Statewide Immunization Registry Research Articles

Understanding Over-immunization in North Dakota's Adult Population.

Over-immunization, or administration of excess doses of vaccine, is an understudied topic in immunization. Adult over-immunization is particularly understudied, so building a basic understanding of the sources and scope of over-immunization is necessary to direct action. The aim of this evaluation was to quantify the extent of over-immunization in North Dakota's adult population from 2016 to 2021. Records for all pneumococcal, zoster, and influenza vaccines administered to adults in North Dakota were extracted from the North Dakota Immunization Information System (NDIIS) from January 1, 2016, through December 31, 2021. The NDIIS is a state-wide immunization registry that captures all childhood and most adult immunizations. North Dakota. North Dakotan adults 19 years or older. The number and percentage of adults identified as over-immunized as well as the number and percentage of doses identified as an extra dose. Frequency of over-immunization was less than 3% for all vaccines over the 6-year period assessed. Pharmacies and private practices were the most common sources of over-immunization of adults. These data show that over-immunization is still an issue in North Dakota, although the percentage of the adult population impacted is low. Reducing over-immunization is worth pursuing but should be balanced with the importance of improving low immunization coverage rates in the state. Improving utilization of the NDIIS by adult providers can help prevent over-immunization and under-immunization alike.

Real-world uptake of COVID-19 vaccination among individuals expressing vaccine hesitancy: A registry-linkage study.

Uptake of COVID-19 vaccination remains suboptimal in the United States and other settings. Though early reports indicated that a strong majority of people were interested in receiving the COVID-19 vaccine, the association between vaccine intention and uptake is not yet fully understood. Ourobjective was todescribe predictors of vaccine uptake, and estimate the sensitivity, specificity, and predictive values of self-reported COVID-19 vaccine status compared to a comprehensive statewide COVID-19 vaccine registry. A cohort of California residents that received a molecular test for SARS-CoV-2 infection during 24 February-5 December 2021 were enrolled in a telephone-administered survey. Survey participants were matched with records in a statewide immunization registry. Cox proportional hazards model were used to compare time to vaccination among those unvaccinated at survey enrollment by self-reported COVID-19 vaccination intention. Among 864 participants who were unvaccinated at the time of interview, 272 (31%) had documentation of receipt of COVID-19 vaccination at a later date; including 194/423 (45.9%) who had initially reported being willing to receive vaccination, 41/185 (22.2%) who reported being unsure about vaccination, and 37/278 (13.3%) who reported unwillingness to receive vaccination.Adjusted hazard ratios (aHRs) for registry-confirmed COVID-19 vaccination were 0.49 (95% confidence interval: 0.32-0.76) and 0.21 (0.12-0.36) for participants expressing uncertainty and unwillingness to receive vaccination, respectively, as compared with participants who reported being willing to receive vaccination. Time to vaccination was shorter among participants from higher-income households (aHR=3.30 [2.02-5.39]) and who reported co-morbidities or immunocompromising conditions (aHR=1.54 [1.01-2.36]).Sensitivity of self-reported COVID-19 vaccination status was 82% (80-85%) overall, and 98% (97-99%) among those referencing vaccination records; specificity was 87% (86-89%). Willingness to receive COVID-19 vaccination was an imperfect predictor of real-world vaccine uptake. Improved messaging about COVID-19 vaccination regardless of previous SARS-CoV-2 infection status may help improve uptake.

Influenza immunization coverage of children with sickle cell disease

ObjectivesTo assess receipt of annual flu immunization among children living with sickle cell disease (SCD). MethodsReceipt of flu immunization (2014–2019) by SCD status was assessed among all Michigan children <18 years of age using the statewide immunization registry. Logistic regression was used to estimate the odds of annual flu immunization by SCD status and age. ResultsAnnual flu immunization coverage was higher among children with SCD (46.9%; n = 751) than without (23.2%; n = 2,012,846). The annual adjusted odds of flu immunization for those with SCD were 2.8 (95% CI: 2.5–3.1) times higher than for those without SCD; there were no significant differences by age among children with SCD. Among those without SCD, adolescents aged 13–17 were 2.2 (95% CI: 2.2–2.2) times less likely to receive annual flu immunization than children 6–35 months. ConclusionsChildren with SCD had higher annual flu immunization rates than those without SCD, but >50% remain unimmunized.

Identifying Area-Level Disparities in Human Papillomavirus Vaccination Coverage Using Geospatial Analysis.

Human papillomavirus (HPV) is the most common sexually transmitted infection within the United States (US). Despite clinical agreement on the effectiveness and widespread availability of the prophylactic HPV vaccine, vaccination coverage in the US is suboptimal and varies by geographic region and area-level variables. The goals of this article were to model the variation in vaccination rates among boys and girls within ZIP Codes in Virginia, determine whether neighborhood sociodemographic variables explain variation in HPV vaccination, and identify areas with significantly depressed vaccination coverage. We used Bayesian hierarchical spatial regression models with statewide immunization registry data to consider the correlation in vaccination among boys and girls, as well as the spatial correlation in vaccination for each sex. The results showed low vaccination coverage in our birth cohort (28.9% in girls and 23.8% in boys) relative to the national level (56.8% and 51.8%, respectively). Several area-level variables were significantly and positively associated with vaccination coverage, including population density, percentage of Hispanic population, and average number of vehicles. In addition, there were several areas of significantly lowered vaccination coverage, including predominantly rural ones, and overall large geographic disparities in HPV vaccination. Determining the geospatial patterning and area-level factors associated with HPV vaccination within a prescribed geographic area helps to inform future planning efforts. The results of this study will help inform future planning efforts for geographically targeted interventions and policies, as well as drive new research to implement clinical and community strategies to increase HPV vaccination.

RATES AND PREDICTORS OF HUMAN PAPILLOMAVIRUS VACCINATION AMONG YOUNG MEN RECRUITED FROM URBAN CLINICAL AND COMMUNITY SETTINGS

Background and Objective&#x0D; Human papillomavirus (HPV) vaccination rates are suboptimal in young men, representing a missed opportunity to prevent cancers caused by HPV. Data about factors associated with vaccination over time are important to design interventions that improve vaccination rates. The aims of this study were to determine HPV vaccine initiation and completion rates in young men 13-26 years of age recruited from clinical and community settings from 2013-2014 and 2016-2017, and to determine factors associated with vaccination.&#x0D; Material and Methods&#x0D; Men (N=747) were recruited from a hospital-based teen health center (THC), health department sexually transmitted disease clinic (HDSTD) and the general community. Participants completed a self-administered survey assessing demographic and behavioral factors. Vaccination status was determined using the electronic medical record and a statewide immunization registry. We determined vaccine initiation and completion rates, by recruitment site and year. We determined factors independently associated with vaccine initiation and completion, overall and stratified by recruitment year, using multivariable logistic regression.&#x0D; Results&#x0D; Mean age was 21.2 years, 258 (34.5%) had initiated the vaccine series and 154 (20.8%) had completed it. Those recruited from the THC (vs. community and HDSTD) were more likely to initiate (71.3%, 23.2%, and 19.5%, respectively, p&lt;.0001) and complete (50.7%, 11.7%, and 8.3%, p&lt;.0001) the series. In multivariable analysis, variables associated with vaccine initiation were younger age (13-17 vs. 22-26 years: AOR 5.31), insurance plan (Private vs. Medicaid: OR 0.39; Medicaid vs. others: AOR 2.22), no cigarette smoking (no vs. yes: AOR 1.78) and recruitment site (THC vs. HDSTD: AOR 3.74; THC vs. community: AOR 3.01). Variables associated with vaccine completion were younger age (13-17 vs. 22-26 years: AOR 3.55; 18-21 vs. 22-26 years: AOR 4.26), insurance plan (Private vs. Medicaid: AOR 0.51; Medicaid vs. others: AOR 2.62), fewer lifetime female partners (1 vs. 2-10: AOR 2.55; 1 vs. 11+: AOR 2.23) and recruitment site (THC vs. HDSTD: AOR 4.99; THC vs. community: AOR 3.95).&#x0D; Conclusion&#x0D; HPV vaccine initiation and completion rates were low among young men over the 6 years after vaccine recommendations for men. Men who reported behaviors that have been associated with a higher risk for HPV were less likely to be vaccinated. Interventions that improve access to a primary care medical home and insurance programs that cover vaccination costs may increase HPV vaccination rates in young men.

Changes in Influenza Vaccination Rates After Withdrawal of Live Vaccine.

Before the start of the 2016-2017 influenza season, the Advisory Committee on Immunization Practices withdrew its recommendation promoting the use of live attenuated influenza vaccines (LAIVs). There was concern that this might lessen the likelihood that those with a previous LAIV would return for an injectable influenza vaccine (IIV) and that child influenza immunization rates would decrease overall. Using Oregon's statewide immunization registry, the ALERT Immunization Information System, child influenza immunization rates were compared across the 2012-2013 through 2016-2017 seasons. Additionally, matched cohorts of children were selected based on receipt of either an LAIV or an IIV during the 2015-2016 season. Differences between the IIV and LAIV cohorts in returning for the IIV in the 2016-2017 season were assessed. Overall, influenza immunization rates for children aged 2 to 17 years were unchanged between the 2015-2016 and 2016-2017 seasons. Children aged 3 to 10 with a previous IIV were 1.03 (95% confidence interval, 1.02 to 1.04) times more likely to return for an IIV in 2016-2017 than those with a previous LAIV, whereas children aged 11 to 17 years with a previous IIV were 1.08 (95% confidence interval, 1.05 to -1.09) times more likely to return. Withdrawal of the LAIV recommendation was not associated with an overall change in child influenza immunization rates across seasons. Children with a previous (2015-2016) IIV were slightly more likely to return during the 2016-2017 season for influenza immunization than those with a previous LAIV.

Opportunities for increasing human papillomavirus vaccine provision in school health centers.

Uptake of human papillomavirus (HPV) vaccine remains low among adolescents in the United States. We sought to assess barriers to HPV vaccine provision in school health centers to inform subsequent interventions. We conducted structured interviews in the fall of 2010 with staff from all 33 school health centers in North Carolina that stocked HPV vaccine. Centers had heterogeneous policies and procedures. Out-of-pocket costs for children and youth to receive privately purchased HPV vaccine were a key barrier to providing HPV vaccine within school health centers. Other barriers included students not returning consent forms, costs to clinics of ordering and stocking privately purchased HPV vaccine, and difficulty using the statewide immunization registry. Most (82%) school health centers were interested in hosting interventions to increase HPV vaccine uptake, especially those that the centers could implement themselves, but many had limited staff to support such efforts. Activities rated as more likely to raise HPV vaccine uptake were student incentives, parent reminders, and obtaining consent from parents while they are at school (all ps < .05). Although school health centers reported facing several key barriers to providing HPV vaccine, many were interested in partnering with outside organizations on low-cost interventions to increase HPV vaccine uptake among adolescents.

A Population-Level Assessment of Factors Associated With Uptake of Adolescent-Targeted Vaccines in Michigan

Increases in adolescent vaccine coverage are needed. The aim of this study was to identify population-level clinical and demographic factors associated with adolescent vaccination. A retrospective analysis of data from the Michigan Care Improvement Registry (MCIR), a statewide immunization registry, was performed for 2006-2010. The sample included 1,252,655 adolescents aged 11-18 years. Vaccine coverage levels were calculated for tetanus-diphtheria-acellular pertussis (Tdap), meningococcal conjugate (MCV4), flu (seasonal influenza), and human papillomavirus, females only (HPV) vaccines. For the subset of adolescents enrolled in Medicaid, claims data were used to obtain information about the type of visits in which vaccines were administered. As of 2010, statewide coverage levels for Tdap and MCV4 vaccines were 46.0% and 46.5%, respectively whereas only 15% of females had completed the HPV vaccine series. Only one in four female adolescents were up to date for all three of these vaccines. Statewide coverage among adolescents for flu vaccine during the 2009-2010 season was 8%. Age was the most significant predictor of HPV vaccination, whereas health care-associated factors (provider type and childhood immunization history) were the strongest predictors for the other three vaccines. Older adolescents were less likely to have received the flu vaccine but more likely to have receive HPV vaccine doses than younger adolescents. Among Medicaid-enrolled adolescents, most Tdap, MCV, and first-dose HPV vaccines, but only 29% of flu doses, were administered during preventive visits. Noted variability in adolescent vaccine coverage by age, vaccine type, and health care-associated factors provides a framework for developing future outreach activities to increase adolescent vaccine use.

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Background: The CDC established a national objective to create population-based tracking of immunizations through regional and statewide registries nearly 2 decades ago, and these registries have increased coverage rates and reduced duplicate immunizations. With increased adoption of commercial electronic medical records (EMR), some institutions have used unidirectional links to send immunization data to designated registries. However, access to these registries within a vendor EMR has not been previously reported.Purpose: To develop a visually integrated interface between an EMR and a statewide immunization registry at a previously non-reporting hospital, and to assess subsequent changes in provider use and satisfaction.Methods: A group of healthcare providers were surveyed before and after implementation of the new interface. The surveys addressed access of the California Immunization Registry (CAIR), and satisfaction with the availability of immunization information. Information Technology (IT) teams developed a “smart-link” within the electronic patient chart that provides a single-click interface for visual integration of data within the CAIR database.Results: Use of the tool has increased in the months since its initiation, and over 20,000 new immunizations have been exported successfully to CAIR since the hospital began sharing data with the registry. Survey data suggest that providers find this tool improves workflow and overall satisfaction with availability of immunization data. (p=0.009).Conclusions: Visual integration of external registries into a vendor EMR system is feasible and improves provider satisfaction and registry reporting.

Identifying Children With Chronic Conditions for Influenza Vaccination Using a Statewide Immunization Registry

Children with chronic medical conditions are at increased risk of complications from influenza, yet their vaccination rates are low. The Michigan Care Improvement Registry (MCIR), a statewide immunization registry, was expanded in 2006 to include an indicator, based on Medicaid administrative claims, that prompts providers to offer influenza vaccine to high-risk children (ie, those with chronic conditions). To assess primary care providers' experiences with the MCIR high-risk indicator. A cross-sectional, self-administered survey mailed in July 2009. State of Michigan. A total of 300 family physicians and 300 pediatricians who served as primary care providers for children in Michigan's Medicaid program. Provider experiences with the high-risk indicator; suggestions for improvement. Response rate was 79%. Only 32% of pediatricians and 17% of family physicians recalled seeing the high-risk indicator during the 2008-2009 influenza season. Of those who saw the indicator, 48% rated it as "helpful" or "very helpful" in identifying which children should receive flu vaccine. To improve its usefulness, 77% of respondents wanted the indicator to reflect all children, rather than only those enrolled in Medicaid, and 71% wanted MCIR to generate a list of high-risk children in their practice. Three years after implementation, the registry-based high-risk indicator is not viewed by most providers. Half of those who saw the indicator found it helpful, and most respondents endorsed enhancements to broaden its scope. Future work should explore whether enhanced capabilities help to facilitate identification of priority cases by providers.

Assessing the immunization status of pediatric cochlear implant recipients using a state-maintained immunization registry

Objective To demonstrate the use of a state-maintained database (CHILD Profile) to monitor immunization status of pediatric cochlear implant recipients, and to assess compliance with current vaccination recommendations for cochlear implant users managed at Seattle Children's Hospital. Study Design Cross-sectional study. Setting Tertiary academic pediatric hospital. Subjects and Methods Subjects were 260 patients with cochlear implants managed at Seattle Children's Hospital between July 1, 1995, and May 1, 2008. Patients were stratified by age groups (0-2 years, 2-5 years, 5-10 years, > 10 years). Using a statewide children's immunization registry (CHILD Profile), subjects were assessed with regard to their immunization status for Haemophilus influenzae type B vaccination (HiB), 7-valent pneumococcal conjugate vaccination (PCV-7), and 23-valent pneumococcal polysaccharide vaccine (PPV-23). Results Two hundred twenty-five of 260 subjects (87%) were registered in CHILD Profile; 126 of 225 (56%) were up to date with CDC recommendations for patients with cochlear implants. PPV-23 was the vaccination most likely to be incomplete. Age was predictive of immunization status only with HiB vaccination. Conclusion A statewide immunization registry can be used to monitor the immunization status of cochlear implant recipients. Subjects were significantly more likely to be incomplete for PPV-23 than for either PCV-7 or HiB vaccinations.

Measles immunization coverage determined by serology and immunization record from children in two Chicago communities.

We compared the prevalence of measles immunization determined by serology with the prevalence of measles immunization determined by immunization records, and identified factors predictive of measles immunization among a sample of children from two Chicago communities. We collected demographic information and blood specimens from a sample of children aged 12-71 months in two Chicago communities at risk for low measles immunization coverage levels. We collected immunization information from provider records, parent-held records, and the statewide immunization registry. We compared evidence of immunization determined by serology with evidence of immunization from these three sources of immunization records. The sample of children from the two communities had serologic measles immunity levels of 85% and 90%. Significantly fewer children had evidence of immunization by record in both communities (45% and 63%, respectively). Immunization coverage levels determined using immunization records were significantly lower than immunization coverage determined using serology. A fully populated immunization registry used by all immunization providers could prevent the problems of record loss and scatter.

Providers’ perceptions of an immunization registry

Objective: To determine providers’ perceptions of a statewide immunization registry. Design: Mail survey. Setting: King County, Washington. Methods: A random sample of 700 pediatricians, family physicians, and RN/NPs were surveyed. In addition to their perceptions of registries, respondents reported their immunization procedures in the absence of immunization histories. Results: Of 544 eligible participants, 344 returned surveys (63% response rate). Seventy-seven percent of RN/NPs, 60% of pediatricians and 47% of family physicians ( p < 0.001) responded that they thought that electronic immunization registries represented the “best chance to solve the lack of documentation problem.” Fifty-seven percent of RN/NPs, 61% of pediatricians, and 43% of family physicians reported that the incompleteness of registry data presented a barrier to their using one ( p < 0 .01). Fewer than 14% of all specialties had concerns about potential compromises of patient confidentiality as a result of registries, although RN/NPs were more concerned about this possibility than both pediatricians and family physicians ( p = 0.02). In a multivariate analysis, pediatricians were 43% less likely ( p = 0.15) and family physicians were 73% less likely ( p < 0.01) than RN/NPs to think registries are the solution to the lack of documentation problem. Familiarity with the existing registry was associated with a significant decrease in the likelihood of thinking that registries are the solution (OR .49 [.26–.90]) and an increase in the likelihood of thinking that registries will take a long time to become of practical value (OR 2.21 [1.09–4.29]). Conclusions: Specialties differ with respect to their opinions regarding the promise immunization registries hold. Immunization registries appear to be well regarded in theory but may disappoint in practice. Incompleteness of immunization data may be the largest obstacle for registries to overcome.

Coordinating Care for Children’s Health: A Public Health Integrated Information Systems Approach

Many programs in Rhode Island address the health and development needs of children and their families; however, a significant portion of this population remains unserved. To better meet the health needs of the state’s childhood population, nine different infant/toddler programs were about to develop their own automated individual registries and tracking systems. Recognizing the need to establish cost-effective public health infrastructures that would assure better case management and reduce patient and provider frustration about redundant questions and competing outreach needs, the Rhode Island Department of Health (RIDH) is establishing KIDS NET. KIDS NET is a comprehensive program that will coordinate screening, tracking, risk response, follow-up, and home-visiting services by integrating data management for preventive pediatric programs. Integrating services and data management across programs to enhance delivery of care is challenging and time-consuming and requires broad participation by affected individuals. To accomplish this task, a work group representing all RIDH programs potentially affected by KIDS NET was convened. Under the leadership of this intradepartmental team, all nine infant/toddler programs agreed to pool some financial and staff resources to develop, implement, and maintain KIDS NET. Importantly, pediatric providers and parents are also involved in developing KIDS NET. KIDS NET is designed to consist of two components. The first component will be a centralized data management information tracking and communication system. This system will link all existing and newly developed (i.e., immunization registry) RIDH pediatric data bases to each other and to pediatric providers and other authorized users. The second component of KIDS NET is the coordination between programs to establish regional community networks that will provide comprehensive (as opposed to categorical) follow-up and risk response (including home visiting if warranted) services for children identified through the data system to be in need of pediatric services. RIDH is creating a statewide immunization registry as part of a larger pediatric public health tracking and information system. Although developing a comprehensive pediatric public health information system is a very lengthy process (moreso than for an immunization registry), the benefit of this approach is the assurance of complete children’s preventive services and efficient coordination of community risk response and follow-up services.

Ten Steps to a Successful Statewide Immunization Registry

Lessons learned play a valuable role in understanding the dynamics of building immunization registries. These extend beyond technical issues. Arizona has identified 10 steps in the natural evolution of a system that are leading to a successful state immunization registry development project. Identifying the technical solutions for implementing a registry is somewhat straightforward. Providing a cost-constrained, user-efficient, timely, and implementable solution is somewhat harder. Eliminating barriers and convincing providers to participate to create a “win-win” environment for all involved is harder still. Maintaining user enthusiasm and energy is the challenge. The Arizona immunization project has identified and is following 10 steps that are key to meeting these challenges and achieving the required success. The steps are as follows: (1) establish a coalition of statewide private and public partners; (2) develop a technical plan; (3) review the plan with the community of providers and associated immunization organizations; (4) secure adequate funding; (5) create an integrated development team that includes technical, immunization-specialist, and user-support members; (6) market, educate, and sell the solution to providers, schools, nurse associations, managed care organizations, and parents on the system; (7) develop and test components of the system in a pilot mode, building and expanding upon success and not being afraid of failure; (8) maintain project visibility; (9) provide ongoing and timely user support and interaction, listening to providers; and (10) change with the times, adapt the program as the need arises.