National Immunization Conference Validation of an Immunization Information System Against the National Immunization Survey and Improvement of Hepatitis B Birth Dose Coverage in New York City Melissa A. Mickle-Hope, MPH, Christopher M. Zimmerman, MD, MPH, Vikki Papadouka, PhD, MPH and Jane R. Zucker MD, MSc National Immunization Conference March 20, 2008 Atlanta, Georgia

Overview Background Hepatitis B virus infection Universal hepatitis B vaccine birth dose recommendations Methods of performing vaccine coverage assessment Validation of immunization coverage Improvement of hepatitis B vaccine birth dose coverage in NYC

Hepatitis B Virus Infection Prevalence 0.2%-0.5% of the U.S. population is chronically infected with hepatitis B Transmission 30%-40% of chronic infections come from perinatal or early childhood transmission Increased risk of cirrhosis Increased risk of hepatocellular carcinoma Vaccination at birth (birth dose) is effective in preventing perinatal transmission

ACIP Recommendations First recommendation for birth dose was made in 1991 Preference for birth dose reiterated in 2002 Language became stronger in 2005 recommendation: “For all medically stable infants weighing >2,000 g at birth and born to HBsAg-negative mothers, the first dose of vaccine should be administered before hospital discharge.”

Coverage Assessment: National Immunization Survey (NIS) Implemented by the National Immunization Program and the National Center for Health Statistics, CDC Track Healthy People 2000 and Healthy People 2010 goals Monitor vaccine coverage nationally Standard for measuring immunization coverage across 50 states, the District of Columbia and 27 large urban areas Data is retrospective, results are 2-3 years old Limited vaccine coverage information for localities

Coverage Assessment: Immunization Information Systems (IIS) National Vaccine Advisory Committee (NVAC) definition: “Confidential, computerized information systems that contain information about immunizations and children” Population- based analysis Assess vaccination coverage for various age groups and geographic areas in a timely manner Data Concerns Nationally low rates of provider and child participation Data quality procedures are not uniform nationwide

Citywide Immunization Registry (CIR) The IIS for the entire New York City area Implemented in 1997 Meets all the functional standards for a fully operational IIS NYC has mandatory reporting of vaccines for children 0-18 years of age Over 3.3 million records with over 33 million immunizations >90% of pediatric providers in NYC enrolled in CIR Birth certificate data is loaded weekly

Objectives Validate CIR birth dose coverage Compare CIR to NIS coverage Use CIR to track birth dose coverage in “real-time” Assess impact of multiple efforts to improve birth dose coverage in NYC

Hepatitis B Birth Dose Validation Methods Evaluated hepatitis B vaccine given to infants less than 3 days old Used NIS birth cohorts to calculate birth dose coverage from CIR Compared birth dose coverage from NIS to CIR coverage for NYC Used CIR to measure yearly birth dose coverage from 2000-2007

Birth Dose Reporting Reporting sources 47 birthing facilities Birth dose date reportable on the birth certificate >85% of birth dose immunizations reported on the birth certificate

Why Validate Birth Dose? First vaccination event Reliable data source Birth certificate data loaded regularly Mobility not a issue for study population Easy to perform coverage assessment Single dose Clearly defined age interval

Hepatitis B Birth Dose Coverage NIS vs. CIR NIS Survey Year Age Cohort CIR HBBD* Coverage NIS HBBD* 2003 02/2000- 05/2002 26.0% (73,768/283,680) 33.7%±7.0 2004 01/2001- 07/2003 27.5% (86,763/315,095) 34.1% ± 7.4 2005 02/2002- 07/2004 29.9% (91,526/305,945) 31.5%± 8.0 2006 02/2003- 06/2005 32.7% (96,841/295,824) 38.7%± 7.0 *HBBD= Hepatitis B Birth Dose

Birth Dose Coverage NIS vs. CIR

Validation Summary For birth dose CIR coverage falls within confidence intervals of NIS estimates CIR is a reliable assessment tool for hepatitis B birth dose Real-time coverage assessment can be performed using CIR data to: Identify birthing hospitals with low birth dose coverage for targeted intervention strategies Closely monitor improvement by hosptial

Birth Dose Coverage by Birthing Hospital, 2006 = 5 hospitals with most deliveries to hepatitis B positive women in 2006.

Efforts To Improve Birth Dose Free Vaccine Program Program to give hepatitis B vaccine at no cost to birthing hospitals with a written policy to universally immunize newborns started in 2004 Targeted Outreach Calls made to birthing facilities with low rates of birth dose administration initiated in 2005 Health Commissioner Correspondence Letter sent to all birthing facilities from the Commissioner of Health in 2007 Facilities were given their birth dose coverage rates based on CIR Birthing facilities received packets of information addressing the importance of the birth dose Monthly Birth Dose Tracking

Timely Coverage Assessment- NYC

Timely Coverage Assessment: Hospital Specific

CIR Hepatitis B Vaccine Birth Dose Coverage 2000-2007 Outreach Activities Initiated

Summary CIR birth dose coverage matches NIS estimates CIR timely barometer for clinical practice Birth dose coverage increased after Immunization Program began implementing intervention strategies Outreach efforts to improve birth dose coverage have been successful

Next Steps For Birth Dose Improvement Continued Outreach Another letter from the Commissioner of Health will be sent to birthing facilities with updated coverage estimates from CIR Birth dose coverage for every birthing facility will be made available to the public

Future Directions Expand validation efforts using other vaccine groups Continue to improve CIR data quality Add reminder recall capabilities to the Online Registry Continue to provide feedback to providers using quarterly coverage reports Implement real time data capture through Electronic Medical Record (EMR) systems Exchange data with neighboring states and localities