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Improve Texas’ Child Immunization Rate


Texas ranks 43rd among the states and the District of Columbia in its early childhood immunization rates. Preschool vaccinations help all children enter school healthy and ready to learn, and they reduce the state’s expenses for health services. Texas should adopt a series of new strategies to ensure that as many of its children as possible receive immunizations.


Over the years, local, state and national immunization programs have prevented millions of illnesses and many deaths in the U.S. Texas, however, ranks poorly among the states in its rate of early childhood immunizations. In the Centers for Disease Control (CDC) 2001 National Immunization Survey, which collects immunization data in all 50 states, the District of Columbia and 28 selected urban areas, Texas ranked 43rd in its immunizations of children under the age of two.[1] The survey indicated that just 74.9 percent of all Texas children between the ages of 19 and 35 months were vaccinated in 2001. By contrast, the highest-ranking states were Vermont (89.2 percent), North Carolina (85.7 percent) and Rhode Island (84.8 percent).[2]

The Texas Department of Health (TDH) attributes the state’s poor immunization rates to poor parental education, widespread poverty and high birth rates. Another factor is the reluctance of some medical professionals to become involved with state/federal immunization programs, due to the amount of administrative paperwork involved.[3] Health care professionals also have voiced concerns about the increased personal liability that could result from participation in public immunization programs.[4] In addition, as noted by the State Auditor’s Office, implementation of a statewide immunization registry to record and track child immunizations has been slow.[5]

Child immunization rates rise substantially once children enter daycare programs or public school, since these institutions routinely require proof of immunization for admission.[6] Every state requires immunization for entry into its public schools, a requirement that has served to ensure immunization rates of 95 percent or more among school-aged children nationwide.[7]

Texas’ low immunization rates have contributed to several widespread occurrences of preventable childhood illnesses, such as substantial measles outbreaks in Dallas and Houston between 1988 and 1992. These involved a total of 9,400 measles cases, 26 resulting in death. The cases represented more than $8.5 million in increased medical costs for public and private health care providers. The vaccines needed to immunize these children against measles would have cost $12,000.[8]

This measles outbreak is also cited by health officials as an example of a disease that started in one city (Houston) and eventually spread nationwide, causing 55,000 cases and 120 deaths.[9] Although data from the TDH indicate that there has not been another substantial measles outbreak in the state since this period, measles can easily reappear without continued vaccination efforts.[10]

More recently, whooping cough, another vaccine-preventable disease, has reappeared in Texas. Whooping cough can lead to pneumonia, seizures, brain damage and even death. In 2001, 615 cases of whooping cough, five resulting in death, were reported in 70 Texas counties, the largest number of such cases in a year since 1968.[11] As of September 2002, 725 more cases and four more deaths had been reported throughout the state. TDH has urged families to make sure that their children are vaccinated against this deadly childhood disease.[12]

Best practices

Rhode Island enjoys one of the nation’s highest immunization rates. It is one of only a few states that provide childhood vaccines to doctors free of charge; health insurance companies share in the cost of providing these vaccines.[13] In addition, 95.5 percent of all Rhode Island children are covered by health insurance.[14] Dr. Patricia Nolan, Rhode Island director of Health, has stated, “Our success shows what can be accomplished when health care providers, health insurance companies, schools, private organizations and government all work together.”[15]

North Carolina also partners with public and private organizations inside and outside of the state to increase its immunization rates.[16] Dr. Jonathan Sher, President of the North Carolina Child Advocacy Institute, attributes the state’s top rankings in early childhood immunization to sustained, long-term collaborative efforts.[17]

North Carolina has 170 federally qualified health care centers and rural health clinics, all of which provide free immunizations. It also operates a “Health Check” program designed to improve patient education and information, simplify administrative paperwork and increase payments to private health care providers. Other advantages include an automated data management system and outreach coordinators in each county. One study of 1,200 Medicaid-eligible North Carolina children participating in Health Check found an increased rate of immunizations due to participation in the program. Another strong correlation was found between early childhood immunization levels and the use of outreach workers in each county.[18]

North Carolina’s immunization registry demonstration project, PAIRS (Provider Access to Immunization Registry Securely), allows doctors and other health providers to view immunization records over a secure Internet connection. This project received a 2002 Excellence in Immunization Award from the National Partnership for Immunization.[19] The PAIRS initiative includes the North Carolina state immunization department and several private technology corporations. The 140 health care providers who have participated in PAIRS to date report that the system is user-friendly and effective in accessing individual children’s immunization records. PAIRS contains immunization records for more than 1.5 million children throughout North Carolina.[20]

Texas efforts

TDH participates in the federal Vaccines for Children Program, a program initiated in October 1994. The program provides free vaccines to health care providers for all children who lack insurance coverage for vaccinations and whose parents or guardians cannot pay for them.[21]

TDH also is part of the Texas Immunization Partnership, which includes representatives from medical groups, consumer organizations, parents, pharmaceutical companies and other interested parties.[22] This partnership has developed a state plan for increasing Texas’ immunization rates that identifies barriers and provides recommendations for improvement. These recommendations include reinstating the “Shots Across Texas” program; developing education programs for parents and health care providers; improving ImmTrac, the state’s immunization registry; simplifying immunization data collection and reporting; addressing funding issues; increasing Medicaid vaccination administration fees for providers participating in the federal Vaccines for Children program; and maintaining and continuing strong immunization partnerships.[23]

A fiscal 2001 report from TDH, Rider 45—Plan to Increase Immunization Rates in Texas, listed short- and long-term strategies designed to increase Texas’ preschool immunization rates. These include community involvement, provider awareness and participation, parent awareness and participation, improved data systems and a strategic plan for the agency’s immunization program.[24] A sharp improvement in Texas’ early childhood immunization rate, from 69.5 percent in 2000 to 74.9 percent in 2001, reflects the success of the strategies in this plan.[25]

Bexar County has made significant efforts to improve its childhood immunization rate through public information activities. These have helped the county move from one of the nation’s worst immunization rates to a level slightly above the state average (75.1 percent versus 74.9 percent).[26] Immunization rates in other urban areas, however, such as Houston (70.5 percent), Dallas (68.9 percent) and El Paso (69.2 percent) fall well below the state average.[27]

Another Texas program, the Seniors/Volunteers for Childhood Immunizations Program, is an award-winning public-private partnership designed to increase early childhood immunization rates. Senior volunteers contact new mothers in the hospital about the need for early childhood vaccinations. These volunteers follow up by telephone and mail to remind mothers of additional vaccinations as they are needed. This project receives limited funding through the federal Health Resources and Services Administration.[28] Texas Comptroller Carole Keeton Strayhorn requested state funding for this outstanding program from the 2001 Texas Legislature, but no money was appropriated.[29]

Another initiative, Shots Across Texas/The Boots are Back II, increases immunization awareness and access to vaccinations. The original Shots Across Texas effort began in 1994, under the leadership of the Texas Medical Association. Texas’ immunization rates rose from 40 percent to 71 percent as a result of the program.[30] As part of its initiative, TDH is providing four projects with $25,000 each in federal funds from the CDC to develop local immunization coalitions.[31]

The Shots Across Texas/The Boots are Back II initiative has generated a variety of local partnerships. In Fort Worth, for example, the “Hot Shots” program recruits firemen and paramedics who are qualified to administer vaccines to participate in local immunization partnerships.[32] The El Paso Shots Across Texas Immunization Coalition sponsors health fairs, television spots, articles in local media and “back-to-school” immunization campaigns.[33]

TDH also has implemented ImmTrac, a statewide immunization tracking system for children from birth through age 18, with a special focus on two year-olds. But ImmTrac has faced a number of implementation challenges. For example, TDH has found it difficult to add doctors in private practice to its database, due to these doctors’ concerns about paperwork. The Texas Medical Association supports ImmTrac, however, and is also interested in improving access to the system for doctors, insurance companies and other health care providers.[34] The Texas State Auditor’s Office, in its review of the ImmTrac program, noted that the system remains incomplete, underused and controversial with respect to public concerns about the confidentiality of patient information.[35]

Additional strategies needed

Clearly, Texas should consider additional strategies to enhance parental awareness of the need for vaccinations and to increase the number and availability of immunization providers. Texas provides national leadership for a number of children’s issues, most notably in the area of public education reform. This know-how should be extended to the area of early childhood immunizations, to move the state from among the lowest to first place in national immunization rankings.


A. The Texas Department of Health (TDH) should initiate new and expand existing public-private partnerships to support the state’s early childhood immunization activities.

TDH should establish new public-private partnerships and collaborate with existing programs such as the Seniors/Volunteers for Childhood Immunization initiative to increase public and private awareness of and support for early childhood immunizations.

B. TDH and the Texas Education Agency (TEA) should develop a joint statewide initiative to increase immunization awareness and participation among parents of preschool and school-aged children.

TDH and TEA should partner to ensure that all Texas children enter school healthy and ready to learn. They should jointly apply for federal funds for immunization awareness and vaccination programs. For example, the U.S. Office of Housing and Urban Development offers competitive Resident Opportunities and Self-Sufficiency grants that can be used for door-to-door immunization outreach programs for public housing projects.[36] The state also will receive increased federal funds under the No Child Left Behind Act of 2001.[37] TDH and TEA should jointly consider using these federal resources to increase the state’s early childhood immunization rates.TDH and TEA also should partner with public and private health, service and education organizations such as parent-teacher associations, the United Way, schools and local businesses, community-based organizations, chambers of commerce and athletic booster clubs to increase immunization awareness and participation in the state’s early childhood vaccination program.

C. The Legislature should reduce or eliminate liability for private health care providers who participate in immunization awareness programs, shot administration and the state immunization registry.

Private providers should be able to participate in large-scale early childhood immunization programs without fear of increased personal liability.

D. The Texas Legislature should require certain Texas state agencies to include strategies for increasing public awareness of the need for early childhood immunizations within their strategic plans.

This should apply to all Texas state agencies that have contact with Texas families via telephone, mail, Internet or direct contact, including the Texas Department on Aging, Texas Department of Human Services, Texas Department of Mental Health and Mental Retardation, Texas Education Agency, Texas Higher Education Coordinating Board and the Texas Department of Protective and Regulatory Services.

Fiscal Impact

The state agencies involved in these initiatives should fund their efforts with current resources.


[1]These figures are for standard “4/3/1” series of immunizations, which include four doses of diphtheria, tetanus and pertussis vaccine, three or more doses of poliovirus vaccine, and one or more doses of measles vaccine. Definition from the Center for Disease Control’s National Immunization Survey.

[2]U.S. Centers for Disease Control, “National, State, and Urban Area Vaccination Coverage Levels Among Children Aged 19-35 Months, United States, 2001,” MMWR Weekly (August 2, 2002), pp. 3-6, (Last visited September 12, 2002.)

[3]Tammy Fonce-Olivas, “Anita Perry, Health Chief Urge More Vaccinations,” El Paso Times, (April 4, 2002), (Last visited August 1, 2002.)

[4]John Donaldson, “Doctors Should Lead the Way in Forcing Tort Reform Issue,” Fort Myers News-Press (July 12, 2002), Local-State, p. 9B.

[5]State Auditor’s Office, A Review of the Management Controls at the Department of Health’s Immunization Program (Austin, Texas, December 1999), pp. 3-4.

[6]Roy Hogan, “Immunization Policies and Funding in Texas,” in Calling the Shots: Immunization Finance Policies and Practices (National Academy Press, Washington D.C., 2000), p. 10.

[7]Children’s Defense Fund, “Immunization,” (Last visited August 22, 2002.)

[8]Roy Hogan, “Immunization Policies and Funding in Texas,” in Calling the Shots: Immunization Finance Policies and Practices, Institute of Medicine, p. 5.

[9] Houston Chronicle, “Immunization Rate Among Worst; Despite Study, Official Says City Working to Avoid an Epidemic,” July 7, 2000, Section A, p. 28.

[10] Texas Department of Health, 1977 Epidemiology Annual Report, Table 1, “Reported Selected Diseases 1988-1997.” (Austin, Texas, 1997); Texas Department of Health, 1999 Epidemiology Annual Report, Table 1, “Reported Selected Diseases, 1990-1999) (Austin, Texas, 1999); and Texas Department of Health, Division of Epidemiology, “Measles,” http:/

[11]Texas Department of Health, “Health Officials Focusing on Infants as Whooping Cough Surge Continues,” July 18, 2002, (Last visited August 1, 2002.)

[12]Debra Dennis, “Tarrant Whooping Cough Cases Surge: As Number More than Doubles, Experts Say Rise is ‘Still a Mystery to Us,’’’ Dallas Morning News (September 5, 2002), Northeast Tarrant, p. 1N.

[13]Rhode Island Department of Health, “Rhode Island Immunization Rates Are Best in the Nation,” August 20, 2002, (Last visited August 22, 2002.) p.1.

[14]David Averill, “Oklahoma’s Child Health, Welfare Trends Not Pretty,” Tulsa World (May 19, 2002), Opinion Section.

[15]Rhode Island Department of Health, “Rhode Island Immunization Rates Are Best in the Nation.”

[16]North Carolina Department of Health and Human Services, “August is National Immunization Awareness Month: North Carolinians Urged to Learn More About Immunization’s Importance,” (August 2, 2002). Press release.

[17]Dr. Jonathan Sher, “Lessons in North Carolina’s Rise to No. 1 in Immunization,” The News and Observer, (August 11, 2001), p. A19.

[18]Wilhelmine Miller, “Immunization Policies and Funding in North Carolina, in Calling the Shots: Immunization Finance Policies and Practices (National Academy Press, Washington D.C., 2000), pp. 3-10.

[19]North Carolina Healthcare Information and Communications Alliance, “NCHICA to Receive Excellence in Immunization Award,” July 30, 2002, (Last visited August 1, 2002.)

[20]National Partners for Immunization, “Non-Traditional Partner Award,” (Last visited August 1, 2002.)

[21]Texas Department of Health, “Texas Vaccines for Children (TVFC) Provider Questions and Answers,” (Last visited August 1, 2002.)

[22]Texas Immunization Partnership, Immunizing Texas: A State Plan to Increase Immunization Rates in Texas (Austin, Texas, September 2002). p. 3.

[23]Texas Immunization Partnership, Immunizing Texas: A State Plan to Increase Immunization Rates in Texas, p. 12.

[24]Texas Department of Health, Rider 45 – Plan to Increase Immunization Rates in Texas, (Last visited July 31, 2002). pp. 1-2.

[25]U.S. Centers for Disease Control, “National, State, and Urban Area Vaccination Coverage Levels Among Children Aged 19-35 Months—United States, 2000,” MMWR Weekly (August 3, 2001),; and U.S. Centers for Disease Control, “National, State, and Urban Area Vaccination Coverage Levels Among Children Aged 19—35 Months— United States, 2001,” MMWR Weekly (August 2, 2002).

[26]Tom Kim, “Health Rise in Immunizations: Bexar Gives Vaccination Stats a Shot in the Arm,” San Antonio Express News (August 7, 2002), Section A, p. 1a.

[27]U.S. Centers for Disease Control, “National, State, and Urban Area Vaccination Coverage Levels Among Children Aged 19-35 Months—United States, 2001.”

[28]University of North Texas, “Seniors/Volunteers for Childhood Immunization,” (Last visited July 31, 2002.)

[29]Texas State Comptroller, “A Tough Shot,” Fiscal Notes (October 2001), p. 3, (Last visited September 12, 2002.)

[30]Texas Medical Association, “Projects Funded and in Need of Funding,” (Last visited September 12, 2002.)

[31]Texas Department of Health, “Public Funding Opportunities—Shots Across Texas/The Boots are Back II,” (Last visited September 17, 2002.)

[32]Texas Department of Health, “Shots Across Texas Goes to the Fire Station,” (Last visited August 1, 2002.)

[33]Texas Department of Health, “El Paso Shots Across Texas,” (Last visited August 1, 2002.)

[34]Every Child by Two, “Immunization Registry Progress in Texas,” (Last visited July 31, 2002.)

[35]State Auditor’s Office, A Review of the Management Controls at the Department of Health’s Immunization Program (Austin, Texas, December 1999), pp. 3-4.

[36]U.S. Department of Housing and Urban Development, “Categorical Grants,” (Last visited August 1, 2002.)

[37]Jim Suydam, “21 Percent More Federal Money to Go to Schools,” Austin American Statesman (July 27, 2002), Metro/State Section, p. B 4.