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OBJECTIVES: To assess vaccination status in a cohort of 2 year olds with access to health care at no cost and to delineate factors associated with failure to be fully vaccinated. DESIGN: Retrospective cross-sectional study. Children not up-to-date on vaccinations by age 2 years compared with children up-to-date by medical record review. A telephone survey was conducted for those without medical records or whose records lacked complete documentation. SETTING: Large military tertiary care hospital. PARTICIPANTS: A cohort of 844 children born between August 31, 1988, and September 1, 1989. MAIN OUTCOME MEASURES: Timeliness of vaccination, factors associated with undervaccination, number and nature of missed opportunities. RESULTS: Best estimate of coverage with entire primary vaccination series was 72% by age 2 years. Attendance at military day care was associated with full vaccination (odds ratio [OR] = 1.80, confidence interval [CI] = 1.12 to 3.24) as was completion of well-baby visits. Increasing number of other visits did not predict full vaccination. Children followed up by family practice were more likely to be up-to-date than children followed up by pediatrics (OR = 3.67, CI = 1.47 to 9.73). Seventy-two percent of children who were not up-to-date had at least one missed opportunity for vaccination. If vaccinations had been offered at all visits, 93% of children could have been fully vaccinated by age 2 years. CONCLUSIONS: Offering free vaccinations in a "barrier-free" system will not ensure vaccination levels of 90%. Health care providers should offer vaccinations during acute, non-well visits to improve coverage.
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