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Background: The most recent National Immunization Survey found that 74% of 19-35 month old children in Indiana were complete for the basic immunization series, well below the national goal of 90% coverage set by the Healthy People 2000/2010 initiative. Although vaccine-preventable disease incidence rates are at an all-time low, these sub-optimal immunization coverage levels highlight the fact that providers and parents are failing to recognize the importance of completing the immunization series by the child�s second birthday. By conducting immunization assessments among both public and private health care providers throughout Indiana, the ISDH Immunization Program is working with providers to improve immunization coverage levels throughout the state.

Current status of immunization assessments in Indiana: Among health care providers, assessments of the coverage levels of children aged 24-35 months have been completed in local health departments, non-health department public providers, and a sample of private providers enrolled in the Vaccines for Children program. Assessments among private providers began in 1998, while assessments among public providers has been completed annually since 1994. Other assessments completed annually in Indiana include the school, daycare, and Head Start immunization assessments, and the public university immunization assessment.

Public Provider Immunization Assessments: Public clinic assessments have been completed throughout Indiana on an annual basis since 1994. Immunization coverage levels for the 94 local health departments and a majority of the non-health department public providers administering vaccine were assessed in 1999 using CASA, special assessment software designed by the CDC. Among local health departments using the ImTIME immunization tracking software, the entire population of active patients aged 24-35 months was determined. For those health departments and non-health department public providers not using ImTIME, the immunization records of a statistically significant sample of two-year old patients were entered into the software. From this data, reports were generated showing each provider�s immunization coverage levels. In 1999, the median coverage level for the 4:3:1:3 series (4 DTaP, 3 Polio, 1 MMR, and 3 Hib vaccines by 24 months of age) was 85% among local health departments and 67% among non-health department public providers. Coverage levels for the 4:3:1:3 series for local health departments from 1997 � 1999 are shown in Table 1. Median coverage levels from the 1999 public provider assessments, both for individual vaccines and the various immunization series are shown in Table 2. These results demonstrate an overall increase in coverage levels among the local health departments in recent years.

Private Provider Immunization Assessments:  Private provider immunization assessments have been completed in Indiana since 1998. The vast majority of private providers included in these assessments are enrolled in the Vaccines for Children Program (VFC), which provides free vaccine to eligible children. In 1998, 112 assessments were completed for private providers throughout the state. In 1999 this number nearly doubled with 215 assessments were completed among private providers. Median coverage levels from the 1998 � 1999 private provider assessments, both for individual vaccines and the various immunization series are shown in Table 3. As can be seen in Table 3, the median 4:3:1:3 coverage level for private providers increased from 50.0% in 1998 to 55.7% in 1999. Despite these increases, coverage levels among VFC-enrolled private providers in Indiana still fall well below the goal of 90% coverage levels among two-year old children in Indiana.

School immunization assessment: All schools in Indiana are required to submit reports detailing the immunization coverage levels for pre-kindergarten, kindergarten, first grade, sixth grade, and new entering students. In the 1999-2000 school year new legislation became effective which required 3 doses of hepatitis B vaccine for all kindergarten and first grade students. Additionally, new rules became effective which standardized the school immunization requirements with the ACIP immunization schedule. In previous years, kindergarten immunization coverage levels have remained constant at 97%. However, this number dropped in the 1999-2000 school year to 81% (Table 4). Now that school administrators and nurses have had a full year to become familiar with and fully implement new school immunization requirements, coverage levels are expected to return to their high rates in the coming school year.

Daycare and Head Start center immunization assessments: All daycare and Head Start centers in Indiana are also required to submit annual immunization reports to ISDH. These reports reflect the age-appropriate immunization coverage levels of children who attend these facilities. Despite the fact that no changes were made to the daycare and Head Start immunization requirements in 1999, statewide immunization coverage levels of children attending these facilities fell compared to previous years� levels (Table 5).

University immunization assessments: On an annual basis six universities in Indiana (Ball State University, Indiana State University, Indiana University, Purdue University, the University of Southern Indiana, and Vincennes University) are required to submit immunization reports indicating the immune status of their matriculating students. These students are required to provide documented proof of immunity to measles, mumps, rubella, tetanus, and diphtheria prior to their matriculation. If students do not provide the proper documentation of immunity, they are to be denied second semester enrollment. Through improved enforcement of these requirements, immunization coverage levels have steadily increased, as a whole, among these six universities (Tables 6 and 7).

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