Among the 5,598 children studied, most were African-American (73.4%), approximately one-half were male (51%), and most mothers were in the 20 years and over age group. The designated primary care providers included public health providers (9.3%), and private providers (90.7%). Private providers included family practitioners (10.7%), pediatricians (78.3%), and other specialists. Of the 5,598 children, 2,583 (46.1%) were immunized (4:3:1 series) by 24 months of age and 1,582 (28.3%) were classified as UTD at 18 months. Of the UTD children, 351 (22.2%) were classified as AAI at 18 months. Thus 6.3% of all children were AAI. (See Table 1.)

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Rates of immunization for 5,598 children who were moved from fee-for-service care to a newly implemented primary care case management managed care program were reviewed in 1995 as part of the Quality Assessment and Improvement Project for Medicaid Managed Care in Virginia. Managed care was implemented for Virginia’s Medicaid population through a staged geographic approach. This project studied managed care as implemented in the first geographic area to be included in Medicaid managed care. The managed care program assigned each Medicaid recipient to a primary care physician (PCP) who, in exchange for a monthly per-patient management fee, was responsible for preventive services and functioned as a gatekeeper for access to medical care.

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INTRODUCTION

Although childhood immunization is a primary disease prevention strategy, children, especially low-income children, often do not receive their vaccinations on time. Up to 40% of two-year-olds do not receive their immunizations at age-appropriate intervals. During the last two decades, sporadic outbreaks of measles in the U.S. affected thousands of children and the number of cases of other preventable childhood diseases rose, while immunization levels in some urban areas have even declined.

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Our data suggest that, independent of other risk factors, black race is linked to the occurrence of BV/intermediate vaginal flora. Race is also independently associated with an absence of H₂0₂+ lactobacilli and the presence of G. vaginalis, M. hominis, Gram negative pigmented or non-pigmented anaerobic rods, and Mobiluncus morphotypes from the vagina, as well as N. gonorrhoeae or С trachomatis isolated from the cervix. The remarkable internal consistency in these microbiologic data reassures us as to the internal validity of our findings. Furthermore, our observations may be conservative because race was part of the selection criteria for this high risk sample, thus white-women needed to get more “points” towards enrollment than blacks, implying that whites needed a higher risk profile for study entry. If white women were of higher risk and therefore more likely to have BV, this fact would tend to make the racial differences in BV observed in this study an underestimate.

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Nine hundred (79.3%) women in this analysis were African American and 235 (20.7%) were non-Hispanic white (Table 1). Many characteristics differed between black women and whites including that blacks were less likely to have any education past high school or family incomes >$20,000, to be current smokers, and to have more than one sexual partner or a new partner in the past two months. Black women were more likely to be 25 years or older, to have a history of a sexually transmitted disease including PID, to have been pregnant, and to have douched in the past two months. Frequent douching (>once per month) and recent douching (within zero to seven days) were also more common among black women.

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Between May 1999, and June 2001, women 13 to 36 years of age were recruited from five sites located in the eastern, southern, and western regions of the US into the GYN Infections Follow-through (GIFT) Study, a cohort investigation of the health consequences of douching. Human subjects approval was obtained at each participating institution and all women signed informed consent. Women enrolled from public and private gynecology clinics, student health services, and health departments, were eligible for the GIFT study if they were not specifically seeking care for an STI, yet were at elevated risk based on a previous risk stratification paradigm for chlamydial cervicitis, as described below.

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Growing literature suggests that black women are more likely than non-Hispanic white women to have clinical and microbiologic evidence of bacterial vaginosis (В V), a condition in which the normally protective hydrogen peroxide producing (H₂0₂+)  lactobacilli are over­ grown by disease-promoting endogenous anaerobic and facultative aerobic bacteria, including Gardnerella vaginalis, Mycoplasma hominis, Mobiluncus species, and anaerobic Gram negative rods. Reported rates of BV range from 9% to 57% among reproductive age women with the variability explained by sexual patterns, В V definition, and race. The association between black race and BV has been demonstrated among both pregnant and non-pregnant women in the US and non-pregnant women in the UK. Caution in the interpretation of this link is warranted, however, since a number of sociode-mographic and lifestyle factors increase the risk of BV and are more common among black women. These sociodemographic and lifestyle factors, which include douching, low income and low educational attainment, number of sexual partners, a history of sexually transmitted infection including PID, previous pregnancies, and lack of hormonal contraceptive use, may produce the appearance of a relationship between race and BV when, indeed, such a relationship does not, in truth, exist. Since race is a social construct, it is rational to suggest that relevant lifestyle, sociodemographics and healthcare factors could explain racial differences in the occurrence of В V.

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