Issue: June 2013
June 01, 2013
10 min read

Gaps closing in immunization coverage rates

Issue: June 2013
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In 2009, data from the National Immunization Survey demonstrated disparities in vaccination coverage between white children and those of other races or ethnicities.

During a recent CDC Public Health Grand Rounds, immunization experts discussed the ways immunization efforts have served to reduce disparities in childhood infectious diseases and demonstrated an effective and cost-effective tool for advancing health equity. Targeted efforts to reach children in certain ethnic and racial groups helped to bridge the coverage gaps, and the current coverage levels for most vaccines among other racial/ethnic groups are similar to or higher than coverage levels among white children, according to CDC data.

“Immunization, even when it can’t lead to eradication of disease with current tools, can make remarkable improvements in health and remarkable reductions in health disparities,” CDC Director Thomas Frieden, MD, MPH, said during his presentation. “As such, it’s important to understand how immunization has been successful and what the lessons are for our other programs in public health in working to reduce health disparities, to work effectively with clinical systems and to unleash the power of science and public health on tackling leading health problems of our times.”

Chesley Richards, MD, MPH, director of the Immunization Services Division in the National Center for Immunization and Respiratory Diseases at CDC, said immunization rates have changed in recent years as a result of targeted immunization efforts and more widespread access to certain vaccines, including the measles-mumps-rubella, polio, and diphtheria-tetanus-acellular pertussis vaccines.

Despite these strides, more work remains to maintain the progress that has been made so far, according to the panel of Grand Round speakers.

Alan R. Hinman, MD, MPH, from the Center for Vaccine Equity, said that vaccination campaigns need to be increased across the globe.

Alan R. Hinman, MD, MPH, from the
Center for Vaccine Equity, said that
vaccination campaigns need to be
increased across the globe.

Photo courtesy of Hinman AR

“Important ongoing priorities include eliminating remaining coverage disparities, continuing to assure that cost is not a barrier to vaccination and preventing disease through maintaining high coverage at the overall population level and for vulnerable population groups,” Richards said.

The good news

Regarding MMR vaccine, CDC data indicate that in 1985, 64% of preschool-aged white children and 49% of nonwhite children were reported by their parents to be appropriately vaccinated with a measles-containing vaccine. As a result of outreach efforts designed specifically to close the disparities between whites and other ethnicities, this gap closed considerably with provider-verified coverage. The rates increased to 92% for whites and 89% for blacks by June 2001.

As for polio, Richards said disparities existed previously between white children and Hispanic and black children. However, concerted efforts to boost vaccination rates among minorities resulted in vaccination increases among hispanics, from 87% in 1995 to 93% by 2004. Since then, gaps in polio vaccine coverage have closed, and by 2007, rates for white, Hispanic and black children have been nearly equal.

Coverage also has increased for the DTaP vaccine, increasing from 75% to 84% among black children between 1995 and 2011; from 74% to 81% for black children; and from 80% to 85% for white children. According to CDC data from the 2011-2012 school year on vaccination coverage among kindergarten children, the median coverage levels for DTaP, poliovirus and HepB vaccines were at or above the Healthy People 2020 target of 95%.

Trudy Murphy, MD, team lead for Vaccine Research and Policy at the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at CDC, highlighted the success seen with hepatitis A vaccine. In the early 1990s, she said, “striking disparities were noted by race and ethnicity, with American Indian and Alaska Native people at 104 cases per 100,000 population, which was 10 times higher than the national average. The rate among Hispanics was 21, which was twice the national average.”

After the approval of the hepatitis A vaccines, however, and a push between 1996 and 1999 for vaccination in the 17 states with the highest hepatitis A rates, and then subsequent recommendations in 2006 for routine childhood hepatitis A vaccination, the rates decreased drastically.

“Striking declines were noted by race and ethnicities, with rates among Native American and Alaska Native peoples, Hispanics, blacks and whites all dropping by at least 95%,” Murphy said.

This progress toward elimination of hepatitis A disease, with the near elimination of vaccination disparities by race and geography, must be maintained, she said. Therefore, it will be important to increase routine hepatitis A vaccination among children and other at-risk groups, and adolescents also should be considered for routine hepatitis A vaccination, Murphy added.

Thomas W. Hennessy, MD, MPH, who is director of the Arctic Investigations Program in the National Center for Emerging and Zoonotic Infectious Diseases at CDC, said similar progress was seen with hepatitis B vaccination and Alaska Natives.

“Hepatitis B immunization coverage among Alaska Natives has been high since 1996. … As a result of this, acute symptomatic infection has dropped from 19 cases per 100,000 in 1981 to no cases since 1992,” Hennessy said.

Opportunities for continued progress

Despite a report from the Department of Health and Human Services that stated “the majority of Healthy People 2010 objectives for early childhood vaccination coverage were met by the end of 2010,” opportunities remain to reach those people who continue to fall through the immunization cracks, according to the CDC panel.

The Vaccines for Children program — a federal entitlement program that provides vaccine at no cost for eligible children — has been effective in reducing potential gaps in coverage levels resulting from poverty status and should be discussed in clinicians’ offices as an effective tool for assisting families who want their children to receive the recommended Advisory Committee on Immunization Practices vaccines.

“School immunization requirements have increased pressure on parents and the VFC program has helped assure that financing is not a barrier to immunizations,” said Alan R. Hinman, MD, MPH, who is director for programs at the Center for Vaccine Equity at The Task Force for Global Health. “When you combine those factors with an enthusiastic core of providers, that’s how you ensure success.”

Infectious Diseases in Children Editorial Board member William T. Gerson, MD, said beyond discussing vaccine availability with parents, it also is important to address directly any concerns over vaccines. In his Vermont practice, Gerson said he frequently sees parents who are hesitant about childhood vaccinations and mention concern over the number of vaccines in the schedule and issues about specific vaccines.

“Whatever issue it is, we try to address it,” Gerson said. “Some practices here will not continue to see patients who choose not to vaccinate. While I don’t agree with that, I understand it because it does take a lot of time and effort in terms of reassuring parents who may be hesitant about vaccines.”

Talking one-on-one to parents and patients also is important. Results of behavioral studies have indicated that there are sensitive issues among ethnicities related to attitudes about various vaccines.

One study recently demonstrated wider acceptance of the HPV vaccine among Latina women for themselves and their daughters because of the potential for cancer prevention. In contrast, results of studies that involved black women have indicated they are less concerned about cervical cancer and therefore less likely to see value in the HPV vaccine. Knowledge of these types of issues can help guide communication between clinicians and patients and their parents, according to Gerson.

Trudy Murphy

Trudy Murphy

“There are a lot of ideas about vaccination issues, and the health care communities sometime treat people in sort of a homogeneous way. But each person comes in with their own distinct issues,” Gerson said. “That is what makes instituting some of these edicts that come from way above sometimes way more difficult than what they’re supposed to be. We are dealing with the local issues and local capabilities.”

Also, as Murphy indicated with hepatitis A vaccination, communicating with different age groups — including adolescents and adults — can be a successful approach to close the gaps in immunization coverage.

Adolescent and adult immunizations

In a CDC analysis of influenza vaccination rates published in 2011, researchers reported that although rates of vaccine coverage for adults aged older than 65 years have increased, racial and ethnic disparities among this age group persist.

CDC researchers reported that about 74% of non-Hispanic whites in this age group received influenza vaccine during the 2009-2010 seasons, whereas only 61% of Hispanics and 58% of non-Hispanic blacks were immunized. Because older adults can transmit illness to household contacts, including children and grandchildren, reducing immunization disparities in these age groups is just as important as the pediatric population.

In an interview with Infectious Diseases in Children, William Schaffner, MD, professor and chairman of the department of preventive medicine and professor of medicine in the division of infectious diseases at Vanderbilt University School of Medicine in Nashville, Tenn., said there is “no magic wand” that will address all of the issues related to disparities in immunization rates among different races and ethnicities. However, reaching adolescents and adults of all ethnicities is important for continued progress and providing herd immunity.

“Reaching adolescents, particularly as they get older, is so difficult because at this age they are becoming more independent of their parents and they are generally healthy. So that presents some challenges,” Schaffner said. “Even though there are some opportunities to see these patients, like sports physicals, these are frequently very quick, and the circumstances are not conducive to offering immunizations.”

Schaffner said immunization rates among adults are slight in comparison to rates among children.

“When we get to adults, that’s where immunization rates plummet, and they have a whole array of issues, not the least of which is funding for immunizations,” he said. “Hopefully, one partial answer will come with the implementation of the Affordable Care Act in 2014, which will include many millions of dollars for preventive health measures for both younger and older adults.”

Addressing vaccine access globally

Beyond domestic efforts to boost immunization efforts among all ethnic groups, improved access to vaccines is needed across the globe.

According to a recent Infectious Diseases in Children editorial by board member Walter A. Orenstein, MD, children in developing countries are often disproportionately affected. As recently as 2000, an estimated 733,000 children from around the world died of measles; even in 2008, 164,000 cases were reported. Further, measles is frequently imported into the United States through susceptible US residents traveling to countries where measles is endemic or epidemic and from travelers from those countries who come to the United States (three to eight importations a year from 2001 to 2010). These introductions can lead to measles outbreaks, Orenstein said.

William Schaffner

William Schaffner

“Measles is not the only vaccine-preventable disease of concern. An estimated 53,800 chronic hepatitis B cases were imported into the United States annually from 2004 to 2008 from immigrants,” he said. “Polioviruses have been detected, silently circulating in the United States as recently as 2005. In 2003, a US citizen died in Pennsylvania of diphtheria, which was acquired in Haiti.”

Hinman said increasing vaccine campaigns across the globe, although costly in the short term, would be a long-term cost-effective measure.

“It now costs more than $1,700 to purchase the vaccines to fully immunize a child from birth to 18, and it used to be $176. Granted, we are now using more vaccines, but it creates the question, ‘How in the world can poorer countries afford these vaccines?’” Hinman said.

The answer, according to Hinman, is in the form of buying pools through organizations such as UNICEF and others that can negotiate better prices for vaccines in developing countries.

“Compared to what we pay in the United States, the cost to fully immune a child in a GAVI-eligible area is about $50. That clearly is a bargain,” Hinman said. “However, we must take into account the fact that there are 15 countries with annual per capita health expenditures of less than $25, so even $50 per child can be out of reach.”

That is why bargaining partnerships are so integral to increasing health across the board, according to Hinman. Taking into consideration that Americans spend “more than $50 billion per year on our pets,” the investment would be well worth the return, he said. – by Colleen Zacharyczuk

For more information:

Cates JR. J Rural Health. 2009;25:93-97.
CDC Public Health Grand Rounds:, accessed May 17, 2013.
CDC. MMWR. 2012;61:647-652.
CDC. MMWR. 2010;59:1171-1177.
CDC. MMWR. 2011;60;38-41.
CDC. MMWR. 1992; 41: 522-525.
CDC. MMWR. 1992; 40: 36-39.
Hughes J. Cancer Epidemiol Biomarkers Prev. 2009;18:363-372.
US Department of Health and Human Services. Healthy people 2010: midcourse review. 2nd ed. Washington, DC: US Department of Health and Human Services; 2006. Available at:
US Department of Health and Human Services, Office of Minority Health, Advisory Committee. Ensuring That Health Care Reform Will Meet the Health Care Needs of Minority Communities and Eliminate Health Disparities. Washington, DC: 2009. Available at:
Watts LA. Gynecol Oncol. 2009;112:577-582.
William T. Gerson, MD, can be reached at:

For more information:

Thomas W. Hennessy, MD, MPH, can be reached at:
Alan R. Hinman, MD, MPH, can be reached at: Task Force for Global Health, 325 Swanton Way, Decatur GA 30030; email:
Trudy Murphy, MD, can be reached at:
William Schaffner, MD, can be reached at: 1500 21st Ave. South, Suite 2600, Nashville TN 37212; email:

Disclosure: Gerson, Hennessy, Hinman, Murphy, Orenstein and Richards report no relevant financial disclosures. Schaffner is a paid consultant for Pfizer, Sanofi-Pasteur, Merck and GlaxoSmithKline.


Should patients be targeted by group or by disease state for reducing disparities in immunization?


Disease state should be targeted.

Keith Klugman

The next frontier, I believe, will be maternal immunization to reduce sepsis in neonates and perhaps also reduce infection-induced prematurity and illness in the mom. Most of these burdens are much more common in poorer communities.

Currently, the focus is on influenza vaccines, for which pregnant women are the No. 1 risk group identified by the World Health Organization.

DTaP immunization in this group will also have an impact on both pertussis and tetanus rates. Future maternal vaccines to protect the newborn may also include RSV vaccines based on the F protein and conjugate vaccines directed against group B streptococcal capsules.

Keith P. Klugman, MD, is the William H. Foege Chair of Global Health, Department of Hubert Department of Global Health Epidemiology, Rollins School of Public Health, Emory University in Atlanta.
Disclosure: Klugman reports no relevant financial disclosures.


Adult population should be targeted.

Amy Middleman

I don’t think the importance of primary prevention of disease through immunization can be overstated. The Vaccines for Children Program has done so much to reduce socioeconomic status immunization disparities among children and adolescents. Immunization rate gaps associated with culture may require more targeted interventions. The values a culture places on primary prevention health strategies may differ based on historical context, prior experience in countries other than the United States, priorities that may have greater import at the time, among other concerns. These concerns warrant more qualitative study and attention in both the adolescent and adult populations. When the "school requirements" for vaccination that help eliminate childhood immunization disparities, regardless of cause, are no longer applicable for older adolescents and adults, cultural disparities become much more important. Because adolescents most often look to parents for immunization decisions, I believe it is very important to address these disparities among adults, which will likely, in turn, affect both adolescent and adult immunization rates.

Amy Middleman, MD, MPH, is associate professor of pediatrics in the adolescent medicine and sports medicine section at Baylor College of Medicine. She is also director of adolescent and young adult immunization at Texas Children’s Center for Vaccine Awareness & Research. In addition, Middleman is a member of the Infectious Diseases in Children Editorial Board. Middleman can be reached at: Disclosure: Middleman reports no relevant financial disclosures.