1. Diana L. Bartlett and Karen A. Cullen
Newborn Hepatitis B vaccination coverage among children aged 3,5, and months– Immunization Information System Sentinel Sites, United States,
Diana L. Bartlett and Karen A. Cullen
CDC/NCIRD/ISD/IISSB
2010 National Immunization Conference
Atlanta, GA
April 20, 2010
Hello! My name is Karen Cullen and I am a health scientist at the CDC. This presentation describes current vaccination coverage for the birth dose of Hepatitis B vaccine among eight CDC immunization grantees participating in the immunization information system (IIS) sentinel sites project.
National Center for Immunization and Respiratory Diseases
Immunization Information System Support Branch

2. Objective
Describe the administration of the birth dose of Hepatitis B vaccine between date of birth and up to five days among children aged 3, 5, and months from
Our study objective was to describe the administration of the birth dose of Hepatitis B vaccine at between the date of birth and up to five days later for children in the 3, 5, and month old age groups. We began to collect Hepatitis B birth dose prospectively since January 2008 and our analysis continued through December Looking at the month old age group will permit us to make some comparisons to the National Immunization Survey estimates and looking at the youngest age groups would enable us to see the most current vaccine administration patterns in our sites.

3. ACIP Recommendation December 2005:
All medically stable newborns who weigh ≥2000g (4.4 lbs) should receive the first dose of Hepatitis B vaccine before hospital discharge
Administration within 12 hours of birth if mothers test positive or are admitted with unknown status for hepatitis B surface antigen
ACIP: Advisory Committee on Immunization Practices

4. Immunization Information Systems (IIS)
Confidential, population-based, computerized information systems that were designed primarily to consolidate vaccination records for all children within an geographic area from multiple vaccine providers
66% of year olds have ≥2 vaccinations recorded in IIS
Data sources include:
Birth certificate data
Clinical data
Billing data
CDC uses various methods to assess vaccination coverage. This study focuses on Immunization Information Systems or IIS, also known as Immunization Registries, which allow for timely assessment of vaccine coverage estimates. For those of you who aren’t familiar, IIS are confidential, population-based computerized data systems based usually in state health departments that were designed primarily to consolidate vaccination records for all children within a geographic area from multiple vaccine providers.
Although the focus of IIS has primarily been on children <6 years of age, as of the end of 2008, about 75% of the children <6 years of age in the U.S. have 2 or more records in an IIS.
The primary sources of IIS data are clinical data entered in by health provider staff and health departments, billing data, and downloads of birth certificate information, many of which contain the vaccination date of the birth dose of Hepatitis B.

5. IIS Sentinel Sites Project
Assesses vaccination coverage for persons aged <19 years
Implement enhanced data quality procedures
Usually a subset of the state IIS coverage area with contiguous geographic counties, postal code areas, or census tracts
At a minimum, sites need to have:
At least 85% vaccine provider sites enrolled in the IIS;
At least 85% of the children <19 years of age in the population with at least 2 vaccinations recorded in the IIS
At least 70% of the doses administered from this sentinel site area should be submitted to and processed by the IIS within 30 days of vaccine administration.
Just so you have a little bit of background on our data source, the IIS sentinel site project includes 8 CDC immunization grantees who have chosen a subset of their state or city IIS for analysis.
Data collection for evaluation projects is limited to persons <19 years of age, uses enhanced data quality procedures in these areas, and has at least 85% child and provider participation in the area with the majority of vaccination data processed by the IIS within 30 days.

6. IIS Sentinel Sites Profiles
Area
# of Children <6 yrs old enrolled in IIS and living in sentinel site area
% children <19 years old in population with ≥2 doses in IIS
% of enrolled provider sites
% vaccinations recorded in the IIS within 30 days AZ
Seven counties in northern AZ
85,531
87%
99%
91% CO
14 counties in southwestern CO
13,294
90%
98% MI
81/83 counties in state
518,901
100% MN
Hennepin County (Minneapolis)
107,089
86%
88%
NYC
Manhattan, Bronx, Brooklyn, Staten Island, Queens
899,328
95% ND
Entire state
56,713
97% OR
Washington and Multnomah counties (greater Portland)
94,081
94%
89% WI
5 counties in southern WI (includes Madison)
95,288
This slide just demonstrates the diversity among the sites and includes data from their Quarter quarterly vaccination reports and 2009 mid-year progress reports.
They are not nationally representative and may not be entirely representative of their state.
The eight participating grantees include Arizona, Colorado, Michigan, Minnesota, New York City, North Dakota, Oregon, and Wisconsin.
Although New York City and North Dakota use their entire geographic area for analysis, grantees like Oregon limit their analysis to the greater Portland area and Arizona focuses on the northern part of the state. The smallest site in CO has just over 13,000 children <6 years of age in their 14-county region compared to our most populous site of NYC with almost 900,000 children <6 years of age enrolled in the IIS.
Sites have very timely data with 88% or more of vaccination records processed and entered into the IIS within 30 days.

7. Methods
For each quarter and year (1st quarter 2006 – 4th quarter 2009) each IIS reported # vaccine recipients 3, 5, and months of age
Denominator included all children by age group enrolled in the IIS (i.e. with a demographic record in the database with or without vaccination data)
Data analyzed by:
Quarter
Sentinel site
Age group (3 months, 5 months, months)
Vaccination after days since birth (0-2 days in 2008; 0-5 days in 2009)
For each quarter and year from the 1st quarter of 2008 to the 4th quarter of 2009, each IIS reported the number of vaccine recipients who were 3, 5, and months of age.
To calculate the percent of children receiving the birth dose of Hepatitis B vaccine, we divided vaccine recipients by the total number of children in each age group enrolled in the IIS.
Data were analyzed by quarter, sentinel site, age group, and the days after birth before receiving their first dose of Hepatitis B vaccine. In 2008, we only collected data on Hepatitis B vaccine administered from date of birth to age 2 days. To improve comparability with the National Immunization Survey results which go through age 3 days, we began to collect data from date of birth up to age 5 days.

8. Distribution of Hepatitis B birth dose by day, assessed at 3, 5, and 19-35 months, 2009

9. Percent of children who received Hepatitis B birth dose by day of life, assessed at 3, 5, and months, 2009
Adding days 4 and 5 for coverage only adds ~1 percentage point.

10. Percentage of 19-35 month old children with birth dose of Hepatitis B by age 3 days by Sentinel Site

11. Percentage of month old children with birth dose of Hepatitis B on Day 0 and Day 1 by Sentinel Site, 2009

12. Comparison of % children vaccinated by day, assessed at 3 months, 2008 vs. 2009

13. Comparison of % children vaccinated by day, assessed at 5 months, 2008 vs. 2009

14. Comparison of % children vaccinated by day, assessed at 19-35 months, 2008 vs. 2009

15. Study Strengths & Limitations
IIS Sentinel Site enrollees exceed 1.8 million children <6 years of age.
Timely reporting of vaccine administration
Limitations:
Data are reported by date only
Possible that not all birthing hospitals are reporting data completely to the IIS (White et al., J Public Health Management Practice 2009, 15(6): )
One important strength of this study is that its dataset includes data from over 1.8 million enrolled children <6 years of age. These data also provide timely estimates of Hepatitis B birth dose vaccine uptake as 88-95% of vaccines administered are entered into the IIS within 30 days of vaccine administration and, the IIS sentinel sites provided the most current data available by reporting on children born within the last 3 months of 2009.
Some limitations include that the data are reported to CDC in aggregate format and don’t have discrete vaccination dates for each child. Not having a time stamp for the time of birth, the time of the birth dose of Hepatitis B vaccine, and the hepatitis B surface antigen results of the mother do not enable us to accurately measure the adherence to the recommendation to administer the birth dose within 12 hours, but we use vaccinations given on the birth date as a proxy measure for this practice.
Additionally, some birthing hospitals may not be reporting the birth dose of Hepatitis B completely to the IIS. MN reported in a 2009 article of the Journal of Public Health Management and Practice that at least three of their birthing hospitals were not reporting the birth dose data accurately and completely to Vital Records for the birth certificates. Since many states rely on downloads of birth certificate data to populate the IIS with patient demographics and the first dose of Hepatitis B, incomplete reporting on birth certificates could affect the coverage calculations for the birth dose in more states than MN.

16. Conclusions
The majority of children are receiving the birth dose by age 2 days.
Vaccination coverage calculated with IIS is comparable to NIS estimates.
Examining the coverage at age 5 days does not increase coverage significantly.
Although adherence to the ACIP recommendations is high, there remains room for improvement.
In conclusion, receipt of the birth dose by age 2 days is comparable to NIS estimates at age 3 days.
Examining coverage at age 5 days does not increase coverage significantly.
Although adherence to the ACIP recommendations is high, there remains room for improvement.

17. Recommendations
Outreach to birthing hospitals to report data to Vital Records and/or the IIS could help to improve proper documentation of Hepatitis B birth dose
Assess Hepatitis B birth dose by 3 days
Conduct further analyses linking birth certificate data with hospital discharge data to examine adherence to the ACIP recommendation, specifically by birth weight and by date of discharge

18. Acknowledgements Sentinel Site Colleagues:
Arizona: Lisa Rasmussen and Patty Gast
Colorado: Diana Herrero and Kimberly Dugger
Michigan: Rachel Potter and Bea Salada
Minnesota: Karen White and Emily Peterson
North Dakota: Keith LoMurray and Molly Sander
New York City: Vikki Papadouka and Michael Hansen
Oregon: James Gaudino and Mary Beth Kurilo
Wisconsin: Tom Maerz and Stephanie Schauer
National Center for Immunization and Respiratory Diseases: Lisa Jacques-Carroll, Sharad Aggarwal
I would like to acknowledge my colleagues from the sentinel site areas and my colleagues at the CDC.

19. Contact: For More Information Karen Cullen KCullen@cdc.gov
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The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention