Strengthening National Immunization Technical Advisory Groups in resource-limited settings: current and potential linkages with polio national certification committees.

BACKGROUND: Countries are transitioning assets and functions from polio eradication to integrated immunization and surveillance activities. We assessed the extent of linkages between and perceptions of National Immunization Technical Advisory Groups (NITAGs) and National Certification Committees (NCCs) for polio eradication to understand how linkages can be leveraged to improve efficiencies of these expert bodies. METHODS: During May 2017 to May 2018, we administered a 15-question survey to a NITAG chair or member and an NCC counterpart in all countries of the WHO Regions for Africa (AFR) and for the Eastern Mediterranean (EMR) that had both a NITAG and an NCC. Data were analysed using frequency distributions. RESULTS: Of countries with both a NITAG and an NCC (n = 44), the response rate was 92% (22/24) in AFR and 75% (15/20) in EMR. Some respondents reported being very familiar with the functions of the other technical bodies, 36% (8/22) for NITAG members and 38% (14/37) for NCC members. Over 85% (51/59) of respondents felt it was somewhat useful or very useful to strengthen ties between bodies. Nearly all respondents (98%, 58/59) felt that NCC expertise could inform measles and rubella elimination programmes. CONCLUSIONS: We observed a broad consensus that human resource assets of NCCs may serve an important technical role to support national immunization policy-making. At this stage of the polio eradication initiative, countries should consider how to integrate the technical expertise of NCC members to reinforce NITAGs and maintain the polio essential functions, beginning in countries that have been polio-free for several years.

Development of a District-Level Programmatic Assessment Tool for Risk of Measles Virus Transmission.

All six World Health Organization (WHO) regions have now set goals for measles elimination by or before 2020. To prioritize measles elimination efforts and use available resources efficiently, there is a need to identify at-risk areas that are offtrack from meeting performance targets and require strengthening of programmatic efforts. This article describes the development of a WHO measles programmatic risk assessment tool to be used for monitoring, guiding, and sustaining measles elimination efforts at the subnational level. We outline the tool development process; the tool specifications and requirements for data inputs; the framework of risk categories, indicators, and scoring; and the risk category assignment. Overall risk was assessed as a function of indicator scores that fall into four main categories: population immunity, surveillance quality, program performance, and threat assessment. On the basis of the overall score, the tool assigns each district a risk of either low, medium, high, or very high. The cut-off criteria for the risk assignment categories were based on the distribution of scores from all possible combinations of individual indicator cutoffs. The results may be used for advocacy to communicate risk to policymakers, mobilize resources for corrective actions, manage population immunity, and prioritize programmatic activities. Ongoing evaluation of indicators will be needed to evaluate programmatic performance and plan risk mitigation activities effectively. The availability of a comprehensive tool that can identify at-risk districts will enhance efforts to prioritize resources and implement strategies for achieving the Global Vaccine Action Plan goals for measles elimination.

Immunization information systems to increase vaccination rates: a community guide systematic review.

CONTEXT: Immunizations are the most effective way to reduce incidence of vaccine-preventable diseases. Immunization information systems (IISs) are confidential, population-based, computerized databases that record all vaccination doses administered by participating providers to people residing within a given geopolitical area. They facilitate consolidation of vaccination histories for use by health care providers in determining appropriate client vaccinations. Immunization information systems also provide aggregate data on immunizations for use in monitoring coverage and program operations and to guide public health action. EVIDENCE ACQUISITION: Methods for conducting systematic reviews for the Guide to Community Preventive Services were used to assess the effectiveness of IISs. Reviewed evidence examined changes in vaccination rates in client populations or described expanded IIS capabilities related to improving vaccinations. The literature search identified 108 published articles and 132 conference abstracts describing or evaluating the use of IISs in different assessment categories. EVIDENCE SYNTHESIS: Studies described or evaluated IIS capabilities to (1) create or support effective interventions to increase vaccination rates, such as client reminder and recall, provider assessment and feedback, and provider reminders; (2) determine client vaccination status to inform decisions by clinicians, health care systems, and schools; (3) guide public health responses to outbreaks of vaccine-preventable disease; (4) inform assessments of vaccination coverage, missed vaccination opportunities, invalid dose administration, and disparities; and (5) facilitate vaccine management and accountability. CONCLUSIONS: Findings from 240 articles and abstracts demonstrate IIS capabilities and actions in increasing vaccination rates with the goal of reducing vaccine-preventable disease.

Challenges of maintaining polio-free status of the European Region.

BACKGROUND: The European region, certified as polio free in 2002, had recent wild poliovirus (WPV) introductions, resulting in a major outbreak in Central Asian countries and Russia in 2010 and in current widespread WPV type 1 circulation in Israel, which endangered the polio-free status of the region. METHODS: We assessed the data on the major determinants of poliovirus transmission risk (population immunity, surveillance, and outbreak preparedness) and reviewed current threats and measures implemented in response to recent WPV introductions. RESULTS: Despite high regional vaccination coverage and functioning surveillance, several countries in the region are at high or intermediate risk of poliovirus transmission. Coverage remains suboptimal in some countries, subnational geographic areas, and population groups, and surveillance (acute flaccid paralysis, enterovirus, and environmental) needs further strengthening. Supplementary immunization activities, which were instrumental in the rapid interruption of WPV1 circulation in 2010, should be implemented in high-risk countries to close population immunity gaps. National polio outbreak preparedness plans need strengthening. Immunization efforts to interrupt WPV transmission in Israel should continue. CONCLUSIONS: The European region has successfully maintained its polio-free status since 2002, but numerous challenges remain. Staying polio free will require continued coordinated efforts, political commitment and financial support from all countries.

Trends and characteristics of preventive care visits among commercially insured adolescents, 2003-2010.

OBJECTIVE: To examine preventive care visit patterns among commercially insured adolescents during 2003-2010. In 2005-2007, the Advisory Committee on Immunization Practices (ACIP) recommended 3 vaccines targeted at adolescents. We also investigate the relationship between preventive care visits and immunization. STUDY DESIGN: Data were drawn from the MarketScan database. Adolescents aged 11-21 continuously enrolled in the same insurance plan during the calendar year were included. We calculated the annual proportion of adolescents with at least 1 preventive and 1 vaccination-related visit. Longitudinal analyses were conducted by following the 1992 birth cohort for 8 consecutive years. RESULTS: The proportion of adolescents making at least 1 preventive visit increased from 24.6%-41.1% during 2003-2010. The rate of vaccination-related visits increased from 12.9%-26.3%. The magnitude of the increase in preventive and vaccination-related visits was greater during the years in which ACIP issued recommendations. The rates of preventive and vaccination-related visits were considerably higher among female and early adolescents and adolescents in managed care plans. Longitudinal analyses indicated that only 2.4% of adolescents had an annual preventive visit during the 8 years. CONCLUSIONS: Yearly improvements in preventive care visits by adolescents were substantial. ACIP recommendations may be associated with this improvement. However, ongoing efforts are needed to improve the use and delivery of preventive care services.

Supporting National Immunization Technical Advisory Groups (NITAGs) in development of evidence-based vaccine recommendations and NITAG assessments - New tools and approaches.

Increasing opportunities for prevention of infectious diseases by new, effective vaccines and the expansion of global immunization programs across the life course highlight the importance and value of evidence-informed decision-making (EIDM) by National Immunization Technical Advisory Groups (NITAGs). The U.S. Centers for Disease Control and Prevention (CDC) and Task Force for Global Health (TFGH) have developed and made available new tools to support NITAGs in EIDM. These include a toolkit for conducting facilitated training of NITAGs, Secretariats, or work groups on the use of the Evidence to Recommendations (EtR) approach to advise Ministries of Health (MoH) on specific vaccine policies, and an eLearning module on the EtR approach for NITAG members, Secretariat and others. The CDC and TFGH have also supported final development and implementation of the NITAG Maturity Assessment Tool (NMAT) for assessing maturity of NITAG capabilities in seven functional domains. The EtR toolkit and eLearning have been widely promoted in collaboration with the World Health Organization (WHO) Headquarters and Regional Offices through workshops engaging over 30 countries to date, and the NMAT assessment tool used in most countries in 3 WHO regions (Americas, Eastern Mediterranean, African). Important lessons have been learned regarding planning and conducting trainings for multiple countries and additional ways to support countries in applying the EtR approach to complete vaccine recommendations. Priorities for future work include the need to evaluate the impact of EtR training and NMAT assessments, working with partners to expand and adapt these tools for wider use, synergizing with other approaches for NITAG strengthening, and developing the best approaches to empower NITAGs to use the EtR approach.

Development of a maturity assessment tool to evaluate and strengthen National Immunization Technical Advisory Groups (NITAGs).

As dozens of new National Immunization Technical Advisory Groups (NITAGs) were established worldwide in the past decade, and as existing NITAGs continued to play an important role in vaccine policy, global NITAG partners recognized a need for a standardized assessment tool to evaluate and strengthen their functions. This article describes the development of the NITAG Maturity Assessment Tool (NMAT), a stepwise evaluation tool that assesses NITAGs on seven key indicators of structure and process. A draft tool was developed through an iterative, consensus-based process with an expert working group before it was piloted with an economically and geographically diverse convenience sample of NITAGs. The final NMAT is a flexible tool that can be used by in-country or external evaluators to understand NITAG maturity, identify priorities for optimization, and measure the impact of strengthening efforts.

Region-wide assessment of National Immunization Technical Advisory Groups (NITAGs) using the NITAG Maturity Assessment Tool (NMAT) - Experience from the Eastern Mediterranean Region of the World Health Organization, 2023.

National Immunization Technical Advisory Groups (NITAGs) are independent bodies that help improve national immunization programmes in decision making on immunization policy. The new NITAG Maturity Assessment Tool (NMAT) provided an opportunity to conduct a region-wide assessment to improve NITAG capacity and foster institutional growth. We share experience of the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) in using NMAT and the use of findings to develop improvement plans. NITAG chairs and secretariats from 22 EMR countries attended a virtual NMAT training in 2023. They self-assessed their NITAGs using the tool and developed improvement plans. An algorithm used the data to determine maturity levels for seven indicators. We consolidated results for the region by income groups. Of 22 countries (or NITAGs), 20 (91%) submitted NITAG assessment findings and 19 an improvement plan. The proportion of criteria met per indicator varied from 36% for independence and non-bias to 74% for establishment and composition. Maturity level varied by indicator. Of 20 NITAGs, less than half had an intermediate or higher-level maturity for the indicators of independence and non-bias 1 (5%), operations 3 (15%), making recommendations 4 (20%), stakeholder recognition 6 (30%), and resources and secretariat support 7 (35%). Meanwhile 11 (55%) NITAGs had an intermediate or higher maturity level for the indicators of establishment and composition and for integration into policy making process. Participants described NMAT as a concise, useful, user-friendly tool. NMAT is a practical tool that can be used by NITAGs to provide insights and strategic direction for individual countries and regionally. Prevention and management of conflict of interest is the domain that requires the most improvement in EMR. Planned activities should be implemented, monitored and a follow up assessment conducted in 2025.

National decision-making for the introduction of new vaccines: A systematic review, 2010-2020.

BACKGROUND: Competing priorities make using a transparent and evidence-based approach important when deciding to recommend new vaccines. We conducted a literature review to document the processes and frameworks for national decision-making on new vaccine introductions and explored which key features have evolved since 2010. METHODS: We searched literature published on policymaking related to vaccine introduction from March 2010 to August 2020 in six databases. We screened articles for eligibility with the following exclusion criteria: non-human or hypothetical vaccines, the sole focus on economic evaluation or decision to adopt rather than policy decision-making. We employed nine broad categories of criteria from the 2012 review for categorization and abstracted data on the country, income level, vaccine, and other relevant criteria. RESULTS: Of the 3808 unique references screened, 116 met eligibility criteria and were classified as: a) framework of vaccine adoption decision-making (27), b) studies that analyse empirical data on or examples of vaccine adoption decision-making (45), c) theoretical and empirical articles that provide insights into the vaccine policymaking process (44 + 17 already included in the previous categories). Commonly reported criteria for decision-making were the burden of disease; vaccine efficacy/effectiveness, safety; impact on health and non-health outcomes; economic evaluation and cost-effectiveness of alternative interventions. Programmatic and acceptability aspects were not as often considered. Most (50; 82%) of the 61 articles describing the process of vaccine introduction policymaking highlighted the role of country, regional, or global evidence-informed recommendations and a robust national governance as enabling factors for vaccine adoption. CONCLUSIONS: The literature on vaccine adoption decision-making has expanded since 2010. We found that policymakers and expert advisory committee members (e.g., National Immunization Technical Advisory Group [NITAG]) increasingly value the interventions based on economic evaluations. The results of this review could guide discussions on evidence-informed immunization decision-making among country, sub-regional, and regional stakeholders.

School-based delivery of routinely recommended vaccines and opportunities to check vaccination status at school, a global summary, 2008-2017.

School-based vaccination (SBV) and checking students' vaccination records at school have the potential to optimize vaccination coverage among school-aged children. The primary aim of this paper is to describe adoption of SBV by countries from 2008 to 2017, including target age groups and vaccines delivered in 2017, as reported annually through the World Health Organization (WHO)-United Nations Children's fund (UNICEF) Joint Reporting Form (JRF). Expanding upon previous analyses, country-specific rates of primary school enrollment and home-based record (HBR) ownership were linked to the WHO-UNICEF JRF data, to identify countries with high potential to implement vaccination record checks at school. The proportion of countries reporting delivery of at least one routinely recommended vaccine dose in school settings increased from 95 (of 163 reporting; 58%) in 2008 to 108 (of 181 reporting; 60%) in 2017. The 13 additional countries that reported using SBV in 2017 were among 31 countries for which SBV data from the JRF were unavailable in 2017. The most common antigens delivered through SBV in 2017 were tetanus (94 countries), diphtheria (89 countries), and human papillomavirus (52 countries). Among 93 countries with data available for net primary school enrollment and HBR ownership, 52 (56%) countries had both ≥80% net primary school enrollment and ≥80% of children aged 12-23 months ever owning an HBR; 33 (63%) of these used SBV. If not already doing so, these 33 countries represent an opportunity to introduce routine checking of vaccination status at entry to, or during primary school. With the growing number of new vaccines and booster doses of childhood vaccines targeting school-age children, implementation of SBV and checking of student vaccination records at school may help improve vaccination coverage; however, additional data are needed to assess global prevalence of checking vaccination status at school and to identify factors facilitating optimal implementation of this strategy.

Building immunization decision-making capacity within the World Health Organization European Region.

A National Immunization Technical Advisory Group (NITAG) is a multi-disciplinary body of national experts that provides evidence-based recommendations to policy-makers, assisting them in making sound immunization policy and programme decisions. The World Health Organization (WHO) Regional Office for Europe is working to strengthen the capacity of newly-established NITAGs and has targeted efforts on low- and middle-income countries. The Regional Office, in collaboration with WHO Headquarters and USA Centers for Disease Control and Prevention (CDC), developed a new training strategy and held training workshops to improve NITAGs' functioning and ability to make evidence-based recommendations. Feedback from countries that participated in trainings indicated that the updated training materials and interactive approach with follow-up technical support enabled them to align their NITAG charters and processes with WHO recommendations. To ensure continued progress, global and regional partners such as WHO and CDC should continue providing technical support to recently established NITAGs.

Human papillomavirus (HPV) awareness and vaccination initiation among women in the United States, National Immunization Survey-Adult 2007.

OBJECTIVES: To report awareness of human papillomavirus (HPV) and HPV vaccine among women aged 18-49 years and, for recommended women aged 18-26 years, estimate initiation of HPV vaccination and describe factors associated with vaccination initiation among a national sample. METHODS: Data were analyzed from the National Immunization Survey-Adult, a nationally representative telephone survey conducted May-August 2007. Questions were asked about awareness of HPV and HPV vaccine and vaccine receipt. RESULTS: A total of 1102 women aged 18-49 years were interviewed, 168 were aged 18-26 years. Overall, awareness of HPV (84.3%) and of HPV vaccine (78.9%) were high. Among women 18-26 years of age, vaccination initiation (> or =1 dose) was 10%. Factors associated with vaccination included not being married, living > or =200% of the federal poverty index, having health insurance, and vaccination with hepatitis B vaccine. HPV vaccination initiation among women aged 27-49 years was 1%. CONCLUSIONS: Awareness of HPV and HPV vaccine were high. Two to 5 months after national HPV vaccination recommendations were published, one in ten women 18-26 years old had initiated the HPV vaccine series. Women at a higher socio-economic level were more likely to receive the vaccination. Vaccination initiation and completion will likely increase over the next years. Monitoring uptake is important to identify sub-groups that may not be receiving the vaccination.

Supporting national immunization technical advisory groups (NITAGs) in resource-constrained settings. New strategies and lessons learned from the Task Force for Global Health's Partnership for influenza vaccine introduction.

National Immunization Technical Advisory Groups (NITAGs) are multidisciplinary national experts who provide independent, evidence-informed vaccine policy recommendations to national health authorities. An essential NITAG function is to ensure that these decisions are grounded in the best available evidence generated through a systematic, transparent process. However, in many low- and middle-income countries (LMICs), experience with this decision making method is limited. The Task Force for Global Health manages the Partnership for Influenza Vaccine Introduction (PIVI) program in collaboration with the Centers for Disease Control and Prevention, Ministries of Health, corporate partners and others. During 2017, PIVI worked with its country partners and the World Health Organization regional and local offices to assess NITAG strengthening needs and to provide technical assistance in 7 LMIC countries (Laos Peoples Democratic Republic, Mongolia, Vietnam, Armenia, Côte d'Ivoire; Moldova and the Republic of Georgia). Our workshops supported general NITAG capacity building and the evidence-based review process using vaccines of interest to the country. For NITAGs reviewing evidence on seasonal influenza, we developed an influenza resource package to support their review and provide country-relevant information in an easy to use format. Of the seven NITAGs trained, six have applied some of the concepts learnt: revision or development of formal transparent, systematic procedures for their operations; preparation of recommendations on seasonal influenza vaccination using quality-assessed data from systematic searches and local data; and have applied the principles learned for making other new vaccine recommendations. Our experience confirms that LMIC NITAGs are considerably under-resourced without adequate technical support or access to global peer-reviewed literature. Ongoing support from NITAG partners must be secured and creative approaches might be needed to help countries achieve the GVAP 2020 target and support development of sustainable vaccine policies and programs.

Research priorities for accelerating progress toward measles and rubella elimination identified by a cross-sectional web-based survey.

BACKGROUND: In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan (GVAP) that set a target to eliminate measles and rubella in five of the six World Health Organization (WHO) regions by 2020. Significant progress has been made toward achieving this goal through intensive efforts by countries and Measles & Rubella Initiative (M&RI) partners. Accelerating progress will require evidence-based approaches to improve implementation of the core strategies in the Global Measles and Rubella Strategic Plan. The M&RI Research and Innovation Working Group (R&IWG) conducted a web-based survey as part of a process to identify measles and rubella research priorities. Survey findings were used to inform discussions during a meeting of experts convened by the M&RI at the Pan American Health Organization in November 2016. METHODS: The cross-sectional web-based survey of scientific and programmatic experts included questions in four main topic areas: (1) epidemiology and economics (epidemiology); (2) new tools for surveillance, vaccine delivery, and laboratory testing (new tools); (3) immunization strategies and outbreak response (strategies); and (4) vaccine demand and communications (demand). Analyses were stratified by the six WHO regions and by global, regional, or national/sub-national level of respondents. RESULTS: The six highest priority research questions selected by survey respondents from the four topic areas were the following: (1) What are the causes of outbreaks in settings with high reported vaccination coverage? (epidemiology); (2) Can affordable diagnostic tests be developed to confirm measles and rubella cases rapidly and accurately at the point of care? (new tools); (3) What are effective strategies for increasing coverage of the routine first dose of measles vaccine administered at 9 or 12 months? (strategies); (4) What are effective strategies for increasing coverage of the second dose given after the first year of life? (strategies); (5) How can communities best be engaged in planning, implementing and monitoring health services including vaccinations? (demand); (6) What capacity building is needed for health workers to be able to identify and work more effectively with community leaders? (demand). Research priorities varied by region and by global/regional/national levels for all topic areas. CONCLUSIONS: Research and innovation will be critical to make further progress toward achieving the GVAP measles and rubella elimination goals. The results of this survey can be used to inform decision-making for investments in research activities at the global, regional, and national levels.

Accelerating measles and rubella elimination through research and innovation - Findings from the Measles & Rubella Initiative research prioritization process, 2016.

The Measles & Rubella Initiative (M&RI) identified five key strategies to achieve measles and rubella elimination, including research and innovation to support cost-effective operations and improve vaccination and diagnostic tools. In 2016, the M&RI Research and Innovation Working Group (R&IWG) completed a research prioritization process to identify key research questions and update the global research agenda. The R&IWG reviewed meeting reports and strategic planning documents and solicited programmatic inputs from vaccination experts at the program operational level through a web survey, to identify previous research priorities and new research questions. The R&IWG then convened a meeting of experts to prioritize the identified research questions in four strategic areas: (1) epidemiology and economics, (2) surveillance and laboratory, (3) immunization strategies, and (4) demand creation and communications. The experts identified 19 priority research questions in the four strategic areas to address key areas of work necessary to further progress toward elimination. Future commitments from partners will be needed to develop a platform for improved coordination with adequate and predictable resources for research implementation and innovation to address these identified priorities.

Assessing state immunization requirements for healthcare workers and patients.

BACKGROUND: Laws requiring vaccination for school entry have resulted in high coverage and reduced disease incidence; however, few data exist on the use of similar laws in other settings. This study reviews laws regulating vaccination of healthcare workers (HCWs) and patients in selected healthcare delivery settings. METHODS: From September 2004 to June 2005, Lexis-Nexis and other web-based databases were searched for laws pertaining to HCW and patient vaccination in 50 states and Washington DC. Laws were grouped by population, setting, vaccine type, and voluntary versus mandatory vaccination. Data were analyzed in 2006. RESULTS: Over half of states (n=32) have laws for HCW vaccination in traditional healthcare settings (hospitals, ambulatory care), while only seven states have laws for patients in these settings. Most laws regulating vaccine administration for HCWs were voluntary; requirements for mandatory immunization were most common for institutionalized populations. CONCLUSIONS: Significant state-to-state variation exists in laws for vaccination of HCWs and patients. Additional data are needed on how such vaccination requirements affect coverage in these populations. Model legislation may be helpful to states wishing to implement immunization requirements.

Improving influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among adults aged <65 years at high risk: a report on recommendations of the Task Force on Community Preventive Services.

The Task Force on Community Preventive Services conducted systematic reviews to evaluate the effectiveness of interventions to improve targeted vaccination coverage (i.e., coverage with vaccines recommended for some but not all persons in an age range on the basis of risk for exposure or disease) among adults aged <65 years at high risk when implemented alone (single-component interventions) and in combination with other interventions (multicomponent interventions). A 1999 report by the Task Force examined the effectiveness of interventions to increase coverage with universally recommended vaccinations (i.e., vaccines recommended for all persons in particular age groups). Three targeted vaccinations recommended for populations at risk are addressed in this review: influenza, pneumococcal polysaccharide, and hepatitis B. The Task Force identified evidence that certain combinations of interventions have improved vaccination coverage. To increase targeted vaccination coverage, the Task Force recommends a combination of interventions that include selected interventions from two or three categories of interventions (i.e., increasing community demand for vaccinations, enhancing access to vaccination services, and provider- or system-based interventions). The Task Force also recommends provider reminders, when implemented alone, to improve targeted vaccination coverage. This report provides additional information about population-based interventions to improve the coverage of influenza, pneumococcal polysaccharide, and hepatitis B vaccines among populations at risk, briefly describes how the reviews were conducted, and provides information that can help in applying the interventions locally.

Influenza immunization in nursing homes: who does not get immunized and whose status is unknown?

OBJECTIVE: To identify nursing home resident and facility characteristics associated with patients not receiving influenza immunization and having unknown immunization status. DESIGN: Secondary data analysis using multinomial logistic regression of data from the National Nursing Home Survey, a nationally representative establishment-based survey. SETTING: A total of 1,423 nursing facilities of all ownerships and certifications systematically sampled with probability proportional to number of beds. PATIENTS: A total of 7,350 randomly sampled people aged 65 years or older residing in nursing homes between July and December 1999 (approximately 6 per facility). MAIN OUTCOME MEASURE: Immunization status of residents. RESULTS: Fifteen percent of residents were not immunized and 19% had unknown immunization status. In multivariate analysis, lack of immunization and unknown immunization status were each separately associated with being newly admitted, with no or unknown pneumococcal immunization, and with facility failures to screen for immunization and to record inoculation in the medical record. High-risk status and staff immunization requirements had no effect. Separate analyses showed that residents with unknown immunization status are statistically significantly different from both those vaccinated and those not vaccinated. CONCLUSION: This study indicates that both resident and facility characteristics are associated with failure to be immunized for influenza. Facilities should consider targeting younger, newly admitted, and residential care residents for influenza immunization, since they are more likely to be missed. Further research into the barriers to immunization specific to nursing home resident choice or opportunity may be warranted.

Influenza vaccination of high-risk children: what the providers say.

BACKGROUND: Despite a longstanding national recommendation to administer influenza vaccine to children at high risk for disease complications, physicians' adherence remains low. This study evaluated physicians' perspectives on previously documented and persistent under-utilization of influenza vaccine for high-risk children. METHODS: A cross-sectional survey mailed in 2001-2002 to a nationally representative sample of 1460 U.S. physicians in four key medical specialties. The primary outcome was whether the physician provided annual influenza vaccine to children with asthma or other cardiopulmonary diseases. The hypothesis was that factors predicting reported use would fall into four categories: (1) physician knowledge, (2) physician endorsement of recommendation, (3) perceived barriers, and (4) practice patterns. RESULTS: The overall response rate was 55% (n=600), but differed by specialty. Most physicians were knowledgeable about the recommendation, but collectively tended to overestimate their own achievements in immunizing high-risk children. Adherence varied by physician specialty, endorsement of recommendation, perceived barriers (including difficulty identifying subpopulations of high-risk children and confusion about who should vaccinate those receiving care from multiple providers), and under-utilization of strategies known to improve vaccination rates. CONCLUSIONS: Better communication strategies are needed to resolve confusion about providing influenza vaccine to high-risk children in subspecialty settings. Because of the difficulties in selectively identifying high-risk patient subgroups, research is needed to assist in putting support strategies into practice. Findings from research in promising areas of practice-based quality improvement may be particularly applicable.

Using registry data to evaluate the 2004 pneumococcal conjugate vaccine shortage.

BACKGROUND: The most recent pneumococcal conjugate vaccine (PCV7) shortage occurred between December 2003 and September 2004. To ensure vaccination of the highest-risk children, the Centers for Disease Control and Prevention recommended that providers delay administration of the third and fourth doses of vaccine to healthy children. We used Michigan Child Immunization Registry (MCIR) data collected from September 1, 2001 to November 30, 2004 to evaluate changes in PCV7 coverage. METHODS: Vaccination and demographic data from MCIR were reviewed for 420,733 children born between September 2001 and August 2004. Main outcome measures were the proportion of children who received the third dose of PCV7 by 7 months of age and the fourth dose of PCV7 by 16 months of age. Vaccine coverage for measles, mumps, and rubella vaccine (MMR) and diphtheria, tetanus, and acellular pertussis vaccine (DTaP) was used for comparison, as these vaccines were abundant during this time period and their administration schedule is the same as the third and fourth doses of PCV7, respectively. Data analysis was conducted in spring 2005. RESULTS: Coverage for the third dose of DTaP and the first dose of MMR remained steady, while PCV7 coverage for the third dose dropped from 29% to 11%, and the fourth dose dropped from 27% to 22% in the month following the recommendations to defer doses. Coverage returned close to pre-shortage levels shortly after the recommendations to resume the normal schedule. PCV7 coverage trends were similar for children seen in the private or public sector. CONCLUSIONS: Registry data can be useful for evaluating vaccination coverage trends during a shortage. Our findings suggest that providers were compliant with recommendations to alter vaccine administration during the shortage.