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Objective: After the discontinuation of School Health Policies and Practices Study (SHPPS) in 2016, the US Centers for Disease Control and Prevention (CDC) began exploring innovative ways to gather school health information using existing surveillance systems. School Health Profiles (Profiles) is a school-based system of surveys that monitors school health policies and practices in states and other jurisdictions. The objective of this study was to assess whether prevalence estimates calculated using nationally representative SHPPS as an established benchmark were similar to estimates using aggregated Profiles data. Method: Nationwide 2014 Profiles estimates were calculated from data across all 50 US states and the District of Columbia and compared to national 2014 SHPPS estimates. Fifty-seven questions were identical between the data sources. Equivalence tests were used to determine similarity between data sources. Results: Overall, the median difference between 2014 SHPPS and 2014 Profiles estimate was one percentage point and distribution-free 95% confidence intervals were (-0.8, 3.1). Of the 57 school health policy and practice indicators examined in this study, 38 (66.7%) were found to be equivalent. Of these equivalent indicators, the median percentage point difference between data sources was 0.8 (-0.8, 2.5). A nonparametric sign test showed that none of the medians of the estimate differences examined were significantly different from zero. Conclusion: This study demonstrates the expanded utility of state-level data to meet public health surveillance needs. This study found that aggregated, state-level Profiles data can be used to calculate nationwide prevalence estimates that are reasonably consistent with results from a nationally representative survey.

ObjectiveHigh out-of-pocket (OOP) costs can be an obstacle to health care access and treatment compliance. This study investigated trends in high OOP health care burden in people with diabetes.Research design and methodsUsing Medical Expenditure Panel Survey 2001-2011 data, we examined trends in the proportion of people aged 18-64 years with diabetes facing a high OOP burden. We also examined whether the trend differed by insurance status (private insurance, public insurance, or no insurance) or by income level (poor and near poor, low income, middle income, or high income).ResultsIn 2011, 23% of people with diabetes faced high OOP burden. Between 2001-2002 and 2011, the proportion of people facing high OOP burden fell by 5 percentage points (P < 0.01). The proportion of those who were publicly insured decreased by 22 percentage points (P < 0.001) and of those who were uninsured by 12 percentage points (P = 0.01). Among people with diabetes who were poor and near poor and those with low income, the proportion facing high OOP burden decreased by 21 (P < 0.001) and 13 (P = 0.01) percentage points, respectively; no significant change occurred in the proportion with private insurance or middle and high incomes between 2001-2002 and 2011.ConclusionsThe past decade has seen a narrowing of insurance coverage and income-related disparities in high OOP burden in people with diabetes; yet, almost one-fourth of all people with diabetes still face a high OOP burden.

Estimates of county-level disease prevalence have a variety of applications. Such estimation is often done via model-based small-area estimation using survey data. However, for conditions with low prevalence (i.e., rare diseases or newly diagnosed diseases), counties with a high fraction of zero counts in surveys are common. They are often more common than the model used would lead one to expect; such zeros are called 'excess zeros'. The excess zeros can be structural (there are no cases to find) or sampling (there are cases, but none were selected for sampling). These issues are often addressed by combining multiple years of data. However, this approach can obscure trends in annual estimates and prevent estimates from being timely. Using single-year survey data, we proposed a Bayesian weighted Binomial Zero-inflated (BBZ) model to estimate county-level rare diseases prevalence. The BBZ model accounts for excess zero counts, the sampling weights and uses a power prior. We evaluated BBZ with American Community Survey results and simulated data. We showed that BBZ yielded less bias and smaller variance than estimates based on the binomial distribution, a common approach to this problem. Since BBZ uses only a single year of survey data, BBZ produces more timely county-level incidence estimates. These timely estimates help pinpoint the special areas of county-level needs and help medical researchers and public health practitioners promptly evaluate rare diseases trends and associations with other health conditions. [ABSTRACT FROM AUTHOR]

Objectives. We assessed whether local health departments (LHDs) were conducting obesity prevention programs and diabetes screening programs, and we examined associations between LHD characteristics and whether they conducted these programs. Methods. We used the 2005 National Profile of Local Health Departments to conduct a cross-sectional analysis of 2300 LHDs nationwide. We used multivariate logistic regressions to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Results. Approximately 56% of LHDs had obesity prevention programs, 51% had diabetes screening programs, and 34% had both. After controlling for other factors, we found that employing health educators was significantly associated with LHDs conducting obesity prevention programs (OR=2.08; 95% CI=1.54, 2.81) and diabetes screening programs (OR=1.63; 95% CI=1.23, 2.17). We also found that conducting chronic disease surveillance was significantly associated with LHDs conducting obesity prevention programs (OR=1.66; 95% CI=1.26, 2.20) and diabetes screening programs (OR = 2.44; 95% CI = 1.90, 3.15). LHDs with a higher burden of diabetes prevalence were more likely to conduct diabetes screening programs (OR=1.20; 95% CI=1.11, 1.31) but not obesity prevention programs. Conclusions. The presence of obesity prevention and diabetes screening programs was significantly associated with LHD structural capacity and general performance. However, the effectiveness and cost-effectiveness of both types of programs remain unknown. (Am J Public Health. 2010;100:1434-1441. doi: 10. 2105/AJPH.2009.168831)

Objective. We examined heptavalent pneumococcal conjugate vaccine (PCV7) uptake among children aged 19 to 35 months in the United States and determined how uptake rates differed by state vaccine financing policy. Methods. We analyzed data from the 2001-2003 National Immunization Survey. States that changed their vaccine financing policy between 2001 and 2003 (n=17) were excluded from analysis. Logistic regression was performed to identify the association between state vaccine financing policy and receipt of 3 or more doses of PCV7 after control for demographic characteristics. Results. The proportion of children receiving 3 or more doses increased from 6.7% in 2001 to 69.0% in 2003. After controlling for demographic characteristics, children residing in states that provided all vaccines except PCV7 to all children had lower odds of receiving 3 or more doses compared to children residing in states that provided PCV7 only to children eligible for the Vaccines for Children program (odds ratio = 0.58; 95% confidence interval = 0.51, 0.66). Conclusion. It is essential that we continue to monitor the effect that state vaccine financing policy has on the delivery of PCV7 and future vaccines, which are likely to be increasingly expensive.

Objectives. We determined the effect of diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) and measles, mumps, rubella (MMR) vaccine shortageson timeliness of the third dose of DTaP (DTaP3), the fourth dose of DTaP (DTaP4), and the first dose of MMR (MMR1) among subgroups of preschool children. Methods. Data from the 2001 and 2002 National Immunization Surveys were analyzed. Children age-eligible to receive DTaP3, DTaP4, or MMR1 during the shortages were considered subject to the shortage, and those not age-eligible were not subject to the shortage; timeliness of vaccinations was compared. Results. Among children vaccinated only at public clinics, children residing outside metropolitan Statistical areas, and children in the Southern Census Region, those age-eligible to receive DTaP4 during the shortage were less likely to be vaccinated by 19 months of age than children not subject to the shortage. Conclusions. There was notable disparity in the effects of the recent vaccine shortages; children vaccinated only in public clinics, in rural areas, or in the Southern United States were differentially affected by the shortages. doi: 10.2105/AJPH.2004.053306)

OBJECTIVES. In 1999, the Advisory Committee on Immunization Practices made recommendations for hepatitis A vaccination of children according to historic rates of hepatitis A incidence in different regions of the country. The objective of this study was to examine hepatitis A vaccination coverage rates among children living in states with different vaccination recommendations and to examine individual characteristics associated with vaccination. METHODS. Hepatitis A vaccination status data were collected for children 24 to 35 months of age through the National Immunization Survey, a telephone survey with health care provider-verified vaccination results. Vaccination status data were collected from children in each of the 50 states and 28 selected urban areas. RESULTS. In 2003, 50.9% (95% confidence interval [CI]: 47.6-54.2%) of children living in 11 states where routine hepatitis A vaccination is recommended had received ->1 dose, compared with 25.0% (95% CI: 21.8-28.2%) of children in 6 states where vaccination is suggested and 1.4% (95% CI: 1.0-1.8%) of children in 33 states without a recommendation. Coverage was higher among children who lived in urban areas, were Hispanic or American Indian/Alaska Native, or were born to women with less education. CONCLUSIONS. Hepatitis A vaccination is being targeted successfully to children at higher risk of infection; however, overall vaccination coverage remains lower for hepatitis A vaccination, compared with other routine childhood vaccinations. www.pediatrics.org/cgi/doi/10.1542/ peds.2005-0286 doi:10.1542/peds.2005-0286 Key Words hepatitis A, vaccination coverage, children, race/ethnicity, immunization policy Abbreviations ACIP--Advisory Committee on Immunization Practices AIAN--American Indian/Alaska Native CI--confidence interval NIS--National Immunization Survey OR--odds ratio, HEPATITIS A INCIDENCE rates in the United States have historically differed according to race and ethnicity, socioeconomic status, and region of the country, with rates being highest among American Indian/Alaska [...]

Objective. We examined the timeliness of vaccine administration among children aged 24 to 35 months for each state of the United States and the District of Columbia. Methods. We analyzed the timeliness of vaccinations in the 2000-2002 National Immunization Survey. We used a modified Bonferroni adjustment to compare a reference state with all other states. Results. Receipt of all vaccinations as recommended ranged from 2% (Mississippi) to 26% (Massachusetts), with western states having less timeliness than eastern states. Conclusions. Vaccination coverage measures usually focus on the number of vaccinations accumulated by specified ages. Our analysis of timeliness of administration shows that children rarely receive all vaccinations as recommended. State health departments can use timeliness of vaccinations along with other measures to determine children's susceptibility to vaccine-preventable diseases and to evaluate the quality of vaccination programs. States can use the modified Bonferroni comparison to appropriately compare their results with other states. (doi:10.2105/AJPH.2004.046284)

A study is conducted to determine the extent of delay of vaccination during the first 24 months of life of children in the United States. The study concluded that more than 1 in 3 children were undervaccinated for more than 6 months during their first 24 months of life and 1 in 4 children were delayed for at least 4 vaccines.

Context. Each year 2.1 million children 19 to 35 months of age are undervaccinated. Among these are children who have received no vaccinations. Unvaccinated children are at increased risk of acquiring and transmitting vaccine-preventable diseases. Objectives. To assess whether the characteristics of children with no vaccinations differ from those of undervaccinated children, to monitor trends in the numbers of unvaccinated children, and to identify states with high rates and counties with large numbers of unvaccinated children. Design. A nationally representative probability sample of children 19 to 35 months of age was collected annually between 1995 and 2001. Vaccination histories were ascertained from children&apos;s medical providers. Undervaccinated children had received [greater than or equal to] 1 dose of diphtheria-tetanus-pertussis, polio, measles, Haemophilus influenzae type b, hepatitis B, or varicella vaccine but were not fully vaccinated. Unvaccinated children were children who were reported as having no medical providers and having received no vaccinations or children whose medical providers reported administering no vaccinations. Participants. A total of 151 720 children sampled between 1995 and 2001, 795 of whom were unvaccinated. Results. Undervaccinated children tended to be black, to have a younger mother who was not married and did not have a college degree, to live in a household near the poverty level, and to live in a central city. Unvaccinated children tended to be white, to have a mother who was married and had a college degree, to live in a household with an annual income exceeding $75 000, and to have parents who expressed concerns regarding the safety of vaccines and indicated that medical doctors have little influence over vaccination decisions for their children. Unvaccinated children were more likely to be male than female. Annually, ~17 000 children were unvaccinated. The largest numbers of unvaccinated children lived in counties in California, Illinois, New York, Washington, Pennsylvania, Texas, Oklahoma, Colorado, Utah, and Michigan. States that allowed philosophical exemptions to laws mandating vaccinations for children as they entered school had significantly higher estimated rates of unvaccinated children. Conclusions. Unvaccinated children have characteristics that are distinctly different from those of undervaccinated children. Unvaccinated children are clustered geographically, increasing the risk of transmitting vaccine-preventable diseases to both unvaccinated and undervaccinated children. Pediatrics 2004;114:187-195; exemptor, undervaccinated, unvaccinated. ABBREVIATIONS. CI, confidence interval; NIS, National Immunization Survey; PKAM, Parental Knowledge and Attitudes topical module; RDD, random-digit dialing; UTD, up-to-date; NUTD, not up-to-date; VPD, vaccine-preventable disease; MSA, metropolitan statistical area., Children who have received no vaccinations have not been well studied in the United States. Many studies have assumed that children with no vaccinations are similar to undervaccinated children and [...]

Objectives. We examined current racial/ethnic differences in immunization coverage rates among US preschool children. Methods. Using National Immunization Survey data from 1996 through 2001, we compared vaccination coverage rates between non-Hispanic White, non-Hispanic Black, Hispanic, and Asian preschool children. Results. During the 6-year study period, the immunization coverage gap between White and Black children widened by an average of 1.1% each year, and the gap between White and Hispanic children widened by an average of 0.5% each year. The gap between White and Asian children narrowed by an average of 0.8% each year. Conclusions. Racial/ethnic disparities in preschool immunization coverage rates have increased significantly among some groups; critical improvements in identifying, understanding, and addressing race/ethnicity-specific health care differences are needed to achieve the Healthy People 2010 goal of eliminating disparities.

Background. Insurance status has been shown to have an impact on children&apos;s use of preventive and acute health services. The objective of this study was to determine the relationship between insurance status and vaccination coverage among US preschool children aged 19 to 35 months. Methods. We linked data from 2 national telephone surveys, the National Immunization Survey and the National Survey of Early Childhood Health, conducted during the first half of 2000. Children were considered up to date (UTD) when they had received at least 4 diphtheria-tetanus-acellular pertussis/diphtheria-tetanus-pertussis vaccines, 3 poliovirus vaccines, 1 MMR vaccine, 3 Haemophilus influenza vaccines, and 3 hepatitis B vaccines at the time the interview was conducted. Results. Among the 735 children in our study sample, 72% were UTD. The vast majority (94%) reported some type of health insurance at the time of the survey. Children with private insurance were more likely to be UTD (80%) than those with public insurance (56%) or no insurance (64%). In a multivariate analysis that controlled for child&apos;s race/ethnicity; household income; maternal age/marital status/educational level; location of usual care; and Special Supplemental Nutrition Program for Women, Infants, and Children participation, insurance was no longer an independent predictor of vaccination. Conclusions. The disparity in vaccination coverage among publicly, privately, and uninsured children is dramatic, underscoring its importance as a marker for underimmunization, despite the multivariate findings. The Vaccines for Children Program, a partnership between public health and vaccination providers who serve uninsured children and those enrolled in Medicaid, is well suited to target and improve vaccination coverage among these vulnerable children. Pediatrics 2004;113:1959-1964; children, insurance status, vaccination, vaccination coverage., ABBREVIATIONS. SCHIP, State Children's Health Insurance Program; NIS, National Immunization Survey; NSECH, National Survey of Early Childhood Health; CDC, Centers for Disease Control and Prevention; UTD, up to date; WIC, [...]

The effects of changes in recommendations regarding administration of a hepatitis B birth dose on vaccination coverage is determined. Reductions in hepatitis B vaccine birth-dose coverage persisted after recommendations were made to resume previous newborn vaccination practices.

Objective. To address key gaps in the annual monitoring of breastfeeding prevalence in TIthe United States, 3 breastfeeding questions concerning the initiation, duration, and exclusivity of breastfeeding were added to the rotating modules of the National Immunization Survey (NIS) beginning in the third quarter of 2001. The present study examines the current prevalence of breastfeeding in the United States using NIS data from this initial quarter. Methods. The NIS is a random-digit-dialing survey of households with children aged 19 to 35 months, followed by a mail survey of the eligible children&apos;s vaccination providers to validate the child&apos;s vaccination information. In the third quarter of 2001, a randomly selected subset of households interviewed in the NIS (N = 896) were asked questions about breastfeeding. Results. Almost two thirds (65.1%) of children had ever been breastfed. At 6 and 12 months, 27.0% and 12.3%, respectively, were receiving some breast milk. Non-Hispanic blacks had the lowest rates of breastfeeding initiation and continuation. Exclusive breastfeeding rates were low in the United States with only 7.9% at 6 months. Conclusions. Although breastfeeding initiation is near the national goal of 75%, breastfeeding continuation lags behind the national goals of 50% and 25% at 6 and 12 months, respectively. Strenuous public health efforts are needed to improve breastfeeding practices among blacks. Pediatrics 2003;111:1198-1201; breastfeeding prevalence, surveillance, National Immunization Survey., ABBREVIATION. NIS, National Immunization Survey. Worldwide, breastfeeding is recognized as beneficial for both infants and mothers. (1-3) The American Academy of Pediatrics recommends breast milk as the preferred feeding for [...]

Let [{[X.sub.i]}.sup.n.sub.i=1] be a collection of independent, identically distributed Poisson [theta] random variables. Confidence intervals for [theta] can be constructed by the Wald method, by exact inference, from a variance stabilizing transformation, or by many other techniques. When n[theta] is small, actual and nominal coverage can differ substantially. We compare nine confidence intervals for a Poisson mean with respect to coverage and expected width of confidence limits. We show that, for small n[theta]: of the confidence intervals considered, only the exact interval maintains coverage probabilities; while the scores interval approximately maintains coverage probability, its expected width exceeds the exact interval's; and a modified version of the confidence interval based on the variance stabilized confidence interval has coverage properties near the nominal and an expected width that is not particularly large. Thus, we recommend that investigators desiring true cover not less than nominal use th e exact interval and those willing to accept approximate coverage use a modified form of the variance stabilized interval. KEY WORDS: Confidence interval; Exact inference; Poisson distribution; Small sample; Scores interval., A comparison of nine confidence intervals for a poisson parameter when the expected number of events is [less than or equal to] 5., 1. INTRODUCTION Let [{[X.sub.i]}.sup.n.sub.i=1] be a collection of independent, identically distributed Poisson [theta] random variables. Consider constructing a (1 - [alpha])100% confidence interval for [theta]. The simplest, and perhaps most [...]