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Journal Issue: Children and Divorce Volume 4 Number 1 Spring/Summer 1994

CHILD INDICATORS: Immunization of Young Children
Eugene M. Lewit John Mullahy

Why Are Immunization Rates So Low?

The increase in the immunization rate for measles among preschool children between 1985 and 1991 suggests that it is possible to raise immunization rates among young children to more satisfactory levels than currently exist in the United States. Yet, the fact that rates remain below the 1990 objective of at least 90% coverage of children under age two with the basic immunization series suggests that the United States still faces many obstacles to effectively protecting young children from preventable illnesses.

Many reasons have been cited for the low level of immunizations among preschool children in the United States. Costs may prove a serious impediment for many families, especially those with low or moderate incomes, without health insurance, or with insurance policies that do not cover immunizations. Vaccines to fully immunize a child cost more than $230 in the private sector and more than $160 in the public sector in 1992—a tenfold increase in the past decade. Several factors account for this increase, including the costs of new vaccines (Hib and HBV), general inflation, and a federal excise tax to provide compensation for vaccine-related injuries.14

Rising out-of-pocket costs of vaccines appear to have led to an increase in the number of families that seek immunizations at public health clinics. Many of these facilities are overburdened and have curtailed services in response to budget cuts. Barriers associated with accessing these facilities—including long queues, inconvenient hours and locations, and prerequisites for service such as a comprehensive physical exam or an appointment for an inoculation—all contribute to low vaccination rates.15

Providers and parents also contribute to the problem. Providers' failure to take advantage of every medical opportunity to check a child's immunization status and overly conservative behavior about giving vaccines to children with minor respiratory infections have been cited as important failings in this regard.14 The recently released Standards for Pediatric Immunization Practices, developed by a 35-member expert working group and endorsed by the U.S. Public Health Service, the AAP, and a number of other professional organizations, presents 18 provider-related standards to eliminate health care delivery system barriers and obstacles to the efficient and effective delivery of vaccinations.15

Some experts believe that the failure of some parents to appreciate the seriousness of vaccine-preventable diseases and the value of immunization presents another barrier to achieving high levels of immunization among young children.7,13,14,16 In part, this complacent attitude may reflect the success of the vaccines themselves. Because the incidence of vaccine-preventable diseases is very low by historic standards, the complicated immunization process may frequently be regarded as an inconvenient procedure to prevent diseases hardly anyone has actually experienced rather than as a miracle of modern medicine.16

In addition, some parents may resist vaccinations because of exaggerated fears of side effects. Community education and outreach programs may be necessary to counteract parental complacency and ignorance.