1. 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

2. 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

3. 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

4. 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.”

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Birth Dose Coverage NIS vs. CIR

14. 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

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

16. 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

17. Timely Coverage Assessment- NYC

18. Timely Coverage Assessment: Hospital Specific

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

20. 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

21. 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

22. 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