Article, Pediatrics

Child immunization status in an urban ED


Child immunization status in an urban ED

To the Editor,

Emergency departments (EDs) provide an opportunity to initiate preventive services for both children and adults [1]. Pediatric immunization deficiencies are a Public health concern [1-6]. There have been studies both in favor of administering deficient immunizations in the ED and against such practices [2,7-9]. In previous years, there were a number of epidemic measles outbreaks in various cities within the United States [3,10,11].

To eliminate further epidemic outbreaks, it was recom- mended that all encounters with children, especially those children at a higher risk for missing immunizations, be viewed as an opportunity to close immunization gaps currently in the system [10,11]. The aim of this study was to investigate parental knowledge concerning children immunization history and status in an urban ED setting.

This was a single-center, prospective survey of 106 randomly selected parents presenting to an urban academic ED. Approximately 17500 pediatric patients are evaluated in the ED annually. The pediatric ED is staffed by board- certified emergency medicine and/or pediatric attending physicians with rotating residents from pediatrics, Family Medicine, and emergency medicine. The ED is located within a largely African American and Hispanic neighborhood. This study protocol was reviewed and exempted by the Institu- tional Review Board.

Research team members rotated through the ED at varying times and days of the week in 3-hour intervals during the study period to obtain a representational sample. All parents presenting to the ED during research collection times with children were eligible for participation regardless of presenting complaint. Parents excluded from study participation included those parents whose children pre- sented with an unstable medical condition.

Surveys were verbally administered by the primary investigators for the study. Surveys were performed both in the waiting room and in the main treatment area. Along with the questionnaire, parents were asked to provide their child’s immunization record. All participants verbally consented for participation. Participants who declined were thanked for their time. No record was kept of survey

participation refusals. No identifiable data were collected from participants.

One hundred six surveys were verbally administered. Ten parents had children too young for immunizations. The remainder 96 parent surveys were included in data analysis. Data analysis was purely descriptive.

Of the 96 parent surveys, 51(48%) parents did not have the immunization record present and assumed the status to be current; 27 (26%) parents had the immunization record and the status was verified as current; 13 (12%) parents did not have the immunization record present but acknowledged a deficient status; and 5 (5%) parents had the immunization record, but, upon inspection, the immunization status was deficient (Table 1).

This study was performed as a convenience sample over relatively brief time intervals and represented a small percentage of potentially eligible participants. Continuous data collection over a longer period would decrease the likelihood of selection bias and increase the external validity of this study. In addition, demographic information was not obtained and could have been important in identifying patterns. To confirm and generalize the results, a multicenter study is needed.

Nonetheless, these findings are in agreement with previous studies that do not support administration of pediatric immunizations in the ED for similar reasons of insufficient documentation and parental knowledge [2,6, 12-14]. A recent study by the Public Health and Education Task Force Preventive Services Work Group for the Society of Academic Emergency Medicine recommends against the implementation of pediatric immunizations in the ED, but emphasizes the need for further research in this area [1]. Cunningham found that immunizing children in the ED would be feasible and cost-effective if an accessible vaccine registry was available to ED physicians [2].

Although there may be several obstacles to overcome regarding pediatric immunizations in the ED, there needs to be a continued effort among all health care providers in the realm of parent education. This is particularly important for health care providers in the nontraditional venues for immunizations. Parents need to be constantly reminded of the dangers of allowing their children to remain unimmu- nized until exposure to the school system. Before entering school, most states require proof of current status of

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Correspondence 705

Table 1 Self-reported immunization status and physical presence of immunization record during ED visit

No. of parent responses (%)

(N = 96)

Immunization record


Immunization status


Immunization status verified

51 (48)



Not verifiable

27 (26)




13 (12)



Not verifiable

05 (5)




Parental knowledge of children immunization status both self-reported and verified for those with immunization records present in the ED.

immunizations. Most of the susceptible children in previous outbreaks were those who were only partially immunized [10]. Health care providers must view all pediatric encoun- ters as potential opportunities for parent education. There is a positive documented correlation between accurate parental knowledge about the Relative risks of vaccination and illness and the greater probability for immunization [15].

Heather M. Prendergast MD, FACEP John Graneto DO, FACEP Gregory D. Kelley, BA

Department of Emergency Medicine (MC 724) University of Illinois Medical Center

College of Medicine East Chicago, IL 60612-7354, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2005.03.003


  1. Babcock IC, Wyer PC, Gerson LW. Preventive care in the emergency department, Part II: clinical preventive services–an emergency medicine evidence-based review Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group. Acad Emerg Med 2000;7(9): 1042 – 54.
  2. Cunningham SJ. Providing immunizations in a pediatric emergency department: underimmunization rates and parental acceptance. Pediatr Emerg Care 1999;15(4):255 – 9.
  3. Hutchins SS, Escolan J, Markowitz LE, et al. Measles outbreak among unvaccinated preschool-aged children: opportunities missed by health care providers to administer measles vaccine. Pediatrics 1989;83(3): 369 – 74.
  4. Olson CM. Vaccination in pediatric emergency departments. JAMA 1993;270(18):2222 – 3.
  5. Rudd PT. Childhood immunisation in the new decade. BMJ 1991;302 (6775):481 – 2.
  6. Szilagyi PG, Rodewald LE, Humiston SG, et al. Reducing missed opportunities for immunizations. Easier said than done. Arch Pediatr Adolesc Med 1996;150(11):1193 – 200.
  7. Cove LA, Rodewald LE, Humiston SG, Raubertas RF, Doane CB, Szilagyi PG. Accuracy of documented vaccination status of patients in pediatric emergency departments. Am J Dis Child 1993;147(1):16 – 7.
  8. Goldstein KP, Kviz FJ, Daum RS. Accuracy of immunization histories provided by adults accompanying preschool children to a pediatric emergency department. JAMA 1993;270(18):2190 – 4.
  9. Robinson PF, Gausche M, Gerardi MJ, et al. Immunization of the pediatric patient in the emergency department. Ann Emerg Med 1996; 28(3):334 – 41.
  10. Commissioner of Chicago Board Of Health. Emergency service immunizations. Chicago, IL: Chicago Department of Public Health; 1991 [letter].
  11. Lindegren ML, Atkinson WL, Farizo KM, Stehr-Green PA. Measles vaccination in pediatric emergency departments during a measles outbreak. JAMA 1993;270(18):2185 – 9.
  12. Callahan JM, Reed D, Meguid V, Wojcik S, Reed K. Utility of an immunization registry in a pediatric emergency department. Pediatr Emerg Care 2004;20(5):297 – 301.
  13. Joffe MD, Luberti A. Effect of emergency department immunization on compliance with primary care. Pediatr Emerg Care 1994;10(6):317 – 9.
  14. Rodewald LE, Szilagyi PG, Humiston SG, et al. Effect of emergency department immunizations on immunization rates and subsequent primary care visits. Arch Pediatr Adolesc Med 1996; 150(12):1271 – 6.
  15. Lewis T, Osborn LM, Lewis K, Brockert J, Jacobsen J, Cherry JD. Influence of parental knowledge and opinions on 12-month diphtheria, tetanus, and pertussis vaccination rates. Am J Dis Child 1988;142(3):283 – 6.

Emergency medicine in Cuba: an update

To the Editor,

Like all health care programs, the Cuban health system has its advantages and disadvantages. The Cuban health system was transformed after the revolution led by Fidel Castro in 1959. It is a sophisticated system under tight central control. The Ministry of Health oversees an extensive system of research and Tertiary care centers, provincial and Regional hospitals, and multiservice clinics, called poly- clinics. This system provides free care to 11 million Cubans in 15 provinces. Major indicators of the health of a population, including average Life expectancy (75.0 years for males, 79.3 years for females) [1], infant mortality (5.8 per 1000 live births [2004]), and percentage of children surviving to age 5 years (992 per 1000), are similar to those of developed nations, although Maternal mortality (29.2 deaths per 100000 live births) is higher. Cuba has one of the highest number of physicians per capita worldwide (1 per 169.6 persons). Physicians frequently make home visits to see their patients, often alternating with an office visit.

However, Cuba’s health system is not without prob- lems. Patients may have easy access to physicians, but lack of resources can result in delayed care and patients are often unable obtain needed medications. The Cuban health care system is again undergoing change, as Cuba continues to struggle with the US economic embargo, and emerges from more than a decade of deprivation after the fall of the former Soviet Union. Limited market reform and active promotion of tourism are accepted by the govern- ment, and increased foreign exchange is improving Cuba’s access to resources.