PROBLEM/CONDITION: Elimination of tuberculosis (TB) is defined as reducing TB disease incidence in the United States to less than 1 case per million persons per year. In 2022, TB incidence in the United States was 2.5 TB cases per 100,000 persons. CDC's TB program developed a set of national TB indicators to evaluate progress toward TB elimination through monitoring performance of state and city TB program activities. Examining TB indicator data enables state- and city-level TB programs to identify areas for program evaluation and improvement activities. These data also help CDC identify states and cities that might benefit from technical assistance. PERIOD COVERED: The 5-year period for which the most recent data were available for each of five indicators: 1) overall TB incidence (2018-2022), 2) TB incidence among non-U.S.-born persons (2018-2022), 3) percentage of persons with drug susceptibility results reported (2018-2022), 4) percentage of contacts to sputum acid-fast bacillus (AFB) smear-positive TB patients with newly diagnosed latent TB infection (LTBI) who completed treatment (2017-2021), and 5) percentage of patients with completion of TB therapy within 12 months (2016-2020). DESCRIPTION OF SYSTEM: The National TB Indicators Project (NTIP) is a web-based performance monitoring tool that uses national TB surveillance data reported through the National TB Surveillance System and the Aggregate Reports for TB Program Evaluation. NTIP was developed to facilitate the use of existing data to help TB program staff members prioritize activities, monitor progress, and focus program improvement efforts. The following five indicators were selected for this report because of their importance in Federal TB funding allocation and in accelerating the decline in TB cases: 1) overall TB incidence in the United States, 2) TB incidence among non-U.S.-born persons, 3) percentage of persons with drug susceptibility results reported, 4) percentage of contacts to sputum AFB smear-positive TB cases who completed treatment for LTBI, and 5) percentage of patients with completion of TB therapy within 12 months. For this report, 52 TB programs (50 states, the District of Columbia, and New York City) were categorized into terciles based on the 5-year average number of TB cases reported to National TB Surveillance System. This grouping allows comparison of TB programs that have similar numbers of TB cases and allocates a similar number of TB programs to each category. The following formula was used to calculate the relative change by TB program for each indicator: [(% from year 5 - % from year 1 ÷ % from year 1) × 100]. RESULTS: During the 5-year period for which the most recent data were available, most TB programs had improvements in reducing overall TB incidence (71.2%) and increasing the percentage of contacts receiving a diagnosis of LTBI who completed LTBI treatment (55.8%); the majority of programs (51.0%) also had improvements in reducing incidence among non-U.S.-born persons. The average percentage of persons with drug susceptibility results reported in most jurisdictions (28 of 52, [53.9%]) met or exceeded the 5-year national average of 97% (2018-2022). The percentage of contacts to sputum acid-fast bacillus (AFB) smear-positive TB patients with newly diagnosed latent TB infection (LTBI) who completed treatment increased in 29 of 52 (55.8%) jurisdictions from 2017 to 2021, signifying that, for most jurisdictions, steps have been taken to enhance performance in this area. The average percentage of patients with completion of TB therapy within 12 months was at or above the national average of 89.7% in approximately two-thirds (32 of 52 [61.5%]) of jurisdictions. INTERPRETATION: This report is the first to describe a 5-year relative change for TB program performance. These results suggest that TB programs are making improvements in activities that help identify persons with TB and LTBI and ensure patients complete treatment in a timely manner. PUBLIC HEALTH ACTION: Use of NTIP data from individual TB programs enables a more detailed examination of trends in program performance and identification of areas for program improvement. Assessing indicator trends by TB program provides an opportunity to gain a better understanding of program performance in comparison to other programs. It can also facilitate communication between programs regarding successes and challenges in program improvement. This information is valuable for TB programs to allocate resources effectively and provide additional context on TB control for public health policymakers.

OBJECTIVE: To estimate the number and cost of hospitalizations with a diagnosis of active tuberculosis (TB) disease in the United States. METHODS: We analyzed the 2014 National In-Patient Sample using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes to identify hospitalizations with a principal (TB-PD) or any secondary discharge (TB-SD) TB diagnosis. We used a generalized linear model with log link and gamma distribution to estimate the cost per TB-PD and TB-SD episode adjusted for patient demographics, insurer, clinical elements, and hospital characteristics. RESULTS: We estimated 4985 TB-PD and 6080 TB-SD hospitalizations nationwide. TB-PD adjusted averaged $16 695 per episode (95%CI $16 168-$17 221). The average for miliary/disseminated TB ($22 498, 95%CI $21 067-$23 929) or TB of the central nervous system ($28 338, 95%CI $25 836-$30 840) was significantly greater than for pulmonary TB ($14 819, 95%CI $14 284-$15 354). The most common principal diagnoses for TB-SD were septicemia (n = 965 hospitalizations), human immunodeficiency virus infection (n = 610), pneumonia (n = 565), and chronic obstructive pulmonary disease and bronchiectasis (COPD-B, n = 150). The adjusted average cost per TB-SD episode was $15 909 (95%CI $15 337-$16 481), varying between $8687 (95%CI $8337-$9036) for COPD-B and $23 335 (95%CI $21 979-$24 690) for septicemia. TB-PD cost the US health care system $123.4 million (95%CI $106.3-$140.5) and TB-SD cost $141.9 million ($128.4-$155.5), of which Medicaid/Medicare covered respectively 67.2% and 69.7%. CONCLUSIONS: TB hospitalizations result in substantial costs within the US health care system.

OBJECTIVE: To describe tuberculin skin test (TST) and interferon-gamma release assay (IGRA) (i.e., QuantiFERON-TB and T-SPOT.TB [T-SPOT]) use among privately insured persons in the United States over a 15-year period. METHODS: We used current procedural terminology (CPT) codes for the TST and IGRAs to extract out-patient claims (2000-2014) and determined usage (claims/100,000). The chi2 test for trend in proportions was used to describe usage trends for select periods. RESULTS: The TST was the dominant (>80%) test in each year. Publication of guidelines preceded the assignment of QFT and T-SPOT CPT codes by 1 year (2006 for QFT; 2011 for T-SPOT). QFT usage was higher (P < 0.01) than T-SPOT in each year. The average annual increase in the use of QFT was higher than that of T-SPOT (35 vs. 3.8/100,000), and more so when the analytic period was 2011-2014 (65 vs. 38/100,000). However, during that 4-year period (2011-2014), TST use trended downward, with an average annual decrease of 28/100,000. The annual proportion of enrollees tested ranged from 1.1% to 1.5%. CONCLUSIONS: These results suggest a gradual shift from the use of the TST to the newer IGRAs. Future studies can assess the extent, if any, to which the shift from the use of the TST to IGRAs evolved over time.

BACKGROUND: Post-exposure prophylaxis administered to infants shortly after birth prevents approximately 90% of cases of perinatal Hepatitis B Virus (HBV) transmission. The Advisory Committee on Immunization Practices (ACIP) recommends that all pregnant women be tested for hepatitis B surface antigen (HBsAg) at an early prenatal visit during each pregnancy to detect active infection with HBV. This study sought to determine the proportion and characteristics of pregnant women tested\not tested according to ACIP recommendations METHODS:: We analyzed MarketScan databases to assess prenatal HBsAg testing among women with commercial and Medicaid health care coverage according to demographic and clinical characteristics. Pregnant women age 15-44 years continuously enrolled in a health plan in the MarketScan database during 2013 and 2014 and with a live birth in 2014 were included. RESULTS: Among commercially-insured women, 239,955 (87.7%) received HBsAg testing and 59.6% were tested during their first trimester. Among Medicaid-enrolled women, 57,268 (83.6%) received HBsAg testing and 39.4% were tested during their first trimester. Among women with high risk pregnancies, HBsAg testing occurred in 87.3% of those with commercial insurance and 84.8% with Medicaid. Testing also varied by maternal age; among women with commercial insurance, testing was greatest among women age 26-44 years, and among women with Medicaid, testing was greatest among younger women (15-25 years). Testing was lowest among women residing in the Northeast (commercial insurance only). CONCLUSION: Prenatal HBsAg testing identifies HBV-infected pregnant women so their infants can receive timely immunoprophylaxis. Efforts to optimize HBsAg testing among all pregnant women are needed to further prevent perinatal HBV transmission.

BACKGROUND: School-located vaccination against influenza (SLV-I) has the potential to improve current suboptimal influenza immunization coverage for U.S. school-aged children. However, little is known about SLV-I's cost-effectiveness. The objective of this study is to establish the cost-effectiveness of SLV-I based on a two-year community-based randomized controlled trial (Year 1: 2009-2010 vaccination season, an unusual H1N1 pandemic influenza season, and Year 2: 2010-2011, a more typical influenza season). METHODS: We performed a cost-effectiveness analysis on a two-year randomized controlled trial of a Western New York SLV-I program. SLV-I clinics were offered in 21 intervention elementary schools (Year 1 n = 9,027; Year 2 n = 9,145 children) with standard-of-care (no SLV-I) in control schools (Year 1 n = 4,534 (10 schools); Year 2 n = 4,796 children (11 schools)). We estimated the cost-per-vaccinated child, by dividing the incremental cost of the intervention by the incremental effectiveness (i.e., the number of additionally vaccinated students in intervention schools compared to control schools). RESULTS: In Years 1 and 2, respectively, the effectiveness measure (proportion of children vaccinated) was 11.2 and 12.0 percentage points higher in intervention (40.7 % and 40.4 %) than control schools. In year 2, the cost-per-vaccinated child excluding vaccine purchase ($59.88 in 2010 US $) consisted of three component costs: (A) the school costs ($8.25); (B) the project coordination costs ($32.33); and (C) the vendor costs excluding vaccine purchase ($16.68), summed through Monte Carlo simulation. Compared to Year 1, the two component costs (A) and (C) decreased, while the component cost (B) increased in Year 2. The cost-per-vaccinated child, excluding vaccine purchase, was $59.73 (Year 1) and $59.88 (Year 2, statistically indistinguishable from Year 1), higher than the published cost of providing influenza vaccination in medical practices ($39.54). However, taking indirect costs (e.g., averted parental costs to visit medical practices) into account, vaccination was less costly in SLV-I ($23.96 in Year 1, $24.07 in Year 2) than in medical practices. CONCLUSIONS: Our two-year trial's findings reinforced the evidence to support SLV-I as a potentially favorable system to increase childhood influenza vaccination rates in a cost-efficient way. Increased efficiencies in SLV-I are needed for a sustainable and scalable SLV-I program.

The reduction in morbidity and mortality associated with vaccine-preventable diseases in the United States has been described as one of the 10 greatest public health achievements of the first decade of the 21st century. A recent analysis concluded that routine childhood vaccination will prevent 322 million cases of disease and about 732,000 early deaths among children born during 1994-2013, for a net societal cost savings of $1.38 trillion. The National Immunization Survey (NIS) has monitored vaccination coverage among U.S. children aged 19-35 months since 1994. This report presents national, regional, state, and selected local area vaccination coverage estimates for children born from January 2011 through May 2013, based on data from the 2014 NIS. For most vaccinations, there was no significant change in coverage between 2013 and 2014. The exception was hepatitis A vaccine (HepA), for which increases were observed in coverage with both ≥1 and ≥2 doses. As in previous years, <1% of children received no vaccinations. National coverage estimates indicate that the Healthy People 2020 target* of 90% was met for ≥3 doses of poliovirus vaccine (93.3%), ≥1 dose of measles, mumps, and rubella vaccine (MMR) (91.5%), ≥3 doses of hepatitis B vaccine (HepB) (91.6%), and ≥1 dose of varicella vaccine (91.0%). Coverage was below target for ≥4 doses of diphtheria, tetanus, and acellular pertussis vaccine (DTaP), the full series of Haemophilus influenzae type b (Hib) vaccine, hepatitis B (HepB) birth dose,dagger ≥4 doses pneumococcal conjugate vaccine (PCV), ≥2 doses of HepA, the full series of rotavirus vaccine, and the combined vaccine series. section sign Examination of coverage by child's race/ethnicity revealed lower estimated coverage among non-Hispanic black children compared with non-Hispanic white children for several vaccinations, including DTaP, the full series of Hib, PCV, rotavirus vaccine, and the combined series. Children from households classified as below the federal poverty level had lower estimated coverage for almost all of the vaccinations assessed, compared with children living at or above the poverty level. Significant variation in coverage by state paragraph sign was observed for several vaccinations, including HepB birth dose, HepA, and rotavirus. High vaccination coverage must be maintained across geographic and sociodemographic groups if progress in reducing the impact of vaccine-preventable diseases is to be sustained.

OBJECTIVES: To assess and compare among parents of healthy children in urban and rural areas: (1) reported influenza vaccination status; (2) attitudes regarding influenza vaccination; and (3) attitudes about collaborative models for influenza vaccination delivery involving practices and public health departments. METHODS: A mail survey to random samples of parents from 2 urban and 2 rural private practices in Colorado from April 2012 to June 2012. RESULTS: The response rate was 58% (288/500). In the prior season, 63% of urban and 41% of rural parents reported their child received influenza vaccination (P < .001). No differences in attitudes about influenza infection or vaccination between urban and rural parents were found, with 75% of urban and 73% of rural parents agreeing their child should receive an influenza vaccine every year (P = .71). High proportions reported willingness to participate in a collaborative clinic in a community setting (59% urban, 70% rural, P = .05) or at their child's provider (73% urban, 73% rural, P = .99) with public health department assisting. Fewer (36% urban, 53% rural, P < .01) were likely to go to the public health department if referred by their provider. Rural parents were more willing for their child to receive vaccination outside of their provider's office (70% vs. 55%, P = .01). CONCLUSIONS: While attitudes regarding influenza vaccination were similar, rural children were much less likely to have received vaccination. Most parents were amenable to collaborative models of influenza vaccination delivery, but rural parents were more comfortable with influenza vaccination outside their provider's office, suggesting that other venues for influenza vaccination in rural settings should be promoted.

OBJECTIVES: Little is known about the impact closing a health care facility has on immunization coverage of children utilizing that facility as a medical home. The authors assessed the impact of closing a Medicaid managed care facility in Philadelphia on immunization coverage of children, primarily low income children from racial/ethnic minority groups, utilizing that facility for routine immunizations. STUDY DESIGN: Observational longitudinal cohort case study. METHODS: Eligible children were born 03/01/05-06/30/07, present in Philadelphia's immunization information system (IIS), and were active clients of the facility before it closed in September 2007. IIS-recorded immunization coverage at ages 5, 7, 13, 16 and 19 months through January 2009 was compared between clinic children age-eligible to receive specific vaccines before clinic closing (preclosure cohorts) and children not age-eligible to receive those vaccines prior to closing (postclosure cohorts). RESULTS: Of 630 eligible children, 99 (16%) had no additional IIS-recorded immunizations. Third dose DTaP vaccine coverage at age seven months among preclosure cohorts was 54.4% vs. 40.3% among postclosure cohorts [risk ratio 1.31 (1.15,1.49)]. Fourth dose DTaP coverage at 19 months was 65.9% vs. 57.7% [risk ratio 1.24 (1.08,1.42)]. MMR coverage at 16 months was 79.5% vs. 69.9% [risk ratio 1.47 (1.22, 1.76)]. Coverage for the 431331 vaccination series at 19 months was 63.8% vs. 53.8% [risk ratio 1.28 (1.12,1.88)]. CONCLUSIONS: Immunization coverage declined at key age milestones for active clients of a Medicaid managed care that closed as compared with preclosure cohorts of clients from the same facility. When a primary health care facility closes, efforts should be made to ensure that children who had received vaccinations at that facility quickly establish a new medical home.

BACKGROUND: Vaccination promotion strategies are recommended in Women, Infants, and Children (WIC) settings for eligible children at risk for under-immunization due to their low-income status. PURPOSE: To determine coverage levels of WIC and non-WIC participants and assess effectiveness of immunization intervention strategies. METHODS: The 2007-2011 National Immunization Surveys were used to analyze vaccination histories and WIC participation among children aged 24-35 months. Grantee data on immunization activities in WIC settings were collected from the 2010 WIC Linkage Annual Report Survey. Coverage by WIC eligibility and participation status and grantee-specific coverage by intervention strategy were determined at 24 months for select antigens. Data were collected 2007-2011 and analyzed in 2013. RESULTS: Of 13,183 age-eligible children, 5,699 (61%, weighted) had participated in WIC, of which 3,404 (62%, weighted) were current participants. In 2011, differences in four or more doses of the diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine by WIC participation status were observed: 86% (ineligible); 84% (current); 77% (previous); and 69% (never-eligible). Children in WIC exposed to an immunization intervention strategy had higher coverage levels than WIC-eligible children who never participated, with differences as great as 15% (DTaP). CONCLUSIONS: Children who never participated in WIC, but were eligible, had the lowest vaccination coverage. Current WIC participants had vaccination coverage comparable to more affluent children, and higher coverage than previous WIC participants.

In the United States, among children born during 1994-2013, vaccination will prevent an estimated 322 million illnesses, 21 million hospitalizations, and 732,000 deaths during their lifetimes. Since 1994, the National Immunization Survey (NIS) has monitored vaccination coverage among children aged 19-35 months in the United States. This report describes national, regional, state, and selected local area vaccination coverage estimates for children born January 2010-May 2012, based on results from the 2013 NIS. In 2013, vaccination coverage achieved the 90% national Healthy People 2020 target* for ≥1 dose of measles, mumps, and rubella vaccine (MMR) (91.9%); ≥3 doses of hepatitis B vaccine (HepB) (90.8%); ≥3 doses of poliovirus vaccine (92.7%); and ≥1 dose of varicella vaccine (91.2%). Coverage was below the Healthy People 2020 targets for ≥4 doses of diphtheria, tetanus, and pertussis vaccine (DTaP) (83.1%; target 90%); ≥4 doses of pneumococcal conjugate vaccine (PCV) (82.0%; target 90%); the full series of Haemophilus influenzae type b vaccine (Hib) (82.0%; target 90%); ≥2 doses of hepatitis A vaccine (HepA) (54.7%; target 85%); rotavirus vaccine (72.6%; target 80%); and the HepB birth dose (74.2%; target 85%). Coverage remained stable relative to 2012 for all of the vaccinations with Healthy People 2020 objectives except for increases in the HepB birth dose (by 2.6 percentage points) and rotavirus vaccination (by 4.0 percentage points). The percentage of children who received no vaccinations remained below 1.0% (0.7%). Children living below the federal poverty level had lower vaccination coverage compared with children living at or above the poverty level for many vaccines, with the largest disparities for ≥4 doses of DTaP (by 8.2 percentage points), full series of Hib (by 9.5 percentage points), ≥4 doses of PCV (by 11.6 percentage points), and rotavirus (by 12.6 percentage points). MMR coverage was below 90% for 17 states. Reaching and maintaining high coverage across states and socioeconomic groups is needed to prevent resurgence of vaccine-preventable diseases.

OBJECTIVE: To assess effectiveness and feasibility of public-private collaboration in delivering influenza immunization to children. METHODS: Four pediatric and four family medicine (FM) practices in Colorado with a common public health department (PHD) were randomized at the beginning of baseline year (10/2009) to Intervention (joint community clinics and PHD nurses aiding in delivery at practices); or control involving usual care without PHD. Generalized estimating equations compared changes in rates over baseline between intervention and control practices at end of 2nd intervention year (Y2=5/2011). Barriers to collaboration were examined using qualitative methods. RESULTS: Overall, rates increased from baseline to Y2 by 9.2% in intervention and 3.2% in control (p<.0001), with significant increases in both pediatric and FM practices. The largest increases were seen among school-aged and adolescent children (p<.0001 for both), with differences for 6-month-old to 5-year-old children and for children with high-risk conditions not reaching significance. Barriers to collaboration included uncertainty regarding the delivery of vaccine supplies, concerns about using up all purchased vaccine by practices, and concerns about documentation of vaccination if collaboration occurred. CONCLUSIONS: In spite of barriers, public-private collaboration resulted in significantly higher influenza immunization rates, particularly for older, healthy children who visit providers less frequently.

BACKGROUND: Although previous studies have found reminder/recall to be effective in increasing immunization rates, little guidance exists regarding the specific ages at which it is optimal to send reminder/recall notices. PURPOSE: To assess the relative effectiveness of centralized reminder/recall strategies targeting age-specific vaccination milestones among children in urban areas during June 2008-June 2009. METHODS: Three reminder/recall strategies used capabilities of the Michigan Care Improvement Registry (MCIR), a statewide immunization information system: a 7-month recall strategy, a 12-month reminder strategy, and a 19-month recall strategy. Eligible children were randomized to notification (intervention) or no notification groups (control). Primary study outcomes included MCIR-recorded immunization activity (administration of ≥1 new dose, entry of ≥1 historic dose, entry of immunization waiver) within 60 days following each notification cycle. RESULTS: A total of 10,175 children were included: 2,072 for the 7-month recall, 3,502 for the 12-month reminder, and 4,601 for the 19-month recall. Immunization activity was similar between notification versus no notification groups at both 7 and 12 months. Significantly more 19-month-old children in the recall group (26%) had immunization activity compared to their counterparts that did not receive a recall notification (19%). CONCLUSIONS: Although recall notifications can positively affect immunization activity, the effect may vary by targeted age group. Many 7- and 12-month-olds had immunization activity following reminder/recall; however, levels of activity were similar irrespective of notification, suggesting that these groups were likely to receive medical care or immunization services without prompting.

The Presidential Childhood Immunization Initiative was developed in 1993 to address major gaps in childhood vaccination coverage in the United States. Eliminating the cost of vaccines as a barrier to vaccination was one strategy of the Childhood Immunization Initiative; it led to Congressional legislation that authorized creation of the Vaccines for Children program (VFC) in 1994. CDC analyzed National Immunization Survey data for 1995-2011 to evaluate trends in disparities in vaccination coverage rates between non-Hispanic white children and children of other racial/ethnic groups. VFC has been effective in ireducing disparities in vaccination coverage among U.S. children. CDC's Office of Minority Health and Health Equity selected the intervention analysis and discussion that follows to provide an example of a program that has been effective in reducing childhood vaccination coverage-related disparities in the United States. At its inception in 1994, VFC was implemented in 78 Immunization Action Plan areas that covered the entire United States; within each area, concerted efforts were made to improve childhood vaccination coverage. The findings in this report demonstrate that there have been no racial/ethnic disparities in vaccine coverage for measles-mumps-rubella and poliovirus in the United States since 2005. Disparities in coverage for the diphtheria-tetanus-pertussis/diphtheria-tetanus-acellular pertussis vaccine were absent, declining, or inconsistent during this period, depending on the racial/ethnic group examined. The results in this report highlight the effectiveness of VFC.

During 2010-2011, varicella vaccination was an added requirement for school entrance in Wyoming. Vaccination exemption rates were compared during the 2009-2010 and 2011-2012 school years, and impacts of implementing a new childhood vaccine requirement were evaluated. All public schools, grades K-12, were required to report vaccination status of enrolled children for the 2009-2010 and 2011-2012 school years to the Wyoming Department of Health. Exemption data were analyzed by exemption category, vaccine, county, grade, and rurality. The proportion of children exempt for ≥1 vaccine increased from 1.2% (1,035/87,398) during the 2009-2010 school year to 1.9% (1,678/89,476) during 2011-2012. In 2011, exemptions were lowest (1.5%) in urban areas and highest (2.6%) in the most rural areas, and varicella vaccine exemptions represented 67.1% (294/438) of single vaccination exemptions. Implementation of a new vaccination requirement for school admission led to an increased exemption rate across Wyoming.

BACKGROUND: Influenza vaccination coverage for U.S. school-aged children is below the 80% national goal. Primary care practices may not have the capacity to vaccinate all children during influenza vaccination season. No real-world models of school-located seasonal influenza (SLV-I) programs have been tested. PURPOSE: Determine the feasibility, sustainability, and impact of an SLV-I program providing influenza vaccination to elementary school children during the school day. DESIGN: In this pragmatic randomized controlled trial of SLV-I during two vaccination seasons, schools were randomly assigned to SLV-I versus standard of care. Seasonal influenza vaccine receipt, as recorded in the state immunization information system (IIS), was measured. SETTING/PARTICIPANTS: Intervention and control schools were located in a single western New York county. Participation (intervention or control) included the sole urban school district and suburban districts (five in Year 1, four in Year 2). INTERVENTION: After gathering parental consent and insurance information, live attenuated and inactivated seasonal influenza vaccines were offered in elementary schools during the school day. MAIN OUTCOME MEASURES: Data on receipt of ≥1 seasonal influenza vaccination in Year 1 (2009-2010) and Year 2 (2010-2011) were collected on all student grades K through 5 at intervention and control schools from the IIS in the Spring of 2010 and 2011, respectively. Additionally, coverage achieved through SLV-I was compared to coverage of children vaccinated elsewhere. Preliminary data analysis for Year 1 occurred in Spring 2010; final quantitative analysis for both years was completed in late Fall 2012. RESULTS: Results are shown for 2009-2010 and 2010-2011, respectively: Children enrolled in suburban SLV-I versus control schools had vaccination coverage of 47% vs 36%, and 52% vs 36% (p<0.0001 both years). In urban areas, coverage was 36% vs 26%, and 31% vs 25% (p<0.001 both years). On multilevel logistic analysis with three nested levels (student, school, school district) during both vaccination seasons, children were more likely to be vaccinated in SLV-I versus control schools; ORs were 1.6 (95% CI=1.4, 1.9; p<0.001) and 1.5 (95% CI=1.3, 1.8; p<0.001). CONCLUSIONS: Delivering influenza vaccine during school is a promising approach to improving pediatric influenza vaccination coverage. TRIAL REGISTRY: ClinicalTrials.govNCT01224301.

OBJECTIVES: We evaluated the use of a statewide immunization information system (IIS) to target influenza vaccine reminders to high-risk children during a pandemic. METHODS: We used Michigan's IIS to identify high-risk children (i.e., those with ≥ 1 chronic condition) aged 6 months to 18 years with no record of pH1N1 vaccination among children currently or previously enrolled in Medicaid (n = 202 133). Reminders were mailed on December 7, 2009. We retrospectively assessed children's eligibility for evaluation and compared influenza vaccination rates across 3 groups on the basis of their high-risk and reminder status. RESULTS: Of the children sent reminders, 53 516 were ineligible. Of the remaining 148 617 children, vaccination rates were higher among the 142 383 high-risk children receiving reminders than among the 6234 high-risk children with undeliverable reminders and the 142 383 control group children without chronic conditions who were not sent reminders. CONCLUSIONS: Midseason reminders to parents of unvaccinated high-risk children with current or past Medicaid enrollment were associated with increased pH1N1 and seasonal influenza vaccination rates. Future initiatives should consider strategies to expand targeting of high-risk groups and improve IIS reporting during pandemic events.

School-located vaccination against influenza (SLV-I) has been suggested to help meet the need for annual vaccination of large numbers of school-aged children with seasonal influenza vaccine. However, little is known about the cost and cost-effectiveness of SLV-I. We conducted a cost-analysis and a cost-effectiveness analysis based on a randomized controlled trial (RCT) of an SLV-I program implemented in Monroe County, New York during the 2009-2010 vaccination season. We hypothesized that SLV-I is more cost effective, or less-costly, compared to a conventional, office-located influenza vaccination delivery. First and second SLV-I clinics were offered in 21 intervention elementary schools (n=9027 children) with standard of care (no SLV-I) in 11 control schools (n=4534 children). The direct costs, to purchase and administer vaccines, were estimated from our RCT. The effectiveness measure, receipt of ≥1 dose of influenza vaccine, was 13.2 percentage points higher in SLV-I schools than control schools. The school costs ($9.16/dose in 2009 dollars) plus project costs ($23.00/dose) plus vendor costs excluding vaccine purchase ($19.89/dose) was higher in direct costs ($52.05/dose) than the previously reported mean/median cost [$38.23/$21.44 per dose] for providing influenza vaccination in pediatric practices. However SLV-I averted parent costs to visit medical practices ($35.08 per vaccine). Combining direct and averted costs through Monte Carlo Simulation, SLV-I costs were $19.26/dose in net costs, which is below practice-based influenza vaccination costs. The incremental cost-effectiveness ratio (ICER) was estimated to be $92.50 or $38.59 (also including averted parent costs). When additionally accounting for the costs averted by disease prevention (i.e., both reduced disease transmission to household members and reduced loss of productivity from caring for a sick child), the SLV-I model appears to be cost-saving to society, compared to "no vaccination". Our findings support the expanded implementation of SLV-I, but also the need to focus on efficient delivery to reduce direct costs.

This study qualitatively assesses the acceptability and feasibility of a school-located vaccination for influenza (SLIV) project that was conducted in New York State in 2009-2011, from the perspectives of project participants with different roles. Fourteen in-depth semistructured interviews with participating schools' personnel and the mass vaccinator were tape-recorded and transcribed. Interviewees were randomly selected from stratified lists and included five principals, five school nurses, two school administrators, and two lead personnel from the mass vaccinator. A content analysis of transcripts from the interviews was completed and several themes emerged. All participants generally found the SLIV project acceptable. School personnel and the vaccinator viewed the SLIV project process as feasible and beneficial. However, the vaccinator identified difficulties with third-party billing as a potential threat to sustainability.

OBJECTIVE: Examine impact of provider chart audits and parental outreach in improving immunization coverage among children not up-to-date (NUTD) for immunizations in Philadelphia's immunization information system (IIS). METHODS: We identified 10-month-old children NUTD for age-appropriate immunizations using Philadelphia's IIS. Immunization rates at 10, 13, and 19 months were compared before and after contact with providers and parents. RESULTS: Of 5 610 children NUTD in the IIS at 10 months and living in areas with populations at risk for underimmunization, provider chart audits indicated that 3 612 (64%) were actually up-to-date (UTD); the majority of these (2 203) received additional age-appropriate immunizations and were also UTD at 19 months. Of 1 998 children truly NUTD at 10 months, half received overdue immunizations by 13 months following contact with parents via telephone, postcards, and home visits, but only 23 percent were UTD for age-appropriate vaccines at 19 months. CONCLUSIONS: Provider chart audits improved IIS data completeness, indicating that providers need to submit more complete and timely data to the IIS. Outreach to parents likely contributed to half of the children NUTD at 10 months receiving overdue immunizations by 13 months. However, most were again NUTD at 19 months, indicating that outreach efforts should be continued through 19 months or until children are brought UTD. Furthermore, in spite of outreach, about half of the NUTD children were not brought UTD by 13 or 19 months. New strategies should be developed to ensure that these children receive recommended vaccinations.