Immunizing children Phila. mission

Anjanette Velazco-Miranda knocks on a beat-up old steel door under the El on Kensington Avenue. No one home, she leaves a card and moves on. On Cambria Street, a woman sticks her head out a second-floor window: "She don't live here anymore!"

At each of these addresses, in theory, is a baby who is behind in childhood immunizations. Velazco-Miranda's job: Find the parents. Get the kid into a clinic for shots.

With several recent outbreaks of preventable diseases traced to unvaccinated children, public health officials say it is more important than ever to maintain the high immunization rates that provide an extra layer of protection for everyone.

Philadelphia has among the highest vaccination rates in the nation, often topping all other big cities and most states. For Hib, a deadly disease that has reappeared for the first time in years, the most recent National Immunization Survey estimates the city's vaccine coverage at 96.3 percent - the best in the country, period.

Philadelphia does more than the rest of Pennsylvania and New Jersey to ensure that children get vaccinated.

Every day, for example, armed with records showing missed immunizations, Velazco-Miranda and other outreach workers for a community organization contracted by the city Department of Public Health visit 10, 20, 30 homes around the city. They carry no vaccine, and have no enforcement authority.

They can, however, help with the hurdles - no transportation, no money, no medical records, no English - that prevent children from getting immunized. And they are on a mission.

"We don't stop. No water, no lunch break, no nothing. We keep going until we are finished," said Betzabe Toledo, who insisted she was not exaggerating about the day that she and Velazco-Miranda knocked on 65 doors. Half were not home, so they had to go back.

Vaccines are one of the great success stories of public health, along with clean drinking water and good nutrition. Once invented, however, they still had to make it into children, particularly poor children.

As recently as the early 1990s, up to half of infants and preschoolers in some neighborhoods here and elsewhere still were not getting immunized on time. Measles infected more than 1,200 children in Philadelphia in 1991; eight died in the epidemic.

A year later, the city created an online registry to track vaccinations. Two years after that, Congress approved Vaccines for Children, an entitlement program that delivers free vaccine directly to providers for uninsured and underinsured children in all 50 states and six major cities, including Philadelphia. VFC now supplies half the nation's vaccine.

Jim Lutz, who manages Philadelphia's program, attributes its success to the "high standards" of local doctors and nurses, "strong support" from teaching hospitals and other factors. Others credit Lutz, who started the program 15 years ago, oversees the online database of childhood vaccinations, and created the unusual outreach component.

Within two weeks of every birth, a record is created in the Kids Immunization Database/Tracking System (KIDS). Every time a child is vaccinated, doctors are mandated by city health regulations to update the secure database; city workers make the updates for providers without compatible technology.

At 10 months of age, every child missing any of the 16 recommended vaccines is automatically flagged by the registry. It happens again at 20 months.

The names of those children - nearly 800 a month - go to Concilio (Council of Spanish-Speaking Organizations), which has a citywide contract to track them down. Perhaps 40 percent turn out to be errors, such as records that were not updated, said Ana Rijo, who supervises the Concilio program.

Her 10 outreach workers, between them fluent in Spanish, English, Creole, French and sign language, end up visiting most of the rest at home, usually several times, to deal with a range of issues that are getting in parents' way.

"Sometimes they don't know where they can get a shot," Rijo said. "Sometimes they forget. Or they'll say, 'Oh no, my child is up-to-date,' " she said, not realizing that a particular vaccine is given in a series of three doses.

Eleven-month-old Emery Torres had gotten some shots before her mother, Hazelline Torres, 18, lost her health insurance. She took Emery to a clinic for the next set but couldn't afford the $95 charge.

The registry flagged Emery. Velazco-Miranda tracked her down last month and told her mother that a city health center would vaccinate the child for free. Torres said she had no way to get to the center on Girard Avenue.

So Velazco-Miranda drove her.

Few other places go to such lengths. Although every state and a handful of cities are required to develop an online registry, for example, many are incomplete.

State law in Pennsylvania and New Jersey currently leaves it up to doctors to voluntarily update a child's vaccination status. Updates will be mandatory in New Jersey starting in 2011, as they are in Philadelphia now. The Pennsylvania Department of Health is looking at ways to link more providers to the database, an official said; about 30 percent are now.

All the registries, which are designed to follow children through age 18, are widely used by school districts to check for vaccinations required for enrollment. Several new ones will be required this fall for entry into sixth grade in Philadelphia and New Jersey. Updates have been proposed for the state of Pennsylvania.

Last week, an unvaccinated sixth grader from North Philadelphia was hospitalized with bacterial meningitis. Health officials said the student probably would have been protected by the meningococcal vaccine that is part of the new mandate.

Nationwide, an estimated 33,000 lives and nearly $10 billion in direct medical costs - plus $43 billion in indirect costs - were saved between 1995, when the Vaccines for Children program was implemented, and 2001, when researchers published their analysis in the Archives of Pediatrics and Adolescent Medicine. The program cost $3.1 billion this fiscal year.

Philadelphia has made particularly good use of its annual $20 million allocation, said Lance Rodewald, director of the immunization services division at the U.S. Centers for Disease Control and Prevention.

When the city introduced the varicella vaccine immediately after it was licensed in 1995, for example, an independent study showed a dramatic drop in chickenpox, Rodewald said, and that "helped the whole immunization community to see the value of this vaccine."

He also noted the city's own study of whether a change in the law to mandate vaccination for enrollment in day care meant that more children were, in fact, being vaccinated. (They were not.)

Like any infectious-disease specialist, Caroline Johnson, director of the city health department's Division of Disease Control, puts a high value in vaccines. But for a poor community with inadequate access to health care, she has an even broader goal.

"Our focus is not so much getting the shot into the kid as getting the kid to the doctor," Johnson said.

And then getting the shot into the kid.