Cumulative Incidence of SARS-CoV-2 Infections Among Adults in Georgia, United States, August to December 2020.

BACKGROUND: Reported coronavirus disease 2019 (COVID-19) cases underestimate true severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Data on all infections, including asymptomatic infections, are needed. To minimize biases in estimates from reported cases and seroprevalence surveys, we conducted a household-based probability survey and estimated cumulative incidence of SARS-CoV-2 infections adjusted for antibody waning. METHODS: From August to December 2020, we mailed specimen collection kits (nasal swabs and blood spots) to a random sample of Georgia addresses. One household adult completed a survey and returned specimens for virus and antibody testing. We estimated cumulative incidence of SARS-CoV-2 infections adjusted for waning antibodies, reported fraction, and infection fatality ratio (IFR). Differences in seropositivity among demographic, geographic, and clinical subgroups were explored with weighted prevalence ratios (PR). RESULTS: Among 1370 participants, adjusted cumulative incidence of SARS-CoV-2 was 16.1% (95% credible interval [CrI], 13.5%-19.2%) as of 16 November 2020. The reported fraction was 26.6% and IFR was 0.78%. Non-Hispanic black (PR, 2.03; 95% confidence interval [CI], 1.0-4.1) and Hispanic adults (PR, 1.98; 95% CI, .74-5.31) were more likely than non-Hispanic white adults to be seropositive. CONCLUSIONS: As of mid-November 2020, 1 in 6 adults in Georgia had been infected with SARS-CoV-2. The COVID-19 epidemic in Georgia is likely substantially underestimated by reported cases.

The Role of Staff in Transmission of SARS-CoV-2 in Long-term Care Facilities.

BACKGROUND: US long-term care facilities (LTCFs) have experienced a disproportionate burden of COVID-19 morbidity and mortality. METHODS: We examined SARS-CoV-2 transmission among residents and staff in 60 LTCFs in Fulton County, Georgia, from March 2020 to September 2021. Using the Wallinga-Teunis method to estimate the time-varying reproduction number, R(t), and linear-mixed regression models, we examined associations between case characteristics and R(t). RESULTS: Case counts, outbreak size and duration, and R(t) declined rapidly and remained low after vaccines were first distributed to LTCFs in December 2020, despite increases in community incidence in summer 2021. Staff cases were more infectious than resident cases (average individual reproduction number, R i = 0.6 [95% confidence intervals [CI] = 0.4, 0.7] and 0.1 [95% CI = 0.1, 0.2], respectively). Unvaccinated resident cases were more infectious than vaccinated resident cases (R i = 0.5 [95% CI = 0.4, 0.6] and 0.2 [95% CI = 0.0, 0.8], respectively), but estimates were imprecise. CONCLUSIONS: COVID-19 vaccines slowed transmission and contributed to reduced caseload in LTCFs. However, due to data limitations, we were unable to determine whether breakthrough vaccinated cases were less infectious than unvaccinated cases. Staff cases were six times more infectious than resident cases, consistent with the hypothesis that staff were the primary drivers of SARS-CoV-2 transmission in LTCFs.

Implementation of close contact elicitation at the time of COVID-19 testing-Atlanta, GA, October-November 2020.

BACKGROUND: Contact tracing during the Coronavirus Disease 2019 (COVID-19) pandemic in the USA has been met with various challenges. In an attempt to improve the yield of close contact collection, the Fulton County Board of Health implemented a pilot approach to contact elicitation at the time of testing. METHODS: Between October and November 2020, close contacts were elicited from persons under investigation (PUIs) at one COVID-19 testing site in Fulton County, GA. Secure online data collection forms were used to record PUI demographic data, close contact information and reasons for not providing contacts. RESULTS: Of 1238 PUIs, 48% reported at least one contact. Among the 66 people who tested positive, 16 (24%) reported contacts compared to 578/1165 (50%) who tested negative. PUIs of increasing age were less likely to provide contacts; Black and Hispanic PUIs were also less likely to report any contacts compared to White and Asian PUIs. CONCLUSIONS: Our study revealed that PUIs testing positive were less likely to provide contacts compared to PUIs testing negative. Age and racial differences were also noted in the provision of contacts. Further investigation is needed to understand these discrepancies in order to devise more effective strategies for contact elicitation.

MomsTalkShots, tailored educational app, improves vaccine attitudes: a randomized controlled trial.

BACKGROUND: Many pregnant women and parents have concerns about vaccines. This analysis examined the impact of MomsTalkShots, an individually tailored educational application, on vaccine attitudes of pregnant women and mothers. METHODS: MomsTalkShots was the patient-level component of a multi-level intervention to improve maternal and infant vaccine uptake that also included provider- and practice-level interventions. The impact of these interventions was studied using a two-by-two factorial design, randomizing at both the patient- and the practice-level. Study staff recruited pregnant women from a diverse set of prenatal care practices in Colorado and Georgia between June 2017 and July 2018. All participants (n = 2087) received a baseline survey of maternal and infant vaccine intentions and attitudes, and two follow-up surveys at least 1 month and 1 year after their infant's birth, respectively. Half of participants (n = 1041) were randomly assigned to receive educational videos through MomsTalkShots, algorithmically tailored to their vaccine intentions, attitudes, and demographics. Since the practice/provider intervention did not appear impactful, this analysis focused on MomsTalkShots regardless of the practice/provider intervention. RESULTS: By 1 month post-birth, MomsTalkShots increased perceived risk of maternal influenza disease (61% among MomsTalkShots recipients vs 55% among controls; Odds Ratio: 1.61, 95% Confidence Interval: 1.23-2.09), confidence in influenza vaccine efficacy (73% vs 63%; OR: 1.97, 95%CI: 1.47-2.65), and perceived vaccine knowledge (55% vs 48%; OR: 1.39, 95%CI: 1.13-1.72). Among those intending not to vaccinate at baseline, MomsTalkShots increased perceived risk of maternal influenza disease (38% vs 32%; OR: 2.07, 95%CI: 1.15-3.71) and confidence in influenza vaccine efficacy (44% vs 28%; OR: 2.62, 95%CI: 1.46-4.69). By 1 year post-birth, MomsTalkShots increased perceived vaccine knowledge (62% vs 50%; OR: 1.74, 95%CI: 1.36-2.24) and trust in vaccine information from obstetricians and pediatricians (64% vs 55%; OR: 1.53, 95%CI: 1.17-2.00). Among those uncertain about vaccinating at baseline, MomsTalkShots increased perceived vaccine knowledge (47% vs 12%; OR: 6.89, 95%CI: 1.52-31.25) and reduced infant vaccine safety concerns (71% vs 91%; OR: 0.24, 95%CI: 0.06-0.98). CONCLUSIONS: MomsTalkShots improved pregnant women's and mothers' knowledge and perceptions of maternal and infant vaccines and the diseases they prevent, and offers a scalable tool to address vaccine hesitancy. TRIAL REGISTRATION: Registered at Clinicaltrials.gov on 13/09/2016 (registration number: NCT02898688).

Association between having a regular healthcare provider and pre-exposure prophylaxis use among men who have sex with men: a cross-sectional survey.

Healthcare providers whom people see regularly (e.g., primary care providers [PCPs]) are likely to interact with individuals at risk of human immunodeficiency virus (HIV). However, most PCPs report never prescribing pre-exposure prophylaxis (PrEP), a medication that prevents HIV infection. This study examined the association between having a regular healthcare provider and PrEP use among men who have sex with men (MSM). We analyzed health survey data from Black (n = 151) and White (n = 113) MSM in Atlanta, GA using log binomial regressions. Among Black MSM, the proportion who used PrEP was nearly three times higher for those with a regular provider compared to those without one (aPR 2.58; 95% CI: 0.96, 6.93). Conversely, the proportion of White MSM who used PrEP was slightly lower among those with a regular provider (aPR 0.67; 95% CI: 0.36, 1.27). Findings suggest having a regular provider may be more strongly associated with PrEP among Black MSM.

Estimating the Unknown: Greater Racial and Ethnic Disparities in COVID-19 Burden After Accounting for Missing Race and Ethnicity Data.

BACKGROUND: Black, Hispanic, and Indigenous persons in the United States have an increased risk of SARS-CoV-2 infection and death from COVID-19, due to persistent social inequities. However, the magnitude of the disparity is unclear because race/ethnicity information is often missing in surveillance data. METHODS: We quantified the burden of SARS-CoV-2 notification, hospitalization, and case fatality rates in an urban county by racial/ethnic group using combined race/ethnicity imputation and quantitative bias analysis for misclassification. RESULTS: The ratio of the absolute racial/ethnic disparity in notification rates after bias adjustment, compared with the complete case analysis, increased 1.3-fold for persons classified Black and 1.6-fold for those classified Hispanic, in reference to classified White persons. CONCLUSIONS: These results highlight that complete case analyses may underestimate absolute disparities in notification rates. Complete reporting of race/ethnicity information is necessary for health equity. When data are missing, quantitative bias analysis methods may improve estimates of racial/ethnic disparities in the COVID-19 burden.

The 6 E Framework of Public Health Preparedness for Mass Gatherings-Lessons Learned From Super Bowl LIII, Fulton County, Georgia, 2019.

CONTEXT: On February 3, 2019, Atlanta, Georgia, hosted Super Bowl LIII, which is classified as a National Special Security Event. The festivities comprising this major sporting event brought approximately half a million people to Atlanta, which posed significant challenges to the local public health community. As the lead local agency for public health planning, preparedness, and response efforts, Fulton County Board of Health (FCBOH) needed to address multiple specific tasks based on core functional areas outlined in the Emergency Support Function (ESF) 8 (eg, bioterrorism preparedness and epidemiological surveillance). PROGRAM: To prepare for the Super Bowl, FCBOH developed a systematic approach to ensure community-wide public health preparedness for mass gatherings. This approach came to be known as the 6 E framework, which consists of (1) engaging stakeholders, (2) examining current capabilities and identifying gaps, (3) establishing roles and responsibilities, (4) executing plans to fill gaps, (5) exercising plans, and (6) evaluating impact. IMPLEMENTATION: We define each step of the 6 E framework and present practical examples of how FCBOH implemented each step when preparing for the Super Bowl. Challenges that FCBOH faced and the lessons learned in the process are illustrated. The 6 E framework provides a systematic approach to community preparedness and allows local health departments to tailor the approach to serve local public health needs. EVALUATION: The successful implementation of the 6 E framework allowed for stakeholders at the federal, state, and local levels (including law enforcement) to effectively coordinate an epidemiological investigation and response when 4 staff members reported gastrointestinal symptoms after eating at a feeding station. DISCUSSION: Preparation for the Super Bowl required months of diligent cross-sectoral and cross-jurisdictional partnership building, and the 6 E framework can help other local public health jurisdictions prepare to host major mass gatherings.

Excess Pneumonia Mortality During a 2014-2015 Legionnaires' Disease Outbreak in Genesee County, Michigan.

BACKGROUND: From June 2014 to October 2015, the Michigan Department of Health and Human Services reported an outbreak of 90 cases of Legionnaires' disease, including 10 deaths, in Genesee County, Michigan. As Legionnaires' disease is not routinely tested for as a cause of community-acquired pneumonia, we hypothesized that the size of the outbreak was underestimated. METHODS: We used Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research data to compare pneumonia mortality in Genesee to similar counties from 2011 to 2017. We used data from the Genesee County Vital Records Division to assess geographic overlap of pneumonia mortality with reported Legionnaires disease cases by census tract. RESULTS: We estimated 70.0 excess pneumonia deaths (90% uncertainty interval: 36-103) in Genesee County during the outbreak. Areas of high pneumonia mortality overlapped with those with high Legionnaires' disease incidence. CONCLUSIONS: These findings are consistent with the hypothesis that the Legionnaires' disease outbreak was larger than reported. Earlier outbreak detection and response may have facilitated identification of additional cases.

Preventing COVID-19 Outbreaks in Long-Term Care Facilities Through Preemptive Testing of Residents and Staff Members - Fulton County, Georgia, March-May 2020.

Long-term care facility (LTCF) residents are at particularly high risk for morbidity and mortality associated with infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), given their age and high prevalence of chronic medical conditions, combined with functional impairment that often requires frequent, close contact with health care providers, who might inadvertently spread the virus to residents (1,2). During March-May 2020 in Fulton County, Georgia, >50% of COVID-19-associated deaths occurred among LTCF residents, although these persons represented <1% of the population (3,4). Mass testing for SARS-CoV-2 has been an effective strategy for identifying asymptomatic and presymptomatic infections in LTCFs (5). This analysis sought to evaluate the timing at which mass testing took place in relation to the known presence of a COVID-19 infection and the resulting number of infections that occurred. In 15 LTCFs that performed facility-wide testing in response to an identified case, high prevalences of additional cases in residents and staff members were found at initial testing (28.0% and 7.4%, respectively), suggesting spread of infection had already occurred by the time the first case was identified. Prevalence was also high during follow-up, with a total of 42.4% of residents and 11.8% of staff members infected overall in the response facilities. In comparison, 13 LTCFs conducted testing as a preventive strategy before a case was identified. Although the majority of these LTCFs identified at least one COVID-19 case, the prevalence was significantly lower at initial testing in both residents and staff members (0.5% and 1.0%, respectively) and overall after follow-up (1.5% and 1.7%, respectively). These findings indicate that early awareness of infections might help facilities prevent potential outbreaks by prioritizing and adhering more strictly to infection prevention and control (IPC) recommendations, resulting in fewer infections than would occur when relying on symptom-based screening (6,7).

Using PrEP to #STOPHIVATL: Findings from a Cross-Sectional Survey Among Gay Men and Transgender Women Participating in Gay Pride Events in Atlanta, Georgia, 2018.

Assessing pre-exposure prophylaxis (PrEP) coverage and identifying reasons for disproportionate uptake among the varied social and cultural sub-groups of men who have sex with men (MSM) and transgender women who have sex with men (TWSM) are necessary precursors to setting attainable local PrEP. We report on findings of a cross-sectional survey among MSM/TWSM attending Gay pride events in Atlanta, Georgia, in 2018. Associations between PrEP awareness, uptake, and respondent characteristics were assessed using logistic regression. PrEP awareness did not differ by race, but current use was significantly lower among Blacks at substantial risk of HIV (p = .008). In multivariate analysis, clinician encounter in the past year was associated with awareness while age, income, drug use, sero-discordant sex, and multiple male partners were associated with current use. Among PrEP-naïve MSM/TWSM, the most common reasons for nonuse differed by race (poor knowledge of PrEP: Black-45% vs. non-Black-27%, p = .010, low perception of risk: Black-26% vs. non-Black-52%, p = .001). Key racial and socioeconomic disparities in active PrEP use and reasons for nonuse remain despite the recent increases in PrEP awareness and use among MSM/TWSM in Atlanta. Achieving overall improvement in uptake among all MSM/TWSM sub-groups will require tailoring PrEP educational messaging, optimizing communication modalities, expanding provider outreach, and identifying ways to defray costs for high-risk, underserved sub-groups in these populations.

Trends and Characteristics Associated With Human Papillomavirus Vaccination Uptake Among Men Who Have Sex With Men in the United States, 2014-2017.

BACKGROUND: Human papillomavirus (HPV) and HPV-associated cancer rates are high among men who have sex with men (MSM). The US Advisory Committee on Immunization Practices recommends HPV vaccination for all MSM through age 26 years. We examined trends in HPV vaccine uptake among young US MSM between 2014 and 2017. METHODS: Cochran-Armitage tests and estimated annual percentage changes were used to examine annual trends (2014-2017) in HPV vaccination initiation among US MSM ≤26 years as of 2011 who participated in a nationwide annual cross-sectional online survey. We identified independent correlates of HPV vaccination in 2017 using Poisson regression modeling. RESULTS: There were 2,381 participants in 2014; 4,143 in 2015; 3,926 in 2016; and 3,407 in 2017. Mean age was 23.5 years, 39% lived in metropolitan areas, and 37% lived in the South. HPV vaccination significantly increased (P < 0.0001) from 22.5% in 2014 to 37.6% in 2017 (estimated annual percentage change = 17.4%). HPV vaccination was significantly greater for MSM who were younger, had health insurance, saw a healthcare provider in the past 12-months, resided in the Northeast, resided in metropolitan areas, had higher household income, disclosed their sexual identity to health care provider, and had gonorrhea/chlamydia diagnosis in the past 12-months. CONCLUSIONS: Human papillomavirus vaccination among MSM increased from 2014 to 2017, but vaccine uptake varied significantly by MSM subgroup. Despite favorable trends, the HPV vaccination coverage for this population (37.6%) is less than half of the Healthy People 2020 target (80%). Additional efforts are needed to increase coverage.

A survey-based study of Zika virus communication preferences among pregnant women in Georgia, United States.

BACKGROUND: Because of the particularly severe perinatal outcomes associated with antenatal Zika virus infection, it is important for prenatal care providers to communicate Zika virus risks and strategies for prevention to their patients. Although face-to-face communication is ideal, clinic visits may not allow for in-depth discussion of all concerns. While previous studies have shown prenatal providers to be pregnant women's most trusted sources of health information, there is little knowledge on what secondary communication modalities pregnant women prefer for receiving information from their providers about an evolving public health emergency. METHODS: A cross-sectional, descriptive anonymous 27-item survey was distributed to pregnant women at four clinics around Atlanta, Georgia from May 5th to June 20th, 2016. The survey assessed women's interest in and communication preferences about prenatal topics, including Zika virus. Descriptive statistics were calculated and chi-square tests were used to evaluate associations between the primary outcomes and patient characteristics. RESULTS: Four-hundred and eight women completed the survey. The most popular resource for obtaining Zika virus information was the Centers for Disease Control and Prevention (CDC) website (73.0%). While their prenatal provider's own website for Zika information ranked 5th among sources currently accessed for Zika information, it ranked third behind educational brochures and emails for ways in which women wanted to receive information. The characteristics of Zika virus information deemed most important were: evidence-based (87.5%), endorsed by the CDC (74.1%), and endorsed by their own provider (67.9%). CONCLUSION: In any public health emergency affecting pregnant women, women are going to seek advice from their obstetric providers. Because providers may lack sufficient time to discuss concerns with every patient, they may consider providing patient education in other ways. For the women included in this study, educational brochures, emails and providers' own practice websites were preferred. Providers should consider taking greater advantage of these modalities to supplement in-person exchanges, particularly during a public health emergency.

Use of Obstetric Practice Web Sites to Distribute Zika Virus Information to Pregnant Women During a Zika Virus Outbreak.

OBJECTIVE: To describe the current use of obstetric practice Web sites to disseminate Zika virus information to patients. DESIGN: Review of 913 randomly selected practice Web sites and associated social media accounts in January and August 2016. SETTING: Obstetric practice Web sites and associated social media accounts, United States of America. PARTICIPANTS: N/A. MAIN OUTCOME MEASURES: Proportion of obstetric practice Web sites and linked social media accounts providing Zika virus information. RESULTS: Twenty-five percent and 35% of obstetric practice Web sites had information posted about Zika virus in January 2016 and August 2016, respectively. Between the 2 time points, the proportion of practices posting Zika virus content on Facebook and Twitter declined (Facebook: 15% in January, 9% in August; Twitter: 12% in January, 8% in August). In August, the most frequently observed Zika virus-related content themes were the use of insect repellent (14%) and travel advisories (14%). At both time points, practices affiliated with large university hospitals were more likely to have posted information on Zika virus than independent OB/GYN-only practices: January: odds ratio (OR) (95% confidence interval [CI]) = 5.68 (3.50-9.20); August: OR (95% CI) = 8.37 (5.31-13.17). Similarly, practices associated with nonuniversity hospitals were more likely to have posted information than independent OB/GYN-only practices: January: OR (95% CI) = 2.71 (1.88-3.92); August: OR (95% CI) = 6.75 (4.75-9.60). CONCLUSION: Obstetric care practices are not fully utilizing their practice Web sites to relay Zika virus information to their patients. Since practitioner-sponsored Web sites have the capacity to directly reach the populations at greatest risk for Zika virus complications, public health professionals should consider adapting their materials and provider outreach campaigns to more easily accommodate Web site-based information dissemination during this type of public health emergency. There must be greater recognition of the value information gains in the eyes of the patient when it is validated by their own provider, especially when that patient is part of the highest-risk population for a given emergency. Public health organizations should strive to minimize the burden it takes for providers to relay useful resources to patients in order to maximize the impact that those resources can have.

Impact of Statins on Influenza Vaccine Effectiveness Against Medically Attended Acute Respiratory Illness.

BACKGROUND: Statins have antiinflammatory effects that may impact vaccine-induced immune responses. We investigated the impact of statin therapy on influenza vaccine effectiveness (VE) against medically attended acute respiratory illness (MAARI). METHODS: We conducted a retrospective cohort study over nine influenza seasons using research databases of a large managed care organization in the United States. Influenza vaccination and statin prescription statuses of cohort members and MAARI cases were ascertained on a per-season basis. Incidence rate ratios (IRRs) of MAARI were estimated using Poisson regression and stratified by statin use. Using a ratio of ratios approach, we compared IRRs from periods during to IRRs from periods before influenza circulation and then used relative IRRs to compute VE. RESULTS: After adjustment for multiple prespecified covariates, the influenza VE against MAARI was lower among statin users than nonusers during periods of local (14.1% vs 22.9%; mean difference, 11.4%; 95% confidence interval [CI], -1.7% to 26.1%) and widespread (12.6% vs 26.2%; mean difference, 18.4%; 95% CI, 2.9%-36.2%) influenza circulation. CONCLUSIONS: In this study, statin therapy was associated with reduced influenza VE against MAARI. Since many cases of MAARI are not caused by influenza, studies of the impact of statins on influenza VE against laboratory-confirmed influenza are needed.

Comparative effectiveness of alternative intervals between first and second doses of the mRNA COVID-19 vaccines.

The optimal interval between the first and second doses of COVID-19 mRNA vaccines has not been thoroughly evaluated. Employing a target trial emulation approach, we compared the effectiveness of different interdose intervals among >6 million mRNA vaccine recipients in Georgia, USA, from December 2020 to March 2022. We compared three protocols defined by interdose interval: recommended by the Food and Drug Administration (FDA) (17-25 days for Pfizer-BioNTech; 24-32 days for Moderna), late-but-allowable (26-42 days for Pfizer-BioNTech; 33-49 days for Moderna), and late ( ≥ 43 days for Pfizer-BioNTech; ≥50 days for Moderna). In the short-term, the risk of SARS-CoV-2 infection was lowest under the FDA-recommended protocol. Longer-term, the late-but-allowable protocol resulted in the lowest risk (risk ratio on Day 120 after the first dose administration compared to the FDA-recommended protocol: 0.83 [95% confidence interval: 0.82-0.84]). Here, we showed that delaying the second dose by 1-2 weeks may provide stronger long-term protection.

Success Of The Rollins Epidemiology Fellowship In Rebuilding Georgia's Epidemiologic Workforce.

Over the course of the past two decades, attrition within the US governmental public health workforce has passed concerning and become dire. The practice sector has struggled to recruit and retain new talent, despite the infusion of considerable federal investment in workforce expansion initiatives. In 2020, Emory University's Rollins School of Public Health partnered with the Georgia Department of Public Health to establish the Rollins Epidemiology Fellowship Program. Initially created to recruit and place early-career master of public health-level epidemiologists into Georgia's public health system for COVID-19 pandemic response, the two-year service-learning program has evolved into an effective and replicable model of direct academic involvement in strengthening the governmental public health workforce. Here we describe the program's structure and early results, spotlighting it for consideration by the federal government and other jurisdictions interested in directly engaging academia in efforts to revitalize the public health workforce.

Missed opportunities: a national survey of obstetricians about attitudes on maternal and infant immunization.

The recent reoccurrence of several vaccine-preventable diseases demonstrates the need for new techniques to promote childhood vaccination. Many mothers make decisions regarding vaccination of their children during pregnancy. As a result, obstetricians have a unique opportunity to influence maternal decisions on this crucial component of child health. Our objective was to understand OB/GYNs' attitudes, beliefs, and current practices toward providing vaccinations to pregnant patients and providing information about routine childhood immunizations during standard prenatal care. We surveyed OB/GYNs in the United States about their vaccination practices and perceptions during the 2009 H1N1 outbreak. Most (84%) respondents indicated their practice would be administering H1N1 vaccines to pregnant patients. While a majority (98%) of responding providers felt childhood vaccination is important, relatively few (47%) felt that they could influence mothers' vaccination choices for their children. Discussion of routine childhood immunization between obstetricians and their patients is an area for future improvements in childhood vaccination.

Lessons learned from the 2007 to 2009 Haemophilus influenzae type B vaccine shortage: implications for future vaccine shortages and public health preparedness.

OBJECTIVE: To understand immunization programs' experience managing the 2007 to 2009 Haemophilus influenzae type B (Hib) vaccine shortage and identify ways in which the US immunization system can be improved to assist in responses to future shortages of routine vaccines and large-scale public health emergencies. METHODS: An Internet-based survey was conducted from July 2009 to October 2009 among the 64 city, state, and territorial immunization program managers (IPMs). RESULTS: Fifty-eight percent (37 of the 64) of IPMs responded. Forty percent of responding IPMs indicated not having enough Hib vaccine within their Vaccines for Children program to fulfill the temporary 3-dose recommendation issued in December 2007 in response to the Hib vaccine shortage. While 73% of IPMs indicated success in monitoring provider inventory and 68% indicated success in monitoring doses administered during the shortage, fewer than half indicated success in monitoring providers' compliance with shortage-specific recommendations regarding Hib vaccine. Forty-six percent of IPMs used their immunization information system (IIS) to monitor provider compliance with recommendations regarding Hib vaccine use, and of these, nearly 60% reported success in monitoring provider compliance with recommendations compared with 35% of IPMs who did not use their IIS in this way. Forty-two percent of IPMs felt that the Centers for Disease Control and Prevention (CDC) was successful in determining stockpiled vaccine allocations to their program, and 56% felt that the CDC was successful in communicating its rationale for their immunization program's Hib allocation during the shortage. CONCLUSIONS: Experiences from the 2007 to 2009 Hib vaccine shortage offer insights on how the US immunization system and system-wide response to vaccine shortages can be improved. Results from this survey suggest that improving vaccine transfer between jurisdictions and using IIS to track provider compliance with shortage recommendations are 2 ways that can help the US immunization system respond to future vaccine shortages and large-scale public health emergencies like influenza pandemics.