Integrating the New York Citywide Immunization Registry with Immunization Program Core Functions NYC Department of Health and Mental Hygiene Bureau of Immunization 39th National Immunization Conference Washington DC March 22, 2005 Presented by: Sheila L Palevsky, MD MPH

New York City - Background Population of ~8,000,000 Annual birth cohort of ~125,000 ~340 births per day Large immigrant population High mobility of the population within the city Child immunizing sites ~1,200 Number of pediatric practitioners estimated to be >5,000 New York City has just over million residents. There are about 125,000 infants born each year in New York City – an average of about 340 births per day. The population of NYC is diverse with many immigrants – in fact, the 2000 census demonstrates individuals comes from over 75 countries…. And within the city there is much movement as families relocate from one area to another – and from one health care provider to another.

New York City Bronx Manhattan Queens Brooklyn Staten Island

NYC DOHMH Bureau of Immunization (BOI) Assessment Unit Imm Clinics Provider Liaison Community Outreach & Education Surveillance Program Operations Director (CDC) Medical Director Assistant Commissioner Perinatal Hep B Program Support Services Vaccine Supply Adult Unit WIC Schools Registry (CIR)

The Citywide Immunization Registry (CIR) Profile Mandatory reporting of immunizations administered to children < age 7 since January 1, 1997 Voluntary reporting of immunizations for children 8-18 years of age Birth certificates loaded weekly 2.4 million children and over 20.8 million immunizations are in the CIR The Citywide Immunization Registry was developed and implemented citywide in 1997/ By City regulation, all immunizations given in NYC to children up to the eighth birthday must be reported to the CIR. Immunization events for children 8 to 18 may be included on a voluntary basis. Birth certificates are uploaded in the CIR on a weekly basis ensuring that all children born in NYC are entered into the registry. Currently there are over 2 million children and over 14 million immunizations in the CIR.

CIR: How complete are the data? Fairly good compliance with reporting - 929/1,248 (74%) sites reported in the last 6 months 99% of public providers report (80/81) 73% of non-public providers report (849/1,167) Record completeness is fairly good but not perfect 81% of children 6 months-5 years of age have 2 or more immunizations Average of 14.1 immunizations per 24-35 mo old child Captures ~80% of immunizations given

How do CIR data get used? Program units currently using the CIR: Surveillance Perinatal Hepatitis B prevention Vaccines for Children (VFC) Assessment Provider education

Perinatal Hep B Prevention Goal: to prevent vertical transmission of Hepatitis B CIR data is used to confirm vaccine (including HBIG) administered to infants born to surface antigen positive mothers Minimizes outreach to pediatricians and to affected families already engaged in proper intervention

Surveillance Goal: to identify and control the spread of vaccine-preventable disease (VPD) CIR data is accessed during outbreak investigations to identify those most at risk all children exposed are looked up in the CIR to assess their immunization status those with no recorded immunizations in the CIR for the specific VPD are contacted first during contact investigation CIR helps prioritize resources by targeting those at risk for disease first

Assessment CIR provides assessment unit with lists of patients Goal: to assess practice specific vaccine coverage rates and to identify and eliminate barriers to complete immunization CIR provides assessment unit with lists of patients A list of all children 24-35 months of age who received at least one immunization by this provider are printed A random sample of patients is selected Chart reviews are conducted From 2002-2004: 244 lists were generated with names of 20,905 children 11,473 children were randomly selected 8,464 charts were analyzed

VFC Program Goal: to provide free vaccine to doctors who serve eligible children CIR produces reports of number of doses administered by antigen and by age for each participating provider Report is used as a proxy of the provider vaccine use Doses administered report functionality will be added to the on-line registry for provider use and will become the primary mechanism for vaccine accountability Since 2003, >850 reports for 600 sites were produced These reports are used to supplement VFC QA visit

Provider Education Goal: to update health professionals on immunization related topics to improve immunization practices CIR can help quickly identify common pitfalls in immunization practices: MMR < 1 year of age Varicella < 1 year of age Invalid intervals between DTaP #3 and #4 Final Hep B given before 24 weeks of age

Provider Education - Process In-service for clinics, hospitals, training programs, professional organizations, MCOs, etc. Includes review of the recommended schedule, use of new vaccines, common errors, etc. Remind of CIR reporting mandate Present site specific results from CIR to: Identify practice patterns for a facility Provide feedback on CIR reporting Identify obstacles in clinical and reporting practices Translate into a tool for practice quality improvement

MMR and Varicella given before the first birthday in CIR Of all doses of MMR and Varicella reported to the CIR for NYC: 3.2% of MMR are given < 365 days (59,907/1,865,923) 1.7% of Varicella are given < 365 days (12,372/711,713)

Provider education results Since 2002, presentations were made at 31 sites for which site-specific data of early (invalid) doses of MMR and Varicella were presented 10 public and 21 non-public sites 3% of all MMR were given <365 days (4,256/142,912) 1.7% of all Varicella were given <365 days (1,405/81,689)

% of MMR and Varicella doses given < 365 days of age by facility type % of doses given before 365 days 21 non-public facilities; 10 public facilities

Looking at doses given Compared the % of early doses of MMR before and since the educational session Only sites visited prior to 9/1/04 were included to allow for patient visits and for sufficient data to be entered into the CIR (n=20)

% of doses of early MMR given before and after educational session % of MMR given < 365 days sites Average before: 2.9; after: 0.6

Results: Summary Public sites give fewer doses of MMR and Varicella early than non-public sites 19/20 sites visited before 9/1/2004 improved % of MMR given before the 1st birthday decreased from: 2.9% (2,814/95,435) to 0.6% (189/29,020) Did presenting data from the CIR change practice behavior ?

What we have learned Using the CIR in day-to-day activities of the Bureau of Immunization can facilitate individual program component operations CIR data augments, reinforces, and streamlines tasks of program units Illustrative data from the CIR may be associated with clinical practice change

Thanks to all of the staff participating in this project Stephen Friedman Jane R Zucker Sharmilah Shah Sam Anim-Addo Dileep Sarecha Karen Fernandez Julie Lazaroff Jane Tubridy Amy Metroka Shirley Huie Vicky Papadouka Angel Aponte Lennon Turner Ukachukwu Nkwocha

incomplete data are useful it doesn’t need to be a perfect registry – incomplete data are useful