1. 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

2. 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.

3. New York City
Bronx
Manhattan
Queens
Brooklyn
Staten Island

4. 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)

5. 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.

6. 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 mo old child
Captures ~80% of immunizations given

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

8. 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

9. 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

10. 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 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 :
244 lists were generated with names of 20,905 children
11,473 children were randomly selected
8,464 charts were analyzed

11. 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

12. 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

13. 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

14. 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)

15. 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)

16. % 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

17. 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)

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

19. 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 ?

20. 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

21. 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

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