Surveillance data confirm multiyear predictions of rotavirus dynamics in New York City.

Prediction skill is a key test of models for epidemic dynamics. However, future validation of models against out-of-sample data is rare, partly because of a lack of timely surveillance data. We address this gap by analyzing the response of rotavirus dynamics to infant vaccination. Syndromic surveillance of emergency department visits for diarrhea in New York City reveals a marked decline in diarrheal incidence among infants and young children, in line with data on rotavirus-coded hospitalizations and laboratory-confirmed cases, and a shift from annual to biennial epidemics increasingly affecting older children and adults. A published mechanistic model qualitatively predicted these patterns more than 2 years in advance. Future efforts to increase vaccination coverage may disrupt these patterns and lead to further declines in the incidence of rotavirus-attributable gastroenteritis.

Measuring Adolescent Human Papillomavirus Vaccine Coverage: A Match of Sexually Transmitted Disease Clinic and Immunization Registry Data.

PURPOSE: Human papillomavirus (HPV) vaccine is recommended for adolescents. By the end of 2013, 64% of female and 40% of male New York City residents aged 13-18 years had received ≥1 HPV vaccine dose. Adolescents attending sexually transmitted disease (STD) clinics are at high risk for HPV exposure and could benefit from vaccination. Our objective was to estimate HPV vaccination coverage for this population. METHODS: We matched records of New York City's STD clinic patients aged 13-18 years during 2010-2013 with the Citywide Immunization Registry. We assessed HPV vaccine initiation (≥1 dose) and series completion (≥3 doses among those who initiated) as of clinic visit date and by patient demographics. We compared receipt of ≥1 dose for HPV, tetanus-diphtheria-acellular pertussis, and meningococcal conjugate vaccine. RESULTS: Eighty-two percent of clinic attendees (13,505/16,364) had records in the Citywide Immunization Registry. Receipt of ≥1 HPV dose increased during 2010-2013 (females: 57.6%-69.7%; males: 1.5%-36.3%). Among females, ≥1-dose coverage was lowest among whites (53.4%) and highest among Hispanics (73.3%); among males, ≥1-dose coverage was lowest among whites (6.9%) and highest among Asians (20.9%). Series completion averaged 57.7% (females) and 28.0% (males), with little variation by race/ethnicity or poverty level. Receipt of ≥1 dose was 59.7% for HPV, 82% for tetanus-diphtheria-acellular pertussis, and 76% for meningococcal conjugate vaccines. CONCLUSIONS: HPV vaccine initiation and completion were low among adolescent STD clinic patients; coverage was lower compared with other recommended vaccines. STD clinics may be good venues for delivering HPV vaccine, thereby enhancing efforts to improve HPV vaccination.

Effects of Health Level 7 Messaging on Data Quality in New York City's Immunization Information System, 2014.

OBJECTIVE: We compared the quality of data reported to New York City's immunization information system, the Citywide Immunization Registry (CIR), through its real-time Health Level 7 (HL7) Web service from electronic health records (EHRs), with data submitted through other methods. METHODS: We stratified immunizations administered and reported to the CIR in 2014 for patients aged 0-18 years by reporting method: (1) sending HL7 messages from EHRs through the Web service, (2) manual data entry, and (3) upload of a non-standard flat file from EHRs. We assessed completeness of reporting by measuring the percentage of immunizations reported with lot number, manufacturer, and Vaccines for Children (VFC) program eligibility. We assessed timeliness of reporting by determining the number of days from date of administration to date entered into the CIR. RESULTS: HL7 reporting accounted for the largest percentage (46.3%) of the 3.8 million immunizations reported in 2014. Of immunizations reported using HL7, 97.9% included the lot number and 92.6% included the manufacturer, compared with 50.4% and 48.0% for manual entry, and 65.9% and 48.8% for non-standard flat file, respectively. VFC eligibility was 96.9% complete when reported by manual data entry, 95.3% complete for HL7 reporting, and 87.2% complete for non-standard flat file reporting. Of the three reporting methods, HL7 was the most timely: 77.6% of immunizations were reported by HL7 in <1 day, compared with 53.6% of immunizations reported through manual data entry and 18.1% of immunizations reported through non-standard flat file. CONCLUSION: HL7 reporting from EHRs resulted in more complete and timely data in the CIR compared with other reporting methods. Providing resources to facilitate HL7 reporting from EHRs to immunization information systems to increase data quality should be a priority for public health.

Influence of Gender and Gender-Specific Recommendations on Adolescent Human Papillomavirus Vaccination.

INTRODUCTION: The human papillomavirus (HPV) vaccine was introduced for female adolescents prior to male adolescents. Understanding coverage patterns related to gender-specific recommendations and factors associated with early adoption and timely completion may be important for future vaccines. METHODS: Retrospective analysis of HPV vaccine initiation (one or more dose) and completion (three or more doses) patterns in adolescents aged 11-18 years using 2009-2013 New York Citywide Immunization Registry data. Log binomial models assessed patient-specific (age, insurance) and practice-specific (facility type, number of adolescents, poverty level) variables on early adoption (within 1 year of recommendation) and timely completion (within 12 months) by gender. RESULTS: Of 1,494,767 adolescents, 50.2% were male, 57.5% were vaccinated in private practices, 58.7% in practices with more adolescents, and 48.8% in highest poverty locations. More female (54.0%) than male (33.5%) adolescents initiated vaccination (p<0.001). Of those, 56.1% received three or more doses, 34.1% within 12 months (30.0% male, 36.8% female, p<0.001). In 2009-2012, the proportion of still-eligible male adolescents who newly initiated increased from 0.1% to 17.0%; rates for female adolescents increased from 15.4% to 17.3%. Vaccination initiation within 1 year of gender-specific recommendations was similar (27.4% female, 27.3% male). For both genders, the uninsured were less likely to have early adoption and timely completion. Being publicly insured was associated with early adoption in both genders, but with timely completion in male adolescents only. Being seen in a public facility and in a practice with more adolescents was also associated with early adoption. CONCLUSIONS: Changing HPV vaccine recommendations had minimal cross-gender impact. Early adoption and timely completion patterns were mostly similar across genders.

Invasive Pneumococcal Disease Following the Introduction of 13-Valent Conjugate Vaccine in Children in New York City From 2007 to 2012.

IMPORTANCE: Invasive pneumococcal disease (IPD) is a leading cause of pneumonia, meningitis, and bacteremia in children. In March 2010, a 13-valent pneumococcal conjugate vaccine (PCV13) was introduced to the routine childhood immunization schedule. The PCV13 contains 6 serotypes not included in the previously recommended 7-valent pneumococcal conjugate vaccine, including serotype 19A, the predominant cause of IPD prior to the introduction of PCV13. OBJECTIVES: To describe changes in the epidemiology and incidence of IPD in children younger than 5 years in New York City (NYC) after the introduction of PCV13 and assess PCV13 coverage in NYC. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of population-based IPD surveillance data of the general population residing in NYC between January 1, 2007, and December 31, 2012. Invasive pneumococcal disease cases were identified by laboratory reporting of positive pneumococcal cultures from a normally sterile body site in NYC residents younger than 5 years. Isolates were serotyped. Participants included 468 cases younger than 5 years with IPD reported through routine surveillance to the NYC Department of Health and Mental Hygiene. MAIN OUTCOMES AND MEASURES: Absolute differences and percentage changes in IPD incidence before and after the introduction of PCV13 by serotype grouping, age, and race/ethnicity. The number of PCV13 doses administered to children younger than 5 years was calculated using the NYC immunization information system. RESULTS: There were 468 IPD cases from 2007 to 2012. The incidence of IPD decreased by 69.6% (95% CI, -79.3% to -55.5%) from 21.0 cases per 100 000 (2007-2009 mean) pre-PCV13 to 6.4 cases per 100 000 (2011-2012 mean) post-PCV13. Estimates of disease caused by serotypes included in the PCV13 decreased by 82.5% (95% CI, -90.0% to -69.3%), including a 79.7% reduction in serotype 19A (95% CI, -89.0% to -62.4%). Reductions in IPD incidence were seen in all age groups, with the largest reduction in children younger than 12 months (80.4%; P = .005). Incidence decreased significantly in all racial/ethnic groups. The percentage of children younger than 5 years in NYC with 1 or more doses of PCV13 increased from 47.8% in 2010 to 89.8% in 2012. CONCLUSIONS AND RELEVANCE: The incidence of IPD in NYC children younger than 5 years and, particularly, the incidence of IPD caused by serotype 19A decreased dramatically following the introduction of PCV13, with reductions among all age and racial/ethnic groups. This represents a significant achievement for public health immunization programs and underscores the importance of achieving high immunization coverage.

Adolescent vaccine co-administration and coverage in New York City: 2007-2013.

OBJECTIVES: To investigate adolescent vaccination in New York City, we assessed tetanus, diphtheria, and acellular pertussis (Tdap), meningococcal conjugate (MCV4), and human papillomavirus (HPV) vaccine uptake, vaccine co-administration, and catch-up coverage over time. METHODS: We analyzed data from the Citywide Immunization Registry, a population-based immunization information system, to measure vaccine uptake and co-administration, defined as a Tdap vaccination visit where MCV4 or HPV vaccine was co-administered, among 11-year-olds. Catch-up vaccinations were evaluated through 2013 for adolescents born 1996 to 2000, by birth cohort. HPV vaccination among boys included data from 2010 to 2013. RESULTS: Adolescent vaccine administration was greatest during the back-to-school months of August to October and was highest for Tdap. Although MCV4 uptake improved over the study years, HPV vaccine uptake among girls stagnated; boys achieved similar uptake of HPV vaccine by 2012. By 2013, 65.4% had MCV4 co-administered with Tdap vaccine, whereas 28.4% of girls and 25.9% of boys had their first dose of HPV vaccine co-administered. By age 17, Tdap and MCV4 vaccination coverage increased to 97.5% and 92.8%, respectively, whereas ≥1-dose and 3-dose HPV vaccination coverage were, respectively, 77.5% and 53.1% for girls and 49.3% and 21.6% for boys. Age-specific vaccination coverage increased with each successive birth cohort (P < .001). CONCLUSIONS: From 2007 to 2013, there were greater improvements in Tdap and MCV4 vaccination than HPV vaccination, for which co-administration with Tdap vaccine and coverage through adolescence remained lower. Parent and provider outreach efforts should promote timely HPV vaccination for all adolescents and vaccine co-administration.

Distribution of pandemic influenza vaccine and reporting of doses administered, New York, New York, USA.

In 2009, the New York City Department of Health and Mental Hygiene delivered influenza A(H1N1)pdm09 (pH1N1) vaccine to health care providers, who were required to report all administered doses to the Citywide Immunization Registry. Using data from this registry and a provider survey, we estimated the number of all pH1N1 vaccine doses administered. Of 2.8 million doses distributed during October 1, 2009-March 4, 2010, a total of 988,298 doses were administered and reported; another 172,289 doses were administered but not reported, for a total of 1,160,587 doses administered during this period. Reported doses represented an estimated 80%-85% of actual doses administered. Reporting by a wide range of provider types was feasible during a pandemic. Pediatric-care providers had the highest reporting rate (93%). Other private-care providers who routinely did not report vaccinations indicated that they had few, if any, problems, thereby suggesting that mandatory reporting of all vaccines would be feasible.

Reaching children never previously vaccinated for influenza through a school-located vaccination program.

OBJECTIVES: We determined the success of the school-located vaccination (SLV) program, implemented in 2009 in New York City to deliver pandemic influenza A (H1N1) monovalent vaccine (pH1N1), versus provider offices in reaching children who had never previously received influenza vaccine. METHODS: We compared the immunization history of children vaccinated in school versus provider offices. We included records in the Citywide Immunization Registry with pH1N1 administered between October 2009 and March 2010 to elementary school-aged children. RESULTS: In total, 96,524 children received pH1N1 vaccine in schools, and 102,933 children received pH1N1 vaccine in provider offices. Of children vaccinated in schools, 34% had never received seasonal influenza vaccination in the past, compared with only 10% of children vaccinated at provider offices (P < .001). Children vaccinated in schools were more likely to have received a second dose of pH1N1 in 2009-2010 than those vaccinated in provider offices (80% vs 45%). CONCLUSIONS: The SLV program was more successful at reaching children who had never received influenza immunization in the past and should be considered as a strategy for delivering influenza vaccine in routine and emergency situations.

Effectiveness of 1 dose of 2009 influenza A (H1N1) vaccine at preventing hospitalization with pandemic H1N1 influenza in children aged 7 months-9 years.

The availability of a well-established immunization registry to provide vaccination information, a school-located vaccination campaign followed by continued 2009 influenza A (H1N1) (pH1N1) activity, and a requirement to report hospitalized influenza cases provided an opportunity to estimate vaccine effectiveness (VE) of an initial dose of pH1N1 monovalent vaccine in children aged 7 months-9 years. Seventy-eight case children and 729 date-of-birth- and zipcode-matched controls were studied. The VE of a single vaccine dose in preventing pH1N1 hospitalization ≥ 14 days after vaccination was 82% (95% confidence interval [CI], 0%-100%; P = .04) in children aged 3-9 years but was zero (-3%; 95% CI, <0%-75%) in children aged 7-35 months. These findings are consistent with those from prelicensure immunogenicity studies and have implications for interpretation of immunogenicity studies and setting priorities for vaccination of young children in future pandemics. Immunization registries can provide a simple, rapid assessment of VE to evaluate and inform vaccination policy.

Using an immunization information system to facilitate a vaccine recall in New York City, 2007.

BACKGROUND: In December 2007, Merck & Co, Inc, initiated a voluntary recall of 10 lots of PedvaxHIB, and 2 lots of COMVAX when the potential of contamination was identified during routine testing of the manufacturing equipment. Merck recommended that providers stop vaccinating children using these vaccine lots. OBJECTIVE: To describe how the New York City (NYC) Immunization Information System was used in the effort to recall vaccines. METHODS: Immediately following Merck's announcement, NYC's Bureau of Immunization used the New York Citywide Immunization Registry (CIR) to (a) fax and e-mail all pediatric facilities a letter informing them of the recall and asking that they immediately remove recalled vaccines from their refrigerators; (b) identify facilities that had used the recalled lots, on the basis of data reported to the CIR, and contact them individually by phone; and (c) monitor the success of the recall by examining the number of recalled doses administered and reported to the CIR before and after the recall. RESULTS: The alert was faxed and e-mailed to 1928 pediatric facilities informing them of the recall. In addition, the Bureau of Immunization identified 105 facilities that had reported doses of vaccine from the recalled lots to the CIR and called to ask them to check their refrigerators for remaining supplies and discontinue use of this vaccine. The number of doses with the affected lot numbers reported to the CIR decreased sharply following CIR recall notification. Furthermore, the Centers for Disease Control and Prevention and Merck reported the return of nearly 50% of publicly and privately purchased vaccines from the recalled lots that had been distributed to NYC providers. CONCLUSION: Immunization Information Systems can be effective tools for quickly identifying providers in possession of recalled vaccine lots, particularly when lot numbers are well reported, and for facilitating rapid vaccine recall in support of vaccine safety.

Development and utilization of best practice operational guidelines for immunization information systems.

OBJECTIVE: To describe collaborative efforts to develop best practice operational guidelines for immunization information systems (IIS) and discuss awareness, acceptance, and utilization of the guidelines by the IIS community. DESIGN: Business analysis and facilitation techniques were used to support collaboration among IIS stakeholders who analyzed existing practices, brainstormed new approaches, and developed consensus-based recommendations. The guideline development process and its impact on IIS were evaluated using a postworkshop questionnaire, the IIS Annual Report, and an online survey for one of the guidelines. SETTING: Immunization information systems domain in the United States. PARTICIPANTS: Staff from IIS; federal agencies; state, regional, and county health departments; privately run registries; and vendors/consultants. MAIN OUTCOME MEASURE(S): These included (1) completion of best practice guidelines; (2) degree of satisfaction among the participating IIS stakeholders with the work process and outcomes, interest, and willingness to implement best practice guidelines in their own IIS; (3) awareness and use of, as well as satisfaction with, the guidelines for patient active/inactive immunization status among IIS; and (4) acceptance and implementation of best practice guidelines across the US IIS. RESULTS: Since 2005, operational guidelines (that contain best practice recommendations) have been developed for 5 IIS functional areas: reminder/recall notifications, data quality assurance, vaccination level deduplication, management of patient active/inactive status, and adverse events reporting. Immunization information systems stakeholders who participated in the development of the recommendations expressed a high level of satisfaction with the process and the recommendations. Based on IIS Annual Report data, from 2007 to 2009 use of the guidelines increased from 46% to 80% of IIS. CONCLUSIONS: Best practice recommendations offer practical guidelines on the most challenging operational areas for IIS. Initial evidence indicates adoption of the recommendations and satisfaction with the development process. Additional studies are needed to assess the degree of guidelines use across the IIS community.

Using an immunization information system to improve accountability for vaccines distributed through the Vaccines for Children program in New York City, 2005-2008.

BACKGROUND: As new, higher-priced vaccines are added to the immunization schedule, Vaccines for Children (VFC) program costs are increasing and attention has been focused on strengthening accountability. In New York City, the VFC program distributes publicly purchased vaccines, worth nearly $117 million annually, to more than 1,500 enrolled facilities to immunize eligible children. In 2006, we changed our policy of requiring facilities to account for administration of VFC vaccines by submitting self-reported, aggregate doses administered reports (DARs) when ordering VFC vaccines to using DARs generated from our immunization information system (IIS), the Citywide Immunization Registry (CIR). New York City providers have been required to report immunizations to the CIR since 1997. OBJECTIVES: To increase VFC accountability and reporting to the CIR by linking vaccine ordering and distribution to reporting of doses administered. METHODS: We matched all VFC facilities to those in the CIR. Using CIR and VFC data, we calculated a CIR-generated DAR percentage for each facility by dividing doses reported by doses distributed. We informed facilities that their CIR-generated DAR must be more than 90 percent or their VFC vaccine orders may be reduced. RESULTS: After the policy change, doses reported to the CIR for children younger than 8 years increased 71 percent, and the percentage of doses distributed that were reported as administered to eligible children increased from 40 to 67. Few facilities protested; none dropped out of VFC. CONCLUSIONS: Replacing self-reported DARs with IIS-generated DARs improved VFC accountability and increased reporting to the IIS. Immunization programs nationwide may achieve similar success using this strategy.

Integrating the New York citywide immunization registry and the childhood blood lead registry.

In February of 2004, the New York City Department of Health and Mental Hygiene completed the integration of its childhood immunization and blood lead test registry databases, each containing over 2 million children. A modular approach was used to build a separate integrated system, called Master Child Index, to include all children in both the immunization and lead test registries. The principal challenge of this integration was to properly align records so that a child represented in one database is matched with the same child in the other database. To accomplish this task as well as to identify internal duplicate records within each database, an artificial intelligence record linkage system was created. The preliminary results show high rates of accurate merging of records both within and between the two databases. The 4,610,585 records contained in both databases before Master Child Index implementation consolidated into 2,977,290 records in the integrated system. The matching system eliminated 523,720 duplicate records within the two databases and matched and merged 1,109,575 records between the two databases. The Department of Health and Mental Hygiene plans to further develop the Master Child Index and use it as the department-wide, record-matching system.