Health Alert : County’s Lagging Vaccination Rates for Preschoolers Caused by Flaws in Delivery System, Experts Say

Alarmed that thousands of preschool children in Los Angeles County are unprotected against dreaded diseases, the Catholic Health Alliance of Los Angeles had its 13 hospitals spend a Saturday last August offering free vaccines.

The results were less than overwhelming.

At Daniel Freeman Hospital in Inglewood, the staff prepared shots for 200 tots. Fewer than 30 showed up. Little Company of Mary in Torrance held a clinic at a site outside the hospital and announced the program in leaflets beforehand but only managed to immunize about 85 children.

In all, the alliance reached 400 children that day--not an encouraging start for a program intended to immunize 50,000 youngsters over five years.

What the alliance learned is something immunization experts already know--good intentions and free vaccines alone will not dramatically alter low immunization rates for preschool children. Just as much attention must be paid to improving the way vaccinations are delivered to those who need them.

The lesson has taken on particular importance in light of President Clinton’s proposal last month to provide free vaccines to every child in America.

“We have had (one-day) clinics, free clinics, and only two parents will bring kids in,” said Charles H. Alexander of the U.S. Centers for Disease Control, who heads immunization efforts in Los Angeles County.

More than 90% of kindergarten-aged children in the county are properly immunized, thanks largely to the state’s no-shot-no-school law. But only 42% of the county’s children have been immunized by the age of 2, when youngsters are supposed to have received all their vaccinations.

Low immunization rates among preschool children can bring tragic consequences, as was illustrated by the measles epidemic that swept California between 1988 and 1991, killing 51 people. In this county, 40 people died, 28 of them preschoolers under 4.

Dr. David Wood, a pediatrician at Cedars Sinai Hospital in Los Angeles who also teaches at UCLA, said low immunization rates reflect the failure of the public health system, not ignorance or neglect by parents.

Wood, now conducting one of two local CDC studies to identify barriers to immunization, recommends aggressive promotion of vaccinations and making the public health system more user-friendly.

“The Third World does a better job of immunizing its kids,” Wood said. “ . . . We’re really talking about a system that’s completely out of sync with people’s needs, and then you’re trying to change it with a one-day health fair.”

In France, he said, immunization is seen as such a public health benefit that the government pays mothers to immunize their children.

One problem underlying low preschool immunization rates is that many parents do not know immunizations can be obtained free-of-charge at county health clinics in California, regardless of a family’s income.

Consider the 23-year-old mother waiting last week at the Torrance Health Center to have her 6-month-old son vaccinated. She said her private pediatrician never told her about the county service, even though the doctor knew the woman and her husband are in tough financial straits.

She said she heard about the clinic from her sister-in-law.

Given her financial situation, she was glad she had. The computer firm where the woman worked went bankrupt the month before she had her baby. And her husband, a plumber, was laid off by his company and is now self-employed.

“If I had to pay,” said the young mother, who asked not to be identified, “I wouldn’t be here. I don’t have $140 bucks.”

Brian Kelly of Hermosa Beach, whose baby daughter, Jaime, was smiling through tears after receiving three shots at the Torrance clinic, was luckier. Jaime’s pediatrician told Kelly and his wife that they could go to a public clinic when the couple said they didn’t have the money to get their baby her second set of immunizations.

Kelly was laid off from a landscape company. His wife has insurance where she works, Kelly said, but “it doesn’t pay for the shots, which we found out after she had her first ones.”

Even for those who know about the free immunizations, however, other barriers exist. Only a few of the 41 county clinics that provide immunizations offer the service on Saturdays. All the clinics limit immunizations to certain days and hours.

And numerous clinics maintain quotas on the number of immunizations they can provide at one time. In Torrance, immunizations are limited to the first 25 people who get there during the appointed hours. The quota used to be 30 but it dropped a week ago when the county added the new hepatitis vaccine to the group it gives children.

County health officials attribute such quotas to funding shortages brought on by the state budget crisis.

Based in Inglewood, Glen Fujimoto is the county’s regional immunization coordinator for an area that stretches from Malibu to San Pedro. One of his jobs is to police day-care centers to see that all the children there are immunized in keeping with state law.

“I don’t have the staff to go out and ask the preschools to show (us) the records,” said Fujimoto, who used to have five staff members and now has two.

Public health officials also say that they have difficulty reaching a population that is poor and therefore has more immediate concerns than preventive medicine.

“The bottom line is there’s a lot of people out there who have other priorities that are more important than health care,” said Alexander, the county immunization chief. “The parents we’re concerned with are the same ones who are more concerned about jobs, rent, food and all the other things that are basics.”

Although Wood is sympathetic to such concerns, he remains critical of the health system. He and his research team cite the limited immunization hours at public health clinics, and Wood says the attitude of many clinic nurses is an impediment.

“On paper it’s free (to the poor), but you pay a big cost, you wait eight hours, you get treated rudely,” he said.

Wood said that 90% to 95% of the population could be easily reached with better-designed public immunization services. Already, providers are experimenting with new ways to deliver vaccines.

Centinela Hospital in Inglewood spent years providing free vaccines at clinics in the hospital and at other locations. Now, thanks to Peter Morton, owner of the Hard Rock Cafe, the hospital has a mobile vaccine van than spends as many as four days a week traveling throughout the county immunizing children.

The bulk of its sites are regular stops. Because the van has its own computers, it can record the children’s names and vaccination records and send cards to the parents alerting them when their child is due for the next set of shots and telling them when the van will return.

Another experiment has been taking place in one of the poorest neighborhoods in Los Angeles, between 3rd Avenue and Manchester Boulevard, just east of the Harbor Freeway (110). There, a CDC-funded project directed by Dr. Suzanne Westman nearly doubled the immunization rate for 2-year-olds, raising it from 23% in May, 1990, to 43% in May, 1992.

Among other steps, Westman made immunizations available on Saturdays and produced puppet shows in clinic lobbies to entertain visiting children. Then the parents were located and, if vaccinations were needed, the children were immunized on the spot.

Westman trained clerks to screen which vaccines children needed, a duty usually performed by higher-paid registered nurses. She also had licensed vocational nurses give shots, another job usually done by registered nurses.

The nation that sold Coca-Cola to the world and convinced poor mothers that baby bottles were better than mother’s milk can figure out a way to sell universal immunization, Westman said, with a hint of sarcasm.

“We can’t just sit around complining,” she said. “We’ve got to use resources better . . . We just don’t have any other choice.”

Shot In the Arm

Here are the American Academy of Pediatrics’ recommendations on when children should be immunized.

MONTHS YEARS Birth 1-2 2 4 6 6-18 12-15 15 15-18 4-6 11-12 14-16 Diphtheria- I I I I I tetanus- pertussis ------ Polio I I I I Measles- I I Mumps- Rubella * ------ Hepatitis B ** I I I ------ Hemophilus I I I I influenza ------ Tetanus- diphtheria

* The Los Angeles County Department of Health Services recommends that children receive shots for measles, mumps and rubella at 12 months and again upon entering kindergarten.

** Assumes that mother tested negative for Hepatitis B. If mother tested positive, doctor must be consulted.