Immunizations and Infectious diseases in rural Areas

by Linnae Hutchison and Jennifer Peck

 

Scope of Problem

 

 

Goals and Objectives

 

The Healthy People 2010 goal relating to immunizations and infectious diseases is to “prevent disease, disability, and death from infectious diseases, including vaccine-preventable diseases.”3 This review addresses the following HP2010 objectives:

 

 

The Rural Healthy People 2010 survey found the “immunization and infectious disease” focus area virtually tied with “injury and violence prevention” as the 13th ranking rural health priority among the 28 Healthy People 2010 focus areas.2 Urban and rural immunization rates appear fairly similar for school-age children, with the exception of vaccinations for the varicella zoster virus (causative agent of chicken pox), which has a lower rate in rural areas. Rates of influenza and pneumonia vaccination among the elderly are similar in rural and urban areas but fall below the HP2010 goal.4 Minorities, foreign-born individuals, the uninsured, and the poor exhibit lower immunization rates and higher infectious disease prevalence. Other populations at risk are those residing on the U.S./Mexico border and in rural Colonias, where rates of tuberculosis (TB) and hepatitis A are significantly higher than in other regions of the country.

 

Prevalence

 

There is considerable variation by age, ethnicity, region, socioeconomic, and insurance status regarding prevalence and susceptibility to infectious diseases, immunization rates, and associated morbidity and mortality.

 

Children

 

Childhood morbidity and mortality have been dramatically reduced in the past 50 years with routine vaccinations.5 DTP (diphtheria, tetanus, and pertussis), polio, and MMR (measles, mumps, and rubella) vaccination coverage levels for school-aged children (five to six years old) have surpassed 95 percent every year since 19806 due to state-mandated completion of the immunization series by the time of school entry.7 Coverage levels for infants and toddlers, however, have been much lower and are in need of improvement.8 The varicella zoster vaccine for chicken pox had the lowest coverage of all vaccines at 68 percent.8 

 

Studies evaluating immunization coverage in infants and toddlers from 1991 through the present have revealed poor rates in both rural and urban areas.9, 10 According to the Centers for Disease Control (CDC) National Immunization Survey (NIS) data from 2002, children ages 19 to 35 months residing in non-central city metropolitan statistical areas (MSA) reported the highest immunization rates for the basic 4:3:1 series and 4:3:1:3 series followed, in order, by nonMSAs and MSAs with a central city.11 Children residing in rural or nonMSAs, however, had significantly lower levels of varicella zoster immunization coverage than urban and suburban children.12 

 

Disparities in infectious disease prevalence also exist among ethnic and special populations. Latino children are 13 times more likely to be infected with tuberculosis than white children.13 Children of farm laborers also have higher rates of tuberculosis, parasites, and sexually transmitted diseases.14 

 

Adults

 

Hepatitis, tuberculosis, HIV, influenza, and pneumonia together represent significant causes of morbidity and mortality among adults.

 

Pneumonia and Influenza

 

The national immunization rate for influenza among adults ages 18 to 65 is 31 percent, while the rate for pneumonia immunization is 18.4 percent.15 Nonmetropolitan areas had comparable or slightly higher rates of adult immunizations for influenza and pneumonia.10 

 

Tuberculosis

 

Globally, tuberculosis is the leading cause of death by infectious disease.16 In the U.S., the rate of TB has been declining over the past decade; however, the rate of decline between 2000 and 2001 was the smallest rate of decline in nine years (only 2 percent). While TB affects all age groups, the percent of total cases is highest among adults ages 25-44 years old (35 percent), followed by adults age 45-64 (28 percent), and those greater than 65 years of age (21 percent).17 Thirty-six percent of the total reported cases occur in African Americans, 29 percent in whites, and 20 percent in Hispanics.18 However, the highest incidence (cases/100,000) rates are observed among Asian/Pacific Islanders (33/100,000), followed by African Americans (14/100,000), Hispanics (12/100,000), American Indian/Alaskan Natives (11/100,000), and whites (2/100,000).18

 

Three-fourths of the TB cases are found in the four states that border Mexico.19 The research is limited regarding disparities in TB rates among urban and rural populations; however, studies have found TB rates increase with increasing population density and decreasing income.20

 

TB rates along the border are significantly higher than those of Mexico or the U.S. (27/100,000, 19/100,000, and 6.8/100,000, respectively),21 including a higher rate of multi-drug resistant TB (MDRTB).22 The U.S./Mexico border also suffers from a higher incidence of a number of other infectious diseases including measles, mumps, botulism, brucellosis, diphtheria, hepatitis A, rabies, rubella, salmonellosis, and shigellosis.23 

 

Other special rural populations at heightened risk for certain infectious diseases are migrant and seasonal farm workers. A 1998 study found that this population is six times more likely to develop TB than adults in other professions.16 

 

Hepatitis

 

Hepatitis A is two to three times more prevalent along the U.S./Mexico border24 and is particularly problematic in rural areas called Colonias.23 Those at risk for hepatitis B (HBV) include African Americans and immigrants from areas where HBV is endemic (Asia, Sub-Saharan Africa, Amazon Basin, Eastern Europe, and the middle East), Alaskan Natives and Pacific Islanders, households in contact with chronic hepatitis B carriers, people who have sexually transmitted diseases, users of illicit drugs, hemodialysis patients, international travelers, and inmates.25 Black teenagers and young adults are infected three to four times more often than whites.26 Asian and Pacific Islander children are also at a greater risk of contracting hepatitis B (20 to 30 times higher than other children in the United States).27 While Asian Americans and Pacific Islanders represent only 4.5 percent of the U.S. population,26 their numbers are increasing. Asian Americans were second only to Hispanics in population growth between 1990 and 2000. The Asian population grew 56.1 percent in metro areas and 32.2 percent in nonmetropolitan; half of all Asians in nonmetropolitan counties were born outside the U.S.28 

 

Elderly

 

Pneumonia and Influenza among the Elderly

 

Influenza and pneumonia together are the fifth leading causes of death among the elderly in the U.S.29 Ninety percent of deaths from influenza and 80 percent of deaths from pneumococcal infection occur in persons ages 65 and older.30, 31, 32 The vaccination rate for influenza and pneumonia is 66 and 55 percent, respectively, for those age 65 and older.33, 34

 

While influenza and pneumococcal vaccination rates among elderly men and women are equal,35 differences in influenza and pneumococcal immunization rates exist among minorities. Non-Hispanic whites experience the highest influenza immunization rates (68.8 percent), followed by Hispanic whites experience the highest influenza immunization rates (68.8 percent), followed by African Americans (49.6 percent) and Hispanics (48.5 percent).35 Pneumococcal vaccination rates follow a similar pattern: non-Hispanic whites (60.3 percent), African Americans (37.2 percent), and Hispanics (27.1 percent).35 

 

The literature supports that pneumonia and influenza immunization rates among those older than 65 are comparable between rural and urban areas,36 and rural residence was not found to be related to lower rates of receipt of either pneumonia or influenza vaccine.37, 38 However, disparities between racial groups appear more pronounced in rural residents than among urban residents.39 

 

Impact

 

One-fourth of visits to physicians are infectious disease related with annual costs over $120 billion.40 CDC data from 1995 estimated that for every dollar spent on immunizations, $14-25 in health care costs are saved.41 

 

The death rate from complications of vaccine-preventable diseases (VPD) is higher among adults (50,000 to 90,000 annually) than among children42 (300 each year).43 Influenza and pneumonia are responsible for more illnesses and deaths than all other VPDs,42 together constituting the seventh leading cause of death in the U.S.33 Tuberculosis-related deaths have steadily decreased from nearly 20,000 in 1953 to 751 in 2000, or 0.3 per 100,000.17 Hepatitis B is attributed to 5,000 chronic liver disease deaths, while hepatitis C is associated with 8,000 to 10,000 chronic liver disease deaths.44 There were 10,616 reported cases of hepatitis A in 2001, 7,844 cases of hepatitis B, and 4,000 estimated acute hepatitis C cases.44 

 

Barriers

 

Factors that contribute to under-immunization include living in poverty, being an ethnic minority, having a parent with a low level of education, and being from a large family.45, 46, 47 Other barriers include the cost of immunizations, lack of insurance coverage, late initiation of the vaccination series, parental lack of awareness of the child’s immunization status, missed opportunities during clinical visits, and record scatter resulting from the receipt of vaccinations from multiple providers.41, 46, 4 In general, rural residents are more likely than urban residents to be poor, less educated, lack health insurance, and have longer travel times to health providers,48-51 which are all factors associated with lower immunization rates.52 

 

Proposed solutions

 

While the U.S. has been successful in achieving high immunization rates overall, immunization rates among certain subgroups remain below the HP2010 goals. No single solution will increase the rates for all groups; however, it is suggested that organizational change strategies offer the most effective methods to increase immunization rates.53 These strategies include the implementation of a reminder and/or recall system by vaccination providers to improve immunization rates.54 Standing orders programs have also been successful in increasing pneumonia and influenza rates.55 Finally, immunization registries that incorporate reminder and recall notices are fundamental to improving immunization rates by reducing the problem of record scatter¾a problem perhaps more pervasive in rural areas.56 

 

Summary and Conclusions

 

Access to immunization services and up-to-date immunization coverage are essential for protecting every age group from the debilitating and potentially life-threatening effects of infectious diseases. Immunization rates among school-age children demonstrate record high coverage; however, among preschool children, urban and rural area coverage rates fall below the HP2010 target. Similarly, flu and pneumonia vaccinations rates among the elderly are comparable for rural and urban areas; however, rates are also below the HP2010 goals but continue to increase. The strain on resources relating to influenza and pneumonia may be greater in rural areas, where the elderly represent a larger proportion of the total population, and access to quality health care may be more challenging.57 Other populations at risk for low immunization rates include the impoverished, those without insurance, minorities, residents of rural Colonias and border areas, and immigrants.

 

A key finding is that rural and urban areas experience similar immunization rates, both below the HP2010 goals, emphasizing the need for continued efforts to increase immunization rates for both groups (particularly among preschool children, immigrants, minorities, adults, and the elderly). International travel and commerce, increased immigration, and contact with environments where infectious diseases remain leading killers reinforce the importance of full immunization coverage for the United States¾regardless of the degree of urbanicity. Prevention is ultimately the most effective defense system in controlling infectious diseases.

 

MODELS FOR PRACTICE

 

The following models for practice are examples of programs utilized to address this rural health issue.

 

REFERENCES

 

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27. Centers for Disease Control and Prevention News Updates. Hepatitis B a deadly threat to U.S. Asians, April 30, 2003. <http://www.thebody.com/cdc/news_updates_archive/2003/apr30_03/asians_hbv.html> August 27, 2003.

 

28. Economic Research Services. U.S. Department of Agriculture. Race and ethnicity in rural America: The demography and geography of rural minorities. <http://www.ers.usda.gov/Briefing/RaceAndEthnic/geography.htm> August 18, 2003.

 

29. Sahyoun, N.R.; Lentzner, H.; Hoyert, D.; and Robinson, K.N. Trends in causes of death among the elderly. Aging Trends (1):1-10, 2001.

 

30. Zimmerman, R.K. Adult vaccination, part 1: Vaccines indicated by age. Teaching immunization for medical education (time) project. Journal of Family Practice 49(9 Supplement):S41-50, 2000.

 

31. Kingston, B.J., and Wright, C.V., Jr. Influenza in the nursing home. American Family Physician 65(1):72, 75-78, 2002.

 

32. Nichol, K.L.; Grimm, M.B.; and Peterson, D.C. Immunizations in long-term care facilities: Policies and practice. Journal of the American Geriatric Society 44(4):349-355, 1996.

 

33. Zimmerman, R.K.; Raymund, M.; Janosky, J.E.; Nowalk, M.P.; and Fine, M.J. Sensitivity and specificity of patient self-report of influenza and pneumococcal polysaccharide vaccinations among elderly outpatients in diverse patient care strata. Vaccine 21(13-14):1486-1491, 2003.

 

34. Nelson, D.E.; Bland, S.; Powell-Griner, E.; Klein, R.; Wells, H.E.; Hogelin, G.; and Marks, J.S. State trends in health risk factors and receipt of clinical preventive services among U.S. adults during the 1990s. Journal of the American Medical Association 287(20):2659-2667, 2002.

 

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36. Zhang, P.; Tao, G.; and Irwin, K.L. Utilization of preventive medical services in the United States: A comparison between rural and urban populations. Journal of Rural Health 16(4):349-356, 2000.

 

37. Petersen, R.L.; Saag, K.; Wallace, R.B.; and Doebbeling, B.N. Influenza and pneumococcal vaccine receipt in older persons with chronic disease: A population-based study. Medical Care 37(5):502-509, 1999.

 

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42. Bratzler, D.W.; Christiaens, B.F.; Hempstead, K.; and Nichol, K.L. Immunization for seniors. Journal of Law and Medical Ethics 30(3 Supplement):128-134, 2002.

 

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46. Santoli, J.M.; Szilagyi, P.G.; and Rodewald, L.E. Barriers to immunization and missed opportunities. Pediatric Annals 27(6):366-374, 1998.

 

47. Pruitt, R.H.; Kline, P.M.; and Kovaz, R.B. Perceived barriers to childhood immunization among rural populations. Journal of Community Health Nursing 12(2):65-72, 1995.

 

48. Schur, C., and Franco, S. Access to health care. In: Ricketts, T.C. (ed.), Rural Health in the United States. New York: Oxford University Press, 7-24, 1999.

 

49. Ricketts III, T.C. Populations and places in rural America. In: Ricketts, T.C. (ed.), Rural Health in the United States. New York: Oxford University Press, 7-24, 1999.

 

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52. CDC. Vaccination coverage for two-year old children¾United States, 1993. Morbidity and Mortality Weekly Report 16:705-709, 1994.

 

53. Stone, E.G.; Morton, S.C.; Hulscher, M.E.; Maglione, M.A.; Roth, E.A.; Grimshaw, J.M.; Mittman, B.S.; Rubenstein, L.V.; Rubenstein, L.Z.; and Shekelle, P.G. Interventions that increase use of adult immunization and cancer screening services: A meta-analysis. Annals of Internal Medicine 136(9):641-651, 2002.

 

54. Recommendations of the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians: Use of reminder and recall by vaccination providers to increase vaccination rates. Morbidity and Mortality Weekly Report 47(34):715-7, 1998.

 

55. CDC. Facilitating influenza and pneumococcal vaccination through standing orders programs. Journal of the American Medical Association 289(10):1238, 2003.

 

56. Renfrew, B.L.; Kempe, A.; Lowery, N.E.; Chandramouli, V.; Steiner, J.F.; and Berman, S. The impact of immunization record aggregation on up-to-date rates¾implications for immunization registries in rural areas. Journal of Rural Health 17(2):122-126, 2001.

 

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Chapter Suggested Citation

 

Hutchison, L., and Peck, J. (2004). Immunizations and Infectious Diseases in Rural Areas. In Gamm, L. and Hutchison, L. (eds.), Rural Healthy People 2010: A companion document to Healthy People 2010. <www.srph.tamhsc.edu/centers/rhp2010> College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.