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Article |

Parental Compliance With Multiple Immunization Injections FREE

Shoshana T. Melman, MD; Thuan T. Nguyen, MMS; Elizabeth Ehrlich, MMS; Marguerite Schorr, RN; Ran D. Anbar, MD
[+] Author Affiliations

From the Department of Pediatrics, MCP Hahnemann School of Medicine (Dr Melman), Allegheny University of the Health Sciences (Mr Nguyen and Ms Ehrlich), and Department of Nursing, St Christopher's Hospital for Children (Ms Schorr), Philadelphia, Pa; and State University of New York at Syracuse Health Science Center (Dr Anbar). Mr Nguyen is now with the University of Vermont College of Medicine, Burlington; and Ms Ehrlich is now with the New York Medical College, Valhalla.


Arch Pediatr Adolesc Med. 1999;153(12):1289-1291. doi:10.1001/archpedi.153.12.1289.
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Published online

Objective  To assess parents' (or caretakers') willingness to allow multiple immunization injections at a single visit.

Design  A survey of parental demographics and a medical record review to determine immunization status.

Setting  An inner-city pediatric clinic in Philadelphia, Pa.

Participants  A convenience sample of 1059 patients who were due to receive 2 to 5 immunization injections at a single visit and their parents. Patients were excluded if parents had not previously witnessed at least 1 immunization.

Main Outcome Measures  The number of immunizations due, the number of immunizations received, and the reasons for failure to immunize completely.

Results  Almost all (98.8%) of the children included in the study received all immunizations indicated at their visit.

Conclusion  Despite potential parental resistance to multiple simultaneous immunization injections, this inner-city population overwhelmingly complied with physicians' recommendations.

Figures in this Article

MANY CHILDREN remain underimmunized in the United States,1 particularly those in low-income2,3 and inner-city populations,4,5 despite the demonstrated potential of immunizations to eradicate disease. Giving multiple simultaneous immunizations whenever possible would greatly increase vaccine coverage6,7 and is considered safe and effective.8 In 1992, the American Academy of Pediatrics endorsed the recommendation for multiple simultaneous immunizations published by the Centers for Disease Control and Prevention.8

Some physicians fail to give multiple simultaneous injections because of their perceptions that parents will object to the administration of multiple shots at one time.911 The National Medical Association opposed the Centers for Disease Control and Prevention's sequential schedule of polio vaccination, in part because the addition of 2 injections might reduce parental compliance.12 However, a recent study13 found that physicians overestimate the extent of parental objections to multiple immunizations. While it is true that parents surveyed in several studies1417 expressed concern over multiple immunizations, one study18 found that parents preferred to have all injections given during a single visit if recommended by a physician.

Previous studies13,14,17,18 have focused only on eliciting opinions regarding simultaneous injections. This study determines whether parental resistance is a true deterrent for the administration of multiple immunization injections.

From September 1, 1995, through May 20, 1997, a convenience sample of parents (or caretakers) whose children were scheduled for 2 or more immunization injections were interviewed at our inner-city Philadelphia, Pa, pediatric clinic. To ensure that participants understood the immunization process, parents who had not previously witnessed a child receive an immunization injection were excluded.

The number of indicated immunization injections was determined in accordance with the Recommended Childhood Immunization Schedule in effect at the time of the child's visit.1922 Starting in November 1996, routine pertussis immunization was provided using a diphtheria and tetanus toxoids and acellular pertussis vaccine, adsorbed preparation,23 and routine polio immunization was provided using the Centers for Disease Control and Prevention–recommended sequential schedule.24

Parents were asked a series of demographic questions, then provided with educational information regarding their children's indicated immunizations, including a recommendation for simultaneous administration of all vaccines due. Patient records were later reviewed to determine the actual number of immunization injections each child received and recorded reasons for incomplete immunization.

The compliance rate with recommended immunizations was compared in groups, based on the number of scheduled immunization injections, using a trend χ2 analysis.

This study was granted exempt status by the Hahnemann University Hospital Institutional Review Board, Philadelphia.

Of the 1080 eligible parents approached, 1064 (98.5%) agreed to participate in the study. The immunization of 5 children was deferred because of illness at the time of the visit (n = 4) or because of the physician's concern regarding allergy to a vaccine component (n = 1). The median age of the remaining 1059 children was 9 months (range, 1 month to 16.3 years). Five hundred thirty-four children (50.4%) were male.

Only 13 (1.2%) of the 1059 eligible children did not receive all of their indicated immunizations. The percentages of children who received all indicated immunizations are shown in Figure 1. No child was scheduled to receive more than 5 immunization injections. There was a slight but statistically significant trend toward increased resistance with increased number of injections (χ2 = 9.96, P<.01). All children due for 5 immunization injections required at least 1 of these immunizations because of a prior vaccination delay.

Place holder to copy figure label and caption

Percentage of children receiving all indicated immunization injections.

Graphic Jump Location

For 8 children, only 1 of the indicated immunizations was deferred, including the varicella vaccine (n = 7) and the hepatitis B vaccine (n = 1). On 3 occasions, no immunizations were given, due to either general parental concerns regarding vaccination (n = 2) or religious beliefs (n = 1). One child left with a parent before being seen by a physician. Finally, on 1 occasion, a parent requested splitting of the vaccination doses between 2 visits.

The median age of the 13 children who did not receive all their injections was 12 months (range, 4-18 months). Seven (54%) of these 13 children were boys. Eleven (85%) of these 13 children were black, and 2 (15%) were Hispanic. Eleven of the 13 children (including all 8 whose caretakers declined permission for the varicella or the hepatitis B vaccine) had government-sponsored payment for immunizations through medical insurance or the Vaccines for Children Program.

Most children at this inner-city clinic received all indicated immunizations in a single visit. The excellent compliance in this study demonstrates the efficacy of a policy of routine multiple simultaneous immunizations, and indicates that parental resistance may be less of a barrier than previously feared.

In July 1999, the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices published recommendations for routine poliomyelitis vaccinations, which replaced the sequential schedule with an all-inactivated poliovirus vaccine schedule. The committee no longer recommends use of the oral polio vaccine, except in special circumstances such as when an unvaccinated child will be traveling in less than 4 weeks to areas where polio is endemic.25,26 This new recommendation, combined with recent guidelines favoring the routine use of acellular pertussis and varicella vaccines, has increased the number of routine childhood immunization injections.27 Despite the increasing availability of combination immunizations,28,29 the possible addition of new vaccines (such as conjugated pneumococcal30 and hepatitis A vaccines31) may cause a further increase. The additional injections recommended for pediatric populations necessitate simultaneous immunization to avoid vaccination delay and a potential decrease in the level of population immunity.

There was a slight trend toward increasing parental resistance with increasing numbers of immunization injections in this study, particularly when 5 immunizations were due. However, for more than half the children not receiving all indicated immunization injections, the varicella vaccine was the only immunization deferred. This may reflect previously demonstrated parental concerns regarding the varicella vaccine.32 If concerns regarding the varicella vaccine were fewer, compliance in this study might have been even greater. In addition, continued development and use of combination vaccines, such as the diphtheria and tetanus toxoids with acellular pertussis vaccine–Haemophilus influenzae type b vaccine,3335 should further increase compliance. Finally, if progress continues toward reducing the number of children with delayed immunization status,1 fewer children are likely to need 5 simultaneous immunization injections.

A limitation of this study is the focus on children whose caretakers seek medical attention. In a 1998 Philadelphia Department of Public Health audit of our clinic's overall immunization rates, 66% of a random sample of children had received all age-appropriate vaccines at the time of the assessment (Philadelphia Department of Public Health, unpublished data, 1998). Some parents of the remaining children may not have brought their children in for medical care because of concern regarding multiple immunization injections.

The results of this study may not be generalizable to non–inner-city patient populations, in which parental compliance may be more difficult to obtain.17 However, since physician factors may impact more strongly on immunization levels than parental attitudes,36,37 the health care community should focus strongly on modification of physician attitudes to achieve maximal compliance with immunization schedules in all pediatric populations.

Accepted for publication May 28, 1999.

We thank Christine Obata, MMS, for her assistance in preparing the final version of the manuscript.

Editor's Note: I wonder what the results of this study would have been if the parents were agreeing to multiple injections for themselves . . . and I would like to have the sex-specific data. Any bets?—Catherine D. DeAngelis, MD

Reprints: Shoshana T. Melman, MD, Department of Pediatrics, MCP Hahnemann School of Medicine, 231 N Broad St, Philadelphia, PA 19107 (e-mail: melmans@auhs.edu).

Centers for Disease Control and Prevention, Status report on the childhood immunization initiative national, state, and urban area vaccination coverage levels among children aged 19-35 months: United States, 1996. MMWR Morb Mortal Wkly Rep. 1997;46657- 664
Centers for Disease Control and Prevention, Vaccination coverage by race/ethnicity and poverty level among children aged 19-35 months: United States, 1996. MMWR Morb Mortal Wkly Rep. 1997;46963- 969
Williams  ITMilton  JDFarrell  JBGraham  NMH Interaction of socioeconomic status and provider practices as predictors of immunization coverage in Virginia children. Pediatrics. 1995;96439- 446
Wood  DDonald-Sherbourne  CHalfon  N  et al.  Factors related to immunization status among inner-city Latino and African-American preschoolers. Pediatrics. 1995;96295- 301
Guyer  BHughart  NHolt  E  et al.  Immunization coverage and its relationship to preventive health care visits among inner-city children in Baltimore. Pediatrics. 1994;9453- 58
Dietz  VJStevenson  JZell  ERCochi  SHadler  SEddins  D Potential impact on vaccination coverage levels by administering vaccines simultaneously and reducing dropout rates. Arch Pediatr Adolesc Med. 1994;148943- 949
Link to Article
Centers for Disease Control and Prevention, Impact of missed opportunities to vaccinate preschool-aged children on vaccination coverage levels: selected US sites, 1991-92. MMWR Morb Mortal Wkly Rep. 1994;43709- 718
Ad Hoc Working Group for the Development of Standards for Pediatric Immunization Practices, Standards for pediatric immunization practices. JAMA. 1993;2691817- 1822
Link to Article
Szilagyi  PGRodewald  LEHumiston  SG  et al.  Immunization practices of pediatricians and family physicians in the United States. Pediatrics. 1994;94517- 523
Szilagyi  PGRodewald  LEHumiston  SG Immunization practices of pediatric residents: are they meeting current standards? Pediatr Infect Dis J. 1994;13536- 538
Link to Article
Zimmerman  RKSchlesselman  JJBaird  ALMieczkowski  TA A national survey to understand why physicians defer childhood immunizations. Arch Pediatr Adolesc Med. 1997;151657- 664
Link to Article
Willis  ESherrod  JL Childhood immunizations: position on the enhanced inactivated poliovirus vaccine and live attenuated oral poliovirus vaccine dilemma. J Natl Med Assoc. 1997;89785- 789
Halperin  BAEastwood  BJHalperin  SA Comparison of parental and health care professional preferences for the acellular or whole cell pertussis vaccine. Pediatr Infect Dis J. 1998;17103- 109
Link to Article
Melman  STChawla  TKaplan  JMAnbar  RD Multiple immunizations: ouch! Arch Fam Med. 1994;3615- 618
Link to Article
Pruitt  RHKline  PMKovaz  RB Perceived barriers to childhood immunization among rural populations. J Community Health Nurs. 1995;1265- 72
Link to Article
Lannon  CBrack  VStuart  J  et al.  What mothers say about why poor children fall behind on immunizations: a summary of focus groups in North Carolina. Arch Pediatr Adolesc Med. 1995;1491070- 1075
Link to Article
Madlon-Kay  DJHarper  PG Too many shots? parent, nurse, and physician attitudes toward multiple simultaneous childhood vaccinations. Arch Fam Med. 1994;3610- 613
Link to Article
Woodin  KARodewald  LEHumiston  SGCarges  MSSchaffer  SJSzilagyi  PG Physician and parent opinions: are children becoming pincushions from immunizations? Arch Pediatr Adolesc Med. 1995;149845- 849
Link to Article
Centers for Disease Control and Prevention, Recommended childhood immunization schedule: United States, 1995. MMWR Morb Mortal Wkly Rep. 1995;44(RR-5)1- 9
Centers for Disease Control and Prevention, Recommended childhood immunization schedule: United States, January-June 1996. MMWR Morb Mortal Wkly Rep. 1996;44940- 943
Centers for Disease Control and Prevention, Recommended childhood immunization schedule: United States, July-December 1996. MMWR Morb Mortal Wkly Rep. 1996;45635- 638
Centers for Disease Control and Prevention, Recommended childhood immunization schedule: United States, 1997. MMWR Morb Mortal Wkly Rep. 1997;4635- 40
Centers for Disease Control and Prevention, Pertussis vaccination: use of acellular pertussis vaccines among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1997;46(RR-7)1- 25
Centers for Disease Control and Prevention, Poliomyelitis prevention in the United States: introduction of a sequential vaccination schedule of inactivated poliovirus vaccine followed by oral poliovirus vaccine. MMWR Morb Mortal Wkly Rep. 1997;46(RR-3)1- 25
Centers for Disease Control and Prevention, Impact of the sequential IPV/OPV schedule on vaccination coverage levels: United States, 1997. MMWR Morb Mortal Wkly Rep. 1998;471017- 1019
Centers for Disease Control and Prevention, Notice to readers: recommendations of the Advisory Committee on Immunization Practices: revised recommendations for routine poliomyelitis vaccination. MMWR Morb Mortal Wkly Rep. 1999;48590
Centers for Disease Control and Prevention, Recommended childhood immunization schedule: United States, 1998. MMWR Morb Mortal Wkly Rep. 1998;478- 12
Walter  EBSimmons  SSBland  CL Modified varicella-like syndrome in children previously vaccinated with live attenuated measles, mumps, rubella and varicella vaccine. Pediatr Infect Dis J. 1997;16626- 627
Link to Article
Mills  EGold  RThipphawong  J  et al.  Safety and immunogenicity of a combined five-component pertussis-diphtheria-tetanus-inactivated poliomyelitis-Haemophilus B conjugate vaccine administered to infants at two, four and six months of age. Vaccine. 1998;16576- 585
Link to Article
Ashman  HKayhty  HLehtonen  H  et al.  Streptococcus pneumoniae capsular polysaccharide-diphtheria toxoid conjugate vaccine is immunogenic in early infancy and able to induce immunologic memory. Pediatr Infect Dis J. 1998;17211- 216
Link to Article
Rosenthal  P Hepatitis A vaccine: current indications. J Pediatr Gastroenterol Nutr. 1998;27111- 113
Link to Article
Watson  BHaupt  RM Varicella vaccine: removing the roadblocks. Contemp Pediatr. 1997;14166- 181
Pichichero  MELatiolais  TBernstein  DI  et al.  Vaccine antigen interactions after a combination diphtheria-tetanus toxoid-acellular pertussis/purified capsular polysaccharide of Haemophilus influenzae type b-tetanus toxoid vaccine in two-, four- and six-month-old infants. Pediatr Infect Dis J. 1997;16863- 870
Link to Article
Paradiso  PR Combination vaccines for diphtheria, tetanus, pertussis, and Haemophilus influenzae type b. Ann N Y Acad Sci. 1995;754108- 113
Link to Article
Centers for Disease Control and Prevention, Combination vaccines for childhood immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1999;48(RR-05)1- 15
Taylor  JADarden  PMSlora  EHasemeier  CMAsmussen  LWasserman  R The influence of provider behavior, parental characteristics, and a public policy initiative on the immunization status of children followed by private pediatricians: a study from pediatric research in office settings. Pediatrics. 1997;99209- 215
Link to Article
Taylor  JACufley  D The association between parental health belief and immunization status among children followed by private pediatricians. Clin Pediatr (Phila). 1996;3518- 22
Link to Article

Figures

Place holder to copy figure label and caption

Percentage of children receiving all indicated immunization injections.

Graphic Jump Location

Tables

References

Centers for Disease Control and Prevention, Status report on the childhood immunization initiative national, state, and urban area vaccination coverage levels among children aged 19-35 months: United States, 1996. MMWR Morb Mortal Wkly Rep. 1997;46657- 664
Centers for Disease Control and Prevention, Vaccination coverage by race/ethnicity and poverty level among children aged 19-35 months: United States, 1996. MMWR Morb Mortal Wkly Rep. 1997;46963- 969
Williams  ITMilton  JDFarrell  JBGraham  NMH Interaction of socioeconomic status and provider practices as predictors of immunization coverage in Virginia children. Pediatrics. 1995;96439- 446
Wood  DDonald-Sherbourne  CHalfon  N  et al.  Factors related to immunization status among inner-city Latino and African-American preschoolers. Pediatrics. 1995;96295- 301
Guyer  BHughart  NHolt  E  et al.  Immunization coverage and its relationship to preventive health care visits among inner-city children in Baltimore. Pediatrics. 1994;9453- 58
Dietz  VJStevenson  JZell  ERCochi  SHadler  SEddins  D Potential impact on vaccination coverage levels by administering vaccines simultaneously and reducing dropout rates. Arch Pediatr Adolesc Med. 1994;148943- 949
Link to Article
Centers for Disease Control and Prevention, Impact of missed opportunities to vaccinate preschool-aged children on vaccination coverage levels: selected US sites, 1991-92. MMWR Morb Mortal Wkly Rep. 1994;43709- 718
Ad Hoc Working Group for the Development of Standards for Pediatric Immunization Practices, Standards for pediatric immunization practices. JAMA. 1993;2691817- 1822
Link to Article
Szilagyi  PGRodewald  LEHumiston  SG  et al.  Immunization practices of pediatricians and family physicians in the United States. Pediatrics. 1994;94517- 523
Szilagyi  PGRodewald  LEHumiston  SG Immunization practices of pediatric residents: are they meeting current standards? Pediatr Infect Dis J. 1994;13536- 538
Link to Article
Zimmerman  RKSchlesselman  JJBaird  ALMieczkowski  TA A national survey to understand why physicians defer childhood immunizations. Arch Pediatr Adolesc Med. 1997;151657- 664
Link to Article
Willis  ESherrod  JL Childhood immunizations: position on the enhanced inactivated poliovirus vaccine and live attenuated oral poliovirus vaccine dilemma. J Natl Med Assoc. 1997;89785- 789
Halperin  BAEastwood  BJHalperin  SA Comparison of parental and health care professional preferences for the acellular or whole cell pertussis vaccine. Pediatr Infect Dis J. 1998;17103- 109
Link to Article
Melman  STChawla  TKaplan  JMAnbar  RD Multiple immunizations: ouch! Arch Fam Med. 1994;3615- 618
Link to Article
Pruitt  RHKline  PMKovaz  RB Perceived barriers to childhood immunization among rural populations. J Community Health Nurs. 1995;1265- 72
Link to Article
Lannon  CBrack  VStuart  J  et al.  What mothers say about why poor children fall behind on immunizations: a summary of focus groups in North Carolina. Arch Pediatr Adolesc Med. 1995;1491070- 1075
Link to Article
Madlon-Kay  DJHarper  PG Too many shots? parent, nurse, and physician attitudes toward multiple simultaneous childhood vaccinations. Arch Fam Med. 1994;3610- 613
Link to Article
Woodin  KARodewald  LEHumiston  SGCarges  MSSchaffer  SJSzilagyi  PG Physician and parent opinions: are children becoming pincushions from immunizations? Arch Pediatr Adolesc Med. 1995;149845- 849
Link to Article
Centers for Disease Control and Prevention, Recommended childhood immunization schedule: United States, 1995. MMWR Morb Mortal Wkly Rep. 1995;44(RR-5)1- 9
Centers for Disease Control and Prevention, Recommended childhood immunization schedule: United States, January-June 1996. MMWR Morb Mortal Wkly Rep. 1996;44940- 943
Centers for Disease Control and Prevention, Recommended childhood immunization schedule: United States, July-December 1996. MMWR Morb Mortal Wkly Rep. 1996;45635- 638
Centers for Disease Control and Prevention, Recommended childhood immunization schedule: United States, 1997. MMWR Morb Mortal Wkly Rep. 1997;4635- 40
Centers for Disease Control and Prevention, Pertussis vaccination: use of acellular pertussis vaccines among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1997;46(RR-7)1- 25
Centers for Disease Control and Prevention, Poliomyelitis prevention in the United States: introduction of a sequential vaccination schedule of inactivated poliovirus vaccine followed by oral poliovirus vaccine. MMWR Morb Mortal Wkly Rep. 1997;46(RR-3)1- 25
Centers for Disease Control and Prevention, Impact of the sequential IPV/OPV schedule on vaccination coverage levels: United States, 1997. MMWR Morb Mortal Wkly Rep. 1998;471017- 1019
Centers for Disease Control and Prevention, Notice to readers: recommendations of the Advisory Committee on Immunization Practices: revised recommendations for routine poliomyelitis vaccination. MMWR Morb Mortal Wkly Rep. 1999;48590
Centers for Disease Control and Prevention, Recommended childhood immunization schedule: United States, 1998. MMWR Morb Mortal Wkly Rep. 1998;478- 12
Walter  EBSimmons  SSBland  CL Modified varicella-like syndrome in children previously vaccinated with live attenuated measles, mumps, rubella and varicella vaccine. Pediatr Infect Dis J. 1997;16626- 627
Link to Article
Mills  EGold  RThipphawong  J  et al.  Safety and immunogenicity of a combined five-component pertussis-diphtheria-tetanus-inactivated poliomyelitis-Haemophilus B conjugate vaccine administered to infants at two, four and six months of age. Vaccine. 1998;16576- 585
Link to Article
Ashman  HKayhty  HLehtonen  H  et al.  Streptococcus pneumoniae capsular polysaccharide-diphtheria toxoid conjugate vaccine is immunogenic in early infancy and able to induce immunologic memory. Pediatr Infect Dis J. 1998;17211- 216
Link to Article
Rosenthal  P Hepatitis A vaccine: current indications. J Pediatr Gastroenterol Nutr. 1998;27111- 113
Link to Article
Watson  BHaupt  RM Varicella vaccine: removing the roadblocks. Contemp Pediatr. 1997;14166- 181
Pichichero  MELatiolais  TBernstein  DI  et al.  Vaccine antigen interactions after a combination diphtheria-tetanus toxoid-acellular pertussis/purified capsular polysaccharide of Haemophilus influenzae type b-tetanus toxoid vaccine in two-, four- and six-month-old infants. Pediatr Infect Dis J. 1997;16863- 870
Link to Article
Paradiso  PR Combination vaccines for diphtheria, tetanus, pertussis, and Haemophilus influenzae type b. Ann N Y Acad Sci. 1995;754108- 113
Link to Article
Centers for Disease Control and Prevention, Combination vaccines for childhood immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1999;48(RR-05)1- 15
Taylor  JADarden  PMSlora  EHasemeier  CMAsmussen  LWasserman  R The influence of provider behavior, parental characteristics, and a public policy initiative on the immunization status of children followed by private pediatricians: a study from pediatric research in office settings. Pediatrics. 1997;99209- 215
Link to Article
Taylor  JACufley  D The association between parental health belief and immunization status among children followed by private pediatricians. Clin Pediatr (Phila). 1996;3518- 22
Link to Article

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