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October 25, 2000

Effects and Ethics of Sanctions on Childhood Immunization Rates

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(16):2056-2057. doi:10.1001/jama.284.16.2053

To the Editor: Dr Kerpelman and colleagues1 found that monetary sanctions increased the rate of age-appropriate immunization for children in Georgia, although they provide little information to explain these findings. By contrast, we2 found that such incentives did not increase the vaccination rate for children in Maryland, which we attributed to inconsistent state policies, faulty implementation, and a flawed conceptual framework that ignored the role of providers on influencing vaccination rates.

Numerous studies have shown that children's immunization coverage reflects a complex interaction of parental behavior, access to care, and provider behavior.3 However, Kerpelman et al assumed that only parental behavior was important and did not measure missed opportunities, health care visits, or practice characteristics. In our study, we found no change in preventive health care visits and a small decrease in missed opportunities that did not lead to increased vaccination rates.

The Preschool Immunization Project (PIP) that Kerpelman et al evaluated had significant implementation difficulties. Only 11 families were sanctioned, suggesting that either the program was truly not in effect or that the threat of sanction was adequate to change behavior. The authors raised several issues regarding selection and consent bias but did not acknowledge that these may have altered their findings. For example, the younger age of children in the intervention group for whom permission was received to review records may have led to disproportionate inclusion of children with more visits and, therefore, more opportunity to be vaccinated.

These results may be misinterpreted as suggesting that nothing further needs to be done to improve the primary health care system and immunization programs. The US Task Force on Community Preventive Services recently emphasized the need to adopt provider-based interventions including clinician reminder and recall, assessment and feedback, and standing orders to increase vaccination rates.4 While the task force also recommended increasing community demand for and access to vaccinations, the PIP intervention did not provide these components. Strong political motivations to support welfare sanctions are likely to persist. We do not believe that states should use results from this single county in Georgia as the basis for making important public policy decisions.

Kerpelman  LCConnell  DBGunn  WJ Effect of a monetary sanction on immunization rates of recipients of Aid to Families With Dependent Children.  JAMA. 2000;284:53-59.Google Scholar
Minkovitz  CHolt  EHughart  N  et al.  The effect of parental monetary sanctions on the vaccination status of young children: an evaluation of welfare reform in Maryland.  Arch Pediatr Adolesc Med. 1999;153:1242-1247.Google Scholar
Shefer  ABriss  PRodewald  L  et al.  Improving immunization coverage rates: an evidence-based review of the literature.  Epidemiol Rev. 1999;21:96-142.Google Scholar
 Vaccine-preventable diseases: improving vaccination coverage in children, adolescents, and adults: a report on recommendations from the Task Force on Community Preventive Services.  MMWR Morb Mortal Wkly Rep. 1999;48(RR-8):1-15.Google Scholar