Guadalupe Ramirez holds her son, Angel, 2, as he gets a flu shot Dec. 19 from Rebecca Randle of the Southern Nevada Health District. Photo by Sara Tramiel.

They're the cheapest and most effective way to prevent disease in the very young, yet federal statistics show that only 59 percent of Clark County infants and toddlers receive scheduled vaccines -- the worst rate among major urban areas.

Larry Matheis, executive director of the Nevada State Medical Association, has called the vaccination rate a low-point in Southern Nevada health care, saying it could lead to a deadly outbreak or children growing up with weakened immune systems.

"If a measles outbreak occurs at a day care center, it'll go through this valley like the plague. From there, it will go to an even more vulnerable population in seniors,'' he said. "This is not acceptable.''

Although the answer appears clear -- provide more children with vaccines -- getting there is no easy task, said Bonnie Sorenson, director of nursing and clinical services for the Southern Nevada Health District.

The agency provides vaccinations to children and adults.

"Not one size fits all,'' Sorenson said. "There are a couple of things to keep in mind. We have very strict rules when it comes to children entering school. They must have their vaccines before admission, so we are just as good as any state with school-aged children having their vaccines. Where we have a problem is children up to age 2. Our families are not getting those children immunized on time.''

Not only are parents ignoring recommendations on childhood vaccinations, health officials say, some parents can't afford them or their insurance providers are refusing to pay for the vaccines. Families of uninsured children, who often have minimal access to pediatricians or primary care, never even get the message.

And health insurance providers that do reimburse for vaccinations don't pay the entire cost, said Dr. Echezona Ezeanolue, professor of pediatrics at the University of Nevada School of Medicine.

In Nevada, as with some other states, private insurance covers and pays less than Medicaid.

"Some insurance providers won't pay for the MMRV (measles, mumps, rubella and varicella) vaccine," he said. They say, "It's too expensive for a multidose vaccine. Well, if a parent has to bring their child back three or four times to get one vaccine, they have to pay a co-pay each visit. That can be expensive for a parent. They may even have to miss work to make the appointment. What do you think is going to happen? They're not coming back.''

As a result, parents often wait until the last minute before getting their child vaccinated, such as when enrolling in day care or elementary school where vaccines are a requirement.

Exacerbating the problem is Clark County's rapidly growing population, with many newcomers being immigrants from other countries, said Ezeanolue, who also is chairman of the Southern Nevada Immunization Coalition's subcommittee on childhood immunizations.

"The rapid influx of new immigrants also plays in, because it takes a while for them to access health care due to lack of insurance," he said. "However, the problem in Clark County is spread across all ethnicity and nationalities -- black, whites and new immigrants."

Matheis said the county has "a very large population of children, especially among immigrants. Making sure they are in the system is just a tremendous challenge.

"We've always had problems because of the migration of people within the state, but this is at an extra level with the people moving in from other states. We just don't catch these children until they get into our schools. That's a large population of children who could be reservoirs for infection.''

According to the Centers for Disease Control and Prevention's annual National Immunization Survey, Nevada ranks second to last among states for vaccination rates among children between 19 and 35 months, at 63.2 percent.

"If you take out Clark County, the vaccine rate (for the state) would be 75.8 percent,'' Ezeanolue said. "It's obvious Clark County is dragging down the state's numbers.''

Although Nevada's rates appear grim, childhood vaccination rates are rising nationally, said Dr. Jeanne Santoli, deputy director of the CDC's immunization services division in Atlanta.

Santoli said the statistics are based on telephone surveys conducted at the national and state level and in certain urban areas such as Clark County, where about 400 families were surveyed. Families here were asked about demographics, ethnicity, their child's immunization history and their knowledge of the recommended vaccines for children.

"In addition, we ask for permission to contact their child's immunization provider to verify the information,'' Santoli said. "The only results that come in the final analysis are based on the information verified by the provider.''

The CDC did not provide an ethnic breakdown of those surveyed in Clark County because the sample size was too small, Santoli said. For the first time in 10 years, data from the national survey no longer show racial or ethnic disparities in immunization rates for the full series of recommended vaccines. Disparities do remain for certain vaccines.

For example, black and Hispanic children are significantly less likely to receive vaccinations for diphtheria, whooping cough, tetanus and pneumococcal disease compared to white children. White children are lagging behind in receiving the chicken pox vaccine.

Children who need vaccinations in Clark County can get them through the Health District, the federal Vaccines for Children Program (which is operated by both the Health District and the state's Health Division), and through their pediatrician or primary care physicians.

Children eligible for the Vaccines for Children program include those who are under age 18; are American Indian or Native Alaskan; uninsured for vaccinations; are on Medicaid; or are covered under Nevada Check-Up. For these children, vaccines cost $16 per shot and $20 for two or more at the Health District.

Families who can't pay aren't charged.

For all other children, vaccines cost between $32 and $140 each at the Health District.

A child's initial vaccine is for hepatitis B and is given at birth, said Kathleen McElroy, clinical manager of the family birth center at University Medical Center.

During post-partum education, parents are given a packet that includes detailed information about the childhood vaccine schedule.

"Children are to receive two subsequent hepatitis B vaccines within the first months of life,'' McElroy said. "We provide parents with that information as well as where they can go and get the vaccine. If they don't have a pediatrician, we try to locate one for them or we refer them to a clinic. In some cases, we make appointments for them.''

Whether parents follow through is anybody's guess, she said.

Ezeanolue said a couple of efforts are taking place statewide to raise immunization rates in Nevada.

He said the Southern Nevada Immunization Coalition is surveying pediatricians about why some children are leaving their offices without vaccinations.

Additionally, the Nevada Chapter of the American Association of Pediatrics and Southern Nevada Immunization Coalition is working with the state's Department of Health and Human Services to start an effort to engage insurance companies in conversations about re-evaluating reimbursement rates for vaccinations.

The coalition also is advocating a statewide immunization registry be put in place. Such registries are secure, confidential computerized information systems that provide authorized health care providers with immediate access to their patients' immunization status.

Similar registries have been established in East Coast states such as Massachusetts, which has the highest vaccination rate at more than 90 percent.

Nevada has received federal funding to create a statewide immunization registry.

During a meeting by the Task Force for the Fund for a Healthy Nevada on Thursday, state Sen. Joe Heck inquired about the registry's status.

Douglas Banghart, a program manger for the state Health Division's immunization program, said the system is partially complete because the Southern Nevada Health District's computer system isn't compatible with the state's system.

The Southern Nevada Health District has its own immunization registry.

Banghart and Health District officials said a meeting is scheduled this week to discuss ways to connect the two systems.

Heck, an emergency room physician and member of the state's Legislative Committee on Health Care, requested a "white paper" from the Health Division on the immunization registry and the amount of money put into creating it.

"We received CDC funding to start this, and we really have nothing to show for it,'' he said.