Immunizations and Infectious diseases in rural Areas: A LITERATURE REVIEW

by Linnae Hutchison and Jennifer Peck


Scope of Problem



Goals and Objectives


The Healthy People 2010 goal relating to immunizations and infectious diseases is to “prevent disease, disability, and death from infectious diseases, including vaccine-preventable diseases.”3 This review addresses the following HP2010 objectives:



Infectious respiratory diseases were the leading cause of death in the United States during the first half of the 20th century. However, during the second half of the 20th century, with the successful implementation of an aggressive childhood immunization program controlling such diseases such as measles, mumps, rubella, pertussis, diphtheria, polio, and Haemophilus influenza type b, the leading killer became chronic diseases such as heart disease, diabetes, and cancer.58


Disparities among subpopulations in immunization rates have been reduced by a number of programs designed to address barriers to full immunization: access, cost, and knowledge. The Vaccines for Children Program, Medicare coverage of pneumonia and influenza vaccines, and expansion of immunization registries significantly contributed to improved immunization rates. Despite these programs, immunization rates vary by region, racial/ethnic group, socio-economic and insurance status.


Urban and rural immunization rates appear fairly similar for school-age children, with the exception of vaccinations for the varicella zoster virus (causative agent of chicken pox), which have lower rates in rural areas. Research examining immunization rates among preschool children in rural and urban areas reveal mixed results with studies reporting lower, comparable, and, in some cases, higher immunization rates in rural areas compared to urban areas. What is clear is that immunization rates among preschoolers for certain vaccines and vaccine series in rural and urban areas fall below the HP2010 goals.


Rates of influenza and pneumonia vaccination among the elderly are also similar in rural and urban areas but fall below the HP2010 goal.4 Minorities, foreign-born individuals, the uninsured, and the poor exhibit lower immunization rates and higher infectious disease prevalence. Other populations at risk are those residing on the U.S./Mexico border and in rural Colonias, where rates of tuberculosis (TB) and hepatitis A are significantly higher than in other regions of the country. These disparities among the aforementioned subpopulations serve as the focus of this review.


The nation as a whole has been successful in increasing immunization rates to record highs and controlling many infectious diseases; however, this is not the case in many countries. Endemic, emergent, and re-emergent infectious diseases are leading causes of morbidity and mortality throughout the world and represent a global public health challenge by nature of the transmissibility of pathogens across borders. International travel and commerce, increased use of antimicrobial agents,59 and persistence of immunization disparities in special populations (e.g., the elderly, minorities, and foreign-born individuals) represent opportunities to introduce and promulgate microbial threats to this country, reinforcing the need for vigilant immunization and surveillance programs at home and abroad.


Key definitions used in this discussion include:



Identified by People Living in Rural Areas as a high priority health issue for them


The Rural Healthy People 2010 survey found the “immunization and infectious disease” focus areas virtually tied with “injury and violence prevention” for the 13th ranking rural health priority among the 28 Healthy People 2010 focus areas.2 It was nominated by an average of 17 percent of the four groups of state and local rural health leaders. Of these four groups, local public health agencies were most likely to select, and state organizations were least likely to select, immunization and infectious disease as a rural priority. There were no significant differences among the four regions of the country with respect to selection of this topic as a rural priority area.


Prevalence and disparities in rural areas


There is considerable variation by age, ethnicity, region, socioeconomic, and insurance status regarding prevalence and susceptibility to infectious diseases, immunization rates, and morbidity and mortality. To capture the variation among these various subgroups, this review focuses primarily on the following special population groups: children, adults, elderly, minorities, and immigrants.




Childhood vaccination rates are considered a marker of the general quality of pediatric care given the high correlation between immunizations and other measures of preventive care.69 Thus, disparities in immunization coverage rates may reflect problems in the quality of pediatric health care for these subgroups. High immunization rates have resulted in low rates of vaccine-preventable diseases (VPD) and subsequently, insulated the U.S. from many of the consequences of such diseases. Without vaccines, children under age 18 are estimated to be 22 times more likely to acquire measles and six times more likely to acquire pertussis (whooping cough). Children in day care facilities would be 60 times likely to acquire pertussis (whooping cough). Children in day care facilities would be 60 times more likely to acquire measles and 16 times more likely to acquire pertussis.70


Childhood morbidity and mortality have been dramatically reduced in the past 50 years with routine vaccinations.5 The public health practice of promoting vaccine use among all U.S. children has resulted in the eradication of smallpox, the elimination of poliomyelitis from the Western Hemisphere, and the control of other infectious diseases such as measles, rubella, tetanus, diphtheria, and Haemophilus influenzae type b.6 As of 1998, the annual number of cases for nine vaccine-preventable diseases (smallpox, diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella, and Haemophilus influenza type b) decreased between 95 percent and 100 percent since 1900.6 


Children are currently recommended to receive vaccinations for 10 childhood diseases including diphtheria, tetanus, whooping cough, bacterial meningitis, polio, hepatitis B, chicken pox, measles, mumps, and rubella.71 A total of 16 to 20 doses of seven different vaccines are recommended by 18 months of age.72 In 2000, the national childhood immunization coverage for the combined 4:3:1:3:3 series (four or more doses of diphtheria and tetanus toxoids and pertussis vaccine; three or more doses of oral poliovirus vaccine; one or more dose of measles, mumps, and rubella vaccine; three or more doses of Haemophilus influenzae type b [Hib] vaccine; and three or more doses of hepatitis B vaccine) was 73 percent, well below the target of greater than 90 percent set by Healthy People 2010.3, 8 The varicella vaccine for chicken pox had the lowest coverage of all vaccines at 68 percent.8 The pneumococcal conjugate vaccine was added to the schedule of recommended vaccines in 2001 by the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices, the American Academy of Family Physicians, and the American Academy of Pediatrics.72 


DTP, polio, and MMR vaccination coverage levels for school-aged children (five to six years old) have surpassed 95 percent every year since 19806 due to state-mandated completion of the immunization series by the time of school entry.7 Coverage levels for infants and toddlers, however, have been much lower and are in need of improvement.8 


Immunization Coverage in Rural and Non-Rural Areas


Studies evaluating immunization coverage in infants and toddlers have revealed poor rates in both rural and urban areas. Data from the 1991 National Maternal and Infant Health Survey (NMIHS) and the 1993 National Health Interview Survey (NHIS) were evaluated to compare urban and rural immunization rates for the basic 4:3:1 series before 36 months of age.9, 10 No differences in immunization rates were detected between metropolitan urban and nonmetropolitan areas, though rates failed to exceed 70 percent for either area. CDC data from 1994 reveal 66 percent of rural children (19-35 months) were immunized for the basic 4:3:1 series compared to 71 percent of suburban and 62 percent of urban children.73 Thus, roughly one-third of urban and rural children under three years of age could be characterized as underimmunized in 1993 and 1994.


According to 1995 county-level immunization data from 11 state public health agencies, nonmetropolitan counties had higher immunization coverage for the 4:3:1 series for two-year-old children in the public sector (by 2.5 percentage points) than metropolitan counties.4 However, in a cross-sectional survey of two- and three-year-old children visiting selected private pediatric practices, Taylor, et al. reported that children seen in practices located in small towns with a population less than 50,000 were less likely to be fully immunized than those visiting practices in large (> 250,000) or mid-sized cities (50,000–250,000).74


More recently, the vaccination coverage rates of preschool-aged children were compared among urban, suburban, and rural children aged 19 to 35 months who participated in the 1999 National Immunization Survey.12 In this study, urban, suburban, and rural residence was defined by using telephone exchanges to determine county and city of residence, which were then assigned one of five metropolitan statistical area (MSA) categories as described by the Office of Management and Budget. Urban was defined as those living within the central city of a MSA, and rural included those living outside MSAs. Suburban included all others (those living outside the central city of a MSA but within the county containing the central city, in the MSA but not in the central city county, or in an MSA that does not contain a central city). Coverage levels for the basic 4:3:1:3 series (four doses of DTP, three does of poliovirus vaccine, one dose of MMR vaccine, and three doses of Hib vaccine) were slightly higher for rural children (79.6 percent) compared to urban children (76.7 percent) and no different than suburban children (79.1 percent), but all remained well below the Healthy People 2010 goal of 90 percent.3 


According to CDC National Immunization Survey (NIS) data from 2002, children ages 19 to 35 months residing in non-central city metropolitan statistical areas reported the highest immunization rates (see Figure 1) for the basic 4:3:1 series, 4:3:1:3 series, and varicella vaccine compared to children in MSAs with a central city and nonMSA areas.11

*Includes all 50 states and 25 immunization action plan areas. ¶¶ Four or more doses of DTP, three or more doses of poliovirus vaccine, one or more doses of any measles-containing vaccine (MCV), three or more doses of Hib, *** Four or more doses of DTP, three or more doses of poliovirus vaccine, one or more doses of any MCV, three or more doses of Hib, and three or more doses of HepB.


Stokey, 2001, found when vaccination coverage for individual vaccines was evaluated, significantly lower levels of varicella coverage were observed among rural children (47.2 percent) compared to urban (58.9 percent) and suburban (60.5 percent) children.12 Rates for pneumococcal conjugate immunization (three or more doses) among children ages 19-35 months were also lower in nonMSAs than MSAs with and without a central city (~32 percent, versus ~41 percent and ~45 percent, respectively); however, immunization rates among nonMSAs and MSAs with and without central cities were comparable for three or more doses of hepatitis B vaccines (~90 percent, versus ~89 percent and ~ 91 percent, respectively).11


Vaccination coverage levels were also found to differ by rural, urban, and suburban residence when evaluated by various subgroups defined by race, ethnicity, education, and income. Counter-intuitively, socially advantaged rural children faired worse than disadvantaged rural children when compared to their urban and surburban counterparts. Rural children living above the poverty level with household incomes exceeding $75,000 had lower coverage levels (76.2 percent) than similar urban (84.9 percent) and suburban (83.4 percent) children.12 Conversely, rural children who were non-Hispanic blacks, those whose mother had less than a high school education, and those who received their vaccinations from public facilities each had better coverage levels than their urban and suburban counterparts.12 


Utilization and Referral Patterns


One barrier to high immunization rates is the problem of record scatter, which occurs when patients visit multiple providers to receive immunizations. A number of studies have evaluated the impact of referral patterns and provider type on immunization rates. Hueston, et al. tracked the year (mid-1988 to mid-1989) in two rural counties and four urban census tracts in Kentucky.75 This study found rural children utilized public health clinics more often for immunization services than urban children. Furthermore, children seeing public providers were less likely to have up-to-date immunization records compared to those seeing private providers (44 percent versus 66 percent).75 A statewide survey of children born in Kentucky in 1990-1991, however, showed different results. Rural children served by the public health sector had higher rates of adequate immunization coverage (4:3:1 basic series) by age two than rural children served by the private sector and urban children served by public health departments or private providers.76 Immunization coverage in this study ranged from 56 percent (urban children served by public health departments) to 68 percent (rural children served by public health departments).


A national study conducted in 1994 of the 36,000 members of the American Academy of Pediatrics further examined the referral practices of pediatricians in an attempt to understand low immunization rates during the early 1990s. Researchers found immunization referrals to public health clinics were more common among pediatricians in nonmetropolitan areas (63.9 percent) than pediatricians in large (44.7 percent) and small (52.5 percent) metro areas.77 This same study found that in states with programs providing free or reduced cost vaccines to providers, pediatricians were less likely to refer patients for immunizations. Note: During this 1994 study, only 16 states had vaccine programs in place that provided some or all vaccines free or at reduced cost to providers. More recent studies have found that since the implementation of the Vaccines for Children Program, providers participating in VFC may be less likely to refer uninsured children to public clinics for their vaccinations than those who do not participate in the program (44 percent versus 90 percent).78 Although the preceding study did not include comparisons of rural versus urban,78 a study of rural Colorado physicians found that 40 percent of patients are referred for immunizations for insurance reasons.79 


Referral patterns also are found to vary by specialty type. In a 1997 Texas study,80 rural pediatricians and family practitioners were more likely than general practitioners to offer immunizations to children (80 percent, 76 percent, and 54 percent, respectively). In the same study, rural pediatricians were significantly more likely than family practitioners and general practitioners to participate in the VFC program (52.9 percent, 40.8 percent, and 33.3 percent, respectively). Forty percent of pediatricians in this study participated in VFC, accepted Medicaid, and did not refer the uninsured for immunizations compared to 31.5 percent of family practitioners (FPs) and 25.5 percent of general practitioners (GPs).80 While this study suggests pediatricians are less likely than other provider types to refer children for immunizations (even in rural areas), there are fewer pediatricians in rural areas,2 and children may be referred more often to public health providers in rural areas, compounding the problem of record scatter. Overall, a study of 1999 National Immunization Survey data found that rural children are more frequently vaccinated at public clinics than suburban and urban children.12


A component of full immunization coverage is also timely coverage. Williams, 1994, reported considerable delays in vaccine administration before school entry for urban, suburban, and rural children in Maryland.81 By the age of two, children in rural areas experienced delayed immunization more often than suburban children but less frequently than urban children.81


Disparities in infectious diseases prevalence also exist among ethnic and special populations. Latino children, representing the largest minority group of children (11.6 million), are 13 times more likely to be infected with tuberculosis than white children.13 Children of farm laborers, predominantly of Latino descent (94 percent), also have higher rates of tuberculosis, parasites, and sexually transmitted diseases.13 In a Florida study, migrant farm worker children ages six to 11 years were found to have a higher seroprevalence of hepatitis A than the same age group in the general U.S. population (57 percent versus 10 percent).82 One study found that the prevalence of hepatitis A in children residing in rural Texas Colonias areas was 37 percent compared to 17 percent in the urban border area of McAllen, Texas, and 6 percent in the San Antonio, Texas, metro area. However, the prevalence of hepatitis B and C in these Colonias studied was comparable to U.S. rates.14 Cryptosporidium parvum, a parasite, was also higher in Colonias areas than urban border and urban nonborder communities.83 (Note: Colonias are unincorporated and impoverished rural areas along the U.S./Mexico border. These areas are home to 350,000 residents in 1,450 Colonias in Texas alone. Over half of the residents do not have access to adequate water supplies and waste water systems.84 These substandard conditions make residents particularly vulnerable to hepatitis A, which is transmitted person to person through unsanitary conditions, such as poor hand-washing practices and contaminated cooking utensils and overcrowding.85)


Otitis media (OM), also known middle ear infection, is the most common childhood bacterial infection¾accounting for an estimated 24 million cases annually. Amoxicillin is the recommended first line antibiotic treatment for otitis media. Appropriate use of first line antibiotics slows antibiotic resistance. One Healthy People 2010 objective is to decrease the number of courses of antibiotics for ear infections. In a study analyzing the antibiotic prescribing patterns of rural and urban physicians in a midwestern health plan, researchers found urban physicians more likely to prescribe amoxicillin for OM than rural physicians (31 percent versus 28 percent), although the differences were modest.86 The same study found the prescribed duration of antibiotic treatment for children over two years old was longer than the recommended duration of five to seven days for acute infections; however, for individuals of all ages with recurrent infection, the prescribed duration was less than recommended (10 versus $ 14 days).


Another HP2010 goal is to reduce the number of antibiotics prescribed for the common cold. In a Kentucky study of Medicaid claims from 1993 to 1994, 60 percent of the patients filled a prescription for the common cold. Urban physicians were significantly more likely to prescribe antibiotics for the common cold than rural physicians in this study.87 In a study of the use of broad-spectrum antibiotics using 1997 to 1999 data from the National Ambulatory Medical Care Survey, prescribing practices of broad-spectrum antibiotics for the common cold (51 percent), acute sinusitis (53 percent), acute bronchitis (62 percent), and otitis media (65 percent) revealed no significant difference in prescribing choice based on urban versus rural location.88 Specialty type and geographic regions were the strongest predictors of broad-spectrum antibiotic prescription practices. Internal medicine physicians were more likely than generalists and family physicians to prescribe broad-spectrum antibiotics, while physicians in the South and Northeast were more likely to prescribe these same antibiotics than physicians in the West.88




Hepatitis, tuberculosis, HIV, influenza, and pneumonia together represent significant causes of morbidity and mortality among adults. The primary focus of this section is on influenza, pneumonia, hepatitis, and tuberculosis among adults. HIV, with an estimated 40,000 new infections each year, 800,000 to 900,000 people living with the disease,89 and a significant risk factor for TB,90 is not discussed in depth in this chapter as it is a separate HP2010 focus area.3 


Pneumonia and Influenza


The HP2010 goal for influenza and pneumonia vaccination coverage is 60 percent for those 18 to 65 years of age (not high risk, non-institutionalized).3 Nationwide, the immunization rate for influenza among adults ages 18 to 65 is 31 percent, while the rate for pneumonia immunization is 18.4 percent.15 There are limited data evaluating the effect of urbanicity on adult immunization rates; however, Steiner, et al. using 1993 National Health Interview Survey data, found nonmetro areas had comparable or slightly higher rates of adult immunizations for influenza and pneumonia.10 Unlike those 65 and older, for whom Medicare covers the cost of these two vaccines, adults must cover the cost either through insurance or private pay. In one study of rural Appalachian 18-64 year olds, the most significant predictor of influenza and pneumonia immunization was insurance status; in fact, those with insurance were 1.75 to 3.5 times more likely to receive these immunizations than the uninsured.15 




Globally, 1.9 million people die of tuberculosis each year¾the leading cause of death by infectious disease globally.16 In the U.S., the rate of TB has been declining over the past decade; however, the rate of decline between 2000 and 2001 was the smallest rate of decline in nine years (only 2 percent). Those at risk include the immuno-compromised such as babies and the frail elderly, those with HIV infection, and substance abusers.91 In 2001, there were 15,989 cases of TB reported to the CDC,92 with an associated death rate of 0.3 percent.17 While TB affects all age groups, the percent of total cases is highest among adults ages 25-44 years old (35 percent), followed by adults age 45-64 (28 percent), and those greater than 65 years of age (21 percent).17 The percent of total cases among residents of long term care (LTC) facilities is 2.8 percent.17 


Declining rates of TB mask racial disparities among ethnic groups:93 36 percent of the total reported cases occur in African Americans, 29 percent in whites, and 20 percent in Hispanics.18 However, incidence (cases/100,000) rates from 2001 reveal the highest incidence rates are observed among Asian/Pacific Islanders (33/100,000), followed by African Americans (14/100,000), Hispanics (12/100,000), American Indian/Alaskan Natives (11/100,000), and whites (2/100,000).18 


Three-fourths of the cases of TB are found in the four states that border Mexico.19 The research is limited regarding disparities in TB rates among urban and rural populations. One study in Georgia94 found rural persons were more likely to report a history of syphilis and TB. In one study of TB case rates along the Texas border, 14 counties were studied (four were classified as metro and 10 were nonmetropolitan). The three counties with the highest rates were nonmetropolitan.95 However, in a North Carolina study reviewing TB rates from 1966 to 1986, researchers found TB rates increase with increasing population density and decreasing income. 20 Other studies have linked low socio-economic status with increased incidence of TB as well.93 


The most significant change in the demographics of TB is the rise in the number of cases among foreign-born individuals,92 where the case rate for this population is seven times higher than the rate among U.S.-born individuals.96 Between 1990 and 1999, the number of TB cases reported among foreign-born individuals increased from 24 to 43 percent.22 In 22 states in 2002, over half the TB cases were in foreign-born residents, and 70 percent of the cases were in foreign-born residents of New Hampshire, Idaho, Minnesota, California, Massachusetts, Hawaii, and Colorado.97 The most common birth country for persons with TB is Mexico (24.8 percent), followed by Philippines, Vietnam, India, China, Haiti, and South Korea. Multi-drug resistant tuberculosis has also increased among foreign-born individuals, increasing from 31 percent in 1993 to 72 percent in 2000.96


The changing demographics in the prevalence of TB, particularly among Hispanics of foreign origin, represent an important rural health challenge. Seventy-five percent of the states reported Hispanic population growth rates of 50 percent, while half of all states reported growth rates of 100 percent.28 In nonmetropolitan areas, Hispanics represent the fastest growing minority group,98 comprising 5.5 percent of the total non-metropolitan population99 and accounting for 25 percent of the total nonmetropolitan population growth during the 1990s.98 Some nonmetropolitan counties experienced a 150 percent growth in the Hispanic population compared to only 14 percent growth for non-Hispanic minorities.28 The growth rate for Hispanics in nonmetropolitan areas overall for 1990-2000 was 70.4 percent versus 60.4 percent in urban areas¾the highest growth rate for all population groups regardless of urbanicity.28 Furthermore, according to Race and Ethnicity and Rural America, one-third of all Hispanics in nonmetropolitan counties were born outside the U.S.28 (It should be noted that African Americans are the most numerically dominant minority group in nonmetropolitan areas.28)


While HIV infection is a significant risk factor for TB for all racial/ethnic groups, the association between HIV and TB has been found to be two to three times higher among Hispanics.100 A study by Pablo-Mendez, et al. also found diabetes mellitus to be a significant risk factor for TB, especially among Hispanics where diabetes tripled the risk of TB in this group.100 


The U.S./Mexico border suffers from a higher incidence of a number of infectious diseases. According to the Health Resources and Services Administration (HRSA), if the U.S. territory along the border were a separate state, it would rank last in access to health care, second in hepatitis deaths, and third in deaths due to diabetes. The rates of measles and mumps are twice the national rate. The border area also has higher rates of botulism, brucellosis, diphtheria, hepatitis A, rabies, rubella, salmonellosis, and shigellosis than nonborder areas.23 TB rates along the border are significantly higher than those of Mexico or the U.S. (27/100,000, 19/100,000, and 6.8/100,000, respectively).21 The border also has a higher rate of MDRTB.22 


Surveillance and control of border areas is a mammoth task given an estimated 320 million persons cross the northbound border between Mexico and the U.S. each year.101 The Border Infectious Disease (BIDs) program was established to increase surveillance101 along the U.S./Mexico border of certain infectious diseases such as hepatitis, measles, mumps, rubella, dengue, and typhus through a binational collaborative prevention and control effort.


Other special rural populations at heightened risk for certain infectious diseases are migrant and seasonal farm workers. While difficult to determine the number of migrant farm workers, one estimate places this population at 4.2 million.102 Poss (1998) found that this population is six times more likely to develop TB than adults in other professions.16 In addition to higher rates of TB, migrant farm workers also have higher rates of parasitic diseases and other communicable diseases¾a finding attributed in part to overcrowded conditions.102 The rural health center plays a vital role in the health of migrant workers; an estimated 74 percent of migrant farm workers and seasonal workers receive care in these health centers.103 




Hepatitis A, B, and C are viral infections of the liver, transmitted through person-to-person contact (e.g., hepatitis A) and contact with infected body fluids (e.g., hepatitis B and C). In 2001, there were 10,616 reported cases of acute hepatitis A, 7,844 reported cases of acute hepatitis B, and an estimated 4,000 acute cases of hepatitis C. During the same year, there were 1.25 and 2.7 million persons with chronic hepatitis B and C infections, respectively.44


Hepatitis A is endemic in 17 states, with the highest prevalence in the U.S. in Arizona, followed by Alaska, Oregon, New Mexico, Utah, Washington, Oklahoma, South Dakota, Idaho, Nevada, California,104 Arkansas, Colorado, Missouri, Texas, and Wyoming.105 The first 11 states mentioned had a rate twice the national hepatitis average or 20 cases per 100,000.105 Nearly 50 percent of the reported cases occur in these 17 states, where only 22 percent of the population resides.105 Approximately 200,000 Americans are infected each year; 22 percent of infected adult patients require hospitalization, and 100 people die annually from the disease. The cost to the U.S. economy is estimated at $450 million annually. The highest incidence rates are among children, where 30 percent of cases occur among those ages five to 14 years old. Day care workers, by nature of the route of transmission, are also at heightened risk.105 


Hepatitis A is two to three times more prevalent along the U.S./Mexico border24 and is particularly problematic in rural Colonias.23 In children, this disease is usually asymptomatic; however, the high incidence of the virus among children increases the likelihood of transmission to adults, in whom, hepatitis A is symptomatic.106 


The hepatitis B vaccine has been available since 1982, with routine vaccination for all children ages 0-18 years old recommended.25 The control of perinatal infection (transmission from mother to infant) is a key element of the hepatitis B elimination strategy, and screening has been recommended since 1988.107 While the hepatitis B vaccination program has been very successful in targeting children, the greatest challenge lies in vaccinating high-risk adults.107 


Those at risk include African Americans and immigrants from areas where HBV is endemic (Asia, Sub-Saharan Africa, Amazon Basin, Eastern Europe, and the middle East), Alaskan Natives and Pacific Islanders, households in contact with chronic hepatitis B carriers, people who have sexually transmitted diseases, users of illicit drugs, hemodialysis patients, international travelers, and inmates.25 African-American teenagers and young adults are infected three or four times more often than whites.26 Asian and Pacific Islander children are also at a greater risk of contracting hepatitis B (20 to 30 times higher than other children in the United States).27 Fifty percent of individuals with chronic hepatitis B (1.25 million total) and 50 percent of the 5,000 who die from hepatitis B-related liver failure are Asian American and Pacific Islander. While Asian Americans and Pacific Islanders represent only 4.5 percent of the U.S. population,26 their numbers are increasing. Asian Americans were second only to Hispanics in population growth between 1990 and 2000.28 During the same time period, the Asian population grew 56.1 percent in metro areas and 32.2 percent in nonmetropolitan, with half of all Asians in nonmetropolitan counties born outside the U.S.28 


The risk of perinatal infection among infants is also high among children born to first generation immigrant mothers from areas where HBV is endemic.108 It should be noted that since implementation of a HBV program in 1982 targeting Alaskan Natives (adults, infants, and pregnant women), incidence rates have declined 99 percent.108 In 1992, it was recommended that all newborns receive the hepatitis B vaccine as part of their immunization schedule.107 


There are approximately 300,000 HBV infections per year in the U.S.; 90,000 to 120,000 symptomatic episodes; 10,000 to 17,000 hospitalizations; 350 to 450 deaths from fulminate hepatitis¾a condition marked by rapid destruction of the liver;109 and an estimated 4,000 to 5,000 deaths from HBV-relatd liver disease.107 The number of carriers increases 27,000 to 42,000 annually.109


Hepatitis C is the most common chronic viral infection in the United States. An estimated 1.8 percent (3.9 million people) of the United States population is infected. While 15 percent of chronic liver disease is attributed to hepatitis B, 40 to 60 percent of chronic liver disease is related to hepatitis C infection. A major risk factor for contraction of hepatitis C is intravenous (IV) drug use.110 Approximately 80 percent of those who acquire hepatitis C eventually develop chronic liver disease.111 The incidence of hepatitis C, like hepatitis B, is higher among African Americans than whites.26




Pneumonia and Influenza


Influenza and pneumonia together are the fifth leading causes of death among the elderly in the U.S.29 despite the fact that both flu and pneumonia vaccinations are covered by Medicare Part B with no deductible. Ninety percent of the deaths from influenza and 80 percent of deaths from pneumococcal infection occur in persons ages 65 and older.30, 31, 32 The HP2010 goal for noninstitutionalized and institutionalized adults over 65 is 90 percent for influenza and pneumococcal vaccination.3 The vaccination rate for influenza and pneumonia is 66 percent and 55 percent, respectively, for those 65 and older.33, 34 State-by-state data for influenza and pneumococcal immunizations for the elderly revealed a median immunization rate of 69 percent and 55.2 percent, respectively. In 2002, 66.4 percent of adults older than 65 received influenza vaccines compared to 36.4 percent for adults 50 to 64 and 16.4 percent for adults 18 to 29 years.34 


While influenza and pneumococcal vaccination rates among men and women are equal,35 differences in influenza and pneumococcal immunization rates exist among minorities. Non-Hispanic whites experience the highest influenza immunization rates (68.8 percent), followed by African Americans (49.6 percent) and Hispanics (48.5 percent).35 Pneumococcal vaccination rates follow a similar pattern: 60.3 percent among non-Hispanic whites, 37.2 percent for African Americans, and 27.1 percent for Hispanics.35 Household survey data from 1998 and 1999 revealed similar results: 70 percent of older white persons received flu shots while African Americans and Hispanics had rates slightly over 50 percent.112 


Another contributing factor to influenza immunization rates among the elderly is affluence. Using 1993 Medicare Current Beneficiary Survey (MCBS) data, Gornick, et al. found the least affluent had an immunization rate for influenza 26 percent lower than the most affluent group. Among African Americans, the least affluent had a 39 percent lower rate than the most affluent.113


The literature supports that pneumonia and influenza immunization rates among those older than 65 are comparable between rural and urban areas. In a study by Zhang, 2000, evaluating use of preventative services by rural and urban populations, 55 percent of urban and 58 percent of rural elderly residents received flu shots (P=.11).36 This finding is supported by another study by Casey, et al. in which the researchers used the 1997 Behavioral Risk Factor Surveillance System (BRFSS) and 1999 Area Resource File (ARF) data to evaluate the impact of education, income, and urbanicity on receipt of preventive services.38 Rural residence was not found to be related to lower rates of either receipt of pneumonia or influenza vaccine.37, 38 However, disparities among racial groups appeared more pronounced in rural residents versus urban residents. In a study looking at 1993 MCBS data, Slifkin, et al. found rural nonwhites were significantly less likely than rural whites to have received a pneumonia shot.39 The authors also found the gap in the rates of pneumonia immunization between racial groups in rural areas is greater than that between racial groups in urban areas. According to the study, within racial groups, place of residence did not impact the receipt of influenza shots among Medicare beneficiaries.39


In a Pennsylvania study comparing influenza vaccine rates among urban/suburban practices, inner-city health centers, and rural practices to Veterans Administration (VA) outpatient centers, VA centers had the highest immunization rates at 91 percent compared to 79 percent in rural, 79 percent in suburban, and 67 percent in inner-city health centers.114 Sixty-six percent of rural patients in this study indicated the flu shot was not recommended by the provider versus 56 percent of suburban, 57 percent of inner city, and 48 percent of VA patients.


Finally, residents in nursing homes are considered high risk for influenza and pneumonia. The HP2010 goal is 90 percent for these two immunizations.3 In nursing homes, the 1999 immunization rate was 66 percent for influenza and 38 percent for pneumonia,42 well below the HP2010 goal. Another study finds wide variation in influenza immunization rates in long term care facilities ranging from 56 percent to 85 percent.115 


Impact of the condition on mortality


The death rate from complications of vaccine-preventable diseases is higher among adults (50,000 to 90,000 annually) than among children42 (300 each year).43 Influenza and pneumonia are responsible for more illnesses and deaths than all other VPDs,42 together constituting the seventh leading cause of death in the U.S.33 According to the 2001 National Vital Statistics Report, 67,024 deaths were attributed to these two diseases.116 Of all influenza deaths (approximately 20,000),117 more than 90 percent occur in persons over age 65.30 An estimated 40,000 pneumonia deaths are attributed to pneumococcal infection, half of which could be prevented through vaccines.118 While very young children and the elderly are at the highest risk for pneumococcal infection, the vast majority of deaths caused by pneumococcal infection (pneumonia, bacteremia, and meningitis) occur in the elderly. For pneumococcal disease, the case fatality rate is 15 to 20 percent for adults and 40 percent for the elderly.30 Ten to 25 percent of adults with pneumococcal pneumonia develop bacteremia, with a mortality rate of 20 percent.30, 119 


Tuberculosis-related deaths have steadily decreased from near 20,000 in 1953 to 751 in 2000, or .3 per 100,000.17 Data from 2000 and 2001 finds hepatitis B attributed to 5,000 chronic liver disease deaths, while hepatitis C is associated with 8,000 to 10,000 chronic liver disease deaths.44 AIDS death rates are highest among African Americans, with urban areas experiencing much higher death rates among African Americans than rural areas.39 Finally, immigrant women had a 50 percent higher risk for mortality related to infectious diseases than U.S. women.120 


Impact of the condition on morbidity


One-fourth of visits to physicians are infectious disease related, with annual costs over $120 billion40 reinforcing prevention through full immunization coverage as the most cost effective approach to infectious disease control. According to CDC 1995 data, it is estimated that for every dollar spent on immunizations, $14-25 in health care costs are saved.41 


Ten to 20 percent of the population becomes ill with influenza each year, contributing to an estimated 100 to 200 million days of illness, lost work days, and lost school productivity.42 Pneumococcal pneumonia, caused by Streptococcus pneumonia, is the leading cause of community-acquired bacterial pneumonia in very young children and those 65 years and older.121 This disease causes 3,000 cases of meningitis, 50,000 cases of bacteremia, 500,000 cases of pneumonia, seven million cases of otitis media, 118 and leads to 100,000 to 175,000 hospitalizations.42 Annually, 3.9 million cases of chicken pox occur, resulting in the loss of 8.7 school days per case, 10,000 hospitalizations, and 90 to 100 deaths.122 There were 10,616 reported cases of hepatitis A in 2001, 7,844 reported cases of hepatitis B, and 4,000 estimated acute hepatitis C cases.44 It should be noted that the actual number of infections may be significantly higher than the number of reported cases.105 In addition, estimated acute cases of hepatitis A and B are quadruple and triple the actual reported number, respectively.44 Annual medical costs and lost productivity due to hepatitis A are estimated at more than $200 million.123 


Contributor to many other health problems


The primary result of failure to receive recommended vaccinations is increased incidence and transmission of infectious diseases. Other diseases caused by or intensified by infectious agents are diabetes, heart disease, ulcers,59 and some cancers. For example, hepatitis B and C are known to contribute to hepatocellular carcinoma.59 In addition, higher rates of anemia and lead exposure have been reported among children who are under-immunized, because these children also fail to receive the necessary screenings for other illnesses.124 




Factors that contribute to under-immunization include living in poverty, being an ethnic minority, having a parent with a low level of education, and being from a large family.45, 46, 47 Other barriers include the cost of immunizations, lack of insurance coverage, late initiation of the vaccination series, parental lack of awareness of a child’s immunization status, missed opportunities during clinical visits, and record scatter resulting from the receipt of vaccinations from multiple providers.4, 41, 46 In general, rural residents are more likely than urban residents to be poor, less educated, lack health insurance, and have longer travel times to health providers,48, 49, 50, 51 which are all factors associated with lower immunization rates.52


A number of studies have investigated the relation between insurance and immunization rates, finding lower immunization rates among the uninsured and underinsured. Using Behavioral Risk Factor Surveillance System data from 1997, 73 percent of the long-term uninsured reported not receiving a flu shot compared to 57.3 percent of the insured.125 Rates for pneumococcal vaccination were also lower among the uninsured. Madhaven, et al.15 in a study of eight rural counties in Appalachia, found the primary predictor for receipt of influenza and pneumonia vaccination among adults (under 65) was insurance coverage. Those with insurance were found to be 1.75 to 3.5 times more likely to be immunized for influenza and pneumonia. According to the Institute of Medicine Report, “A Shared Destiny,” insurance coverage (public or private) was positively correlated with immunization coverage for both adults and children.126


As mentioned earlier, socioeconomic status is also a predictor of immunization coverage (i.e., low socioeconomic status has been associated with low immunization rates).127 This disparity is evident when comparing receipt of the 4:3:1:3 series among children from different socio-economic backgrounds. In 1999, for children ages 19-35 months, 78 percent received the four doses of DTP, three doses of polio, one dose of measles, and three doses of Hib; however, children living below the poverty level were less likely to receive the basic series than those at or above poverty (73 percent compared with 81 percent).57


Missed opportunities have been identified as a major source of delayed immunizations among children. A missed opportunity is defined as a health care encounter in which an eligible child is due for a vaccination, but no vaccination is given. Missed opportunities for childhood vaccinations were compared among selected urban and rural practices in the Rochester, New York, area, including a hospital clinic, neighborhood health center, health maintenance organization, urban private practice, suburban private practice, rural health center, and rural private practice. Opportunities for vaccination in the first year of life were missed most frequently by the rural private pediatric practice.128 This study estimated that 1.8 visits per person per year, or 12 percent of all office visits, in the rural private practice could be characterized as missed opportunities, compared to 0.26 visits per person per year and 2 percent of all office visits in the suburban practice, which had the lowest number of missed opportunities. In the second year of life, the rate of missed opportunities increased for all practices but the hospital clinic and the suburban practice, which exceeded 20 percent of all office visits. At two years, the rural private practice continued to exhibit the highest number of missed opportunities per patient per year (2.16), and the suburban practice demonstrated the lowest (0.55).128


Programs utilizing reminders and patient education have resulted in increased pneumonia vaccination rates by 20 percent over control groups;129 however, widespread implementation represents a challenge. According to one study, while generalists strongly recommended flu and pneumococcal vaccines (86 percent and 81 percent, respectively), fewer than 30 percent of the providers used standing orders, special clinics, or patient reminders.130 


Another barrier proposed is lack of availability of services in rural areas. Studies during the early 1990s, prior to full implementation of the full VFC program, found physicians in rural areas were less likely to offer immunization services than urban physicians.131, 154 The primary reason cited for not offering immunization services was cost to the patient.154 Patients of physicians who did not offer immunizations were often referred to public health departments for immunization services, and less than two-thirds of physicians followed-up on such referrals.152 Even when rural providers did offer vaccines, they were more likely to refer uninsured77 and Medicaid132 patients to public clinics. The frequency of referrals from private practices to public health clinics was reported to range from 44 percent to as high as 90 percent.78 Referrals to public health clinics contribute further to existing barriers to proper immunization by often exacerbating transportation difficulties, increasing time away from work, and contributing to record scatter.


Knowledge barriers among providers and patients also represent a challenge to achieving full immunization coverage. For example, there may be a gap between the provider’s perceived and actual immunization rates among their patients. In a California study, physicians believed their immunization rates to be at 90 percent; however, in a chart review, the rates were found to be 54 percent for children under two years old.133 Lack of patient knowledge, particularly regarding the need for pneumonia and influenza immunizations, also contributes to underimmunization. A study using Medicare Current Beneficiary Survey data from 1996 found the number one reason cited for not receiving pneumonia and influenza was “not knowing” the two were needed (19 percent and 57 percent, respectively).117 Furthermore, in examining 1996 MCBS data, nonwhites were more likely to than whites to cite not knowing it was needed as the reason for not receiving flu and pneumonia immunizations.117 


A study looking at VA, rural, urban, and suburban health centers and practices found the number one reason for not getting the flu vaccine was fear of contracting the disease, while the primary reasons for getting the vaccination was recommendation by the provider and the habit of receiving a vaccination.114 In this same study, one-third of those not receiving a flu shot stated it was not recommended by the provider.


Finally, balancing patient service needs and provider resource constraints represents a complex barrier to improved access to immunization services. This challenge is highlighted in a Colorado study of 52 nonmetropolitan area counties. The primary organizational barriers identified by providers in this study were not immunizing for sick visits, not providing for walk-ins, not providing evening or weekend hours, failing to perform screening at every visit, no formal reminder system, lack of availability of immunization records, and low reimbursement. Forty percent of providers said their ability to obtain immunization histories from other community providers was fair or poor; two-thirds had no formal tracking system.79 Adding to the complexity, cost, attitudes, language barriers, transportation, and patient mobility were identified by parents as primary barriers.79 A South Carolina study of three rural counties found cost (20 percent) to be second only to waiting time (54 percent) as the primary barriers to up-to-date immunizations.47 Balancing patient and provider constraints remains an ongoing challenge for all areas in improving immunization rates; however, rural providers may face a greater challenge in meeting their patient needs due to difficulties in achieving economies of scale.


Known causes of the condition or problem so effective interventions or solutions can be identified


Poverty,134 low socioeconomic status, low educational levels, lack of insurance, lack of knowledge regarding the need for immunization, cost, record scatter, fear of contracting the diseases or adverse reactions, access issues such as taking time from work, and parental and provider attitudes toward prevention134, 135 have all been cited as possible reasons for low immunization rates.


Proposed solutions or interventions that are feasible in rural communities


While the U.S. has been successful in achieving high immunization rates overall, immunization rates among certain subgroups remain below the HP2010 goals. No single solution will increase the rates for all groups; organizational change strategies offer the most effective methods to increase rates.53 Establishment of separate clinics devoted to screening and prevention, use of continuous quality improvement processes and techniques, and designation of specific prevention responsibilities to nonphysician staff have all been suggested as effective organizational change strategies aimed at increasing immunization rates.53 Other suggestions aimed at improving influenza and pneumonia vaccination rates include mobile health clinics136 and dedicated flu clinics.137 


The Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) recommend the implementation of a reminder and/or recall system by vaccination providers to improve immunization rates.54 As noted earlier, immunization reminder and recall systems have been cited as effective interventions to increase immunization rates.134 


Standing orders programs have also been successful in increasing pneumonia and influenza immunization rates. The Centers for Medicare and Medicaid Services (CMS) has issued an interim rule that removes the physician signature requirement for flu and pneumonia vaccinations from the conditions of participation for Medicare and Medicaid participating hospitals, long term care facilities, and home health agencies as a method to improve immunization rates.55 In the study mentioned earlier, comparing immunization rates in VA centers, rural, suburban, and urban centers, the VA center outperformed the other centers and with minimal racial disparity. The reason cited for the VA’s success was a multi-modal approach that combined a system of patient reminders, standing orders, freestanding vaccinations clinics, and assessment of vaccination rates with feedback and incentive to clinicians¾an approach recommended by the Task Force on Community Preventive Services.114 In a study of LTC facilities in 1996 in Alaska, Idaho, Montana, and Wyoming, pneumonia vaccinations increased from 40 percent to 75 percent in facilities using a system of chart reminders and standing orders.121


Immunization registries, incorporating reminder and recall notices, are fundamental to improving immunization rates. Registries are computerized, confidential, population-based systems designed to capture immunization records in a certain geographic area.138 The gold standard are registries that are able to link data from multiple providers.56 Registries began in the early 1970s, but in 1998, the Immunization Registry Initiative was undertaken by the National Vaccine Advisory Committee (NVAC).139 It is estimated that 44 percent of U.S. children’s (ages six and under) immunization records are housed in immunization registries as of 2002, and half of all states are collecting immunization information on people of all ages.140 Due to resource constraints, often states utilize a linked regional registry system rather than a statewide system.140 Of the 50 states, 44 reported operating registries that targeted their entire catchment area, while seven states reported operating registries that targeted specific counties or regions.138 Among the challenges faced in registry implementation are record scatter, confidentiality concerns, cost, and resource constraints. Challenges are posed by the need to sustain and document high levels of immunization coverage for a growing number of vaccines delivered within multiple health care settings, and persistent disparities in childhood levels of immunization coverage.43


A strength of registries is the ability to decrease the problem of record scatter. Record scatter occurs when children utilize multiple providers for immunizations not only regionally but statewide and nationally. A national study determined that 22 percent of children received their immunizations from more than one provider.141 One study found that one-third of children in public clinics with fragmented record keeping received one or more unnecessary vaccinations, compared to less than 5 percent in private practice or children seen in clinics with integrated record keeping.68 Some studies have suggested that the problem of record scatter is more pervasive in rural areas, because rural children are more frequently referred to public health clinics.56 However, it is difficult to assess the impact of computerized registries in rural areas, given these registries are being developed in urban areas more frequently than in rural areas.155 


A fundamental barrier to registry development is cost. The cost in terms of human resources, capital expenditures, and maintenance is estimated at four man-years of technical effort and approximately $250,000, and $5100 per end user per three year period (1998 dollars).142 Rural areas, unable to achieve economies of scale, may be unable to develop regional registries; however, statewide registries may serve as a vehicle to capture immunization data. To help defray costs associated with registry development, All Kids Count, a program of the Robert Wood Johnson Foundation that began in 1992, funds projects across the country to develop computerized immunization registries.143 It is estimated the savings associated with full implementation of registries far outweighs the costs. It is estimated that $250 million in costs could be saved via registry usage each year by making information readily available to providers and schools.143 Another barrier to registry development is the ability to allocate sufficient resources to comply with HIPAA confidentiality standards.140


To increase access to pneumococcal and influenza vaccines for African Americans and Hispanics, the CDC launched the READII project (Racial and Ethnic Adult Disparities Immunization Initiative)144 in five locations in the U.S. (Chicago, Illinois; Milwaukee, Wisconsin; Rochester, New York; San Antonio, Texas; and 19 rural counties of Mississippi).140, 144, 145 Strategies or interventions vary by site but include such elements as community partnerships, reminder/recall systems, methods to expand and enhance access to services, and outcome measurement.


Finally, despite the ability of vaccines to prevent infectious diseases and, therefore, decrease related health costs, it is estimated that only 50 percent of indemnity plans pay for immunizations.67 This raises the question as to whether or not managed care, with financial incentives to increase delivery of preventive services, increases immunization rates. Study results are mixed. Using 1996 Medicare Current Beneficiary Survey data, one study found managed care was associated with higher influenza immunization rates among whites and African Americans than in fee-for-service plans, but racial disparities were not reduced by managed care.156 In another study, Medicaid managed-care plans demonstrated lower immunization rates than fee-for-service Medicaid plans.146 In a study of the State Children’s Health Insurance Program using data from the National Immunization Survey (1995-2001), researchers found that SCHIP did not increase immunization rates among poor and near poor enrollees compared to nonpoor children, with the exception of varicella immunization rates, which increased 7 to 16 percentage points more among SCHIP enrollees than rates among nonpoor counterparts; SCHIP also did not increase the likelihood of enrollees finding a medical home.147 The impact of SCHIP on immunization rates is particularly relevant to rural areas given SCHIP enrollees tend to be more suburban, rural, and older than Medicaid enrollees.148 


While vaccines and antibiotics have controlled many infectious diseases, the threat of emergent and re-emergent diseases remains a constant public health concern, escalated by changes in demographic and environmental conditions such as international travel and commerce, increased antibiotic use, and increased habitation of areas considered reservoirs for infectious diseases (known and unknown).59 In 1994, under the leadership of the CDC’s National Center for Infectious Diseases (NCID), a nationwide effort to protect the public from infectious diseases was launched. The key elements of the strategy are improving disease surveillance and outbreak response, research support, implementation of disease prevention and information programs, and rebuilding the infectious disease control component of the public health infrastructure.59


Community Models Known to Work


A number of immunization programs are outlined in the Models for Practice section addressing improving childhood and elderly immunization levels and expanding immunization registries to rural areas. Other models suggested in the literature are Pharmacist Immunization Programs (PIPs). In 2002, there were 196,000 licensed pharmacists in the U.S.149 Thirty-one states allow pharmacists to administer immunizations through standing orders programs. Pharmacists may offer increased access given an estimated 250 million people visit a pharmacist each week,150 and while a community may not have access to a physicians, they may have access to a pharmacy. A 1998 survey found only 2.2 percent of pharmacists actually administer immunizations;150 however, there is evidence of program success. For example, an influenza immunization campaign, managed by a team of pharmacists, nearly doubled influenza immunization rates from 28 to 54 percent in the community practice where the intervention was utilized.157 Expanding the role of pharmacists to include immunizations is not without limitations. The nation as a whole is experiencing a shortage of pharmacists, and the problem is particularly challenging in rural areas.149 Additionally, it has been suggested that while pharmacy immunization programs may be utilized to increase adult immunization rates, one study suggests neither parents nor pharmacists prefer to expand the role of pharmacists in providing immunization programs to pediatric patients.150


Another program suggested to improve immunization coverage is AFIX151 (Assessment, Feedback, Incentives, and Exchange), which is a quality improvement initiative initially implemented in Georgia that successfully raised immunization rates from 40 to 91 percent in public clinics during a four-year period (1986 to 2000). AFIX is now a national model to improve immunization rates. Data driven, this program includes four components, with a focus on changing provider behavior:



Summary and Conclusions


The decrease in the number of vaccine-preventable diseases is considered one of the top 10 great public health achievements in the United States.152 Access to immunization services and up-to-date immunization coverage are essential for protecting every age group from the debilitating and potentially life-threatening effects of infectious diseases.


Immunization rates among school-age children demonstrate record high coverage; however, among preschool children, urban and rural areas' coverage rates fall below the HP2010 target. Similarly, while flu and pneumonia vaccinations rates among the elderly are comparable for rural and urban areas, rates are also below the HP2010 goals but continue to increase. The strain on resources relating to influenza and pneumonia may be greater in rural areas, where the elderly represent a larger proportion of the total population, and access to quality health care may be more challenging.57 Other populations at risk for low immunization rates include the impoverished, those without insurance, minorities, residents of rural Colonias and border areas, and immigrants. While whites represent the largest racial/ethnic group in rural America, rural areas experienced record growth of minority populations, particularly Hispanics and Asian Americans. As discussed earlier, these groups may be at heightened risk for certain infectious diseases.


The key finding is that rural and urban areas experience similar immunization rates, both below the HP2010 goals, emphasizing the need for continued efforts to increase immunization rates for both groups (particularly among preschool children, immigrants, minorities, adults, and the elderly). International travel and commerce, increased immigration, and contact with environments where infectious diseases remain leading killers reinforce the importance of full immunization coverage for the United States¾regardless of degree of urbanicity. Prevention is ultimately the most effective defense system in controlling infectious diseases. As the CDC report observes in its strategy, “Protecting the Nation’s Health: It is neither efficient or feasible to examine each person who enters or returns to the U.S. for evidence of infection or to examine all imported goods for evidence of contamination. Investing in global health is an area in which global humanitarian needs and U.S. national interest coincide.”153 




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Chapter Suggested Citation


Hutchison, L., and Peck, J. (2004). Immunizations and Infectious Diseases in Rural Areas. In Gamm, L. and Hutchison, L. (eds.), Rural Healthy People 2010: A companion document to Healthy People 2010. <> College Station, TX: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.