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Objective. To examine the effect of patient selection criteria on immunization practice assessment outcomes. Methods. In 3 high- (50%–85%) and 7 low- ( Results. Of the 1823 charts assessed in the high- and low-Medicaid practices, follow-up identified 61% and 83% as active patients; 78% and 95% were ever seen in the past year. At 24 months, mean practice immunization rates were lower for standard (70%) than all 3 alternative criteria (78%–86%). Immunization rate differences between standard and alternative criteria were greater in high- (17%–23%) than low-Medicaid practices (5%–13%). Conclusion. The standard for practice assessment should be based on a consistent definition of active patients as the immunization rate denominator.

Objectives.To evaluate health care and financial outcomes in a population of Medicaid-insured asthmatic children after a comprehensive asthma intervention program.Design.Controlled clinical trial.Setting.Pediatric allergy clinic in an urban, tertiary care children's hospital.Subjects.Eighty children, 2 to 16 years old, with a history of frequent use of emergent health care services for asthma.Intervention.Children in the intervention group received asthma education and medical treatment in the setting of a tertiary care pediatric allergy clinic. An asthma outreach nurse maintained monthly contact with the families enrolled in the intervention group.Outcome Measures.Emergency department (ED) visits, hospitalizations, and health care charges per patient in the year after enrollment.Results.Baseline demographics did not differ significantly between the 2 groups. In the year before the study, there were no significant differences between intervention and control children in ED visits (mean, 3.5 per patient), hospitalizations (mean, .6 per patient) or health care charges ($2969 per patient). During the study year, ED visits decreased to a mean of 1.7 per patient in the intervention group and 2.4 in controls, while hospitalizations decreased to a mean of .2 per patient in the intervention group and .5 in the controls. Average asthma health care charges decreased by $721/child/year in the intervention group and by $178/patient/year in the control group.Conclusions.A comprehensive asthma intervention program for Medicaid-insured asthmatic children can significantly improve health outcomes while reducing health care costs.asthma education, health care outcomes, Medicaid, asthma outreach, utilization.

Objective. To determine whether anti-Giardia lamblia secretory IgA (sIgA) antibodies in human milk protect infants from acquisition of or symptoms associated with Giardia infection. Methods. One hundred ninety-seven Mexican mother/infant pairs were followed weekly from birth for diarrheal disease and feeding status. Infant stool specimens were collected weekly and were cultured for bacterial pathogens and tested for Giardia and rotavirus by enzyme-linked immunosorbent assay. Maternal milk samples were collected weekly for 1 month postpartum and monthly thereafter. To determine the protective effect of anti-Giardia sIgA in milk against infection and against diarrhea due to Giardia, milk samples from mothers of infected infants and appropriately matched controls were assayed for anti-Giardia sIgA by enzyme-linked immunosorbent assay. Results. Asymptomatic, infected infants ingested significantly (P = .046) higher amounts of milk anti-Giardia sIgA compared with symptomatic, infected infants. However, milk anti-Giardia sIgA concentrations did not differ between Giardia-infected and noninfected infants. Conclusion. The amount of anti-Giardia sIgA in human milk was associated with prevention of symptoms of diarrhea due to Giardia, but not with acquisition of the organism.

It was hypothesized that parents and child care providers are not prepared to accept children infected with human immunodeficiency virus (HIV), who are increasing in number, into the day care center setting. To determine their knowledge and attitudes toward HIV transmission, 219 parents in 4 day care centers and 176 care providers in 12 day care centers were given confidential questionnaires. More than 98% of respondents knew that sex and needle sharing can transmit HIV; 84% of parents and 77% of care providers knew that contact with blood can transmit HIV. There was, however, uncertainty about transmission via many common contacts in day care centers: human bites, urine, stool, tears, and vomit; kissing; sharing of food and eating utensils; and diaper changing areas. Only 43% of parents said they would allow their child to stay in the same room with a child who was infected with HIV. In a multiple logistic regression model, the unwillingness of parents to have their child stay in the same room with a child who was infected with HIV was significantly (P < .0001) associated with black ethnicity, beliefs that such a child is likely to infect others (40%) and is dangerous to others (58%), and fear of their child being exposed to HIV (86%). Care providers' unwillingness to care for a child infected with HIV in the classroom (48%) was significantly (P < .0001) associated with beliefs that such a child is likely to infect others (44%) and that common day care center contacts can transmit HIV (62%). Most parents and care providers wanted to be informed if a child infected with HIV was in the classroom. A serious effort will be needed to educate parents and care providers if children who have been infected with HIV are to be accepted into the day care center setting routinely.

OBJECTIVES. The goals were (1) to compare pediatricians' heptavalent pneumococcal conjugate vaccine shortage experience and adherence to shortage recommendations during 2 heptavalent pneumococcal conjugate vaccine shortages, (2) to assess factors associated with nonadherence to second shortage recommendations, and (3) to assess opinions about national immunization policy during vaccine shortages. METHODS. We mailed surveys to all pediatrician immunization providers in the greater Cincinnati, Ohio, metropolitan area. We assessed heptavalent pneumococcal conjugate vaccine supply and immunization practices during the shortages and provider attitudes regarding immunization shortage policy. RESULTS. The response rate was 61% (171 of 282 providers). Most pediatricians experienced heptavalent pneumococcal conjugate vaccine shortages (first shortage: 86%; second shortage: 84%). The rate of adherence to recommendations to defer the fourth heptavalent pneumococcal conjugate vaccine dose for healthy children was significantly higher during the second shortage, compared with the first shortage (first shortage: 62%; second shortage: 89%). Adherence to recommendations to administer the fourth dose to high-risk children remained unchanged (first shortage: 43%; second shortage: 45%). Controlling for other factors, pediatricians who reported a severe second shortage had greater odds of not fully vaccinating high-risk children, compared with those who reported no shortage. Contrary to recommendations, many pediatricians did not maintain tracking systems during the heptavalent pneumococcal conjugate vaccine shortages (first shortage: 37%; second shortage: 46%). Most pediatricians (91%) thought that national vaccine shortage recommendations were needed to protect them from liability. CONCLUSIONS. The rate of adherence to recommendations to defer heptavalent pneumococcal conjugate vaccine doses for healthy children increased significantly from the first shortage to the second shortage. The nonadherent practice of deferring the fourth dose for high-risk children was associated with more severe shortages and, potentially, an inability to vaccinate.

OBJECTIVE. The American Academy of Pediatrics recommended routine use of varicella vaccine in pediatric practice in 1995. We examined the impact of varicella immunization on population-based rates of pediatric varicella-related hospitalizations and emergency department (ED) visits in the years before and after introduction of varicella vaccine.STUDY DESIGN. Discharge data for hospitalizations and ED encounters from 1990 through 2003 were queried for patients RESULTS. During the 14-year study period, there were 3983 incident varicella cases; 335 patients were hospitalized and 3833 were treated only in the ED. The rate of varicella-related hospitalizations decreased from 15.7 cases per 100000 population to 5.5 cases per 100000 population between the prevaccine period (1990–1995) and the postvaccine period (1996–2003); varicella-related ED use decreased from 178.2 cases per 100000 population to 61.2 cases per 100000 population. In the prevaccine period, hospitalization and ED visit rates were significantly higher for black children than for white children. In the postvaccine period, hospitalization rates did not differ according to race but ED visit rates remained significantly higher for black children, compared with white children.CONCLUSIONS. Varicella-related hospitalization and ED visit rates decreased significantly for both white and black children in Hamilton County, Ohio, after the introduction of varicella vaccine, and the racial disparity found before licensure decreased after licensure.

Substantial costs occur each year due to infectious illness attributable to day-care center attendance by young children.1-3 Estimates of the value of work missed by parents in the US due to day-care-associated upper respiratory tract and diarrheal illness combined have ranged from $1602 million to $4003 million per year. Infectious diarrhea is one of the most common illnesses among young children. Several epidemiologic studies have shown increased risk of developing infectious diarrhea with attendance in group care, especially among children under 3 years of age.4-6 The cost burden of diarrheal illness among children attending day-care centers (DCCs) has not been adequately quantified, and few analyses have considered the effect that the type of care arrangement given ill children exerts on cost. To estimate the cost burden of gastrointestinal-tract illness in day-care centers (DCCs), we used data collected during a 16-month cohort study of rotavirus diarrhea in four DCCs. In addition, we surveyed parents to assess factors affecting cost of illness and to assess the range of ill-child-care options used by parents. METHODS Selection of Day Care Centers Four DCCs in Houston, Texas, were selected for participation in the rotavirus cohort study from a list of licensed DCCs generated by the Texas Department of Human Services. Potential study sites were centers with sufficient numbers of infants and toddlers located within a 7-mile radius of the University of Texas Medical School. Center directors gave informed consent for their centers to participate in the study. Day-Care Center Population From October 1989 through April 1991, children age 1-18 months with no known underlying disease in four licensed DCCs were enrolled in the rotavirus cohort study.

Background.Extreme prematurity is a risk factor for both candidemia and threshold retinopathy of prematurity (ROP) and may confound the reported association between these conditions.Objective.To determine if candidemia is an independent risk factor for threshold ROP.Methods.A cohort study was conducted of infants weighing ≤1000 g at birth using a prospectively maintained neonatal database. The study included infants admitted to the neonatal intensive care unit at ≤3 days of age between January 1, 1993 and December 31, 1997. We excluded infants not screened for ROP because they died, were discharged, or transferred. Threshold ROP (ie, requiring ablative therapy within 72 hours of diagnosis) was defined by the criteria of the American Academy of Pediatrics Section on Ophthalmology ROP subcommittee. Candidemia was defined as Candidaspecies growth from at least 1 blood culture. Cox proportional hazards regression was used to determine independent risk factors for threshold ROP.Results.Six hundred fourteen infants weighing ≤1000 g at birth, of which 165 were excluded: 120 died before ROP screening, 40 were admitted >3 days of age, and 5 were discharged or transferred before ROP screening. A total of 449 infants were included in the study; 58 (13%) developed threshold ROP. Candidemia occurred in 58 (13%) infants before developing the worst stage of ROP. Candidemia occurred in 27 of 73 (37%) at 23 to 24 weeks' gestational age (GA), 25 of 197 (13%) at 25 to 26 weeks' GA, and 6 of 129 (5%) at 27 to 28 weeks' GA, 0 of 50 >28 weeks' GA. Similarly, threshold ROP occurred in 25 of 73 (34%) at 23 to 24 weeks' GA, 26 of 197 (13%) at 25 to 26 weeks' GA, and 6 of 129 (5%) at 27 to 28 weeks' GA, and 1 of 50 (2%) >28 weeks' GA. Threshold ROP developed in 19 of 58 (33%) infants with a history of candidemia and 39 of 391 (10%) without candidemia. Proportional hazards analysis indicated that GA in weeks (hazard ratio = .75; 95% confidence interval [CI]: .61, .93) and non-black ethnicity (hazard ratio = 1.8; 95% CI: 1.05, 3.08) were significantly associated with threshold ROP. After controlling for GA and other factors, candidemia did not remain significantly associated with threshold ROP (hazard ratio = 1.6; 95% CI: .89, 2.89).Conclusion.Candidemia may not be an independent risk factor for threshold ROP in extremely low birth weight infants. The magnitude of the previously reported association between candidemia and threshold ROP (more than fivefold) is unlikely and much of the clinically observed association appears to be mediated by gestational age.

Background. Pediatric immunization rates have increased in the United States since 1990. Nevertheless, national survey data indicate that up to one third of 2-year-old children in some states and urban areas lack at least one recommended dose of diphtheria–tetanus–pertussis (DTP)-, polio-, or measles-containing vaccines. Immunization has become a key measure of preventive pediatric health care in the United States. To achieve and maintain the national immunization goal that 90% of children receive all recommended immunizations by 2 years of age, the role of the health care system in immunization delivery must be examined. Urban eastern Virginia has a diverse population that obtains immunization services from public, private, and military providers and insurers. At the time of this survey, immunization services in Virginia were available free to all children through public health clinics and to military families when using a military facility.Objective. To examine access to pediatric immunization services and health system factors associated with underimmunization in a representative sample of children at 12 and 24 months of age.Methods. We conducted a household survey in urban eastern Virginia from April through September 1993. A total of 12 770 households in Norfolk and Newport News, VA, were selected for inclusion in the study using probability-proportionate-to-size cluster sampling. Use of probability-proportionate-to-size sampling ensured that children within each city had equal probability of being included in the survey. Selected households were visited by trained interviewers to determine their eligibility, defined as having at least one child 12 to 30 months of age residing in the household. In eligible households, parents were asked to participate in a standardized, 15-minute interview. Survey respondents were asked about household demographics, and for each eligible child, the immunization history, health insurance, the name and location of all immunization providers, the usual immunization provider, and any problems the parent had experienced accessing immunization services with that child. Up-to-date (UTD) immunization status was defined as having all recommended doses of DTP, polio, and measles–mumps–rubella at 12 months (three DTP and two polio immunizations) and 24 months (four DTP, three polio, and one measles–mumps–rubella immunizations). The child's immunization history was assessed from parent and provider records only. Data analysis accounted for the survey's cluster sampling design (ie, within-cluster correlation). Because the immunization rates of the two cities did not differ significantly, unweighted analyses were used for ease of computation. Significance was determined for contingency tables by Wald's χ2 test.Results. A total of 749 children (91% of eligible households) participated in the survey. Study children were born between October, 1990, and July, 1992. Immunization records were obtained for 705 children (94%). Eighty-seven percent of respondents were mothers, 44% were African-American, 40% of children were military dependents, and 40% were enrolled in the Women, Infants and Children (WIC) program. Sixty-five percent of children were UTD at 12 months and 53% at 24 months. Parents reported that their children's usual immunization providers were private doctors (34%); public health, hospital clinics, or community health centers (32%); and military clinics or a military contract provider (34%). At least one problem accessing immunization services was reported by 35% of respondents, ranging from 29% among those who used a private doctor as their child's usual immunization provider to 46% among those using a military contract provider. Overall, the most commonly reported problem was clinic waiting time (12%), with reports of waiting time as a problem occurring most often among those using the military contract provider (22%) and public health clinics (17%). The second most common problem was difficulty obtaining a timely appointment (10%), with appointment problems ranging from 18% to 24% among those using military facilities compared with 4% to 6% among those using other providers. Some of the other problems reported were taking time away from work, office hours, cost, and transportation, with the frequency varying by type of usual provider.Household risk factors for children not being UTD at 12 and 24 months included having a greater number of children, single parenthood, lack of education beyond high school, teenage mother, African-American ethnicity, and not finding the child's immunization record at home. After adjusting for these household factors by multiple logistic regression, the system-related factors significantly associated with not being UTD at 12 months were not being in WIC (odds ratio [OR] = 2.1, 95% confidence interval [CI] 1.4–3.3), having Civilian Health and Medical Program of the Uniformed Services (OR = 5.2; CI: 2.9–9.5) or Medicaid (OR = 2.7; CI: 1.4–5.3) insurance, longer clinic waiting time (for each hour, OR = 1.6; CI: 1.2–2.0), and transportation problems (OR = 2.6; CI: 1.3–5.2); and at 24 months were not being in WIC (OR = 2.0; CI: 1.1–3.7), problems obtaining an appointment (OR = 4.5; CI: 1.8–8.6), and use of a military contract clinic (OR = 5.6; CI: 2.6–11.9). Although not all reported problems accessing services were independent risk factors for underimmunization, a dose–response relationship was found between the total number of different reported problems and children not being UTD at 24 months.Conclusions. This is the first population-based study of the association between immunization coverage rates and access to public, private, and military health care systems. Overall, one third of parents perceived barriers to pediatric immunization services, and parent-reported problems accessing services had a dose–response association with underimmunization. The most commonly reported problems were long waiting times and difficulty obtaining appointments, but the pattern and magnitude of problems reported differed among public, private, and military services. Despite free immunizations, parents most often reported problems accessing public and military providers. Thus, parents did not necessarily consider cost-free and geographically available pediatric services to be barrier-free. Enrollment in WIC was associated with significantly increased immunization rates, although this study was conducted before linkage of the WIC program with immunization services. This finding suggests the importance of WIC as a point of access to the health care system for vulnerable families. In this population, significant variation in immunization rates was found among health care providers and insurers that was not readily explained by measured population characteristics or parent-reported access barriers, possibly attributable, in part, to differences in provider practices. Population-level measurement of immunization rates and parent perception of services is critical for improving access to, and quality of, immunization services.

In Reply.— We appreciate Dr Fenster's letter, especially since it underscores issues raised by the possibility of having human immunodeficiency virus(HIV)-infected children in day care centers. There are three issues raised by the letter: (1) the question of parent rights; (2) the role of physicians and public health institutions to assess health risks posed by individuals for the population as a whole; and (3) the content of the educational message that should be provided