1. What’s going on out there
What’s going on out there? Measuring the use of alternative immunization schedules
Mark H Sawyer, MD, Tanya Dansky, MD, David Kopald, BS, Gregory May, MA, Wendy Wang, MPH; Karen Waters-Montijo, MPH

2. Background
Recent vaccine safety concerns have led to increasing numbers of parents seeking alternatives to the ACIP recommended immunization schedule
All of these alternative schedules involve some delay in immunizations
Vaccine delay leads to unimmunized populations that are at risk for outbreaks of disease

3. Background(cont.)
Vaccine delay also impacts measures of immunization delivery (e.g. Pay-for-performance)
Measuring the frequency with which alternative immunization schedules are being used is challenging and may not be reflected in immunization coverage rates
Both IIS and managed care databases offer tools to monitor alternative immunization practices

4. Personal Belief Exemptions (PBE) Kindergarten Entrance Assessment 2001-2008
S:\PHS\Immun\Evaluation\Results\Children\Kindergarten Retro\2008KindExemp ppt

5. 4 Year Trend of Immunization Rates CPMG Managed Care Database

6. IZ Coverage Rates

7. When we overlay the schools’ PBE numbers over median income, we see some clustering of higher numbers of PBEs in higher income zip codes
In geographic analysis, higher PBE rates correlated significantly with higher median income, examined either by zip code or census tract

8. The Sears schedule?

9. Objectives
Explore the utility of an Immunization Information System (San Diego Immunization Registry/SDIR) for tracking the use of alternative immunization schedules
Explore the utility of a managed care (Children’s Primary Care Medical Group/CPMG) claims database for tracking the use of alternative immunization schedules

10. San Diego Immunization Registry SDIR
Regional IIS for San Diego County
Population 3 million
Records for children <2 years: 124,539
Public Health Clinics, non-profit Community Health Centers, and private practice users

11. CPMG Pediatric Office Data
Local Managed Care Organization
9 separate office practices
All patients born in 2007
year olds in high SES practices
year olds in low SES practices
Same PCP throughout 1st year of life

12. Methodology
Queries were developed to monitor the non-simultaneous use of vaccines that are typically given together based on the ACIP immunization schedule
Apply queries to different aged populations and to populations of different SES characteristics
IIS queries run over several consecutive years

13. Methodology (Cont.) Queries for SDIR Query for CMPG database
Children 6 weeks to 7 months of age…
who received DTaP but no IPV on the same day
who received DTaP but no PCV7 on the same day
who received less than 3 vaccines on the same day
Children months of age who received varicella vaccine but no MMR on the same day
Query for CMPG database
Children who did not receive Hib, DTaP, and IPV on the same day

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18. Differences Between Practice Populations CPMG database0% 0%
High SES
Low SES

19. Summary of CPMG Office Data-High SES Practices
Overall, 16% of infants in these 4 offices received “split schedule” for vaccines
Ranged from 7% to 40%
Overall, 84% of the infants were up-to-date with recommended immunizations by age 2
Ranged from 72% to 94%

20. Summary of CPMG Office Data-High SES Practices
Of the “split schedule” group, compliance was only 31% for these 70 infants.
Of the infants who received immunizations at the recommended schedule, 94% were compliant with all immunizations!

21. California Immunization Coalition materials

22. Conclusions
Immunization Information Systems and Managed Care Databases should be useful to track the rate with which alternative vaccine schedules are being used
In San Diego the trend in private practice offices is for increasing use of alternative schedules
There is significant variability in use of alternative schedules between practices

23. Acknowledgements
Coauthors: Tanya Dansky, MD, David Kopald, BS, Gregory May, MA, Wendy Wang, MPH; Karen Waters-Montijo, MPH
Wilma Wooten, MD, MPH, Public Health Officer
Participating providers 
San Diego Immunization Branch staff 23