By simply tracking children's immunizations and calling on those families whose children fall behind on their shots, doctors can dramatically increase the number of children who are vaccinated as well as increase the likelihood of those children returning for regular, preventative checkups, according to a University of Rochester study being published in the January issue of Pediatrics.
In just 18 months, a tracking and outreach program raised rates of child immunization a full 20 percent (from 70 to 90 percent) for children with the lowest rates of immunization: those living in the poorest inner-city neighborhoods. It was so successful that the county of Monroe, New York, where the study originated, adopted and expanded the program in an effort to fully immunize 90 percent of the community's children by 2000. As a result of the program, an additional 256 children were vaccinated who would otherwise have been without defense against debilitating diseases like hepatitis, tetanus and meningitis.
Pediatrician Peter G. Szilagyi of the University of Rochester found that the high rate of child under-immunization is not the result of parents who don't care, but a result of parents who aren't aware of the vaccination schedule, don't have transportation to the doctor's office, or who may have problems more serious than their child's vaccination schedule. Further complicating the matter, doctors themselves are often unaware of which children have had all their shots and which are behind, and even those practices that track their patients closely often have no way of reaching the children and bringing them in. Full immunization requires six visits and sixteen shots before the age of two, making the tracking process extremely complicated.
"This study exposed a lot of the problems in our health care delivery system," explains Szilagyi. "We have to reach out to families, talk to them, and find out what barriers they face in bringing their children to appointments with the doctor. Then we have to remove those barriers. The greatest vaccine in the world is useless if it doesn't get to the children who need it."
Like the vaccines themselves, the cost of the program -- around $63 per child per year -- is a needle-prick compared to the cost of dealing with the actual sickness. Every dollar spent on the prevention of a disease saves from $8-$30 in treating the outbreak of the illness down the road. Previous attempts to raise immunization rates have been prohibitively expensive.
Costly outbreaks of vaccine-preventable diseases have struck America as recently as 1991, when dozens of children died from measles and tens of thousands were hospitalized. American health care leaders were left bewildered as to how the greatest health care system in the world could lose children to such a preventable disease. Surveys taken in the aftermath showed that as many as 70% of children in some U.S. cities were not properly immunized.
The Centers for Disease Control and Prevention (CDC) funded a study at the University of Rochester -- one of the world leaders in vaccine development -- to find a way to raise the immunization rate of children. Since there was a 20 percent difference in immunization rates between urban poor children and children living in the suburbs, Szilagyi and Lance E. Rodewald, now with the CDC, designed a tracking and outreach program aimed at raising the rates among the urban poor. Rodewald served as principal investigator.
"With this program, we raised immunization rates dramatically for children who needed it the most - those living in the inner city," says Szilagyi. "In a follow-up study of immunization rates among children, we found that inner-city children who received tracking and outreach had immunization rates nearly as high as suburban children. We almost leveled the playing field between the inner city and the suburbs. That's something almost unheard of in the health field."
The program used a database to track 2,741 children in nine primary care practices throughout Rochester that collectively serve more than 50% of city preschoolers. Half the preschoolers were placed into a control group that was tracked but received no outreach. The other half was also tracked, but if the child fell behind, the family got a phone call. In the 10 percent of cases where the child fell too far behind, an outreach volunteer made a house call to find out what the trouble was. Outreach workers were usually recruited from within the targeted neighborhoods to make the occasion more of a comfortable visit than if a health care professional were to appear on their doorstep. Taught by the medical staff, the outreach workers were able to learn what was keeping the family from bringing the child to the doctor, and how to break down those barriers.
Some families had no means of getting to the doctor's office, some didn't understand the importance of getting the shots, and others had problems that superseded vaccinations. "It's difficult for a parent to prioritize vaccinations when they can't even feed their child," says Mardy Sandler, senior social worker and clinical supervisor of the outreach workers. "But this is why this program works. It's not just about vaccines; it's about bringing children into the health care system. If we come to a home because the child there isn't vaccinated, but we leave having connected mom with a local food bank, we've still succeeded." When calling on homes, workers have also come across children home alone, abused mothers, and families who didn't even know what a vaccination was. All of these barriers were dealt with before the issue of immunization.
Immunization numbers reveal the health of the health system, says Szilagyi. Under-vaccinated children get behind in all types of health care. In addition to improving immunizations, the tracking and outreach system helped increase preventative care visits by inner-city families, and even raised the proportion of children receiving necessary lead and anemia screenings.
Journal
PEDIATRICS