Vaccination Coverage by Age 24 Months Among Children Born in 2015 and 2016

National Immunization Survey-Child, United States, 2016-2018

Holly A. Hill, MD, PhD; James A. Singleton, PhD; David Yankey, PhD; Laurie D. Elam-Evans, PhD; S. Cassandra Pingali, MPH, MS; Yoonjae Kang, MPH

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(41):913-918.

Abstract and Introduction

Introduction

The Advisory Committee on Immunization Practices (ACIP) recommends that children be vaccinated against 14 potentially serious illnesses during the first 24 months of life.^[1] CDC used data from the National Immunization Survey-Child (NIS-Child) to assess vaccination coverage with the recommended number of doses of each vaccine at the national, state, territorial, and selected local levels* among children born in 2015 and 2016. Coverage by age 24 months was at least 90% nationally for ≥3 doses of poliovirus vaccine, ≥1 dose of measles, mumps, and rubella vaccine (MMR), ≥3 doses of hepatitis B vaccine (HepB), and ≥1 dose of varicella vaccine, although MMR coverage was <90% in 20 states. Children were least likely to be up to date by age 24 months with ≥2 doses of influenza vaccine (56.6%). Only 1.3% of children born in 2015 and 2016 had received no vaccinations by the second birthday. Coverage was lower for uninsured children and for children insured by Medicaid than for those with private health insurance. Vaccination coverage can be increased by improving access to vaccine providers and eliminating missed opportunities to vaccinate children during health care visits. Increased use of local vaccination coverage data is needed to identify communities at higher risk for outbreaks of measles and other vaccine-preventable diseases.

The NIS-Child is a random-digit–dialed telephone survey^† of parents or guardians of children aged 19–35 months. Respondents are asked to provide contact information for all providers who administered vaccines to their children. With parental consent, a survey is mailed to each identified provider, requesting the child's vaccination history. Multiple responses for an individual child are synthesized into a comprehensive vaccination history which is used to estimate vaccination coverage. To estimate coverage for the 25,059 children with adequate provider data^§ born in 2015 and 2016, NIS-Child data from 2016–2018 were combined; for survey year 2018, the Council of American Survey Research Organizations' response rate was 24.6%, and 54.0% of children with household interviews had adequate provider data.^¶ With this report, CDC has transitioned to reporting NIS-Child data by birth year rather than survey year. Vaccination coverage by age 24 months was estimated using Kaplan-Meier (time to event) analysis to account for children who were aged <24 months on the date vaccination status was assessed. Coverage with ≥2 doses of hepatitis A vaccine (HepA) was assessed at 35 months (the maximum age included in the survey), because the second dose of HepA can be administered as late as age 41 months under the current schedule. Previous NIS-Child weighting methods were modified to optimize estimation by birth year and to reflect the shift from a dual landline and cellular telephone sample frame to an exclusively cellular telephone sampling frame in 2018.** Differences in coverage estimates were evaluated using t-tests on weighted data; p-values of <0.05 were considered statistically significant. Analyses were performed using SAS (version 9.4; SAS institute) and SUDAAN (version 11.0.1; Research Triangle Institute). No evidence for a change in survey accuracy from the 2017 to 2018 survey year was detected (https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/pubs-presentations/NIS-child-vac-coverage-estimates-2014-2018-tables.html#supp-table-01).^[2]

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Abstract and Introduction
National Vaccination Coverage
Vaccination Coverage by Selected Characteristics and Geographic Location
Trends in Vaccination Coverage
Discussion
References
Sidebar

* Estimates for states, selected local areas, and the territory of Guam are available online at https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/data-reports/index.html. Certain local areas that receive federal Section 317 immunization funds are sampled separately and included in the NIS-Child sample every year (Chicago, Illinois; New York, New York; Philadelphia County, Pennsylvania; Bexar County, Texas; and Houston, Texas). Other local areas in Texas have been sampled in some survey years and not others, including El Paso County (survey years 2014–2017); Dallas County (survey years 2016 and 2017); Hildago County (survey years 2015 and 2018); Tarrant County (survey year 2018); and Travis County (survey year 2017). The NIS-Child was also conducted in Guam, Puerto Rico, and U.S. Virgin Islands; however, data collection in Puerto Rico and U.S. Virgin Islands was suspended during 2017 because of the severity of the hurricane season and did not occur at all in 2018, resulting in insufficient data for estimation of vaccination coverage by 24 months among children born during 2015–2016. National estimates in this report exclude all territories.
^† NIS-Child used a landline-only sampling frame from 1995 through 2010. From 2011 through 2017, the survey was conducted using a dual-frame design, with both cellular and landline sampling frames included. In 2018, the NIS-Child returned to a single-frame design, with all interviews conducted by cellular telephone.
^§ Children with at least one vaccination reported by a provider and those who had received no vaccinations were considered to have adequate provider data. "No vaccinations" indicates that the vaccination status is known because the parent indicated there were no vaccinations and the providers returned no immunization history forms or returned them indicating that no vaccinations had been given.
^¶ The Council of American Survey Research Organizations (CASRO) household response rate is calculated as the product of the resolution rate (percentage of the total telephone numbers called that were classified as nonworking, nonresidential, or residential), screening completion rate (percentage of known households that were successfully screened for the presence of age-eligible children), and the interview completion rate (percentage of households with one or more age-eligible children that completed the household survey). The CASRO household response rate is equivalent to the American Association for Public Opinion Research type 3 response rate http://www.aapor.org/AAPOR_Main/media/publications/Standard-Definitions20169theditionfinal.pdf. For CASRO response rates and the proportions of children with household interviews that had adequate provider data for survey years 2013–2017, see: https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-PUF17-DUG.pdf, (Appendix G).
** https://www.cdc.gov/vaccines/imz-managers/coverage/childvaxview/pubs-presentations/NIS-child-vac-coverage-estimates-2014-2018.html.

Table 1. Estimated vaccination coverage by age 24 months* among children born during 2013–2016 for selected vaccines and doses — National Immunization Survey-Child, United States, 2014–2018
Vaccine/Dose	% (95% CI)
	Birth years†		Difference (2013–2014) to (2015–2016)
	2013–2014	2015–2016	Difference (2013–2014) to (2015–2016)
DTaP^§
≥3 doses	93.6 (93.0 to 94.2)	93.8 (93.1 to 94.5)	0.2 (-0.7 to 1.1)
≥4 doses	80.6 (79.7 to 81.6)	80.3 (79.0 to 81.5)	-0.4 (-1.9 to 1.2)
Poliovirus (≥3 doses)	91.7 (91.0 to 92.4)	92.7 (92.0 to 93.4)	1.0 (0.0 to 2.0)
MMR (≥1 dose) ^¶	90.0 (89.3 to 90.7)	90.4 (89.5 to 91.2)	0.3 (-0.8 to 1.5)
Hib**
Primary series	92.7 (92.1 to 93.3)	92.7 (91.8 to 93.5)	0.0 (-1.1 to 1.0)
Full series	80.2 (79.3 to 81.1)	79.6 (78.3 to 80.9)	-0.6 (-2.1 to 1.0)
HepB
Birth dose^††	71.8 (70.7 to 72.8)	75.0 (73.7 to 76.2)	3.2 (1.6 to 4.9)^§§
≥3 doses	90.9 (90.2 to 91.6)	91.0 (90.2 to 91.9)	0.1 (-1.0 to 1.2)
Varicella (≥1 dose) ^¶	89.3 (88.6 to 90.1)	90.0 (89.1 to 90.9)	0.7 (-0.5 to 1.8)
PCV
≥3 doses	91.9 (91.2 to 92.5)	92.0 (91.1 to 92.8)	0.1 (-1.0 to 1.2)
≥4 doses	81.5 (80.6 to 82.4)	81.0 (79.8 to 82.3)	-0.4 (-2.0 to 1.1)
HepA
≥1 dose	83.2 (82.4 to 84.1)	84.7 (83.6 to 85.8)	1.5 (0.1 to 2.9)^§§
≥2 doses (by 35 months)	74.0 (72.8 to 75.3)	76.6 (74.7 to 78.4)	2.6 (0.4 to 4.8)^§§
Rotavirus (by 8 months)^¶¶	72.4 (71.3 to 73.4)	73.6 (72.2 to 74.9)	1.2 (-0.5 to 2.9)
Influenza (≥2 doses)***	53.0 (51.9 to 54.1)	56.6 (55.2 to 58.0)	3.6 (1.8 to 5.4)^§§
Combined 7-vaccine series^†††	68.4 (67.3 to 69.5)	68.5 (67.1 to 69.9)	0.1 (-1.7 to 1.9)
No vaccinations	1.1 (1.0 to 1.3)	1.3 (1.1 to 1.5)	0.1 (-0.2 to 0.4)

Abbreviations: CI = confidence interval; DTaP = diphtheria, tetanus toxoids, and acellular pertussis vaccine; HepA = hepatitis A vaccine; HepB = hepatitis B vaccine; Hib = Haemophilus influenzae type b conjugate vaccine; MMR = measles, mumps, and rubella vaccine; PCV = pneumococcal conjugate vaccine.
* Includes vaccinations received by age 24 months (before the day the child turns 24 months), except for the HepB birth dose, rotavirus vaccination, and ≥2 HepA doses by 35 months. For all vaccines, except the HepB birth dose and rotavirus vaccination, the Kaplan-Meier method was used to estimate vaccination coverage to account for children whose vaccination history was ascertained before age 24 months (35 months for ≥2 HepA doses).
^† Data for the 2013 birth year are from survey years 2014, 2015, and 2016; data for the 2014 birth year are from survey years 2015, 2016, and 2017; data for the 2015 birth year are from survey years 2016, 2017, and 2018; data for the 2016 birth year are considered preliminary and come from survey years 2017 and 2018 (data from survey year 2019 are not yet available).
^§ Includes children who might have received diphtheria and tetanus toxoids vaccine or diphtheria, tetanus toxoids, and pertussis vaccine.
^¶ Includes children who might have received measles, mumps, rubella, and varicella combination vaccine.
** Hib primary series: receipt of ≥2 or ≥3 doses, depending on product type received; full series: primary series and booster dose, which includes receipt of ≥3 or ≥4 doses, depending on product type received.
^†† One dose HepB administered from birth through age 3 days.
^§§ Statistically significantly different from 0 at p<0.05.
^¶¶ Includes ≥2 doses of Rotarix monovalent rotavirus vaccine, or ≥3 doses of RotaTeq pentavalent rotavirus vaccine. The maximum age for the final rotavirus dose is 8 months, 0 days.
*** Doses must be at least 24 days apart (4 weeks with a 4-day grace period).
^††† The combined 7-vaccine series (4:3:1:3*:3:1:4) includes ≥4 doses of DTaP, ≥3 doses of poliovirus vaccine, ≥1 dose of measles-containing vaccine, the full series of Hib (≥3 or ≥4 doses, depending on product type), ≥3 doses of HepB, ≥1 dose of varicella vaccine, and ≥4 doses of PCV.

Table 2. Estimated vaccination coverage by age 24 months* among children born during 2015–2016,† by selected vaccines and doses and health insurance status§ — National Immunization Survey-Child, United States, 2016–2018
Vaccine/Dose	Health insurance status, % (95% CI)
Vaccine/Dose	Private only (referent) (n = 12,702)	Any Medicaid (n = 9,442)	Other insurance (n = 2,141)	Uninsured (n = 774)
DTaP ^¶
≥3 doses	96.9 (96.3–97.5)	91.8 (90.5–93.1)**	93.9 (92.2–95.3)**	80.6 (75.2–85.5)**
≥4 doses	87.1 (85.7–88.5)	75.8 (73.6–77.9)**	78.8 (75.4–82.0)**	59.8 (53.8–65.9)**
Poliovirus (≥3 doses)	96.1 (95.4–96.7)	90.7 (89.3–92.0)**	92.3 (90.4–94.0)**	79.3 (73.9–84.3)**
MMR (≥1 dose) ^††	93.7 (92.8–94.5)	88.6 (87.0–90.1)**	89.8 (87.6–91.8)**	73.2 (67.4–78.7)**
Hib ^§§
Primary series	95.7 (94.5–96.8)	90.7 (89.3–92.1)**	93.7 (91.9–95.1)	78.4 (72.8–83.5)**
Full series	85.5 (83.7–87.1)	75.9 (73.8–78.0)**	79.1 (75.8–82.1)**	58.1 (52.1–64.2)**
HepB
Birth dose^¶¶	75.6 (73.9–77.2)	76.1 (74.0–78.1)	68.2 (64.3–71.9)**	67.8 (61.9–73.2)**
≥3 doses	93.0 (91.8–94.0)	90.0 (88.5–91.4)**	91.9 (89.9–93.6)	78.6 (73.3–83.5)**
Varicella (≥1 dose) ^††	93.2 (92.3–94.0)	88.6 (86.9–90.1)**	89.1 (86.8–91.2)**	70.3 (64.5–75.9)**
PCV
≥3 doses	94.9 (93.5–96.0)	90.3 (88.9–91.7)**	92.0 (90.1–93.7)**	77.2 (71.7–82.4)**
≥4 doses	87.3 (85.6–88.8)	76.8 (74.7–78.9)**	80.9 (77.7–83.9)**	62.5 (56.7–68.3)**
HepA
≥1 dose	87.5 (85.9–89.0)	83.7 (81.9–85.4)**	84.0 (81.2–86.6)**	65.5 (59.7–71.3)**
≥2 doses (by 35 months)	80.5 (77.9–83.1)	75.2 (72.2–78.0)**	76.8 (71.3–81.9)	48.2 (41.0–56.0)**
Rotavirus (by 8 months)***	83.5 (81.9–85.0)	65.9 (63.5–68.1)**	72.4 (68.5–76.0)**	59.8 (53.8–65.5)**
Influenza (≥2 doses) ^†††	68.5 (66.6–70.4)	48.2 (45.9–50.5)**	52.7 (48.6–56.9)**	34.7 (29.4–40.7)**
Combined 7-vaccine series ^§§§	75.4 (73.5–77.2)	64.3 (62.0–66.6)**	65.9 (62.1–69.6)**	46.7 (40.9–52.9)**
No vaccinations	0.8 (0.6–1.0)	1.2 (0.9–1.6)	1.8 (1.2–2.6)**	7.4 (4.7–10.7)**

Abbreviations: CI = confidence interval; DTaP = diphtheria, tetanus toxoids, and acellular pertussis vaccine; HepA = hepatitis A vaccine; HepB = hepatitis B vaccine; Hib = Haemophilus influenzae type b conjugate vaccine; MMR = measles, mumps, and rubella vaccine; PCV = pneumococcal conjugate vaccine.
* Includes vaccinations received by age 24 months (before the day the child turns 24 months), except for the HepB birth dose, rotavirus vaccination, and ≥2 HepA doses by 35 months. For all vaccines, except the HepB birth dose and rotavirus vaccination, the Kaplan-Meier method was used to estimate vaccination coverage to account for children whose vaccination history was ascertained before age 24 months (35 months for ≥2 HepA doses).
^† Data for the 2015 birth year are from survey years 2016, 2017, and 2018; data for the 2016 birth year are considered preliminary and come from survey years 2017 and 2018 (data from survey year 2019 are not yet available).
^§ Children's health insurance status was reported by parent or guardian. "Other insurance" includes the Children's Health Insurance Program, military insurance, coverage via the Indian Health Service, and any other type of health insurance not mentioned elsewhere.
^¶ Includes children who might have received diphtheria and tetanus toxoids vaccine or diphtheria, tetanus toxoids, and pertussis vaccine.
** Statistically significant (p<0.05) difference compared with the referent group.
^†† Includes children who might have received measles, mumps, rubella, and varicella combination vaccine.^§§ Hib primary series: receipt of ≥2 or ≥3 doses, depending on product type received; full series: primary series and booster dose, which includes receipt of ≥3 or ≥4 doses, depending on product type received.
^¶¶ One dose HepB administered from birth through age 3 days.
*** Includes ≥2 doses of Rotarix monovalent rotavirus vaccine (RV1), or ≥3 doses of RotaTeq pentavalent rotavirus vaccine (RV5). The maximum age for the final rotavirus dose is 8 months, 0 days.
^††† Doses must be at least 24 days apart (4 weeks with a 4-day grace period).
^§§§ The combined 7-vaccine series (4:3:1:3*:3:1:4) includes ≥4 doses of DTaP, ≥3 doses of poliovirus vaccine, ≥1 dose of measles-containing vaccine, the full series of Hib (≥3 or ≥4 doses, depending on product type), ≥3 doses of HepB, ≥1 dose of varicella vaccine, and ≥4 doses of PCV.

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Vaccination Coverage by Age 24 Months Among Children Born in 2015 and 2016

National Immunization Survey-Child, United States, 2016-2018

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Vaccination Coverage by Age 24 Months Among Children Born in 2015 and 2016

National Immunization Survey-Child, United States, 2016-2018

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