PEDIATRICS Vol. 121 No. 5 May 2008, pp. 938-944 (doi:10.1542/peds.2007-1794)
ARTICLE |
Underimmunization of American Indian and Alaska Native Children
a Immunization Services Division, National Center for Immunization and Respiratory Diseases
c Office of Minority Health and Health Disparities, Office of Strategy and Innovation, Office of the Director, Centers for Disease Control and Prevention, Atlanta, Georgia
b Division of Epidemiology and Disease Prevention, Office of Public Health Support, Indian Health Service, Albuquerque, New Mexico
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVE. The goal was to determine whether disparities in childhood immunization coverage exist between American Indian/Alaska Native children and non-Hispanic white children.
METHODS. We compared immunization coverage with the 4 diphtheria-tetanus-pertussis, 3 poliovirus, 1 measles-mumps-rubella, 3 Haemophilus influenza type b, and 3 hepatitis B(4:3:1:3:3) series and its individual vaccine components (
4 doses of diphtheria, tetanus, and pertussis vaccine; 3 doses of oral or inactivated polio vaccine; 1 dose of measles, mumps, and rubella vaccine; 3 doses of Haemophilus influenzae type b vaccine; and 3 doses of hepatitis B vaccine) between American Indian/Alaska Native children and non-Hispanic white children from 2000 to 2005, using data from the National Immunization Survey.
RESULTS. Although immunization coverage increased for both populations from 2001 to 2004, American Indian/Alaska Native children had significantly lower immunization coverage, compared with non-Hispanic white children, over that time period. In 2005, coverage continued to increase for American Indian/Alaska Native children but decreased for non-Hispanic white children, and no statistically significant disparity in 4:3:1:3:3 coverage was evident in that year.
CONCLUSIONS. Disparities in immunization coverage for American Indian/Alaska Native children have been present, but unrecognized, since 2001. The absence of a disparity in coverage in 2005 is encouraging but is tempered by the fact that coverage for non-Hispanic white children decreased in that year.
Key Words: American Indian • Alaska Native • immunization assessment • health disparities
Abbreviations: AI—American Indian • AN—Alaska Native • IHS—Indian Health Service • NIS—National Immunization Survey • 4:3:1:3:—4 diphtheria-tetanus-pertussis, 3 poliovirus, 1 measles-mumps-rubella, 3 Haemophilus influenza type b, and 3 hepatitis B • DT—diphtheria and tetanus toxoids • DTP—diphtheria-tetanus toxoids-pertussis • DTaP—diphtheria-tetanus-acellular pertussis • Hib—Haemophilus influenza type b
American Indian (AI) and Alaska Native (AN) children receive immunizations in a variety of settings, including Indian Health Service (IHS) and tribal health facilities, urban Indian health organizations, other federal, state, or local public providers, and private providers. Like many minority racial/ethnic populations, they experience a disproportionate burden of morbidity and mortality resulting from a number of health conditions and often face barriers accessing health care services.1–5 Despite persistent health and health care disparities, there have been improvements in the overall health status of AI/AN populations. Before the use of hepatitis A vaccine, for example, hepatitis A infection rates among AI/AN individuals were >5 times higher than rates in other racial/ethnic populations. Since the advent of hepatitis A vaccination programs, hepatitis A rates have decreased 99% for AI/AN populations, compared with the prevaccine era, and are now approximately the same as or lower than those of other racial/ethnic populations.6 In recent decades, rates of deaths of AI/AN individuals resulting from other infectious diseases and pregnancy-associated complications have decreased and life expectancy has increased.1,4
Some studies suggest that improvements in overall immunization coverage among AI/AN children have also occurred and that disparities in coverage between AI/AN and non-AI/AN populations have declined or even disappeared.7,8 In Alaska, for example, AN children seem to have higher immunization coverage levels than non-AN children.9 Relatively high immunization coverage levels for AI/AN children, despite a high prevalence of risk factors for underimmunization, have been attributed to improved access to immunizations through the Vaccines for Children program, broader access to primary care services, and public health outreach efforts by the IHS and tribal health programs.7,9
The IHS is the federal agency charged with providing health care to AI/AN individuals who are members of one of the >560 federally recognized tribes. The IHS provides a range of health services, including immunizations, to eligible patients in 35 states. Immunization coverage is monitored on an ongoing basis by using electronic medical records, and reports on coverage levels are issued quarterly. IHS data indicate that childhood immunization coverage levels for the IHS user population (ie, AI/AN persons who received direct or contract care at an IHS-funded facility at least once in the past 3 years) are increasing and are similar to coverage levels for the general US population.10 The number of children included in IHS reports has been steadily increasing as more rigorous reporting requirements have been implemented, and reports currently include 
25000 AI/AN children 19 to 35 months of age each quarter.10
IHS immunization data, however, apply only to AI/AN children vaccinated at IHS, tribal, or urban Indian health facilities and may not be indicative of coverage in the wider AI/AN population across the United States. On the basis of the IHS user population, 40% of 2-year-old AI/AN children receive services from the IHS (IHS, Division of Epidemiology and Disease Prevention, unpublished data, 2007). The most-recent studies that comprehensively evaluated the immunization coverage among AI/AN children nationally used pooled data from 1998 through 20007 or data limited to a single year (2001) of the National Immunization Survey (NIS).8 Because comprehensive, up-to-date information about AI/AN childhood immunization coverage is lacking, we analyzed NIS data for each year from 2000 through 2005. The objectives of this study were to document, on a national level, the presence or absence of immunization coverage disparities between AI/AN children and other racial/ethnic groups during each year from 2000 through 2005 and to assess whether residence in counties with IHS service availability was associated with improved AI/AN childhood immunization coverage.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The NIS is a random-digit-dialed telephone survey that estimates national and state-level vaccine coverage levels for children 19 to 35 months of age. NIS methods have been described in detail in previous publications.11–13
We analyzed data from 2000 through 2005 and for each year calculated coverage with a combination of 4 doses of diphtheria and tetanus toxoids and pertussis (DTP) vaccine, diphtheria and tetanus toxoids (DT), or diphtheria and tetanus toxoids and any pertussis vaccine (DTAP), 3 doses of oral or inactivated polio vaccine, 1 dose of measles, mumps, and rubella vaccine, 3 doses of Haemophilus influenzae type b (Hib) vaccine, and 3 doses of hepatitis B vaccine. This group of vaccines is referred to as the 4:3:1:3:3 series. In addition to the series coverage, we calculated coverage with the individual vaccines for each year of the study. All analyses were conducted by using the statistical software packages SAS 9.1 (SAS Institute, Cary, NC) and SUDAAN 9.0 (Research Triangle Institute, Research Triangle Park, NC), which allows the sampling weights and the sampling design of the NIS to be taken into account.
To help achieve maximal sample sizes, we defined the AI/AN group as all non-Hispanic children who were identified by their parents as being either AI/AN alone or AI/AN in combination with any other race ("AI/AN all") for the purposes of this study. Hispanic children were excluded from the AI/AN group, because they may include AI children from Central or South America. To determine whether there were differences in coverage estimates depending on the definition used for the AI/AN population, we compared 4:3:1:3:3 coverage estimates for the AI/AN alone and AI/AN all groups. We used a 2-sided t test with an 
level of .05 to determine whether coverage rates were significantly different between the 2 groups.
To measure disparities in coverage, 4:3:1:3:3 coverage levels were calculated for AI/AN children and compared with coverage estimates for 2 other groups of children, namely, (1) non-Hispanic white children and (2) all non-AI/AN children, that is, all children of any race or ethnicity not identified as AI/AN. Because we hypothesized that the coverage level for AI/AN children would be lower than the coverage level for either of the 2 comparison populations, we used a 1-sided t test with an level of .05 to determine whether the coverage level for the AI/AN group was statistically significantly lower.
To estimate the impact that the availability of IHS services might have had on immunization coverage levels, we used IHS service counties, also known as contract health services delivery areas, as a proxy for determining access to IHS services. IHS service counties are defined by IHS and represent the catchment area for IHS-funded services (Fig 1). We compared 4:3:1:3:3 coverage levels for AI/AN children residing in an IHS service county with coverage levels for AI/AN children residing outside an IHS service county. One-sided t tests with an level of .05 were used for this analysis.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The yearly sample size for children whose parents identified them as AI/AN alone ranged from 268 to 486, compared with 424 to 510 for children who were identified as AI/AN all. The white sample ranged from 10317 to 13700 children, and the non-AI/AN sample ranged from 17139 to 23137 children. The difference in 4:3:1:3:3 coverage rates for the AI/AN alone group versus the AI/AN all group was not significant in any year (Table 1). For all subsequent analyses, we defined AI/AN children as children who were identified as AI/AN all.
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Although there was no significant difference in coverage levels in 2000 or 2005, the 4:3:1:3:3 coverage levels were significantly lower for AI/AN children, compared with white children, during 4 of the 6 years we analyzed, from 2001 through 2004 (Table 2); 4:3:1:3:3 coverage for AI/AN children was also significantly lower than coverage for non-AI/AN children during the 3-year period from 2002 through 2004 (Fig 2).
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Analysis of 4:3:1:3:3 coverage stratified according to the component vaccines revealed that, in any single year (including 2005), there were at least 2 vaccines for which coverage was significantly lower for AI/AN children, compared with white children. In 2002 and 2004, coverage with all component vaccines in the 4:3:1:3:3 combination was significantly lower for AI/AN children. Coverage with diphtheria and tetanus toxoids and pertussis vaccine, diphtheria and tetanus toxoids, or diphtheria and tetanus toxoids and any pertussis vaccine was significantly lower for AI/AN children in all 6 years (Table 2).
In each of the 6 years studied, the majority of AI/AN children in the NIS samples (54%–65%) resided within an IHS service county. Higher coverage levels for AI/AN children residing in IHS service counties were not observed in any year. In 2002, 4:3:1:3:3 coverage for AI/AN children residing in an IHS service county was significantly lower than that for AI/AN children residing outside an IHS service county (P > .05) (Table 3). There were no significant differences in any other year.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Observed Disparities in Immunization Coverage
During 4 of the 6 years of NIS data included in this study, AI/AN children were underimmunized compared with other children in the United States. Evidence for this health disparity was present when AI/AN children were compared with either non-Hispanic white children (2001–2004) or all non-AI/AN children (2002–2004). These previously unreported findings highlight an important and potentially persistent health disparity and cast doubt on the existing perception that immunization coverage for AI/AN children is as good as, or better than, coverage for non-AI/AN children.
Although the apparent disappearance of this disparity in 2005 is encouraging, this observation should be interpreted with caution. Despite relatively steady increases in preceding years (Fig 2 and Table 2), coverage for the comparison populations actually declined in 2005, and it is not clear from our data which factor (this decline or the increase in AI/AN coverage that year) had a greater impact on closing this gap in coverage. In addition, disparities did persist in 2005 for 2 component vaccines (DTP/DT/DTaP and Hib b vaccines), which suggests that the gap is not completely closed.
It is also encouraging to note that, overall, immunization coverage seems to be improving for all races and, by 2005, coverage was at or near the Healthy People 2010 goal of 90% for most vaccines in the 4:3:1:3:3 series. As seen in Fig 2, however, the trends in coverage for AI/AN children over the 6 years of this study were more erratic than the steadier upward trends shown for the non-Hispanic white or non-AI/AN comparison populations. This volatility might be a reflection of measurement factors such as small sample sizes or sampling errors related to the methods used by the NIS but also could be an indication of increased vulnerability of the AI/AN population to known risk factors for low immunization coverage, such as lower socioeconomic status and large family size.7 In the absence of larger sample sizes, it is difficult to determine what is driving the overall volatility in immunization coverage for the AI/AN population.
National shortages of individual vaccines, such as the DTaP vaccine, may disproportionately affect AI/AN children and other public-sector vaccine recipients.14,15 To assess whether such shortages might explain the overall disparities in 4:3:1:3:3 coverage that we observed in 2001–2004, we also analyzed the individual vaccines in this series. We found no evidence to suggest that a decline in coverage with any one vaccine was responsible for the lower 4:3:1:3:3 coverage levels experienced by AI/AN children during the years of this study. AI/AN children had significantly lower 4:3:1:3:3 coverage rates (2001–2004) during years with and without vaccine shortages.
We also found that immunization coverage levels were not significantly higher for AI/AN children residing in IHS service counties, compared with AI/AN children living outside IHS service counties. In 1 year, 2002, coverage levels in IHS service counties were actually lower. These findings could suggest that proximity to IHS services did not necessarily enhance immunization coverage for all AI/AN children; however, it is also possible that coverage levels for AI/AN children residing in the IHS service counties might have been lower if IHS services had not been available. In addition, it is important to note that not all children residing in an IHS service county were necessarily eligible for or accessed IHS services; therefore, they might not have benefited from the immunization services offered by IHS.
Comparison With Previous Studies
Published studies that have addressed immunization coverage for AI/AN children are few in number and mixed in terms of comprehensiveness and comparability. The most-recent reviews of racial/ethnic disparities in childhood immunizations did not include AI/AN children.16,17 Others, focusing on individual vaccines and concluding that racial/ethnic disparities in vaccine coverage have been eliminated, did not address AI/AN disparities directly.18,19 Since 2000, only 2 publications assessed AI/AN childhood immunization coverage directly by using NIS data7,8; both studies concluded that immunization coverage for the AI/AN population was similar to coverage for other racial/ethnic groups. Differences between their methods and ours may explain why our findings led to different conclusions.
Our results also contrast with those of the IHS, in that IHS reports consistently show higher immunization coverage levels than we report herein.1,10 IHS, however, serves only a subset of the overall AI/AN population, and AI/AN people often have multiple sources of health care, with up to 49% having insurance through their employers, other private insurance, or Medicare.20 Although most facilities supported by IHS are found in rural and reservation areas, the majority (60%) of the AI/AN population resides in off-reservation and urban areas.21,22 Overall, 46% of AI/AN individuals have no access to IHS facilities.23 Because IHS data are limited to AI/AN children accessing IHS-funded services, results of analyses using those data may not be comparable to results of analyses using data captured in the NIS and are not generalizable to all AI/AN children in the United States, particularly those residing in urban and other areas with limited access to IHS-funded services. Adding questions to the NIS to determine care provided by IHS would allow comparability between these 2 data sources and would facilitate assessment of the impact of IHS services on immunization coverage, as well as informing strategies to improve coverage for the AI/AN population.
Methodologic Challenges
Measuring health disparities affecting AI/AN populations can be challenging, in part because of the small sample sizes found in various national surveys, of which the NIS is just one example.24 In its report on disparities in health care, the Institute of Medicine found that <1% of the studies it reviewed had sample sizes large enough for meaningful analysis of AI/AN data.25,26 Within the NIS, the sample of AI/AN children in any single year is relatively small, making it difficult to identify significant differences. Given this, our analysis illustrates the utility of looking for patterns over time, rather than focusing on a difference in any particular year. Although estimates for coverage for this population were erratic, we consistently found coverage rates to be lower for AI/AN children, which supports the idea that a disparity exists. Determining the magnitude of this disparity is difficult, however. In 2003, for example, our point estimate for AI/AN 4:3:1:3:3 coverage was 74.3%, but with a confidence interval ranging from 69.1% to 79.5%. Comparing this range with that observed for non-Hispanic white children in the same year (82.5 ± 0.9%), the disparity gap could be as wide as 14.3% or as narrow as 2.1%. Such a broad range adds to our uncertainty about the true magnitude of the disparity and makes decisions about the allocation of resources for public health intervention strategies even more difficult. Although we have shown that NIS data can identify disparities on an annual basis, looking for patterns over time may be more useful. Even with this type of analysis, however, larger AI/AN sample sizes would be helpful for characterization of the magnitude of these disparities and would complement efforts to enhance local assessments.
Pooling several years of data is a common approach to increasing sample sizes for AI/AN populations,3,7 but there are limitations to this approach as well. In cases where there is an aberrant or extreme trend in 1 of the years to be pooled, this approach may not be methodologically appropriate. Pooling data also may conceal changes in an individual year. Finally, information gleaned from pooled data is not timely, which diminishes its value for identifying emerging problems.
Small sample sizes in national surveys also limit the ability to perform geographically stratified analyses (eg, county, state, or regional levels) and generally require that data be aggregated on national or multiregional levels. Aggregating data in this manner may mask regional variations (and therefore differences across AI/AN tribal groups). For AI/AN health disparities, regional variation is a relatively common observation.4,14,27 For example, rates of immunization coverage for AN children in Alaska are consistently higher than rates of coverage for the non-AN population residing in Alaska,9 and our finding of a disparity in immunization coverage between AI/AN and white children may not be applicable to AN children in Alaska.
Finally, racial misclassification significantly impedes our ability to detect and to monitor accurately AI/AN health disparities.28–32 Racial misclassification is less likely to occur in NIS data sets because race is self-reported in the NIS, but it may be a problem as we look to additional immunization data sources, such as state immunization registries.
Limitations
The AI/AN samples within NIS data sets are relatively small, and findings may not be representative of the larger AI/AN population. Although telephone surveys such as the NIS may represent a cost-effective survey method, this approach has limitations when used to reach AI/AN populations. According to the 2000 US Census, 2.4% of the US population has no telephone service, compared with 11.9% of AI/AN homes. Within AI/AN populations, access to telephone service varies considerably according to tribe or geographic location, with 0.9% to 49.1% of individuals reporting no access to telephone service.33
Using residence in an IHS service county as a proxy for access to IHS services may not depict accurately the impact of the IHS on immunization coverage levels, because the NIS samples might have included AI/AN children who were not eligible for, or did not access, IHS services in those counties. In addition, we did not control for other factors that may affect immunization coverage, such as income, education level, and family size. It may be that AI/AN children residing in an IHS service county had more risk factors for underimmunization than did AI/AN children residing outside IHS service areas and the similarity in immunization coverage levels between these 2 groups was a result of the provision of IHS services. Additional analyses to examine these factors are needed.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Our analytic approaches were different from those of earlier studies, and our data source encompasses a broader range of AI/AN communities, compared with IHS data. The results of our analyses suggest that disparities in immunization coverage for AI/AN children have been present, but unrecognized, since 2001. Our evaluation of immunization coverage for AI/AN children points to the need for several courses of action, including the development of improved strategies for the delivery of immunization services to AI/AN families, the issuance of authoritative guidance regarding consistent methods for analyzing and reporting AI/AN immunization coverage levels (and eventually other AI/AN health-related data), and the development of more-robust means for monitoring immunization services for AI/AN children. Increasing AI/AN sample sizes in national surveys, including questions regarding the provision of IHS services to better ascertain the role of the IHS in delivering care to the AI/AN population, and conducting ongoing analyses of trends in immunization coverage may improve the monitoring of coverage for this population.
In addition, expanding efforts to ensure the inclusion of accurate race/ethnicity data in state-based immunization registries and implementing more broadly existing mechanisms to facilitate the inclusion of data on AI/AN children in state immunization registries should allow for better monitoring of coverage for this population on the local level. As data in state immunization registries become more complete, state-based evaluations of immunization coverage for AI/AN populations and other racial/ethnic groups ultimately should allow for more-timely and more-precise identification of immunization disparities on a state-by-state basis and should allow for more local analysis within states.
Accurate and timely monitoring of immunization data is a prerequisite for the development of effective interventions and the elimination of disparities in immunization coverage. Improvements in AI/AN immunization data and methodologic approaches are needed to strengthen our ability to detect problems with the delivery of immunization services to AI/AN families in a more-timely manner.
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FOOTNOTES |
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Accepted Sep 12, 2007.
Address correspondence to Amy V. Groom, MPH, Indian Health Service, Division of Epidemiology and Disease Prevention, 5300 Homestead Rd NE, Albuquerque, NM 87110. E-mail: amy.groom{at}ihs.gov
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject Previous studies have found that immunization coverage for American Indian/Alaska Native children has been similar to coverage for other racial groups. Those studies used NIS data from 1998 to 2000 (pooled) and 2001.
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| What This Study Adds This is the first study to use NIS data from 2000 to 2005 to examine immunization coverage at a national level for American Indian/Alaska Native children.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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