1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Use of CIR in H1N1 Vaccination Campaign

10. Results

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

12. 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%

13. Total Registered Facilities
Jan 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

14. 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

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

16. 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%

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

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

19. Online Registry Use Jan 2007 – Mar 2010

20. 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

21. Doses Distributed by the Bureau of Immunization’s VFC Program

22. 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

23. 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%
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

24. 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 box; started sending weekly update letters via CIR blast and fax
Separate databases led to data management problems: provider registration in CIR; vaccine ordering in VACMAN
CDC Data

25. 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

26. 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

27. 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 box, other

28. 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 , fax lists
Already being recruited for influenza season
CDC Data

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

30. Contact Information
Citywide Immunization Registry
NYC Department of Health & Mental Hygiene
Amy Metroka, MSW
Director
Tel.: