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Context: Rotavirus is the most common cause of diarrhea and vomiting in infants and young children. The implementation of the rotavirus vaccination program in the United States has resulted in a marked reduction in diarrhea hospitalizations and related hospital costs among children nationally. There are several existing surveillance systems used by Public Health related to Rotavirus in the United States. Disease incidence can be tracked through medical records and passive reporting. The Vaccine Adverse Event Reporting System (VAERS) serves as an early warning system to ensure the safety of vaccines administered in the United States. Surveillance of national vaccine coverage is captured by the National Immunization Survey (NIS). The NIS is conducted annually and surveys households in the United States with children of ages between 19 and 35 months at the time of the interview. Vaccine coverage data can be a total in the determination of children at highest risk of under immunization. Examination of coverage rates by birth cohort can also supply valuable information regarding areas of need. The various existing surveillance systems can be incorporated into the larger Deming Cycle, as known as the PDSA cycle. This Total Quality Management (TQM) can be applied to public health to focus on change and improvement at the procedural level. Specific Aims: The aims of this dissertation were to examine rotavirus immunization coverage in among children in the United States. (1) Review the application of Total Quality Management (TQM) in public health practice and the implementation regarding the Rotavirus Vaccine United States of America. (2) Examination of demographic and health related risk factors among children who are not up-to-date with their rotavirus immunizations (3) Comparison of immunization rates cross sectionally and by birth cohort. Methods: The first section examined current surveillance systems for the Rotavirus Vaccine. In particular focusing on the role of TQM and surveillance loops that can lead to the procedural improvements in public health practice. The data used for the analysis of the National Immunization Survey (NIS) for the years 2008-2014. Trends in rotavirus vaccination coverage were examined in children 19-35 months of age residing in the United States to assess changes in vaccine uptake in specific groups of participants. The primary outcome measure for this study is participant's rotavirus vaccination status. Descriptive analyses were performed among participants. Bivariate associations for all the risk factors by Rao Scott χ2 were examined. Multivariable logistic regression was used for the binary up-to-date status for rotavirus vaccination. Results: The overall coverage rates for rotavirus vaccination increased progressively across the NIS data collection years from 2010 to 2014 (59.2% to 71.7%) and across birth cohorts 2007-2009 (53.8% to 70.7%). The distribution of the covariates was consistent in both approaches. During both study periods children who were first born had greater odds of under immunization when compared with children born at a later birth order with OR =1.14 (CI 1.13-1.14) in NIS year 2010 and OR =1.21 (CI 1.05-1.39) among children born in 2010. A child being up to date with the 4:3:1:3:3:1 immunization series was shown to be more likely to have full coverage of rotavirus vaccination as well in each year: OR=0.32 (95% CI 0.32-0.32) in NIS year 2010 versus OR=0.20 (95% CI 0.20-0.20) in NIS year 2014. Likewise, this trend was evident when assessing the participants by year of birth. A child being up to date with this same six vaccine series was shown to be more likely to have full coverage of rotavirus vaccination in each year: OR=0.51 (95% CI 0.45-0.58) in birth year 2010 versus OR=0.31 (95% CI 0.26-0.36) in birth year 2012. The risk among children who live in households below the national poverty line decrease compared with households with incomes that lie above the national poverty line: OR =0.99 (95% CI 0.98-0.99) in 2010 versus OR =0.64 (CI 0.64-0.64) in 2014. The risk among children who live in households below the national poverty line decrease compared with household with incomes that lie above the national poverty line: OR =0.99 (95% CI 0.98-0.99) in 2010 versus OR =0.64 (CI 0.64-0.64) in 2014. Conclusion: Surveillance is a core function of public health. It is the ongoing, systematic collection, analysis, and interpretation of health data which is essential to the planning and implementation of public health practice. To be truly effective it needs to include a continuous ongoing system. One existing surveillance system for Rotavirus pretains to vaccine coverage. The National Immunization Survey is the primary source of vaccine estimates. It is conducted annually jointly by National Center for Immunizations and Respiratory Diseases (NCIRD) and the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC). The objective is to provide household, population-based, state and local area estimates of vaccination coverage among children 19-35 months of age. It assess the cumulative incidence of vaccine coverage for 14 childhood vaccines. The vaccines are selected based on recommendations from the Advisory Council of Immunization Practice (ACIP). Rotavirus vaccine coverage rates have steadily increased annually. The comparison of the two different approaches of analysis show that non stratified analysis can give an inaccurate image of coverage rates. For instances, poverty appears to be confounded by year of birth. Therefore it is important to take year of birth into account since trends may not be similar when looking at the two different types of sequential cross sectional survey analysis.

ETD_8474

Ph.D.

Includes bibliographical references

by Nisha C. Jani

doi:10.7282/T33N26HJ

ETD doctoral

The author owns the copyright to this work.