PUBLIC HEALTH BRIEFS
TABLE 1 -Number of Persons Receiving Tetracycline Syrup and Drops, as well as Tetracycline In all Forms, by Age. Tennessee Medicaid, October 1975-March 1976. Total No. Persons Receiving Tetracycline In All Forms Age in Years
0-7 8-14 15-59 260 Total
1,288 1,700 13,227 11,673 27,888
No. Persons Receiving Drops
No. Persons Receiving Syrup No.
in age group
No.
in age group
1,059 419 145 190 1,813
82.2 24.6 1.1 1.6 6.5
67 0 3 1 71
5.2 0.0 0.4 0.0 0.3
straints to make it clear that these compounds were not for pediatric use. The unrestricted availability of potentially harmful drugs which frequently are used incorrectly can not be justified.
ACKNOWLEDGMENTS We gratefully acknowledge the assistance of Jan Winfrey, who assisted in the computer programming required for this investigation and Dr. Jean Lockhart of the American Academy of Pediatrics, who motivated this investigation. This work was supported in part by Tennessee Contract FA 1793 and Department of Health, Education, and Welfare Grants No. HS 01703-02 and HS 02535-01.
REFERENCES 1. Committee on Drugs of the American Academy of Pediatrics: Requiem for tetracyclines. Pediatrics 55:142-143, 1975. 2. Ray, W. A., Federspiel, C. F., Schaffner, W. Prescribing of tetracycline to children less than eight years old: A two-year epidemiologic study among ambulatory Tennessee Medicaid recipients. JAMA in press, 1977. 3. Federspiel, C. F., Ray, W. A., Schaffner, W. Medicaid records as a valid data source: The Tennessee experience. Med Care 14:166172, 1976. 4. Ray, W. A., Federspiel, C. F., Schaffner, W. Prescribing of chloramphenicol in ambulatory practice. An epidemiologic study among Tennessee medicaid recipients. Ann Int Med 84:266-270, 1976.
Immunization: Public Health Programming Through Law Enforcement NICHOLAS ANTHONY, PHD, MARY REED, MSN, ARNOLD M. LEFF, MD, JOYCE HUFFER, BSN, AND BARBARA STEPHENS, MS Despite the recognition of proper immunization as one of the most successful tools available to reduce the incidence of communicable diseases and the administration of inoculations as one of the accepted activities of public health services, there are large numbers of children who have not received their recommended immunizations. In a study of different immunization level techniques, the Denver Elementary School System found that a school immunization record review with special attention to unimmunized children increased the results of a school-based immunization clinic.' A health education program did not produce significant improvement of immunization levels. From the Cincinnati Health Department. Address reprint requests to Dr. Nicholas Anthony, Cincinnati Health Department, 3101 Burnet Avenue, Cincinnati, OH 45229. This paper was submitted to the Journal January 27, 1977, revised and accepted for publication March 17, 1977. AJPH August, 1977, Vol. 67, No. 8
The Cincinnati Board of Health and Board of Education has, for two years, enforced the Board of Health's legal authority to require immunizations for children entering school as a tool to increase immunization levels.
Method Ohio is one of 46 states with laws requiring specific immunization before school entry is allowed; however, a review of all health records in grades kindergarten through nine in the 143 schools served by the Cincinnati Health Department (CHD) initiated in the fall of 1974 found that of the 63,000 children in Cincinnati's public and parochial schools, 37,777 (60 per cent) had inadequate immunizations according to school records. The parents of these children were informed by the principals that the Ohio State Immunization Law required that they have their child adequately immu763
PUBLIC HEALTH BRIEFS
nized or they would be excluded from school. Immunization clinics were established in the 17 clinics throughout the city. Clinic immunization schedules were given to the parents and were also published by the news media. This effort impelled 27,881 additional students to be immunized, or their school records corrected. The immunization rate was thus brought to 84 per cent. In April, 1975, the 9,896 children not in compliance were actually excluded from school for a maximum of five days. At the end of these five days, 4,454 of the excluded students were in compliance, raising the protection level to 91 per cent.2 In June, 1975, the parents of the 5,442 remaining unimmunized children were advised that their children would not be readmitted to school in September unless they were in compliance with the Ohio State Immunization Law. In August, a list of all children still not in compliance was prepared and distributed to all principals. A few schools excluded children in the fall based on the report. This group included an additional 2,400 children entering kindergarten or first grade. The Superintendent of Schools in February, 1976 directed all principals to exclude children identified by CHD as not having their required immunizations. Some principals excluded until the student presented a record of immunization, while some excluded for five days and others did not exclude. By June, 1976, 91 per cent of children enrolled in grades kindergarten through ten had adequate immunizations.
Discussion It is not clear why available legislation is not being utilized in other states with such laws. The appropriate use of legislation regarding immunization in Cincinnati met with strong public support, both by the Board of Education and the public at large. The media informed the community of the need for immunizations in order to prevent exclusion from school and communicable disease outbreaks. Private physicians gave many of the inoculations and were made more aware of the need for proper immunizations. The most
764
serious complaints were from the parents of children whose school immunization records were lost or did not correctly reflect the immunizations their child had received. In such cases, the school nurse contacted the physicians involved when necessary. The exclusions not only kept unimmunized children out of the schools, but also made parents responsible for their children's immunizations. This is in contrast to in-school immunization programs, which relieve the parents of such responsibility and pass it on to the school system. Utilization of the health clinics as immunization sites, rather than the schools, not only fostered parental responsibility for immunization, but also encouraged the entry of these children into a primary health care system. It is suggested that this strategy is worth further consideration in order to achieve not only recent national commitments to adequate immunization levels,3 but also to increase the overall health care of the children.
Summary The pre-inoculation program review of the school immunization records in fall, 1974 found that only 60 per cent of the 63,000 children in the Cincinnati primary school system were adequately immunized. Following a program based upon their legal authority to require immunizations, the Board of Health in collaboration with the Board of Education was able to obtain in a two-year effort a 91 per cent immunization level.
REFERENCES 1. Vernon, T.M., Conner, J.S., Shaw, B.S., Lampe, J.M. and Doster, M.E. An evaluation of three techniques for improving immunization levels in elementary schools. Am. J. Public Health 66:457-460, 1976. 2. Leff,A.M. How Cincinnati immunized 9,900 children. J. of the Ohio Public Health Association 9:14-15, 1975. 3. League leads drive to immunize the nation's children. National League for Nursing News, 24:1-3, 1976.
AJPH August, 1977, Vol. 67, No. 8
TABLE 1 -Number of Persons Receiving Tetracycline Syrup and Drops, as well as Tetracycline In all Forms, by Age. Tennessee Medicaid, October 1975-March 1976. Total No. Persons Receiving Tetracycline In All Forms Age in Years
0-7 8-14 15-59 260 Total
1,288 1,700 13,227 11,673 27,888
No. Persons Receiving Drops
No. Persons Receiving Syrup No.
in age group
No.
in age group
1,059 419 145 190 1,813
82.2 24.6 1.1 1.6 6.5
67 0 3 1 71
5.2 0.0 0.4 0.0 0.3
straints to make it clear that these compounds were not for pediatric use. The unrestricted availability of potentially harmful drugs which frequently are used incorrectly can not be justified.
ACKNOWLEDGMENTS We gratefully acknowledge the assistance of Jan Winfrey, who assisted in the computer programming required for this investigation and Dr. Jean Lockhart of the American Academy of Pediatrics, who motivated this investigation. This work was supported in part by Tennessee Contract FA 1793 and Department of Health, Education, and Welfare Grants No. HS 01703-02 and HS 02535-01.
REFERENCES 1. Committee on Drugs of the American Academy of Pediatrics: Requiem for tetracyclines. Pediatrics 55:142-143, 1975. 2. Ray, W. A., Federspiel, C. F., Schaffner, W. Prescribing of tetracycline to children less than eight years old: A two-year epidemiologic study among ambulatory Tennessee Medicaid recipients. JAMA in press, 1977. 3. Federspiel, C. F., Ray, W. A., Schaffner, W. Medicaid records as a valid data source: The Tennessee experience. Med Care 14:166172, 1976. 4. Ray, W. A., Federspiel, C. F., Schaffner, W. Prescribing of chloramphenicol in ambulatory practice. An epidemiologic study among Tennessee medicaid recipients. Ann Int Med 84:266-270, 1976.
Immunization: Public Health Programming Through Law Enforcement NICHOLAS ANTHONY, PHD, MARY REED, MSN, ARNOLD M. LEFF, MD, JOYCE HUFFER, BSN, AND BARBARA STEPHENS, MS Despite the recognition of proper immunization as one of the most successful tools available to reduce the incidence of communicable diseases and the administration of inoculations as one of the accepted activities of public health services, there are large numbers of children who have not received their recommended immunizations. In a study of different immunization level techniques, the Denver Elementary School System found that a school immunization record review with special attention to unimmunized children increased the results of a school-based immunization clinic.' A health education program did not produce significant improvement of immunization levels. From the Cincinnati Health Department. Address reprint requests to Dr. Nicholas Anthony, Cincinnati Health Department, 3101 Burnet Avenue, Cincinnati, OH 45229. This paper was submitted to the Journal January 27, 1977, revised and accepted for publication March 17, 1977. AJPH August, 1977, Vol. 67, No. 8
The Cincinnati Board of Health and Board of Education has, for two years, enforced the Board of Health's legal authority to require immunizations for children entering school as a tool to increase immunization levels.
Method Ohio is one of 46 states with laws requiring specific immunization before school entry is allowed; however, a review of all health records in grades kindergarten through nine in the 143 schools served by the Cincinnati Health Department (CHD) initiated in the fall of 1974 found that of the 63,000 children in Cincinnati's public and parochial schools, 37,777 (60 per cent) had inadequate immunizations according to school records. The parents of these children were informed by the principals that the Ohio State Immunization Law required that they have their child adequately immu763
PUBLIC HEALTH BRIEFS
nized or they would be excluded from school. Immunization clinics were established in the 17 clinics throughout the city. Clinic immunization schedules were given to the parents and were also published by the news media. This effort impelled 27,881 additional students to be immunized, or their school records corrected. The immunization rate was thus brought to 84 per cent. In April, 1975, the 9,896 children not in compliance were actually excluded from school for a maximum of five days. At the end of these five days, 4,454 of the excluded students were in compliance, raising the protection level to 91 per cent.2 In June, 1975, the parents of the 5,442 remaining unimmunized children were advised that their children would not be readmitted to school in September unless they were in compliance with the Ohio State Immunization Law. In August, a list of all children still not in compliance was prepared and distributed to all principals. A few schools excluded children in the fall based on the report. This group included an additional 2,400 children entering kindergarten or first grade. The Superintendent of Schools in February, 1976 directed all principals to exclude children identified by CHD as not having their required immunizations. Some principals excluded until the student presented a record of immunization, while some excluded for five days and others did not exclude. By June, 1976, 91 per cent of children enrolled in grades kindergarten through ten had adequate immunizations.
Discussion It is not clear why available legislation is not being utilized in other states with such laws. The appropriate use of legislation regarding immunization in Cincinnati met with strong public support, both by the Board of Education and the public at large. The media informed the community of the need for immunizations in order to prevent exclusion from school and communicable disease outbreaks. Private physicians gave many of the inoculations and were made more aware of the need for proper immunizations. The most
764
serious complaints were from the parents of children whose school immunization records were lost or did not correctly reflect the immunizations their child had received. In such cases, the school nurse contacted the physicians involved when necessary. The exclusions not only kept unimmunized children out of the schools, but also made parents responsible for their children's immunizations. This is in contrast to in-school immunization programs, which relieve the parents of such responsibility and pass it on to the school system. Utilization of the health clinics as immunization sites, rather than the schools, not only fostered parental responsibility for immunization, but also encouraged the entry of these children into a primary health care system. It is suggested that this strategy is worth further consideration in order to achieve not only recent national commitments to adequate immunization levels,3 but also to increase the overall health care of the children.
Summary The pre-inoculation program review of the school immunization records in fall, 1974 found that only 60 per cent of the 63,000 children in the Cincinnati primary school system were adequately immunized. Following a program based upon their legal authority to require immunizations, the Board of Health in collaboration with the Board of Education was able to obtain in a two-year effort a 91 per cent immunization level.
REFERENCES 1. Vernon, T.M., Conner, J.S., Shaw, B.S., Lampe, J.M. and Doster, M.E. An evaluation of three techniques for improving immunization levels in elementary schools. Am. J. Public Health 66:457-460, 1976. 2. Leff,A.M. How Cincinnati immunized 9,900 children. J. of the Ohio Public Health Association 9:14-15, 1975. 3. League leads drive to immunize the nation's children. National League for Nursing News, 24:1-3, 1976.
AJPH August, 1977, Vol. 67, No. 8
