Underimmunization of American Indian and Alaska Native Children

Amy V. Groom, Michael L. Washington, Philip J. Smith and Ralph T. Bryan

Pediatrics 2008;121;938-944
DOI: 10.1542/peds.2007-1794

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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ARTICLE

Underimmunization of American Indian and Alaska

Native Children
Amy V. Groom, MPHa,b, Michael L. Washington, PhDa, Philip J. Smith, PhDa, Ralph T. Bryan, MDb,c
a

Immunization Services Division, National Center for Immunization and Respiratory Diseases, and cOfce of Minority Health and Health Disparities, Ofce of Strategy and
Innovation, Ofce of the Director, Centers for Disease Control and Prevention, Atlanta, Georgia; bDivision of Epidemiology and Disease Prevention, Ofce of Public Health
Support, Indian Health Service, Albuquerque, New Mexico
The authors have indicated they have no nancial relationships relevant to this article to disclose.

Whats Known on This Subject

What This Study Adds

Previous studies have found that immunization coverage for American Indian/Alaska
Native children has been similar to coverage for other racial groups. Those studies used
NIS data from 1998 to 2000 (pooled) and 2001.

This is the rst study to use NIS data from 2000 to 2005 to examine immunization
coverage at a national level for American Indian/Alaska Native children.

ABSTRACT
OBJECTIVE. The goal was to determine whether disparities in childhood immunization
coverage exist between American Indian/Alaska Native children and non-Hispanic
white children.
METHODS. We compared immunization coverage with the 4 diphtheria-tetanus-pertussis, 3 poliovirus, 1 measles-mumps-rubella, 3 Haemophilus influenza type b, and 3
hepatitis B(4:3:1:3:3) series and its individual vaccine components (4 doses of
diphtheria, tetanus, and pertussis vaccine; 3 doses of oral or inactivated polio
vaccine; 1 dose of measles, mumps, and rubella vaccine; 3 doses of Haemophilus
influenzae type b vaccine; and 3 doses of hepatitis B vaccine) between American
Indian/Alaska Native children and non-Hispanic white children from 2000 to 2005,
using data from the National Immunization Survey.
RESULTS. Although immunization coverage increased for both populations from 2001

to 2004, American Indian/Alaska Native children had significantly lower immunization coverage, compared with non-Hispanic white children, over that time period.
In 2005, coverage continued to increase for American Indian/Alaska Native children
but decreased for non-Hispanic white children, and no statistically significant disparity in 4:3:1:3:3 coverage was evident in that year.
CONCLUSIONS. Disparities in immunization coverage for American Indian/Alaska Native
children have been present, but unrecognized, since 2001. The absence of a disparity
in coverage in 2005 is encouraging but is tempered by the fact that coverage for
non-Hispanic white children decreased in that year.

MERICAN INDIAN (AI) and Alaska Native (AN) children receive immunizations in

www.pediatrics.org/cgi/doi/10.1542/
peds.2007-1794
doi:10.1542/peds.2007-1794
Key Words
American Indian, Alaska Native,
immunization assessment, health
disparities
Abbreviations
AIAmerican Indian
ANAlaska Native
IHSIndian Health Service
NISNational Immunization Survey
4:3:1:3: 4 diphtheria-tetanus-pertussis,
3 poliovirus, 1 measles-mumps-rubella,
3 Haemophilus inuenza type b, and
3 hepatitis B
DT diphtheria and tetanus toxoids
DTP diphtheria-tetanus toxoids-pertussis
DTaP diphtheria-tetanus-acellular
pertussis
HibHaemophilus inuenza type b
Accepted for publication Sep 12, 2007
Address correspondence to Amy V. Groom,
MPH, Indian Health Service, Division of
Epidemiology and Disease Prevention, 5300
Homestead Rd NE, Albuquerque, NM 87110.
E-mail: amy.groom@ihs.gov
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275); published in the public
domain by the American Academy of
Pediatrics

a variety of settings, including Indian Health Service (IHS) and tribal health
facilities, urban Indian health organizations, other federal, state, or local public
providers, and private providers. Like many minority racial/ethnic populations, they
experience a disproportionate burden of morbidity and mortality resulting from a number of health conditions and
often face barriers accessing health care services.15 Despite persistent health and health care disparities, there have
been improvements in the overall health status of AI/AN populations. Before the use of hepatitis A vaccine, for
example, hepatitis A infection rates among AI/AN individuals were 5 times higher than rates in other racial/ethnic
populations. Since the advent of hepatitis A vaccination programs, hepatitis A rates have decreased 99% for AI/AN
populations, compared with the prevaccine era, and are now approximately the same as or lower than those of other
racial/ethnic populations.6 In recent decades, rates of deaths of AI/AN individuals resulting from other infectious
diseases and pregnancy-associated complications have decreased and life expectancy has increased.1,4
Some studies suggest that improvements in overall immunization coverage among AI/AN children have also
occurred and that disparities in coverage between AI/AN and non-AI/AN populations have declined or even
disappeared.7,8 In Alaska, for example, AN children seem to have higher immunization coverage levels than non-AN
children.9 Relatively high immunization coverage levels for AI/AN children, despite a high prevalence of risk factors
for underimmunization, have been attributed to improved access to immunizations through the Vaccines for
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GROOM et al

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Children program, broader access to primary care services, and public health outreach efforts by the IHS and
tribal health programs.7,9
The IHS is the federal agency charged with providing
health care to AI/AN individuals who are members of
one of the 560 federally recognized tribes. The IHS
provides a range of health services, including immunizations, to eligible patients in 35 states. Immunization
coverage is monitored on an ongoing basis by using
electronic medical records, and reports on coverage levels are issued quarterly. IHS data indicate that childhood
immunization coverage levels for the IHS user population (ie, AI/AN persons who received direct or contract
care at an IHS-funded facility at least once in the past 3
years) are increasing and are similar to coverage levels
for the general US population.10 The number of children
included in IHS reports has been steadily increasing as
more rigorous reporting requirements have been implemented, and reports currently include 25 000 AI/AN
children 19 to 35 months of age each quarter.10
IHS immunization data, however, apply only to
AI/AN children vaccinated at IHS, tribal, or urban Indian
health facilities and may not be indicative of coverage in
the wider AI/AN population across the United States. On
the basis of the IHS user population, 40% of 2-year-old
AI/AN children receive services from the IHS (IHS, Division of Epidemiology and Disease Prevention, unpublished data, 2007). The most-recent studies that comprehensively evaluated the immunization coverage among
AI/AN children nationally used pooled data from 1998
through 20007 or data limited to a single year (2001) of
the National Immunization Survey (NIS).8 Because comprehensive, up-to-date information about AI/AN childhood immunization coverage is lacking, we analyzed
NIS data for each year from 2000 through 2005. The
objectives of this study were to document, on a national
level, the presence or absence of immunization coverage
disparities between AI/AN children and other racial/
ethnic groups during each year from 2000 through 2005
and to assess whether residence in counties with IHS
service availability was associated with improved AI/AN
childhood immunization coverage.
METHODS
The NIS is a random-digit-dialed telephone survey that
estimates national and state-level vaccine coverage levels for children 19 to 35 months of age. NIS methods
have been described in detail in previous publications.1113
We analyzed data from 2000 through 2005 and for
each year calculated coverage with a combination of 4
doses of diphtheria and tetanus toxoids and pertussis
(DTP) vaccine, diphtheria and tetanus toxoids (DT), or
diphtheria and tetanus toxoids and any pertussis vaccine
(DTAP), 3 doses of oral or inactivated polio vaccine,
1 dose of measles, mumps, and rubella vaccine, 3
doses of Haemophilus influenzae type b (Hib) vaccine, and
3 doses of hepatitis B vaccine. This group of vaccines is
referred to as the 4:3:1:3:3 series. In addition to the
series coverage, we calculated coverage with the individual vaccines for each year of the study. All analyses were

conducted by using the statistical software packages SAS

9.1 (SAS Institute, Cary, NC) and SUDAAN 9.0 (Research Triangle Institute, Research Triangle Park, NC),
which allows the sampling weights and the sampling
design of the NIS to be taken into account.
To help achieve maximal sample sizes, we defined the
AI/AN group as all non-Hispanic children who were
identified by their parents as being either AI/AN alone or
AI/AN in combination with any other race (AI/AN all)
for the purposes of this study. Hispanic children were
excluded from the AI/AN group, because they may include AI children from Central or South America. To
determine whether there were differences in coverage
estimates depending on the definition used for the
AI/AN population, we compared 4:3:1:3:3 coverage estimates for the AI/AN alone and AI/AN all groups. We
used a 2-sided t test with an level of .05 to determine
whether coverage rates were significantly different between the 2 groups.
To measure disparities in coverage, 4:3:1:3:3 coverage
levels were calculated for AI/AN children and compared
with coverage estimates for 2 other groups of children,
namely, (1) non-Hispanic white children and (2) all
non-AI/AN children, that is, all children of any race or
ethnicity not identified as AI/AN. Because we hypothesized that the coverage level for AI/AN children would
be lower than the coverage level for either of the 2
comparison populations, we used a 1-sided t test with an
level of .05 to determine whether the coverage level
for the AI/AN group was statistically significantly lower.
To estimate the impact that the availability of IHS
services might have had on immunization coverage levels, we used IHS service counties, also known as contract
health services delivery areas, as a proxy for determining
access to IHS services. IHS service counties are defined
by IHS and represent the catchment area for IHS-funded
services (Fig 1). We compared 4:3:1:3:3 coverage levels
for AI/AN children residing in an IHS service county
with coverage levels for AI/AN children residing outside
an IHS service county. One-sided t tests with an level
of .05 were used for this analysis.
RESULTS
The yearly sample size for children whose parents identified them as AI/AN alone ranged from 268 to 486,
compared with 424 to 510 for children who were identified as AI/AN all. The white sample ranged from 10 317
to 13 700 children, and the non-AI/AN sample ranged
from 17 139 to 23 137 children. The difference in 4:3:1:
3:3 coverage rates for the AI/AN alone group versus the
AI/AN all group was not significant in any year (Table
1). For all subsequent analyses, we defined AI/AN children as children who were identified as AI/AN all.
Although there was no significant difference in coverage levels in 2000 or 2005, the 4:3:1:3:3 coverage
levels were significantly lower for AI/AN children, compared with white children, during 4 of the 6 years we
analyzed, from 2001 through 2004 (Table 2); 4:3:1:3:3
coverage for AI/AN children was also significantly lower
than coverage for non-AI/AN children during the 3-year
period from 2002 through 2004 (Fig 2).
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939

FIGURE 1
IHS designated contract health service delivery areas according to county, 2006.
Contract
County
No
Yes

Analysis of 4:3:1:3:3 coverage stratified according to

the component vaccines revealed that, in any single year
(including 2005), there were at least 2 vaccines for
which coverage was significantly lower for AI/AN children, compared with white children. In 2002 and 2004,
coverage with all component vaccines in the 4:3:1:3:3
combination was significantly lower for AI/AN children.
Coverage with diphtheria and tetanus toxoids and pertussis vaccine, diphtheria and tetanus toxoids, or diphtheria and tetanus toxoids and any pertussis vaccine was
significantly lower for AI/AN children in all 6 years
(Table 2).
In each of the 6 years studied, the majority of AI/AN
children in the NIS samples (54% 65%) resided within
an IHS service county. Higher coverage levels for AI/AN
children residing in IHS service counties were not observed in any year. In 2002, 4:3:1:3:3 coverage for
AI/AN children residing in an IHS service county was
significantly lower than that for AI/AN children residing
outside an IHS service county (P .05) (Table 3). There
were no significant differences in any other year.
DISCUSSION
Observed Disparities in Immunization Coverage
During 4 of the 6 years of NIS data included in this study,
AI/AN children were underimmunized compared with
TABLE 1 Estimated 4:3:1:3:3 Coverage for AI/AN Alone and AI/AN
All Groups in 2000 2005 (NIS)
Proportion (95% CI), %

2000
2001
2002
2003
2004
2005

AI/AN Alone

AI/AN All

73.2 5.0
73.9 5.9
59.6 8.4
76.3 6.2
77.5 5.4
78.0 6.9

71.0 5.5
68.9 5.8
62.1 7.5
74.3 5.2
72.1 5.4
77.7 5.5

The AI/AN all group excludes Hispanic subjects. CI indicates condence interval.

940

GROOM et al

other children in the United States. Evidence for this

health disparity was present when AI/AN children were
compared with either non-Hispanic white children
(20012004) or all non-AI/AN children (20022004).
These previously unreported findings highlight an important and potentially persistent health disparity and
cast doubt on the existing perception that immunization
coverage for AI/AN children is as good as, or better than,
coverage for non-AI/AN children.
Although the apparent disappearance of this disparity
in 2005 is encouraging, this observation should be interpreted with caution. Despite relatively steady increases
in preceding years (Fig 2 and Table 2), coverage for the
comparison populations actually declined in 2005, and it
is not clear from our data which factor (this decline or
the increase in AI/AN coverage that year) had a greater
impact on closing this gap in coverage. In addition, disparities did persist in 2005 for 2 component vaccines
(DTP/DT/DTaP and Hib b vaccines), which suggests that
the gap is not completely closed.
It is also encouraging to note that, overall, immunization coverage seems to be improving for all races and,
by 2005, coverage was at or near the Healthy People
2010 goal of 90% for most vaccines in the 4:3:1:3:3
series. As seen in Fig 2, however, the trends in coverage
for AI/AN children over the 6 years of this study were
more erratic than the steadier upward trends shown for
the non-Hispanic white or non-AI/AN comparison populations. This volatility might be a reflection of measurement factors such as small sample sizes or sampling
errors related to the methods used by the NIS but also
could be an indication of increased vulnerability of the
AI/AN population to known risk factors for low immunization coverage, such as lower socioeconomic status
and large family size.7 In the absence of larger sample
sizes, it is difficult to determine what is driving the
overall volatility in immunization coverage for the
AI/AN population.
National shortages of individual vaccines, such as the

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4:3:1:3:3
4 doses of DTP/DT/DTaP
3 doses of IPV
1 dose of MMR vaccine
3 doses of Hib vaccine
3 doses of hepatitis B vaccine

Percent

60
50
40
30
20

White

10

Non-AI/AN

AI/AN

0
2000

The AI/AN group includes children identied as AI/AN all and excludes Hispanic children. IPV indicates inactivated polio vaccine; MMR, measles, mumps, and rubella; CI, condence interval.
a Signicantly lower than the value for the white group, at .05.
b For an explanation of statistical signicance in the presence of overlapping condence intervals, see ref 34.

White

82.1 1.1
87.2 0.9
91.6 0.8
94.0 0.8
94.3 0.6
93.2 0.7
77.7 5.5
81.3 5.1a
87.1 4.9
91.2 3.7
89.5 4.6a,b
90.8 4.1

AI/AN
White

80

83.8 0.9
88.3 0.8
92.4 0.7
94.0 0.6
94.9 0.6
93.0 0.6

AI/AN

62.1 7.5a
68.2 7.8a
79.4 8.1a
83.6 7.4a
83.0 8.3a
80.1 8.2a

White

75.2 1.0
83.1 0.9
89.6 0.7
91.6 0.6
93.9 0.6
89.6 0.7
68.9 5.8a,b
74.7 5.6a
86.3 4.7
92.6 2.6
91.0 4.1
84.1 5.1a,b

White

75.6 1.0
83.7 0.8
89.9 0.7
91.2 0.6
94.1 0.5
90.9 0.6

AI/AN

71.0 5.5
76.9 5.2a
89.8 3.2
88.0 3.5
89.2 4.2a
89.3 4.2

AI/AN

90

72.1 5.4a
77.8 5.2a
85.8 4.6a
88.2 4.3a
89.8 4.2a
88.5 4.4a,b

AI/AN
White

82.5 0.9
87.7 0.8
93.0 0.6
93.6 0.6
95.2 0.5
93.3 0.6
74.3 5.2a
78.3 5.0a
90.1 3.7
92.3 3.3
90.9 3.7a
93.5 3.2

AI/AN
White

70

77.7 1.0
84.4 0.9
91.2 0.7
92.9 0.6
94.1 0.6
90.9 0.7

2005
2004
2003
Proportion (95% CI), %
2002
2001
2000
Vaccines

TABLE 2 Vaccine Coverage for AI/AN Children and White Children in 2000 2005 (NIS)

100

2001

2002

2003

2004

2005

FIGURE 2
Estimated 4:3:1:3:3 coverage from 2000 to 2005 (NIS). a Non-AI/AN include whites and
other races and ethnicities that are not AI/AN.

DTaP vaccine, may disproportionately affect AI/AN children and other public-sector vaccine recipients.14,15 To
assess whether such shortages might explain the overall
disparities in 4:3:1:3:3 coverage that we observed in
20012004, we also analyzed the individual vaccines in
this series. We found no evidence to suggest that a
decline in coverage with any one vaccine was responsible for the lower 4:3:1:3:3 coverage levels experienced
by AI/AN children during the years of this study. AI/AN
children had significantly lower 4:3:1:3:3 coverage rates
(20012004) during years with and without vaccine
shortages.
We also found that immunization coverage levels
were not significantly higher for AI/AN children residing
in IHS service counties, compared with AI/AN children
living outside IHS service counties. In 1 year, 2002,
coverage levels in IHS service counties were actually
lower. These findings could suggest that proximity to
IHS services did not necessarily enhance immunization
coverage for all AI/AN children; however, it is also possible that coverage levels for AI/AN children residing in
the IHS service counties might have been lower if IHS
services had not been available. In addition, it is important to note that not all children residing in an IHS
service county were necessarily eligible for or accessed
IHS services; therefore, they might not have benefited
from the immunization services offered by IHS.
Comparison With Previous Studies
Published studies that have addressed immunization
coverage for AI/AN children are few in number and
mixed in terms of comprehensiveness and comparability. The most-recent reviews of racial/ethnic disparities
in childhood immunizations did not include AI/AN children.16,17 Others, focusing on individual vaccines and
concluding that racial/ethnic disparities in vaccine coverage have been eliminated, did not address AI/AN disparities directly.18,19 Since 2000, only 2 publications assessed AI/AN childhood immunization coverage directly
by using NIS data7,8; both studies concluded that immuPEDIATRICS Volume 121, Number 5, May 2008

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941

nization coverage for the AI/AN population was similar

to coverage for other racial/ethnic groups. Differences
between their methods and ours may explain why our
findings led to different conclusions.
Our results also contrast with those of the IHS, in that
IHS reports consistently show higher immunization coverage levels than we report herein.1,10 IHS, however,
serves only a subset of the overall AI/AN population, and
AI/AN people often have multiple sources of health care,
with up to 49% having insurance through their employers, other private insurance, or Medicare.20 Although
most facilities supported by IHS are found in rural and
reservation areas, the majority (60%) of the AI/AN
population resides in off-reservation and urban areas.21,22
Overall, 46% of AI/AN individuals have no access to
IHS facilities.23 Because IHS data are limited to AI/AN
children accessing IHS-funded services, results of analyses using those data may not be comparable to results of
analyses using data captured in the NIS and are not
generalizable to all AI/AN children in the United States,
particularly those residing in urban and other areas with
limited access to IHS-funded services. Adding questions
to the NIS to determine care provided by IHS would
allow comparability between these 2 data sources and
would facilitate assessment of the impact of IHS services
on immunization coverage, as well as informing strategies to improve coverage for the AI/AN population.
Methodologic Challenges
Measuring health disparities affecting AI/AN populations can be challenging, in part because of the small
sample sizes found in various national surveys, of which
the NIS is just one example.24 In its report on disparities
in health care, the Institute of Medicine found that 1%
of the studies it reviewed had sample sizes large enough
for meaningful analysis of AI/AN data.25,26 Within the
NIS, the sample of AI/AN children in any single year is
relatively small, making it difficult to identify significant
differences. Given this, our analysis illustrates the utility
of looking for patterns over time, rather than focusing
on a difference in any particular year. Although estimates for coverage for this population were erratic, we
consistently found coverage rates to be lower for AI/AN
children, which supports the idea that a disparity exists.
Determining the magnitude of this disparity is difficult,

TABLE 3 Estimated 4:3:1:3:3 Coverage for AI/AN Children Residing

In and Outside an IHS Service County (NIS)
Survey
Year

Proportion (95% CI), %

2000
2001
2002
2003
2004
2005

In IHS Service
County

Outside IHS Service

County

73.6 6.1
73.2 6.2
55.6 11.0a
79.3 5.8
72.9 6.4
77.2 6.4

67.5 9.7
65.4 9.1
70.0 8.4
68.9 8.8
71.3 9.1
78.0 7.9

CI indicates condence interval.

a Signicantly lower than the value for AI/AN children outside a IHS service county, at .05.

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GROOM et al

however. In 2003, for example, our point estimate for

AI/AN 4:3:1:3:3 coverage was 74.3%, but with a confidence interval ranging from 69.1% to 79.5%. Comparing this range with that observed for non-Hispanic white
children in the same year (82.5 0.9%), the disparity
gap could be as wide as 14.3% or as narrow as 2.1%.
Such a broad range adds to our uncertainty about the
true magnitude of the disparity and makes decisions
about the allocation of resources for public health
intervention strategies even more difficult. Although
we have shown that NIS data can identify disparities
on an annual basis, looking for patterns over time may
be more useful. Even with this type of analysis, however, larger AI/AN sample sizes would be helpful for
characterization of the magnitude of these disparities
and would complement efforts to enhance local assessments.
Pooling several years of data is a common approach to
increasing sample sizes for AI/AN populations,3,7 but
there are limitations to this approach as well. In cases
where there is an aberrant or extreme trend in 1 of the
years to be pooled, this approach may not be methodologically appropriate. Pooling data also may conceal
changes in an individual year. Finally, information
gleaned from pooled data is not timely, which diminishes its value for identifying emerging problems.
Small sample sizes in national surveys also limit the
ability to perform geographically stratified analyses (eg,
county, state, or regional levels) and generally require
that data be aggregated on national or multiregional
levels. Aggregating data in this manner may mask regional variations (and therefore differences across AI/AN
tribal groups). For AI/AN health disparities, regional
variation is a relatively common observation.4,14,27 For
example, rates of immunization coverage for AN children in Alaska are consistently higher than rates of
coverage for the non-AN population residing in Alaska,9
and our finding of a disparity in immunization coverage
between AI/AN and white children may not be applicable to AN children in Alaska.
Finally, racial misclassification significantly impedes
our ability to detect and to monitor accurately AI/AN
health disparities.2832 Racial misclassification is less likely
to occur in NIS data sets because race is self-reported in
the NIS, but it may be a problem as we look to additional
immunization data sources, such as state immunization
registries.
Limitations
The AI/AN samples within NIS data sets are relatively
small, and findings may not be representative of the
larger AI/AN population. Although telephone surveys
such as the NIS may represent a cost-effective survey
method, this approach has limitations when used to
reach AI/AN populations. According to the 2000 US
Census, 2.4% of the US population has no telephone
service, compared with 11.9% of AI/AN homes. Within
AI/AN populations, access to telephone service varies
considerably according to tribe or geographic location,
with 0.9% to 49.1% of individuals reporting no access to
telephone service.33

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Using residence in an IHS service county as a proxy

for access to IHS services may not depict accurately the
impact of the IHS on immunization coverage levels,
because the NIS samples might have included AI/AN
children who were not eligible for, or did not access, IHS
services in those counties. In addition, we did not control
for other factors that may affect immunization coverage,
such as income, education level, and family size. It may be
that AI/AN children residing in an IHS service county had
more risk factors for underimmunization than did AI/AN
children residing outside IHS service areas and the similarity in immunization coverage levels between these 2
groups was a result of the provision of IHS services. Additional analyses to examine these factors are needed.
CONCLUSIONS
Our analytic approaches were different from those of
earlier studies, and our data source encompasses a
broader range of AI/AN communities, compared with
IHS data. The results of our analyses suggest that disparities in immunization coverage for AI/AN children have
been present, but unrecognized, since 2001. Our evaluation of immunization coverage for AI/AN children
points to the need for several courses of action, including
the development of improved strategies for the delivery
of immunization services to AI/AN families, the issuance
of authoritative guidance regarding consistent methods
for analyzing and reporting AI/AN immunization coverage levels (and eventually other AI/AN health-related
data), and the development of more-robust means for
monitoring immunization services for AI/AN children.
Increasing AI/AN sample sizes in national surveys, including questions regarding the provision of IHS services
to better ascertain the role of the IHS in delivering care
to the AI/AN population, and conducting ongoing analyses of trends in immunization coverage may improve
the monitoring of coverage for this population.
In addition, expanding efforts to ensure the inclusion
of accurate race/ethnicity data in state-based immunization registries and implementing more broadly existing
mechanisms to facilitate the inclusion of data on AI/AN
children in state immunization registries should allow
for better monitoring of coverage for this population on
the local level. As data in state immunization registries
become more complete, state-based evaluations of immunization coverage for AI/AN populations and other
racial/ethnic groups ultimately should allow for moretimely and more-precise identification of immunization
disparities on a state-by-state basis and should allow for
more local analysis within states.
Accurate and timely monitoring of immunization
data is a prerequisite for the development of effective
interventions and the elimination of disparities in immunization coverage. Improvements in AI/AN immunization data and methodologic approaches are needed to
strengthen our ability to detect problems with the delivery of immunization services to AI/AN families in a
more-timely manner.

REFERENCES
1. Indian Health Service. Trends in Indian Health 2000 2001. Rockville, MD: US Department of Health and Human Services; 2001
2. Anderson RN, Minino AM, Fingerhut LA, Warner M, Heinen
MA. Deaths: injuries, 2001. Natl Vital Stat Rep. 2004;52(21):
1 86
3. Denny CH, Holtzman D, Goins RT, Croft JB. Disparities in
chronic disease risk factors and health status between American Indian/Alaska Native and white elders: findings from a
telephone survey, 2001 and 2003. Am J Public Health. 2005;
95(5):825 827
4. Espey D, Paisano R, Cobb N. Regional patterns and trends in
cancer mortality among American Indians and Alaska Natives,
1990 2001. Cancer. 2005;103(5):10451053
5. Centers for Disease Control and Prevention. Racial/ethnic and
socioeconomic disparities in multiple risk factors for heart disease and stroke: United States, 2003. MMWR Morb Mortal Wkly
Rep. 2005;54(5):113117
6. Bialek SR, Thoroughman DA, Hu D, et al. Hepatitis A incidence
and hepatitis A vaccination among American Indians and
Alaska Natives, 1990 2001. Am J Public Health. 2004;94(6):
996 1001
7. Strine T, Mokdad A, Barker L, et al. Vaccination coverage of
American Indian/Alaska Native children aged 19 to 35 months:
findings from the National Immunization Survey, 1998 2000.
Am J Public Health. 2003;93(12):2046 2049
8. Bramley D, Hebert P, Tuzzio L, Chassin M. Disparities in indigenous health: a cross-country comparison between New Zealand and the United States. Am J Public Health. 2005;95(5):
844 850
9. Centers for Disease Control and Prevention. Vaccination coverage levels among Alaska Native children aged 19 35 months:
National Immunization Survey, United States, 2000 2001.
MMWR Morb Mortal Wkly Rep. 2003;52(30):710 713
10. Indian Health Service. Quarterly immunization reports. Available
at: www.ihs.gov/medicalprograms/epi/index.cfm?module
healthissues&optionimmunizations&catsub3. Accessed
March 11, 2008
11. Smith PJ, Rao JNK, Battaglia MP, et al. Compensating for
provider nonresponse using response propensities to form adjustment cells: the National Immunization Survey. Vital Health
Stat 2. 2001;(133):117.
12. Smith P, Battaglia M, Huggins V, et al. Overview of the sampling design and statistical methods used in the National Immunization Survey. Am J Prev Med. 2001;20(4 suppl):1724
13. Smith PJ, Hoaglin DC, Battaglia MP, Barker LE, Khare M.
Statistical methodology of the National Immunization Survey,
1994 2002. Vital Health Stat 2. 2005;(138):155.
14. Groom A, Cheek J, Bryan R. Effect of a national vaccine
shortage on vaccine coverage for American Indian/Alaska Native children. Am J Public Health. 2006;96(4):697701
15. Santibanez T, Santoli J, Barker L. Differential effects of the
DTaP and MMR vaccine shortages on timeliness of childhood
vaccination coverage. Am J Public Health. 2006;96(4):691 696
16. Chu S, Barker L, Smith P. Racial/ethnic disparities in preschool
immunizations. Am J Public Health. 2004;94(6):973977
17. Centers for Disease Control and Prevention. National, state,
and urban area vaccination coverage among children aged
19 35 months: United States, 2005. MMWR Morb Mortal Wkly
Rep. 2006;55(36):988 993
18. Hutchins SS, Jiles R, Bernier R. Elimination of measles and of
disparities in measles childhood vaccine coverage among racial
and ethnic minority populations in the United States. J Infect
Dis. 2004;189(suppl 1):S146 S152
19. Luman E, Ching P, Jumaan A, Seward J. Uptake of varicella
vaccination among young children in the United States: a

PEDIATRICS Volume 121, Number 5, May 2008

Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on April 4, 2011

943

20.

21.

22.

23.

24.

25.

26.

success story in eliminating racial and ethnic disparities. Pediatrics. 2006;117(4):999 1008
Zuckerman, S, Haley J, Roubideaux Y, Lillie-Blanton M. Health
service access, use, and insurance coverage among American
Indians/Alaska Natives and whites: what role does the Indian
Health Service play? Am J Public Health. 2005;94(1):5359
Forquera R. Urban Indian Health. Menlo Park, CA: Henry J.
Kaiser Family Foundation; 2001. Publication 6006. Available
at: www.kff.org/minorityhealth/6006-index.cfm. Accessed
August 30, 2006
Ogunwale SU. We the People: American Indians and Alaska Natives
in the United States. Washington, DC: US Census Bureau; 2006.
Available at: www.census.gov/prod/2006pubs/censr-28.pdf.
Accessed August 30, 2006
Office of Research on Womens Health. Women of Color
Health Data Book. Bethesda, MD: National Institutes of
Health; 2006
Waksberg J, Levine D, Marker D. Assessment of Major Federal
Data Sets for Analyses of Hispanic and Asian or Pacific Islander
Subgroups and Native Americans: Inventory of Selected Existing Federal Databases. Rockville, MD: US Department of Health and
Human Services; 2000. Available at: aspe.hhs.gov/hsp/
minority-db00/task2/index.htm. Accessed August 30, 2006
Call K, McAlpine D, Johnson P, et al. Barriers to care among
American Indians in public health care programs. Med Care.
2006;44(6):595 600
Smedley B, Stith A, Nelson A, eds. Unequal Treatment: Confront-

27.

28.
29.

30.

31.

32.

33.

34.

ing Racial and Ethnic Disparities in Health Care. Washington, DC:

National Academies Press; 2003
Indian Health Service. Regional Differences in Indian Health
2000 2001. Rockville, MD: US Department of Health and Human Services; 2001
Korenbrot C, Ehlers S, Crouch J. Disparities in hospitalization
of rural American Indians. Med Care. 2003;41(5):626 636
Stehr-Green P, Bettles J, Robertson L. Effect of racial/ethnic
misclassification of American Indians and Alaska Natives on
Washington death certificates, 1989 1997. Am J Public Health.
2002;92(3):443 444
Epstein M, Moreno R, Bacchetti P. The under-reporting of
deaths of American Indian children in California, 1979
through 1993. Am J Public Health. 1997;87(8):13631366
Thoroughman D, Frederickson D, Cameron H, et al. Racial
misclassification of American Indians in Oklahoma State surveillance data for sexually transmitted diseases. Am J Epidemiol.
2002;155(12):11371141
Grossman D. Measuring disparity among American Indians
and Alaska Natives: whos counting whom? Med Care. 2003;
41(5):579 581
US Census Bureau. Characteristics of American Indians and Alaska
Natives by Tribe and Language (PHC-5). Washington, DC: US
Census Bureau; 2000. Available at: www.census.gov/
census2000/pubs/phc-5.html. Accessed August 30, 2006
Schenker N, Gentleman J. On judging the significance of differences by examining the overlap between confidence intervals. Am Stat. 2001;55(3):182186

PFIZER IS DENIED ACCESS TO JAMA FILES

In a court case pitting Pfizer Incs corporate interests against a medical
journals confidential article-review process, a federal magistrate rejected
Pfizers attempt to gain access to documents of the Journal of the American
Medical Association. The issue was disclosed in an editorial published online
Monday by JAMAs editor, Catherine D. DeAngelis, and its counsel, Joseph P.
Thornton. The editorial is to be published in JAMAs April 23/30 print edition,
but was posted early because of its broad public interest. Dr DeAngelis, in an
interview, said she doesnt know of previous cases in which a medical
company sought to subpoena documents related to a medical journals peerreview process. In this case, Pfizer has sought files from JAMA, the Archives of
Internal Medicine and the New England Journal of Medicine related to its painkilling drugs Bextra, now off the market, and Celebrex, which still is for sale.
The decision against Pfizer by US Magistrate Judge Arlander Keys in Chicago
earlier this month found in favor of JAMA and the Archives of Internal Medicine;
the New England Journal of Medicine matter has yet to be decided. In their
editorial, Dr DeAngelis and Mr Thornton noted that medical journals maintain confidentiality of medical reviewers opinions so these independent
doctors can work in an unrestrained environment . . . Producing any of
these documents, with or without names, would seriously compromise the
process and the trusting relationship among the editors, authors and reviewers, they wrote.
Burton TM. Wall Street Journal. March 25, 2008
Noted by JFL, MD

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Underimmunization of American Indian and Alaska Native Children

Amy V. Groom, Michael L. Washington, Philip J. Smith and Ralph T. Bryan
Pediatrics 2008;121;938-944
DOI: 10.1542/peds.2007-1794
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