV vaccines. The 2007 district coverage rates for these vaccines varied between 72.6% and 100.0%. The 2007 statewide immunization rate for OPV/IPV was 89.8%, which is only slightly higher than the previous year's study rate. Table 10: State and District Immunization Rates for OPV/IPV by Study Year District 2003 Rates 3 OPV/IPV 2004 Rates 3 OPV/IPV 2005 Rates 3 OPV/IPV 2006 Rates 3 OPV/IPV 1-1 84.8% 89.9% 89.0% 1-2 88.9% 92.2% 98.5% 2-0 94.7% 100.0% 97.8% 3-1 83.4% 83.5% 86.2% 3-2 71.7% 85.0% 81.1% 3-3 85.8% 74.4% 68.4% 3-4 90.0% 96.1% 90.2% 3-5 82.0% 89.5% 83.1% 4-0 92.7% 85.6% 87.1% 5-1 5-2 6-0 7-0 8-1 8-2 9-1 9-2 9-3 10-0 State 97.8% 93.7% 91.9% 85.0% 96.0% 80.7% 88.7% 88.4% 89.4% 93.2% 87.7% 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% Note: State rates based on data weighted by health district. 91.4% 100.0% 96.3% 83.5% 80.9% 85.4% 97.4% 81.1% 88.6% 95.8% 96.9% 100.0% 96.0% 91.4% 85.8% 93.5% 92.7% --94.4% 89.1% 2007 Rates 3 OPV/IPV 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% 25 Table 11 shows the 2003, 2004, 2005, 2006, and 2007 state and district rates for MMR. The 2007 district rates for MMR ranged from a low of 72.2% to a high of 100.0%, with a statewide rate of 88.8% coverage. The 2007 statewide rate for the MMR vaccine remained at 88.8%. 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 2003 Rates 1 MMR 88.1% 90.8% 96.8% 80.7% 71.0% 85.1% 90.0% 80.7% 92.7% 97.8% 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% 5-2 96.8% 93.2% 92.1% 6-0 91.9% 95.7% 94.8% 7-0 8-1 8-2 9-1 9-2 9-3 10-0 State 87.9% 95.2% 81.3% 90.0% 90.6% 89.4% 93.8% 88.3% 93.0% 92.1% 97.7% 98.8% 89.6% 89.2% 97.7% 90.9% 93.8% 97.7% 93.5% 92.6% 92.1% 87.0% 98.4% 87.2% Note: State rates based on data weighted by health district. 2006 Rates 1 MMR 92.0% 100.0% 92.6% 87.2% 81.6% 86.0% 95.7% 84.4% 83.2% 100.0% 95.4% 98.6% 95.0% 89.7% 87.4% 91.1% 86.2% --94.4% 88.8% 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% 26 As shown in Table 12, 2007 district immunization rates for the Hib vaccine varied between 69.1% and 97.9%. The statewide Hib coverage rate in 2007 was 87.2%, a slight decrease from the 2006 statewide rate of 88.5%. 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 2003 Rates 3 Hib 84.1% 90.8% 93.6% 82.1% 72.5% 88.4% 90.0% 76.0% 87.3% 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% 5-1 97.8% 87.3% 96.0% 5-2 91.3% 91.2% 90.6% 6-0 7-0 8-1 8-2 9-1 9-2 9-3 10-0 State 93.5% 85.7% 95.2% 81.3% 87.3% 86.2% 89.4% 95.7% 87.3% 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% Note: State rates based on data weighted by health district. 2006 Rates 3 Hib 89.0% 100.0% 96.3% 87.2% 81.6% 86.0% 95.7% 84.4% 83.2% 93.8% 97.7% 98.6% 92.0% 93.1% 91.3% 93.5% 86.2% --97.2% 88.5% 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% 27 Table 13 reports the statewide and district immunization coverage rates for the Hepatitis B vaccine. In 2007, the district coverage rates varied from a low of 72.6% to 100.0%. The 2007 statewide rate of 90.3% for the Hepatitis B vaccine was slightly greater than the 2006 statewide rate of 89.3%. Table 13: State and District Immunization Rates for Hep B by Study Year District 1-1 1-2 2-0 3-1 3-2 3-3 3-4 3-5 4-0 2003 Rates 3 Hep B 83.4% 90.8% 93.6% 86.2% 74.6% 88.8% 90.0% 78.0% 92.7% 2004 Rates 3 Hep B 90.8% 94.1% 98.5% 83.0% 85.4% 77.9% 96.7% 89.1% 86.1% 2005 Rates 3 Hep B 89.0% 98.5% 93.5% 83.6% 81.1% 75.0% 91.3% 82.3% 90.2% 5-1 96.7% 90.9% 96.0% 5-2 93.7% 91.8% 92.1% 6-0 7-0 8-1 8-2 9-1 9-2 9-3 10-0 State 95.1% 87.9% 96.0% 82.0% 79.3% 87.7% 86.2% 95.1% 87.8% 94.0% 93.5% 96.1% 97.7% 100.0% 90.4% 86.7% 94.3% 90.7% 95.7% 93.8% 97.7% 98.4% 96.3% 95.7% 90.4% 98.4% 88.7% Note: State rates based on data weighted by health district. 2006 Rates 3 Hep B 92.0% 100.0% 96.3% 86.7% 78.0% 86.6% 95.7% 80.2% 89.7% 97.9% 96.9% 100.0% 97.0% 94.8% 89.8% 92.9% 90.2% --94.4% 89.3% 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% 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 70.3% to 100.0%, with a statewide coverage rate of 88.1% for the Varicella vaccine. This is a slight decrease from the 2006 Varicella rate of 88.8%. 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 2003 Rates 1 Varicella 86.8% 90.2% 96.8% 80.7% 71.7% 84.7% 90.0% 74.0% 92.7% 95.6% 92.9% 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% 6-0 90.2% 94.8% 93.9% 98.6% 7-0 85.7% 93.5% 93.8% 96.0% 8-1 8-2 9-1 9-2 9-3 10-0 State 94.4% 78.0% 83.3% 91.3% 86.2% 95.7% 86.7% 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% Notes: State rates based on data weighted by health district. 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% 100.0% 89.5% 94.7% 90.3% 88.6% 94.6% --93.3% 88.1% 29 Table 15 reports the statewide and district immunization coverage rates for the PCV vaccine. In 2007, the district coverage rates varied from a low of 73.2% to 96.4%. 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% 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 at three levels: 4:3:1:3:3:1 coverage, 4:3:1:3 coverage, 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, immunization rates during the 2007 study year were slightly higher than the rates measured by this study during 2006. 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 eighth 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: 2007 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, 4:3:1:3 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 197 children born in January 2005. From the 197 children, 182 records were located (Response Rate=92.4%). Of the 182 located records, there were no parental refusals leaving a final sample of 182 records. The 4:3:1:3:3:1 immunization coverage estimate is 82.4% (150/182). This rate is higher than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 4: 4:3:1:3:3:1 Coverage for State and District 1-1 83 82 81 80 79 State 78 Dist 1-1 77 76 75 74 2006 2007 The 4:3:1:3 immunization coverage estimate is 84.6% (154/182). This rate is also higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 80.8% (147/182). This rate is also higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 34 Table 16: District Immunization Rates for Health District 1-1 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 77.5% 85.3% 3 OPV/IPV 84.8% 89.9% 1 MMR 88.1% 91.3% 3 Hib 84.1% 90.8% 3 HepB 83.4% 90.8% 1 Varicella 86.8% 89.0% 3 PCV --- 51.4% 4 PCV --- 15.6% *PCV data not collected before 2004. 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% Table 16 reveals the coverage rates of each vaccine series. Coverage rates ranged from 78.0 to 94.0% for the 2007 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%age 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: 2007 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 179 98.4% 172 94.5% 160 87.9% 2 1.1% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 180 98.9% 172 94.5% 127 69.8% 1 0.5% MMR1 MMR2 10 5.5% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 181 99.5% 173 95.1% 65 35.7% 1 0.5% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 181 99.5% 177 97.3% 151 83.0% 68 37.4% VAR1 VAR2 10 5.5% 0 0.0% PCV1 177 PCV2 168 PCV3 153 PCV4 8 PCV5 0 *Percent = number immunized / sample size sample size = 182 97.3% 92.3% 84.1% 4.4% 0.0% 36 Individual Health District Report: District 1-2 The eligible sample from this district included 46 children born in January 2005. From these children, 45 records were located (Response Rate=97.8%). Of the 45 located records, there was 1 parental refusal leaving a final sample of 44 records. 4:3:1:3:3:1 immunization coverage estimate 93.2% (41/44). This rate is much higher than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 5: 4:3:1:3:3:1 Coverage for State and District 1-2 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 1-2 4:3:1:3 immunization coverage estimate 95.5% (42/44). This rate is also much higher than the statewide 4:3:1:3 immunization rate of 80.8%. 4:3:1:3:3:1:3 immunization coverage estimate 93.2% (41/44). This rate is also much higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 37 Table 18: District Immunization Rates for Health District 1-2 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 86.3% 88.2% 3 OPV/IPV 88.9% 92.2% 1 MMR 90.8% 94.1% 3 Hib 90.8% 94.1% 3 HepB 90.8% 94.1% 1 Varicella 90.2% 95.1% 3 PCV --- 56.9% 4 PCV --- 14.7% *PCV data not collected before 2004. 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% Table 18 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 86.4% to 97.7% for the 2007 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%age 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: 2007 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 44 100.0% 43 97.7% 38 86.4% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 44 100.0% 43 97.7% 33 75.0% 0 0.0% MMR1 MMR2 1 2.3% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 44 100.0% 44 100.0% 13 29.5% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 44 100.0% 43 97.7% 25 56.8% 4 9.1% VAR1 VAR2 1 2.3% 0 0.0% PCV1 43 PCV2 42 PCV3 35 PCV4 0 PCV5 0 *Percent = number immunized / sample size Sample size = 44 97.7% 95.5% 79.5% 0.0% 0.0% 39 Individual Health District Report: District 2-0 The eligible sample from this district included 87 children born in January 2005. From the 87 children, 87 records were located (Response rate = 100%). Of the 87 located records, there were 3 parental refusals leaving a final sample of 84 records. 4:3:1:3:3:1 immunization coverage estimate is 94.0% (79/84). This rate is much higher than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 6: 4:3:1:3:3:1 Coverage for State and District 2-0 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 2-0 4:3:1:3 immunization coverage estimate is 96.4% (81/84). This rate is also much higher than the statewide 4:3:1:3 immunization rate of 80.8%. 4:3:1:3:3:1:3 immunization coverage estimate is 94.0% (79/84). This rate is also much higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 40 Table 20: District Immunization Rates for Health District 2-0 by Study Year* Vaccine 2003 2004 2005 2006 2007 Adequate Adequate Adequate Adequate Adequate Rates Rates Rates Rates Rates 4 DTP/DTaP 95.7% 100% 97.8% 92.6% 97.6% 3 OPV/IPV 94.7% 100% 97.8% 96.3% 98.8% 1 MMR 96.8% 100% 97.8% 92.6% 98.8% 3 Hib 93.6% 100% 95.7% 96.3% 96.4% 3 HepB 93.6% 100% 93.5% 96.3% 98.8% 1 Varicella 96.8% 98.5% 97.8% 92.6% 98.8% 3 PCV --- 77.6% 95.7% 96.3% 96.4% 4 PCV --- 28.4% 65.2% 74.1% 89.3% *PCV data not collected before 2004. Table 20 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 89.3% to 98.8% for the 2007 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%age 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: 2007 District Immunization Rates by Individual Vaccine at 12 months of age for Health District 2-0 Vaccine Dose Number Immunized Percent* DTP1/DTaP1 83 98.8% DTP2/DTaP2 82 97.6% DTP3/DTaP3 81 96.4% DTP4/DTaP4 0 0.0% DTP5/DTaP5 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 83 98.8% 82 97.6% 40 47.6% 0 0.0% MMR1 MMR2 2 2.4% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 83 98.8% 80 95.2% 27 32.1% 1 1.2% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 83 98.8% 83 98.8% 44 52.4% 6 7.1% VAR1 VAR2 2 2.4% 0 0.0% PCV1 81 PCV2 79 PCV3 77 PCV4 0 PCV5 0 *Percent = number immunized / sample size Sample size = 84 96.4% 94.0% 91.7% 0.0% 0.0% 42 Individual Health District Report: District 3-1 The eligible sample from this district included 236 children born in January 2005. From the 236 children, 226 records were located (Response Rate=95.8%). Of the 226 located records, there were no parental refusals leaving a final sample of 226 records. The 4:3:1:3:3:1 immunization coverage estimate is 77.4% (175/226). This rate is lower than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 7: 4:3:1:3:3:1 Coverage for State and District 3-1 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 3-1 The 4:3:1:3 immunization coverage estimate is 79.6% (180/226). This rate is slightly lower than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 77.0% (174/226). This rate is slightly higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 43 Table 22: District Immunization Rates for Health District 3-1 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 76.6% 78.8% 3 OPV/IPV 83.4% 83.5% 1 MMR 80.7% 86.3% 3 Hib 82.1% 82.1% 3 HepB 86.2% 83.0% 1 Varicella 80.7% 83.5% 3 PCV --- 46.7% 4 PCV --- 23.1% *PCV data not collected before 2004. 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% Table 22 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 81.0% to 92.0% for the 2007 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%age 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: 2007 District Immunization Rates by Individual Vaccine at 12 months of age for Health District 3-1 Vaccine Dose Number Immunized DTP1/DTaP1 218 DTP2/DTaP2 211 DTP3/DTaP3 201 DTP4/DTaP4 0 DTP5/DTaP5 0 OPV/IPV1 221 OPV/IPV2 214 OPV/IPV3 149 OPV/IPV4 0 MMR1 10 MMR2 0 HIB1 220 HIB2 209 HIB3 74 HIB4 2 HIB5 0 HEPB1 224 HEPB2 216 HEPB3 160 HEPB4 60 VAR1 9 VAR2 0 PCV1 218 PCV2 212 PCV3 196 PCV4 9 PCV5 0 *Percent = number immunized / sample size Sample size = 226 Percent* 96.5% 93.4% 88.9% 0.0% 0.0% 97.8% 94.7% 65.9% 0.0% 4.4% 0.0% 97.3% 92.5% 32.7% 0.9% 0.0% 99.1% 95.6% 70.8% 26.5% 4.0% 0.0% 96.5% 93.8% 86.7% 4.0% 0.0% 45 Individual Health District Report: District 3-2 The eligible sample from this district included 342 children born in January 2005. From the 342 children, 323 records were located (Response Rate=94.4%). Of the 323 located records, there were 6 parental refusals leaving a final sample of 317 records. The 4:3:1:3:3:1 immunization coverage estimate is 59.3% (188/317). This rate is much lower than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 8: 4:3:1:3:3:1 Coverage for State and District 3-2 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 3-2 The 4:3:1:3 immunization coverage estimate is 61.5% (195/317). This rate is also much lower than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 58.4% (185/317). This rate is also much lower than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 46 Table 24: District Immunization Rates for Health District 3-2 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 68.1% 78.8% 3 OPV/IPV 71.7% 85.0% 1 MMR 71.0% 82.7% 3 Hib 72.5% 84.1% 3 HepB 74.6% 85.4% 1 Varicella 71.7% 81.4% 3 PCV --- 66.8% 4 PCV --- 35.8% *PCV data not collected before 2004. 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% Table 24 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 58.5% to 73.2% for the 2007 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%age 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: 2007 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 263 83.0% 247 77.9% 225 71.0% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 266 83.9% 251 79.2% 172 54.3% 0 0.0% MMR1 MMR2 7 2.2% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 265 83.6% 247 77.9% 80 25.2% 1 0.3% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 265 83.6% 247 77.9% 159 50.2% 7 2.2% VAR1 VAR2 9 2.8% 0 0.0% PCV1 262 PCV2 246 PCV3 213 PCV4 8 PCV5 0 *Percent = number immunized / sample size Sample size = 317 82.6% 77.6% 67.2% 2.5% 0.0% 48 Individual Health District Report: District 3-3 The eligible sample from this district included 186 children born in January 2005. From the 186 children, 152 records were located (Response Rate=81.7%). Of the 152 located records, there were no parental refusals leaving a final sample of 152 records. The 4:3:1:3:3:1 immunization coverage estimate is 69.7% (106/152). This rate is much lower than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 9: 4:3:1:3:3:1 Coverage for State and District 3-3 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 3-3 The 4:3:1:3 immunization coverage estimate is 73.0% (111/152). This rate is lower than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 68.4% (104/152). This rate is also lower than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 49 Table 26: District Immunization Rates for Health District 3-3 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 79.1% 67.4% 3 OPV/IPV 85.8% 74.4% 1 MMR 85.1% 75.6% 3 Hib 88.4% 76.7% 3 HepB 88.8% 77.9% 1 Varicella 84.7% 74.4% 3 PCV --- 30.2% 4 PCV --- 11.6% *PCV data not collected before 2004. 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% Table 26 reveals the coverage rates of each vaccine series. Coverage rates ranged from 54.6% to 91.4% for the 2007 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%age 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: 2007 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 149 98.0% 141 92.8% 127 83.6% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 149 98.0% 142 93.4% 110 72.4% 1 0.7% MMR1 MMR2 15 9.9% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 149 98.0% 140 92.1% 55 36.2% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 148 97.4% 146 96.1% 114 75.0% 4 2.6% VAR1 VAR2 19 12.5% 0 0.0% PCV1 145 PCV2 135 PCV3 118 PCV4 5 PCV5 0 *Percent = number immunized / sample size Sample size = 152 95.4% 88.8% 77.6% 3.3% 0.0% 51 Individual Health District Report: District 3-4 The eligible sample from this district included 87 children born in January 2005. From the 87 children, 82 records were located (Response Rate=94.3%). Of the 82 located records, there was 1 parental refusal leaving a final sample of 81 records. The 4:3:1:3:3:1 immunization coverage estimate is 92.6% (75/81). This rate is much higher than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 10: 4:3:1:3:3:1 Coverage for State and District 3-4 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 3-4 The 4:3:1:3 immunization coverage estimate is 93.8% (76/81). This rate is also much higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 92.6% (75/81). This rate is also much higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 52 Table 28: District Immunization Rates for Health District 3-4 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 90.0% 94.1% 3 OPV/IPV 90.0% 96.1% 1 MMR 90.0% 96.1% 3 Hib 90.0% 96.7% 3 HepB 90.0% 96.7% 1 Varicella 90.0% 94.1% 3 PCV --- 76.5% 4 PCV --- 40.5% *PCV data not collected before 2004. 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% Table 28 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 88.9% to 96.3% for the 2007 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%age 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: 2007 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 78 96.3% 77 95.1% 74 91.4% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 78 96.3% 77 95.1% 50 61.7% 0 0.0% MMR1 MMR2 2 2.5% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 78 96.3% 77 95.1% 24 29.6% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 78 96.3% 78 96.3% 59 72.8% 12 14.8% VAR1 VAR2 3 3.7% 0 0.0% PCV1 77 PCV2 75 PCV3 73 PCV4 2 PCV5 0 *Percent = number immunized / sample size Sample size = 81 95.1% 92.6% 90.1% 2.5% 0.0% 54 Individual Health District Report: District 3-5 The eligible sample from this district included 243 children born in January 2005. From the 243 children, 224 records were located (Response Rate=92.2%). Of the 224 located records, there were 3 parental refusals leaving a final sample of 221 records. The 4:3:1:3:3:1 immunization coverage estimate is 77.8% (172/221). This rate is slightly lower than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 11: 4:3:1:3:3:1 Coverage for State and District 3-5 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 3-5 The 4:3:1:3 immunization coverage estimate is 81.4% (180/221). This rate is slightly higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 76.5% (169/221). This rate is nearly equal to the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 55 Table 30: District Immunization Rates for Health District 3-5 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 66.0% 82.4% 3 OPV/IPV 82.0% 89.5% 1 MMR 80.7% 90.8% 3 Hib 76.0% 88.3% 3 HepB 78.0% 89.1% 1 Varicella 74.0% 89.5% 3 PCV --- 43.5% 4 PCV --- 19.7% *PCV data not collected before 2004. 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% Table 30 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 73.8% to 90.0% for the 2007 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%age 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: 2007 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 212 95.9% 209 94.6% 192 86.9% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 212 95.9% 208 94.1% 106 48.0% 0 0.0% MMR1 MMR2 8 3.6% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 212 95.9% 205 92.8% 54 24.4% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 214 96.8% 208 94.1% 125 56.6% 0 0.0% VAR1 VAR2 9 4.1% 0 0.0% PCV1 208 PCV2 203 PCV3 181 PCV4 6 PCV5 0 *Percent = number immunized / sample size Sample size = 221 94.1% 91.9% 81.9% 2.7% 0.0% 57 Individual Health District Report: District 4-0 The eligible sample from this district included 245 children born in January 2005. From the 245 children, 226 records were located (Response Rate=92.2%). Of the 226 located records, there was 1 parental refusal leaving a final sample of 225 records. The 4:3:1:3:3:1 immunization coverage estimate is 78.7% (177/225). This rate is slightly higher than the statewide 4:3:1:3:3:1 immunization rate of 78% Figure 12: 4:3:1:3:3:1 Coverage for State and District 4-0 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 4-0 The 4:3:1:3 immunization coverage estimate is 81.3% (183/225). This rate is also slightly higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 76.0% (171/225). This rate is slightly lower than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6% 58 Table 32: District Immunization Rates for Health District 4-0 by Study Year Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 84.5% 79.1% 3 OPV/IPV 92.7% 85.6% 1 MMR 92.7% 85.0% 3 Hib 87.3% 86.6% 3 HepB 92.7% 86.1% 1 Varicella 92.7% 85.0% 3 PCV --- 32.1% 4 PCV --- 9.1% *PCV data not collected before 2004. 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% Table 32 reveals the coverage rates of each vaccine series. Coverage rates ranged from 71.1% to 93.3% for the 2007 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%age 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: 2007 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 218 96.9% 214 95.1% 196 87.1% 2 0.9% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 219 97.3% 215 95.6% 153 68.0% 1 0.4% MMR1 MMR2 7 3.1% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 220 97.8% 215 95.6% 51 22.7% 1 0.4% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 219 97.3% 216 96.0% 158 70.2% 30 13.3% VAR1 VAR2 7 3.1% 0 0.0% PCV1 213 PCV2 204 PCV3 172 PCV4 3 PCV5 0 *Percent = number immunized / sample size Sample size = 184 94.7% 90.7% 76.4% 1.3% 0.0% 60 Individual Health District Report: District 5-1 The eligible sample from this district included 68 children born in January 2005. From the 68 children, 67 records were located (Response Rate=98.5%). Of the 67 located records, there was 1 parental refusal leaving a final sample of 66 records. The 4:3:1:3:3:1 immunization coverage estimate 78.8% (52/66). This rate is slightly higher than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 13: 4:3:1:3:3:1 Coverage for State and District 5-1 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 5-1 The 4:3:1:3 immunization coverage estimate 92.4% (61/66). This rate is much higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate 77.3% (51/66). This rate is higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 61 Table 34: District Immunization Rates for Health District 5-1 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 93.3% 85.5% 3 OPV/IPV 97.8% 92.7% 1 MMR 97.8% 90.9% 3 Hib 97.8% 87.3% 3 HepB 96.7% 90.9% 1 Varicella 95.6% 90.9% 3 PCV --- 23.6% 4 PCV --- 3.6% *PCV data not collected before 2004. 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% Table 34 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 78.8% to 98.5% for the 2007 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%age 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: 2007 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 65 98.5% 65 98.5% 59 89.4% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 65 98.5% 65 98.5% 46 69.7% 0 0.0% MMR1 MMR2 4 6.1% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 65 98.5% 65 98.5% 12 18.2% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 65 98.5% 64 97.0% 47 71.2% 6 9.1% VAR1 VAR2 2 3.0% 0 0.0% PCV1 65 PCV2 65 PCV3 57 PCV4 2 PCV5 0 *Percent = number immunized / sample size Sample size = 66 98.5% 98.5% 86.4% 3.0% 0.0% 63 Individual Health District Report: District 5-2 The eligible sample from this district included 86 children born in January 2005. From the 86 children, 81 records were located (Response Rate=94.2%). Of the 81 located records, there were 3 parental refusals leaving a final sample of 78 records. The 4:3:1:3:3:1 immunization coverage estimate is 75.6% (59/78). This rate is lower to the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 14: 4:3:1:3:3:1 Coverage for State and District 5-2 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 5-2 The 4:3:1:3 immunization coverage estimate is 80.8% (63/78). This rate is equal to the statewide 4:3:1:3 immunization rate. The 4:3:1:3:3:1:3 immunization coverage estimate is 74.4% (58/78). This rate is lower than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 64 Table 36: District Immunization Rates for Health District 5-2 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 84.9% 87.1% 3 OPV/IPV 93.7% 93.2% 1 MMR 96.8% 93.2% 3 Hib 91.3% 91.2% 3 HepB 93.7% 91.8% 1 Varicella 92.9% 91.2% 3 PCV --- 39.5% 4 PCV --- 15.0% *PCV data not collected before 2004. 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% Table 36 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 84.6% to 93.6% for the 2007 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: 2007 District Immunization Rates by Individual Vaccine at 12 Months of Age for Health District 5-2 Vaccine Dose Number Immunized DTP1/DTaP1 76 DTP2/DTaP2 75 DTP3/DTaP3 69 DTP4/DTaP4 0 DTP5/DTaP5 0 OPV/IPV1 76 OPV/IPV2 75 OPV/IPV3 59 OPV/IPV4 0 MMR1 2 MMR2 0 HIB1 75 HIB2 73 HIB3 14 HIB4 1 HIB5 0 HEPB1 77 HEPB2 75 HEPB3 50 HEPB4 10 VAR1 2 VAR2 0 PCV1 76 PCV2 74 PCV3 69 PCV4 2 PCV5 0 *Percent = number immunized / sample size Sample size = 78 Percent* 97.4% 96.2% 88.5% 0.0% 0.0% 97.4% 96.2% 75.6% 0.0% 2.6% 0.0% 96.2% 93.6% 17.9% 1.3% 0.0% 98.7% 96.2% 64.1% 12.8% 2.6% 0.0% 97.4% 94.9% 88.5% 2.6% 0.0% 66 Individual Health District Report: District 6-0 The eligible sample from this district included 47 children born in January 2005. From the 47 children, 47 records were located (Response Rate=100%). Of the 47 located records, there were no parental refusals leaving a final sample of 47 records. The 4:3:1:3:3:1 immunization coverage estimate is 97.9% (46/47). This rate is much higher than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 15: 4:3:1:3:3:1 Coverage for State and District 6-0 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 6-0 The 4:3:1:3 immunization coverage estimate is 97.9% (46/47). This rate is also much higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 97.9% (46/47). This rate is also much higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 67 Table 38: District Immunization Rates for Health District 6-0 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 87.8% 90.5% 3 OPV/IPV 91.9% 94.8% 1 MMR 91.9% 95.7% 3 Hib 93.5% 92.2% 3 HepB 95.1% 94.0% 1 Varicella 90.2% 94.8% 3 PCV --- 54.3% 4 PCV --- 23.3% *PCV data not collected before 2004. 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% Table 38 reveals the coverage rates of each vaccine series. Coverage rates ranged from 89.4% to 100.0% for the 2007 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%age 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: 2007 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 46 97.9% 46 97.9% 43 91.5% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 46 97.9% 46 97.9% 33 70.2% 0 0.0% MMR1 MMR2 1 2.1% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 46 97.9% 46 97.9% 19 40.4% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 46 97.9% 46 97.9% 36 76.6% 1 2.1% VAR1 VAR2 1 2.1% 0 0.0% PCV1 44 PCV2 44 PCV3 40 PCV4 0 PCV5 0 *Percent = number immunized / sample size Sample size = 47 93.6% 93.6% 85.1% 0.0% 0.0% 69 Individual Health District Report: District 7-0 The eligible sample from this district included 112 children born in January 2005. From the 112 children, 105 records were located (Response Rate=93.8%). Of the 100 located records, there were no parental refusals leaving a final sample of 105 records. The 4:3:1:3:3:1 immunization coverage estimate is 76.2% (80/105). This rate is lower than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 16: 4:3:1:3:3:1 Coverage for State and District 7-0 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 7-0 The 4:3:1:3 immunization coverage estimate is 77.1% (90/100). This rate is also lower than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 75.2% (79/105). This rate is also lower than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 70 Table 40: District Immunization Rates for Health District 7-0 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 77.1% 88.4% 3 OPV/IPV 85.0% 93.5% 1 MMR 87.9% 93.0% 3 Hib 85.7% 93.0% 3 HepB 87.9% 93.5% 1 Varicella 85.7% 93.5% 3 PCV --- 34.2% 4 PCV --- 10.1% *PCV data not collected before 2004. 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% Table 40 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 68.6% to 91.4% for the 2007 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%age 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: 2007 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 100 95.2% 96 91.4% 87 82.9% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 100 95.2% 96 91.4% 46 43.8% 0 0.0% MMR1 MMR2 3 2.9% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 99 94.3% 95 90.5% 44 41.9% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 101 96.2% 100 95.2% 70 66.7% 2 1.9% VAR1 VAR2 4 3.8% 0 0.0% PCV1 100 PCV2 94 PCV3 80 PCV4 4 PCV5 0 *Percent = number immunized / sample size Sample size = 105 95.2% 89.5% 76.2% 3.8% 0.0% 72 Individual Health District Report: District 8-1 The eligible sample from this district included 104 children born in January 2005. From the 104 children, 95 records were located (Response Rate=91.3%). Of the 95 located records, there were no parental refusals leaving a final sample of 95 records. The 4:3:1:3:3:1 immunization coverage estimate is 86.3% (82/95). This rate is higher than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 17: 4:3:1:3:3:1 Coverage for State and District 8-1 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 8-1 The 4:3:1:3 immunization coverage estimate is 87.4% (83/95). This rate is also higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 84.2% (80/95). This rate is also higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 73 Table 42: District Immunization Rates for Health District 8-1 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 91.9% 89.5% 3 OPV/IPV 96.0% 96.1% 1 MMR 95.2% 92.1% 3 Hib 95.2% 94.7% 3 HepB 96.0% 96.1% 1 Varicella 94.4% 92.1% 3 PCV --- 39.5% 4 PCV --- 13.2% *PCV data not collected before 2004. 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% Table 42 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 80.0% to 97.9% for the 2007 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%age 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: 2007 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 94 98.9% 94 98.9% 90 94.7% 1 1.1% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 94 98.9% 93 97.9% 66 69.5% 0 0.0% MMR1 MMR2 3 3.2% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 94 98.9% 94 98.9% 15 15.8% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 95 100.0% 94 98.9% 58 61.1% 5 5.3% VAR1 VAR2 7 7.4% 0 0.0% PCV1 92 PCV2 91 PCV3 86 PCV4 4 PCV5 0 *Percent = number immunized / sample size Sample size = 95 96.8% 95.8% 90.5% 4.2% 0.0% 75 Individual Health District Report: District 8-2 The eligible sample from this district included 169 children born in January 2005. From the 169 children, 165 records were located (Response Rate=97.6%). Of the 165 located records, there were no parental refusals leaving a final sample of 165 records. The 4:3:1:3:3:1 immunization coverage estimate rate is 81.2% (134/165). This rate is higher than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 18: 4:3:1:3:3:1 Coverage for State and District 8-2 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 8-2 The 4:3:1:3 immunization coverage estimate rate is 81.8% (135/165). This rate is also higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate rate is 80.6% (133/165). This rate is also higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 76 Table 44: District Immunization Rates for Health District 8-2 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 75.3% 94.9% 3 OPV/IPV 80.7% 97.7% 1 MMR 81.3% 97.7% 3 Hib 81.3% 98.3% 3 HepB 82.0% 97.7% 1 Varicella 78.0% 97.7% 3 PCV --- 38.9% 4 PCV --- 8.0% *PCV data not collected before 2004. 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% Table 44 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 70.9% to 93.9% for the 2007 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%age 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: 2007 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 162 98.2% 157 95.2% 147 89.1% 1 0.6% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 162 98.2% 157 95.2% 104 63.0% 0 0.0% MMR1 MMR2 3 1.8% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 162 98.2% 155 93.9% 56 33.9% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 163 98.8% 162 98.2% 123 74.5% 5 3.0% VAR1 VAR2 2 1.2% 0 0.0% PCV1 159 PCV2 149 PCV3 133 PCV4 0 PCV5 0 *Percent = number immunized / sample size Sample size = 165 96.4% 90.3% 80.6% 0.0% 0.0% 78 Individual Health District Report: District 9-1 The eligible sample from this district included 147 children born in January 2005. From the 147 children, 141 records were located (Response Rate=95.9%). Of the 141 located records, there was 1 parental refusal leaving a final sample of 140 records. The 4:3:1:3:3:1 immunization coverage estimate is 76.4% (107/140). This rate is lower than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 19: 4:3:1:3:3:1 Coverage for State and District 9-1 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 9-1 The 4:3:1:3 immunization coverage estimate is 82.1% (115/140). This rate is higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 72.9% (102/140). This rate is lower than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 79 Table 46: District Immunization Rates for Health District 9-1 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 77.3% 97.5% 3 OPV/IPV 88.7% 98.8% 1 MMR 90.0% 98.8% 3 Hib 87.3% 98.8% 3 HepB 79.3% 100% 1 Varicella 83.3% 98.8% 3 PCV --- 53.1% 4 PCV --- 17.3% *PCV data not collected before 2004. 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% Table 46 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 73.6% to 90.7% for the 2007 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%age 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: 2007 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 134 95.7% 128 91.4% 121 86.4% 1 0.7% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 134 95.7% 127 90.7% 95 67.9% 1 0.7% MMR1 MMR2 3 2.1% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 133 95.0% 126 90.0% 39 27.9% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 136 97.1% 128 91.4% 75 53.6% 3 2.1% VAR1 VAR2 1 0.7% 0 0.0% PCV1 127 PCV2 121 PCV3 107 PCV4 2 PCV5 0 *Percent = number immunized / sample size Sample size = 140 90.7% 86.4% 76.4% 1.4% 0.0% 81 Individual Health District Report: District 9-2 The eligible sample from this district included 145 children born in January 2005. From the 145 children, 133 records were located (Response Rate=91.7%). Of the 133 located records, there were 4 parental refusals leaving a final sample of 129 records. The 4:3:1:3:3:1 immunization coverage estimate is 84.5% (109/129). This rate is higher than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 20: 4:3:1:3:3:1 Coverage for State and District 9-2 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 9-2 The 4:3:1:3 immunization coverage estimate is 87.6% (113/129). This rate is also higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 82.2% (106/129). This rate is also higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 82 Table 48: District Immunization Rates for Health District 9-2 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 82.6% 83.0% 3 OPV/IPV 88.4% 90.4% 1 MMR 90.6% 89.6% 3 Hib 86.2% 91.1% 3 HepB 87.7% 90.4% 1 Varicella 91.3% 90.4% 3 PCV --- 39.3% 4 PCV --- 5.2% *PCV data not collected before 2004. 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% Table 48 reveals the coverage rates of each vaccine series. Coverage rates ranged from 75.2% to 94.6% for the 2007 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%age 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: 2007 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 125 96.9% 121 93.8% 113 87.6% 0 0.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 125 96.9% 121 93.8% 92 71.3% 0 0.0% MMR1 MMR2 6 4.7% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 124 96.1% 119 92.2% 18 14.0% 1 0.8% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 127 98.4% 122 94.6% 96 74.4% 16 12.4% VAR1 VAR2 5 3.9% 0 0.0% PCV1 125 PCV2 121 PCV3 107 PCV4 3 PCV5 0 *Percent = number immunized / sample size Sample size = 129 96.9% 93.8% 82.9% 2.3% 0.0% 84 Individual Health District Report: District 10-0 The eligible sample from this district included 111 children born in January 2005. From the 111 children, 105 records were located (Response Rate=94.6%). Of the 105 located records, there was 1 parental refusal leaving a final sample of 104 records. The 4:3:1:3:3:1 immunization coverage estimate is 83.7% (87/104). This rate is higher than the statewide 4:3:1:3:3:1 immunization rate of 78%. Figure 21: 4:3:1:3:3:1 Coverage for State and District 10-0 100 90 80 70 60 50 40 30 20 10 0 2006 2007 State Dist 10-0 The 4:3:1:3 immunization coverage estimate is 85.6% (89/104). This rate is also higher than the statewide 4:3:1:3 immunization rate of 80.8%. The 4:3:1:3:3:1:3 immunization coverage estimate is 82.7% (86/104). This rate is also higher than the statewide 4:3:1:3:3:1:3 immunization rate of 76.6%. 85 Table 50: District Immunization Rates for Health District 10-0 by Study Year* Vaccine 2003 2004 Adequate Adequate Rates Rates 4 DTP/DTaP 93.2% 94.3% 3 OPV/IPV 93.2% 98.9% 1 MMR 93.8% 97.7% 3 Hib 95.7% 95.5% 3 HepB 95.1% 94.3% 1 Varicella 95.7% 94.3% 3 PCV --- 60.2% 4 PCV --- 25.0% *PCV data not collected before 2004. 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% Table 50 reveals the coverage rates of each vaccine series. Vaccine coverage rates ranged from 76.0% to 93.3% for the 2007 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: 2007 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 103 99.0% 102 98.1% 94 90.4% 1 1.0% 0 0.0% OPV/IPV1 OPV/IPV2 OPV/IPV3 OPV/IPV4 103 99.0% 102 98.1% 61 58.7% 0 0.0% MMR1 MMR2 6 5.8% 0 0.0% HIB1 HIB2 HIB3 HIB4 HIB5 103 99.0% 100 96.2% 27 26.0% 0 0.0% 0 0.0% HEPB1 HEPB2 HEPB3 HEPB4 102 98.1% 102 98.1% 43 41.3% 0 0.0% VAR1 VAR2 4 3.8% 0 0.0% PCV1 102 PCV2 100 PCV3 87 PCV4 1 PCV5 0 *Percent = number immunized / sample size Sample size = 104 98.1% 96.2% 83.7% 1.0% 0.0% 87 Section V: Discussion 88 Section V: Discussion Summary The purpose of the eleventh 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 2007. To assess these rates, the study drew an original sample of 2,742 children born in January 2005. The final sample of returned immunization records totaled 2,742. After removal of ineligible children (those deceased, adopted, moved out of state, born in military hospitals) the eligible sample was 2,658. Of these, 2,461 records were located and make up the final sample. The eleventh year of the GIS, 2007, measured immunization coverage for children born in 2005 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 4:3:1:3 coverage, defined as 4 DTaP, 3 OPV/IPV, 1 MMR and 3 Hib Of these three coverage levels, 4:3:1:3 coverage rates were highest and 4:3:1:3:3:1:3 rates were generally the lowest 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. *It must be remembered that the 2007 study is estimating 2005 rates. The 2006 study is estimating 2004 rates, 2005 study estimated 2003 rates, 2004 study estimated 2002 rates and the 2003 study estimated rates for 2001. 89 The 2007 results reflect immunization rates for children born in 2005. The results of the study indicate that, of the 2,461 children whose immunization records were located during data collection: 78.0% of children born in January of 2005 in Georgia were adequately immunized with the 4:3:1:3:3:1 vaccine series. 80.8% of children born in January of 2005 in Georgia were adequately immunized with the 4:3:1:3 vaccine series. 76.6% of children born in January of 2005 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 eleventh study year, 81.2% 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 increased slightly in the 2007 study (76.8% to 78.0%). The 2007 Georgia Immunization Study measured Varicella rates for the tenth 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 stabile statewide from the 2005 study (76.5%) to the 2006 study (76.8%), increasing slightly in the 2007 study (78.0%), as mentioned above. The rates for the 4:3:1:3 90 vaccine series have also been fairly stabile over the past few study years, increasing only slightly from the 2005 study (79.5%) to the 2007 study (80.8%). The results of the previous four years of the study (2003, 2004, 2005 and 2006) show that immunization-specific coverage rates for the state have remained relatively similar. Strengths 1. This study represents Georgia's eleventh 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 2003, 2004, 2005, 2006 and 2007 in Georgia. 4. As a measure of reliability for the data entry process, double data entry was conducted on 5% of all records entered. The data entry error rate is approximately 3% for the 2007 study. 5. The implementation of the Georgia Registry of Immunizations and Transaction Services (GRITS) has assisted with locating immunization records. The response rate for 2007 was 93.5%, which is 5% increase over the 2006 study. 91 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 2005 and, thus, represented a generalizable estimate of coverage rates for all two-year-olds born in 2005, 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). 92 APPENDIX A: DESCRIPTION OF SAMPLING PLAN AND STATISTICAL NOTE 93 APPENDIX A: DESCRIPTION OF SAMPLING PLAN AND STATISTICAL NOTE The target population for this study was children born in the state of Georgia in 2005 who were residing in the state in 2007. 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 2005 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 2005. 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 2007. 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%age they represented of the total population. For a description of sample sizes, see Table 52: Data Used for Sample Size Estimates for the 2007 Study. Response rates and immunization coverage levels from the 2006 study were used in the sample size calculation for the 2007 study. The sample sizes were adjusted for small population size. The desired 94 sample size was then increased by a factor equivalent to the non-response rate (non-locatable immunization records) for each district from the 2005 study. The final calculated sample size is shown in the last column (Column H) of Table 52. 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 81.7% to a high of 100.0%, with the average response rate for the state at 93.5%. 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. 95 Table 52: Data Used for Sample Size Estimates for the 2007 Study A Health District 1-1 B Jan 2005 Total Births 737 C Jan 2005 Eligible Births 721 D 2006 4:3:1 Immunization Rates 0.81 E F 2007 2007 First Second Sample Sample Estimate Estimate 236 178 G Return Rate based on 2006 Eligible Sample 0.907 H 2007 Adjusted Sample Size 196 1-2 556 545 0.999 50 50 0.999 50 2-0 676 666 0.926 105 91 0.966 94 3-1 970 952 0.743 293 224 0.907 247 3-2 1,059 1,033 0.686 331 251 0.77 326 3-3 408 397 0.768 274 162 0.812 200 3-4 1,310 1,280 0.949 74 70 0.945 74 3-5 953 927 0.737 29 225 0.824 274 4-0 892 861 0.739 296 220 0.885 249 5-1 149 148 0.896 143 73 0.98 74 5-2 619 604 0.931 99 85 0.964 88 6-0 538 518 0.986 50 50 0.987 50 7-0 456 388 0.9 138 102 0.909 112 8-1 298 294 0.897 142 96 0.906 106 8-2 415 403 0.764 277 164 0.914 180 9-1 692 585 0.845 201 150 0.949 158 9-2 443 432 0.829 218 145 0.969 149 10-0 448 430 0.903 135 103 0.892 115 State 11,619 11,184 0.808 2,742 96 Figure 22: Explanations of Table 52 Data Used for Sample Size Estimates For the 2007 Study Column A: Health District Column B: January 2005 Total Births Column C: January 2005 Eligible Births Column D: 2006 4:3:1 Immunization Rates Column E: First Sample Estimate 2007 Study Column F: Second Sample Estimate 2007 Study Column G: Estimated Return Rate (Based on 2006 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 2007 Study Formula Used: (Column F) / (Column G) 97 APPENDIX B: LIST OF 2007 PUBLIC HEALTH REPRESENTATIVES FOR THE GEORGIA IMMUNIZATION STUDY 98 APPENDIX B: LIST OF 2007 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. Joy Stymest Karen Dibling, R.N., B.S.N. Georgia Goseer, R.N. Jessica Harris Freda Sheppard, L.P.N. Brenda Crowe Gloria Melvin Vivian Womack Joyce Hess, R.N. Tina Dempsey, L.P.N. Deborah Cox, L.P.N. Amy Fenn, RN Donna Forth, R.N. Kelly Knight Debbie Liby, R.N. Evans Ward, M.S. Melba McNorrill, R.N. Clois Witt, R.N., B.S.N. Beverly Roberson, R.N., B.S.N. Yugonda Thomas Courtney D. Sheeley, M.P.A. D. Geneine Godfrey, M.P.H. Sue Dale Edward W. Sullivan Marianne Pappas, R.N. Cathy Schmidt, R.N. Joanne Burnsed, B.S.N. Nan Swindell, B.S.N. Katie Golden, B.S.N. Barbara Scott, R.N. Annie Washington, R.N. Debbie Melton, R.N. Karen Mikell, R.N. 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 Barbie Bushey, R.N., C.P.N., M.P.H. 99 APPENDIX C: DATA COLLECTION FORM 100 101 102 APPENDIX D: VARICELLA VACCINE AND CHICKEN POX DATA 103 APPENDIX D: Varicella Vaccine and Chicken Pox Data Table 53 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. 104 Table 53: 2007 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 162 42 79 190 215 122 76 186 193 56 65 46 92 88 147 119 116 92 Statewide 2,086 % 89.0 95.5 94.0 84.1 67.8 80.3 93.8 84.2 85.8 84.8 83.3 97.9 87.6 92.6 89.1 85.0 89.9 88.5 84.8 Number 164 43 83 196 223 126 78 197 200 64 72 47 94 90 149 124 122 97 2,169 % 90.1 97.7 98.8 86.7 70.3 82.9 96.3 89.1 88.9 97.0 92.3 100.0 89.5 94.7 90.3 88.6 94.6 93.3 88.1 Number 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 % 0.5 0.0 0.0 0.4 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 0.08 105 Figure 23: 2007 State Varicella Coverage Rates and Percentage of Sample with Chicken Pox Disease 90 80 70 60 50 40 30 20 10 0 STATE Vaccine By Two Vaccine Anytime With disease Figure 23 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%age of children with documented chicken pox disease at any point in time. 106 Appendix E: Provider of Immunizations 107 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%age of shots given at each of the provider categories is shown in Table 54. Table 54: Statewide%age of Shots by Provider: 2003, 2004, 2005, 2006, and 2007 Provider 2003 2004 2005 2006 2007 Public Health Dept Private Physician Total # 5,873 26,95 6 % 16.3 74.8 Total # 5,449 26,73 4 % 14.3 70.1 Total % # 6,013 13.2 35,06 77.1 5 Total # 4,793 33,26 8 % 11.6 80.5 Total # 4,307 35,51 8 % 9.8 81.2 Unknown 3,205 8.9 5,966 15.6 4,407 9.7 3,256 7.9 3,916 9.0 Total 36,03 100.0 38,14 100.0 45,48 100.0 41,31 100.0 43,741 100.0 4 9 5 7 As shown in Table 54, in 2007, over 80% of the shots recorded for the sampled children were given by a private provider. 108 Location of Immunizations by District Table 55 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 55: District Specific%age of Shots by Provider 2007 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 % 335 9.9 76 9.0 157 9.8 376 9.0 170 3.6 202 7.6 63 4.1 116 3.0 415 10.2 167 13.6 236 16.6 101 11.1 269 14.4 271 15.1 80 2.7 346 14.2 739 31.4 188 10.0 4,307 9.8 # Shots Given % 2,975 87.5 705 83.6 1,437 89.4 1,856 44.5 4,413 93.9 1,959 73.9 1,461 95.9 3,601 92.9 3,359 82.5 903 73.4 1,087 76.4 789 86.6 1,557 83.4 1,518 84.9 2,860 95.1 1,942 79.4 1,416 60.1 1,680 89.7 35,518 81.2 # Shots Given % 91 2.7 62 7.4 13 0.8 1,938 46.5 115 2.4 489 18.5 0 0.0 158 4.1 297 7.3 161 13.1 100 7.0 21 2.3 41 2.2 0 0.0 68 2.3 157 6.4 201 8.5 4 0.2 3,916 9.0 Total Shots Given 3,401 843 1,607 4,170 4,698 2,650 1,524 3,875 4,071 1,231 1,423 911 1,867 1,789 3,008 2,445 2,356 1,872 43,741 109 In Year Ten: In seventeen health districts more than 50% of the shots were given by 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 (46.5%). 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 (31.4%). 110 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 56: Location of Immunizations by District Four Year Comparison 2004, 2005, 2006, and 2007 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 2004 8.0 14.4 15.2 16.0 24.8 12.8 0.6 8.9 10.6 13.2 20.1 14.8 25.9 22.1 11.9 11.3 38.3 7.2 9.4 14.3 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 2004 73.9 76.2 85.4 42.6 69.4 69.4 95.5 45.7 50.9 76.1 61.8 85.0 71.5 77.6 86.0 87.4 60.6 88.8 88.6 70.1 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 81.2 111 Four-Year Comparison: Summary of Table 56: In 2004 In 2005 In 2006 In 2007 14.3% of the shots were received at the public health department 70.1% of the shots were given in the private sector 15.6% of the shot locations were unknown 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 112 APPENDIX F: MARGINS OF ERROR FOR IMMUNIZATION COVERAGE RATES 113 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 2007 is between 76.4% and 79.6%. 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. 114 Table 57: Margins of Error for 2007 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) 182 44 84 226 317 152 81 221 225 66 78 47 105 95 165 140 129 104 Statewide Rate (weighted) 2,461 4:3:1:3:3:1 Immunization Coverage Rates (percent) 82.4 93.2 94.0 77.4 59.3 69.7 92.6 77.8 78.7 78.8 75.6 97.9 76.2 86.3 81.2 76.4 84.5 83.7 Margins of Error (percent) +/- 5.5 +/- 7.4 +/- 5.1 +/- 5.5 +/- 5.4 +/- 7.3 +/- 5.7 +/- 5.5 +/- 5.3 +/- 9.9 +/- 9.5 +/- 4.1 +/- 8.1 +/- 6.9 +/- 6.0 +/- 7.0 +/- 6.2 +/- 7.1 95% Confidence Intervals (percent) 76.9 87.9 85.8 100.6 88.9 99.1 71.9 82.9 53.9 64.7 62.4 77.0 86.9 98.3 72.3 83.3 73.4 84 68.9 88.7 66.1 85.1 93.8 102.0 68.1 84.3 79.4 93.2 75.2 87.2 69.4 83.4 78.3 90.7 76.6 90.8 78.0 +/- 1.6 76.4 79.6 115