How ready was the US vaccination infrastructure and network of immunization information systems for COVID-19 vaccination campaigns: Recommendations to strengthen the routine vaccination program and prepare for the next pandemic.

Coronavirus disease 2019 (COVID-19) pandemic vaccination campaigns globally have been unlike any effort in history. In the United States, the success of these efforts, in part, has hinged on the timely capture and reporting of an unprecedented amount of data from a significantly greater number of administering providers than for routine vaccinations. The pandemic response has highlighted the need to explore the status and value of vaccination data as the critical glue that connects all aspects of the upstream US vaccine development and downstream vaccination delivery system. In this review, we examine immunization information systems and the role that data and staffing play in pandemic responses. We offer three strategic recommendations-regarding funding, expanded provider enrollment, and data reporting-informed by a literature review, a survey and focus group from a convenience sample of 22 immunization jurisdictions, and the vision for enhanced data flow to improve future pandemic responses and routine vaccination.

Exemptions From Mandatory Immunization After Legally Mandated Parental Counseling.

BACKGROUND: The success of health care provider counseling-based interventions to address vaccine hesitancy is not clear. In 2011, Washington State implemented Senate Bill 5005 (SB5005), requiring counseling and a signed form from a licensed health care provider to obtain an exemption. Evaluating the impact of a counseling intervention can provide important insight into population-level interventions that focus on interpersonal communication by a health care provider. METHODS: We used segmented regression and interaction and aggregation indices to assess the impact of SB5005 on immunization coverage and exemption rates in Washington State from school years 1997-1998 through 2013-2014. RESULTS: After SB5005 was implemented, there was a significant relative decrease of 40.2% (95% confidence interval: -43.6% to -36.6%) in exemption rates. This translates to a significant absolute reduction of 2.9 percentage points (95% confidence interval: -4.2% to -1.7%) in exemption rates. There were increases in vaccine coverage for all vaccines required for school entrance, with the exception of the hepatitis B vaccine. The probability that kindergarteners without exemptions would encounter kindergarteners with exemptions (interaction index) decreased, and the probability that kindergarteners with exemptions would encounter other such kindergarteners (aggregation index) also decreased after SB5005. Moreover, SB5005 was associated with a decline in geographic clustering of vaccine exemptors. CONCLUSIONS: States in the United States and jurisdictions in other countries should consider adding parental counseling by health care provider as a requirement for obtaining exemptions to vaccination requirements.

A national survey of immunization programs regarding immunization information systems data sharing and use.

OBJECTIVE: To determine and characterize practices regarding data sharing and usage (particularly for research) in immunization information systems (IISs), as well as barriers to using such data for research. DESIGN: We surveyed immunization program managers (IPMs) associated with all 64 Centers for Disease Control and Prevention grantee immunization programs (IPs) between July and September 2012. RESULTS: More than 95% of IPMs (61/64) responded. The top 2 barriers reported by IPMs to using IIS data for research were insufficient time and too few employees, irrespective of whether or not the jurisdiction reported using data for research purposes. Those IPMs who agreed with the statement "Research is part of the mission of an immunization program" were more likely to report using data for research (P = .045). Among those who responded, the most common kind of IIS research conducted involved determinants of vaccination coverage (n = 24/26; 92%). A greater percentage of IPMs in jurisdictions that reported using IIS data for research reported having data-sharing agreements in place. Those IPs that have used IIS data for research were more likely to report online IIS provider enrollment, integration with insurance company records, and integration with hospital records. Alternatively, IPs that did not report using IIS data for research were more likely to have IISs with modules addressing topics such as adverse event reporting, smallpox, and first-responder vaccination. CONCLUSION: Staff size and time were the 2 most cited barriers to conducting research with IIS data. Therefore, focus should also be placed on providing IPs with the resources needed to conduct such research.

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.

Perspectives of immunization program managers on 2009-10 H1N1 vaccination in the United States: a national survey.

In June and July 2010, we conducted a national internet-based survey of 64 city, state, and territorial immunization program managers (IPMs) to assess their experiences in managing the 2009-10 H1N1 influenza vaccination campaign. Fifty-four (84%) of the managers or individuals responsible for an immunization program responded to the survey. To manage the campaign, 76% indicated their health department activated an incident command system (ICS) and 49% used an emergency operations center (EOC). Forty percent indicated they shared the leadership of the campaign with their state-level emergency preparedness program. The managers' perceptions of the helpfulness of the emergency preparedness staff was higher when they had collaborated with the emergency preparedness program on actual or simulated mass vaccination events within the previous 2 years. Fifty-seven percent found their pandemic influenza plan helpful, and those programs that mandated that vaccine providers enter data into their jurisdiction's immunization information system (IIS) were more likely than those who did not mandate data entry to rate their IIS as valuable for facilitating registration of nontraditional providers (42% vs. 25%, p<0.05) and tracking recalled influenza vaccine (50% vs. 38%, p<0.05). Results suggest that ICS and EOC structures, pandemic influenza plans, collaborations with emergency preparedness partners during nonemergencies, and expanded use of IIS can enhance immunization programs' ability to successfully manage a large-scale vaccination campaign. Maintaining the close working relationships developed between state-level immunization and emergency preparedness programs during the H1N1 influenza vaccination campaign will be especially important as states prepare for budget cuts in the coming years.

Gaps in vaccine financing for underinsured children in the United States.

CONTEXT: The number of new vaccines recommended for children and adolescents has nearly doubled during the past 5 years, and the cost of fully vaccinating a child has increased dramatically in the past decade. Anecdotal reports from state policy makers and clinicians suggest that new gaps have arisen in financial coverage of vaccines for children who are underinsured (ie, have private insurance that does not cover all recommended vaccines). In 2000, approximately 14% of children were underinsured for vaccines in the United States. OBJECTIVES: To describe variation among states in the provision of new vaccines to underinsured children and to identify barriers to state purchase and distribution of new vaccines. DESIGN, SETTING, AND PARTICIPANTS: A 2-phase mixed-methods study of state immunization program managers in the United States. The first phase included 1-hour qualitative telephone interviews conducted from November to December 2005 with 9 program managers chosen to represent different state vaccine financing policies. The second phase incorporated findings from phase 1 to develop a national telephone and paper-based survey of state immunization program managers that was conducted from January to June 2006. MAIN OUTCOME MEASURES: Percentage of states in which underinsured children are unable to receive publicly purchased vaccines in the private or public sectors. RESULTS: Immunization program managers from 48 states (96%) participated in the study. Underinsured children were not eligible to receive publicly purchased meningococcal conjugate or pneumococcal conjugate vaccines in the private sector in 70% and 50% of states, respectively, or in the public sector in 40% and 17% of states, respectively. Due to limited financing for new vaccines, 10 states changed their policies for provision of publicly purchased vaccines between 2004 and early 2006 to restrict access to selected new vaccines for underinsured children. The most commonly cited barriers to implementation in underinsured children were lack of sufficient federal and state funding to purchase vaccines. CONCLUSIONS: The current vaccine financing system has resulted in gaps for underinsured children in the United States, many of whom are now unable to receive publicly purchased vaccines in either the private or public sectors. Additional strategies are needed to ensure financial coverage for all vaccines, particularly new vaccines, among this vulnerable population.