Program Set to Immunize Preschoolers : Health: San Diego is one of six U.S. cities picked for the immunization program. The city will unveil its plans during President Bush’s visit this week.

Still reeling from the recent measles epidemic that struck California, killing three children in San Diego and 51 statewide, San Diego County public health authorities plan to unveil an aggressive new immunization program during President Bush’s visit this week.

San Diego is one of six cities in the country, and the only one in California, selected by U.S. health officials to launch a national pilot immunization program.

With the program already being touted as a potential model for the country, health officials hope to meet Bush’s goal: At least 90% of all children fully immunized by age 2 before the year 2000.

The goal, experts concede, is ambitious. In San Diego, 52.3% of toddlers under age 2 lack the recommended immunizations; statewide, the rate is 51%, a rate consistent with the rest of the nation.

“Immunizations levels were grossly inadequate in the mid-80s and they are grossly inadequate now,” said Dr. Walter Orenstein, director of the immunization division at the federal Centers for Disease Control in Atlanta. “We have got to do better. We cannot tolerate that low a level.”

Though the no-shots, no-school state law has ensured that the vast majority of school-age children are immunized, too many younger kids are not, health officials say. Today, this group looms as most vulnerable and most unprotected.

“It’s much more difficult because it isn’t compulsory--you have to motivate the parent,” said John Dunajski, assistant chief of California’s department of health services’ immunization unit. “We don’t have the stick like we do with the school immunization law.”

By law, children entering school are expected to obtain vaccines that will protect against a slew of diseases, including polio, diphtheria, tetanus, measles, and pertussis (or whooping cough).

The recent measles epidemic taught health officials that they must reach preschool children--about 60% of the 12,587 California measles cases were among those too young to attend school. In San Diego, where there were almost 1,000 cases, the 1990 measles outbreak hit preschoolers hard: One of every four was hospitalized, said Sandy Ross, immunization coordinator for the county.

Why don’t more parents get their youngsters immunized before age 2?

The reasons are varied and local health officials explored them during the months of planning the county’s new program--the San Diego County Infant Immunization Initiative, which is contained in a 100-page report.

Sometimes parents don’t immunize their young children because they don’t know they should, or because of the cost and time required. Other times, it’s because many of today’s parents simply aren’t old enough to take seriously the threats of diseases, such as polio.

“There are so many need-to-do things in our society that the ones you do are the ones that are yelling the loudest. If you are having trouble with the car, you are going to take care of the car. If you are having trouble putting food on the table you are going to worry about eating,” said Ross. “If you don’t have time off from work to take the child to the doctor, are you going to do it?”

Under the San Diego program, officials will try to diminish existing hurdles--offering immunizations at more facilities as well as expanding hours of those facilities to accommodate working parents. County officials hope to provide immunizations through a mobile unit at non-medical sites, such as welfare offices.

County Department of Health Services will also double the immunization clinics from six to 12. Officials at community clinics, such as Logan Heights and Episcopal Community Services, will try to make immunization available on a walk-in basis--with no appointment necessary. The Naval Hospital in Balboa Park also has offered to stretch the hours it provides shots, said Lea Cassarino, the county’s supervising public health educator who is coordinating the San Diego effort.

San Diego’s program calls for a number of initiatives that would boost the county’s infant immunization levels at no additional cost. Some efforts, however, would require additional funds.

To oversee the program, which will cost about $4 million a year, health officials plan to hire a coordinator and an evaluation specialist--county officials hope these $50,000-a-year positions would be financed by federal dollars.

The plan also calls for an advisory council of professionals to meet regularly, keeping tabs on the county’s progress.

To successfully enact the program, health officials are banking on community cooperation, leaning on businesses and civic groups as well as health organizations. In fact, the plan itself is the result of meetings last fall with more than 50 health, social, religious, civic and business groups.

More than 25 major health care agencies have made a commitment to adopt the county’s “no barriers to immunization” policy, Cassarino said.

The private sector, said Cassarino, will make these efforts:

* Southern California Kaiser Permanente will establish special clinics for non-members at all of its 17 sites.

* UC San Diego Medical Center will institute a 5-day-a-week immunization service in its pediatric clinics and also provide immunization shots in its emergency room.

* Several health care providers, including Kaiser Permanente, will provide the county with immunization data so health officials can improve their monitoring.

* Employers, such as General Dynamics, one of the county’s largest employers, have offered to provide workers with immunization information.

Health officials are also concerned about targeting minority communities. In one survey of randomly selected San Diego kindergartners, only 20% of blacks were immunized, 34.6% of Latinos and 37.4% of Asians. In comparison, 47.3% of white children were immunized.

“We can see a disproportionate amount of the nonwhite population don’t get immunized,” said Ross, of the county’s health department.

Currently, the health department offers information about immunization in three different languages: English, Spanish and Vietnamese. But Cassarino and others would like to see this expanded to include more languages as well as more culturally-oriented materials, for instance, pamphlets geared toward migrant workers.

With additional funding, the county would like to set up a bilingual team that uses the county’s health department mobile van, providing immunizations in parking lots.

Cassarino would also like to set up a resource center, where a bank of materials would be available that targeted migrant workers, immigrants, pregnant and parenting teens, and parents.

Reaching parents--many of whom do not take seriously the diseases for which the vaccines provide immunity--is a large part of the problem for health officials trying to boost immunization levels.

“For most of today’s parenting population, they are young and have never seen any of these illnesses,” Ross said. “If you don’t see a risk, you don’t see a reason to put out the effort to prevent the disease. If you are a parent born in the 60s, you don’t see kids with wasted limbs, so you don’t worry about polio.”

To better reach parents, health officials say they will diversify their approach, trying to build a wider net to snare families and infants. As a pilot project, immunization forms will be included with the other applications at federal WIC (Women, Infants, Children) offices, which provides nutritional supplements.

County and federal health officials realize that financially-strapped San Diego may not be able to implement all the efforts depicted in its new pilot program. Nonetheless, it’s an important step forward to simply have a plan.

“If you don’t have a blueprint for your dream house, it remains in your mind,” said Dean Mason, chief of program operations with the CDC’s immunization division. “This allows a plan of action, a strategy.”

Health officials also hope the plan will allow them to woo government money to carry it out.

“I don’t have a crystal ball, but I would be surprised if there aren’t more resources,” said Dr. Donald Ramras, deputy director of the county’s health department. “It stands to reason that those communities with plans have a good chance of getting additional funds.”

Ramras and others point to President Bush’ apparent interest in the immunization program, a program that Bush launched and that they don’t believe he will allow to wither.

Last June, Bush met with health officials in the Rose Garden to announce stepped up efforts to immunize youngsters. In hopes of discovering ways to improve immunization levels, Bush and Health Secretary Louis W. Sullivan said “SWAT teams” from the Health and Human Services Department would visit six cities: San Diego, Philadelphia, Detroit, Phoenix, Dallas, and Rapid City, S.D.

San Diego was chosen because not only did it have a measles outbreak but it had a recurrent problem with this disease and other “vaccine-preventable outbreaks,” said Mason of the CDC.

After calling for a more aggressive campaign, Bush immediately came under fire as critics said the low immunization levels reflected the plight of the poor in the health care system.

“Outreach programs are inadequate, clinics are underfunded and vaccines are too expensive,” said Sen. Edward M. Kennedy (D-Mass.), chairman of the Senate Labor and Human Resources Committee, during an interview at the time. “We don’t need a six-city road show to study the problem. We need a genuine federal commitment to see that every child is immunized.”

As a result of such criticism, planners--including those at San Diego--carefully formulated what they hoped would be viewed as more than a mere dog-and-pony show. And in California, state officials say they will carefully monitor the San Diego program.

“We’re going to be watching very closely. We’re going to try to measure and see where we can get the biggest bang for the buck,” said Dunajski of the state’s health department. “I can’t say all will work but I think some will.”

U.S. Measles Cases

Cases per 100,000 population 1989

1 Illinois 28.11 2 Ohio 25.08 3 Texas 19.50 4 Wisconsin 17.76 5 Missouri 13.11 6 California 10.26 7 Nebraska 10.01 8 Wash., D.C. 7.08

1990

1 California 42.30 2 Texas 24.11 3 Nevada 20.72 4 Wisconsin 15.40 5 Alaska 14.55 6 Illinois 11.88 7 New York City 10.84 8 Minnesota 10.56

1991

1 Idaho 44.89 2 New York City 26.63 3 New Jersey 13.30 4 Pennsylvania 13.00 5 Utah 13.00 6 Arizona 12.36 7 New Mexico 8.05 8 California 6.69

Source: Centers for Disease Control