Accounting for H1N1 Vaccine Using the New York City Immunization Information System Bureau of Immunization New York City Department of Health and Mental Hygiene Amy Metroka, Vikki Papadouka, Michael Hansen, Jane R. Zucker National Immunization Conference April 19, 2010

Overview New York City (NYC) Background H1N1 Outbreaks in Spring 2009 H1N1 Plan for Fall 2009 The NYC Immunization Information System (IIS) Use of IIS in H1N1 Campaign Results Challenges, Lessons Learned Next Steps, Conclusions

NYC Background Population: 8.3 million Annual birth cohort of ~127,000 1.4 million school children Annual birth cohort of ~127,000 Immunizing facilities ~ 2,000 childhood sites; ~ 5,000 providers ~ 5,000 adult sites; ~ 10,000 providers

H1N1 Outbreaks in Spring 2009 Large outbreaks in schools Hundreds of students sickened Rapid spread, high disease rates in children > 50 schools closed 12% of New Yorkers reported flu-like illness in May – June 2009 ~ 750,000 to 1 million people were ill

H1N1 Vaccination Plan I Offer vaccine in all elementary schools and at weekend PODs Target school-age children Recruit providers serving adult priority groups OB-GYNs, colleges, uniformed services, pharmacies, residential facilities Distribute vaccine widely to all immunizers Providers named above and hospitals, FQHCs, doctor’s offices serving children and adults

H1N1 Vaccination Plan II Require reporting to IIS of H1N1 doses administered to all individuals Infrastructure already in place: IIS Better accountability for use of vaccine (aggregate numbers often inaccurate) Facilitate more accurate tracking of vaccine uptake in priority groups Establish more accurate denominator for assessing vaccine safety

NYC IIS: Citywide Immunization Registry (CIR) Mandatory reporting of immunizations administered to children from birth to < 19 years > 19 years voluntary, with patient’s written consent Birth certificates loaded weekly ~ 2,000 childhood facilities registered (few adult facilities) ~ 90% report regularly 4.3 million individuals and 47 million immunizations ~ 90% of children < 19 years Used for VFC vaccine accountability since 2006 CIR-generated doses administered reports (DARs) sent out quarterly

H1N1 Enhancements to CIR’s Online Registry Costs covered by PHER funds New Quick-Add Patient and H1N1 Vaccination feature H1N1 vaccine forecasting rules Increased visibility of Report Adverse Event to Vaccination feature

Use of CIR in H1N1 Vaccination Campaign

Results

Number of New Facilities Registered in the CIR by Month (Jan 2009 - Mar 2010)

Number of New Facilities Registered in CIR by Type (August 2009 – March 2010) Facility Type Number Percent Private Adult 1,997 65% Schools/PODs 553 18% Private Hospitals 221 7% Residential 142 5% Private Pediatric 67 2% Pharmacy Chains 34 1% Public Hospitals 30 FQHC 18 0.6% Uniform/Emergency Responders 7 0.2% Total 3,069 100%

Total Registered Facilities Jan 1996 - Aug 2009 Registered ~ 2,000 facilities ~1,800 were active in Aug 2009 Sept 2009 – Mar 2010: Registered > 3,000 facilities 150% increase Current total: ~ 5,000

Adult Private Provider Participation To assess adult private provider participation, matched CIR registered facilities against list of practices who billed Medicare for influenza shots Preliminary results: ~ 54% (1,468 unique practices) were found in CIR

H1N1 Doses Distributed and Reported to the CIR by Facility Type (Oct 2009 – Mar 2010)

H1N1 Doses Distributed and Reported to the CIR by Facility Type (Oct 2009 – Mar 2010) # Facilities Received Reported % Reported Public Hospitals 66 195,500 108,886 56% Private Hospitals 257 522,500 157,391 30% FQHC 126 132,500 56,391 43% Private Pediatric 1,177 637,200 307,446 48% Private Adult 1,471 428,600 87,479 20% DOHMH (schools, PODs, Imm. Clinics, Depot, other) 4 662,000 259,031 39% Colleges 21 18,600 5,310 29% Pharmacy Chains 29 139,600 20,157 14% Uniform/Emergency Resp 10 16,000 11,445 72% Residential 130 36,400 4,030 11% Total 3,291 2,788,900 1,017,566 36%

H1N1 Doses Reported to the CIR by Facility Type (Oct 2009 – Mar 2010)

Doses Reported by Method October 2009 – March 2010 H1N1 All other vaccines

Online Registry Use Jan 2007 – Mar 2010

Timeliness of Reporting by Method Median time between administration of H1N1 dose and reporting: 9 days overall Electronic file transfer: 6 days Online Registry: 2 days Paper forms: 41 days PODs: 46 days Schools: 40 days Hospitals: 59 days

Doses Distributed by the Bureau of Immunization’s VFC Program

Individuals Immunized with H1N1 Based on CIR Data as of April 16, 2010 Age Individuals with at least one dose Individuals with 2 or more doses <6 m 989 232 6m-3 yrs 118,889 58,036 4-10 yrs 243,454 128,150 11-18 yrs 118,804 3,815 19-24 yrs 31,562 342 25-64 yrs 260,737 2,366 65 and older 62,715 563 Total 837,150 193,504 Total number of doses reported: 1,047,527* *Some individuals have more than 2 doses reported - duplicates

Estimated Coverage for H1N1 Based on CIR Data as of April 14, 2010 # with 1 H1N1 (per CIR)* Census Denominator % with 1 dose (per CIR) 6 months - 3 years 119,621 394,475 30.3% 4 -10 years 244,452 716,678 34.1% 11 - 18 years 119,578 839,347 14.2% Total 483,651 1,950,500 24.8% *The number of children in each age group includes all children that were at that age at the time of the H1N1 administration. Some children may have aged out of that cohort at the time of this report. As a consequence, coverage for that age group is slightly overestimated

Challenges I Vaccine allocation Surge in registration and ordering Changing CDC forecasts Not enough vaccine or right kind to meet demand, then huge surplus! Surge in registration and ordering Telephone, fax lines went down repeatedly; constantly busy when up Re-directed providers to nycflu email box; started sending weekly update letters via CIR blast email and fax Separate databases led to data management problems: provider registration in CIR; vaccine ordering in VACMAN CDC Data

Challenges II Facilitating reporting by newly registered providers Set-up of CIR Online Registry accounts, support and training for hundreds of new users Scanned forms reporting delay New vendor took a long time to set up, process, and submit data to CIR Hospital network vaccine distribution Duplicate orders because clinics, satellites not clear vaccine coming from pharmacy; difficulty verifying VPA submission

Lessons Learned Streamline CIR registration and vaccine ordering processes Rely more on Web, less on phone and fax Further integrate CIR and VFC databases and functions Improve ability to track ordering/placement of order with CDC/receipt of order by provider Align classification of provider sites

Next Steps Evaluation underway Initial results of provider survey very positive Integrating CIR and VFC systems, staffing and program functions Biweekly meetings Enhancing CIR to enable online vaccine ordering and order status tracking Release scheduled for May 2010 Improving two-way communication with providers via email box, other

Conclusions Established relationships with adult immunizers CIR facilitated H1N1 vaccine distribution and tracking of vaccine uptake Data source for weekly COH reports, evaluation CIR helped target vaccine re-supply during shortage Facilities reporting > 50% of H1N1 doses distributed automatically re-supplied Established relationships with adult immunizers Registered in CIR database – included in blast email, fax lists Already being recruited for 2010 - 2011 influenza season CDC Data

Acknowledgements Co-authors: Vikki Papadouka, Michael Hansen, Jane R. Zucker Angel Aponte Melissa Mickle-Hope Paul Schaeffer CDC Data

Contact Information Citywide Immunization Registry NYC Department of Health & Mental Hygiene www.nyc.gov/health/cir Amy Metroka, MSW Director Tel.: 212-676-2319 ametroka@health.nyc.gov