PEDIATRICS Vol. 97 No. 4 April 1996, pp. 474-480
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The Contribution of Missed Opportunities to Childhood Underimmunization in Baltimore

Elizabeth Holt DrPH1, Bernard Guyer MD, MPH2, Nancy Hughart RN, MPH2, Virginia Keane MD3, Patrick Vivier MD4, Alan Ross PhD5, and Donna Strobino PhD2

1 Department of International Helath, University of Maryland School of Medicine, Baltimore, Maryland
2 Departments of Maternal and Child Health, University of Maryland School of Medicine, Baltimore, Maryland
3 Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
4 Departments of Health Policy and Management, University of Maryland School of Medicine, Baltimore, Maryland
5 Department of Biostatistics, The Johns Hopkins School of Hygiene and Public Health, University of Maryland School of Medicine, Baltimore, Maryland

Objective. To determine the community-wide incidence of missed opportunities to vaccinate, to describe the clinical settings in which they occur, and to estimate the impact of missed opportunities on immunization coverage.

Design and Methods. We abstracted outpatient medical records from a random, community-based sample of 2-year-old children whose residence was inner-city Baltimore. The date of each vaccine and the date, diagnoses, and temperature at each visit were collected for 502 children at 98 different provider sites.

Main Outcome Measures. Missed opportunities to vaccinate and up-to-date vaccination status.

Results. By 24 months of age, 75% of the children had at least one missed opportunity and only 55% were up-to-date for the 4:3:1 series. Missed opportunities occurred at more than one third of eligible visits for each vaccine, including >20% of preventive care visits. Diagnoses commonly associated with missed opportunities were "well child," otitis media, upper respiratory infection, gastroenteritis, skin infection, and resolving illness. If no missed opportunities had occurred, 73% of the children would have been up-to-date by 24 months.

Conclusions. Missed opportunities occurred commonly at providers serving inner-city children in Baltimore and represent a major factor in underimmunization. Reduction of missed opportunities by accurate screening at all visits and adherence to the contraindication guidelines is a provider-based, low-cost method to increase immunization coverage.

Submitted on January 11, 1995
Accepted on May 18, 1995




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