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Immunization registry as a digital assessment tool during outbreaks

2020; Elsevier BV; Volume: 27; Issue: 2 Linguagem: Inglês

10.1016/j.cmi.2020.09.009

1469-0691

Chen Stein‐Zamir, Avi Israeli, Itamar Grotto,

Child and Adolescent Health

Computerized immunization registries assemble individual vaccinations data in a national database, enabling vaccination coverage monitoring and planning to sustain and increase coverage [[1]Derrough T. Olsson K. Gianfredi V. Simondon F. Heijbel H. Danielsson N. et al.Immunisation information systems—useful tools for monitoring vaccination programmes in EU/EEA countries.Euro Surveill. 2016; 2017: 30519Google Scholar]. Globally, as of 2018, 90% of children received one diphtheria, tetanus and pertussis (DTP) vaccine dose, and 86% received three DTP doses and one dose of measles-containing vaccine, with coverage rates differing between regions, nations and inside countries [[2]Peck M. Gacic-Dobo M. Diallo M.S. Nedelec Y. Sodha S.V. Wallace A.S. Global routine vaccination coverage.MMWR Morb Mortal Wkly Rep. 2018; 2019: 937-942Google Scholar]. Even in locations with high coverage, unvaccinated pockets occur when eligible children are not immunized with recommended vaccines, putting them at risk for illness and limiting herd immunity [[3]Davis M.M. Shah S.K. Outbreaks of vaccine-preventable diseases: responding to system failure with national vaccination requirements.JAMA. 2019; 322: 33-34Crossref PubMed Scopus (5) Google Scholar]. Consequently, vaccination coverage rates against highly contagious pathogens such as the measles virus are inadequate to prevent disease spread and outbreaks [[4]Holzmann H. Wiedermann U. Mandatory vaccination: suited to enhance vaccination coverage in Europe? [editorial].Euro Surveill. 2019; 24: 1900376Crossref Scopus (9) Google Scholar]. Here we describe the practical utilization of Israel's national immunization registry as a digital public health tool during outbreaks of vaccine-preventable diseases. The population of Israel is 9.1 million; children (age 0–17 years) comprise a third of the population. The annual birth cohort was 184 370 in 2018. Health records in Israel identify individuals on the basis of unique identification numbers. By law, all births are notified; they are reported to the Ministry of Interior, and newborns receive identification numbers shortly after birth. Routine childhood vaccinations are offered without charge to all children, although vaccinations are not mandatory. Routine vaccinations are provided at community-based child-health clinics for young children (birth to 6 years) and by school health services for schoolchildren (6–15 years) [[5]Rubin L. Belmaker I. Somekh E. Urkin J. Rudolf M. Honovich M. et al.Maternal and child health in Israel: building lives.Lancet. 2017; 389: 2514-2530Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar]. The routine childhood vaccine schedule for children in Israel is presented in Table 1.Table 1Routine vaccination schedule, Israel, 2019VaccineRecommended ageInfants and toddlers Hepatitis B virus (HBV)Birth, 1 and 6 months Diphtheria, tetanus, acellular pertussis, polio, Haemophilus influenzae type b (DTaP-IPV-Hib)2, 4, 6 and 12 months Rotavirus (Rota)2, 4 and 6 months Pneumococcal conjugate (PCV)2, 4 and 12 months Polio oral bivalent (bOPV)6 and 18 months Measles, mumps, rubella, varicella (MMRV), first dose12 months Hepatitis A virus (HAV)18 and 24 monthsSchoolchildrenMeasles, mumps, rubella, varicella (MMRV), second doseGrade 1 (age 6–7 years) Diphtheria, tetanus, acellular pertussis, polio (Tdap-IPV)Grade 2 (age 7–8 years) InfluenzaGrades 2, 3 and 4 (age 7–10 years) Diphtheria, tetanus, acellular pertussis (Tdap)Grade 8 (age 13–14 years) Human papilloma virus (HPV)Grade 8 (age 13–14 years), 2 dosesSource: State of Israel, Ministry of Health, ‘Vaccines for Babies and Children’, https://www.health.gov.il/English/Topics/Pregnancy/Vaccination_of_infants/Pages/default.aspx. Open table in a new tab Source: State of Israel, Ministry of Health, ‘Vaccines for Babies and Children’, https://www.health.gov.il/English/Topics/Pregnancy/Vaccination_of_infants/Pages/default.aspx. The national immunization registry started as a pilot project involving six clinics in September 2009 (Fig. 1). Within several years, it gradually expanded to include all routine childhood vaccinations, which were collected from electronic health records in child-health clinics and school health services nationally. The database currently incorporates data on vaccine doses and dates, characteristics of children (ID number, name, date of birth) and sociodemographic information [[6]Stein-Zamir C. Zentner G. Tallen-Gozani E. Grotto I. The Israel national immunization registry.Isr Med Assoc J. 2010; 12: 296-300PubMed Google Scholar]. Ongoing vaccination coverage rate monitoring based on national immunization registry data was first utilized during the 2013 polio vaccination campaign. In June 2013, Israel reported to the World Health Organization the isolation of wild poliovirus type 1 (WPV1) in sewage samples from southern Israel (mainly in Arab Bedouin communities); no paralytic polio cases were reported [[7]Moran-Gilad J. Kaliner E. Gdalevich M. Grotto I. Public health response to the silent reintroduction of wild poliovirus to Israel, 2013–2014.Clin Microbiol Infect. 2016; 22: S140-S145Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar]. The containment measures combined enhanced environmental and clinical surveillance, health promotion and immunization campaigns. The campaigns included inactivated polio vaccine (IPV) catch-up vaccinations in June–July 2013, as well as the polio oral bivalent (bOPV; Sabin 1 and Sabin 3 polio vaccine strains) ‘2 Drops’ campaign, which started in August 2013 in the southern district and expanded nationwide in 2 weeks. The bOPV vaccine was introduced in 2013 (as a supplemental immunization) in response to WPV1 transmission and later was included in the routine schedule. Most of the 1.2 million target cohort (children under 10 years old) were rapidly vaccinated, with coverage rates 79% nationally and 90% in southern Israel. The cumulative numbers of vaccine doses and coverage rates were monitored daily via the registry; rates were calculated for localities, districts and nationally. The ongoing monitoring provided timely data on coverage and campaign performance supporting decision making. The control of the WPV1 event was successful [[7]Moran-Gilad J. Kaliner E. Gdalevich M. Grotto I. Public health response to the silent reintroduction of wild poliovirus to Israel, 2013–2014.Clin Microbiol Infect. 2016; 22: S140-S145Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar]. During 2014–2017, the vaccination registry was technologically improved as a computerized population-based database. The registry data showed overall high vaccination coverage rates (>95% for measles, mumps and rubella vaccine (MMR1)/measles, mumps, rubella and varicella vaccine (MMRV1) and combined diphtheria, tetanus, acellular pertussis, polio, Haemophilus influenza type b (DTaP-IPV-Hib4) at age 2 years in 2017). Yet according to the schedule, vaccination timeliness was inappropriate, with MMR1/MMRV1 due at 12 months having a 66% coverage rate at 13 months, and DTaP-IPV-Hib4 due at 12 months having a 79% coverage rate at 18 months. The accumulation of unvaccinated susceptible children, especially among high-risk overcrowded population groups, has been associated with vaccine-preventable disease outbreaks (measles, mumps and pertussis) [[8]Stein-Zamir C. Israeli A. Timeliness and completeness of routine childhood vaccinations in young children residing in a district with recurrent vaccine-preventable disease outbreaks.Jerusalem Isr Euro Surveill. 2019; 24: 1800004Google Scholar]. In a 2015 pertussis outbreak in Jerusalem, 104 cases occurred in infants under 1 year, with three infant deaths. An accelerated pertussis vaccination programme at ages 6, 10 and 14 weeks was used (the routine schedule is 2, 4 and 6 months). The vaccination registry was used at the district level to evaluate real-time vaccination coverage as well as programme progress and effectiveness [[9]Stein-Zamir C. Sokolov I. Abramson N. Shoob H. Pertussis outbreak in infants and an immunization campaign based on providing pertussis vaccine doses at 6 weeks, 10 weeks, and 14 weeks.Pediatr Infect Dis J. 2019; 38: e63-e64Crossref PubMed Scopus (1) Google Scholar]. The national immunization registry was utilized in the measles outbreak in Israel (n = 4300 notified cases) during March 2018 to July 2019. About 2200 cases occurred in the Jerusalem district; 8% to 10% were hospitalized (the leading complication was pneumonia/pneumonitis), and there were 3 deaths. Most cases in Jerusalem occurred in children in Jewish ultraorthodox communities; 75% were younger than 15 (median age was 5 years), and 85% were unvaccinated [[10]Ben-Chetrit E. Oster Y. Jarjou’i A. Megged O. Lachish T. Cohen M.J. et al.Measles-related hospitalizations and associated complications in Jerusalem.2018–2019 Clin Microbiol Infect. 2020; 26: 637-642Scopus (6) Google Scholar,[11]Stein-Zamir C. Abramson N. Shoob H. Notes from the field: large measles outbreak in Orthodox Jewish communities—Jerusalem District, Israel, 2018–2019.MMWR Morb Mortal Wkly Rep. 2020; 69: 562-563Crossref PubMed Scopus (4) Google Scholar]. The ultraorthodox population is heterogeneous; subgroups reside in defined neighbourhoods characterized by large households and overcrowding. An outbreak control programme considering the affected communities' sociocultural features was promptly applied. The programme included a mass measles vaccination campaign focusing on eligible unvaccinated children (age 1–14 years). Unvaccinated children were detected through the registry, and outreach was performed via community-based activities. The campaign included lengthening the hours that child-health clinics were open; families were encouraged to bring all unvaccinated children in without scheduling appointments beforehand. Additionally, to improve accessibility, a mobile unit traveled though affected neighbourhoods offering measles vaccinations, which resulted in high compliance. All the measles campaign locations were linked online to the registry. This enabled a two-way link: receiving information on the child vaccination status and reporting on vaccines administered. The number of measles vaccine doses and coverage rates were monitored daily. The coverage rates were determined for each child-health clinic (thus representing the specific neighbourhood) for localities, districts and nationally. The vaccination campaign led to increase of MMR1/MMRV1 coverage rates from 80% to 95% within 3 months among children in affected neighbourhoods, and it led to a marked decline in measles incidence [[11]Stein-Zamir C. Abramson N. Shoob H. Notes from the field: large measles outbreak in Orthodox Jewish communities—Jerusalem District, Israel, 2018–2019.MMWR Morb Mortal Wkly Rep. 2020; 69: 562-563Crossref PubMed Scopus (4) Google Scholar]. Immunization registries should provide monitoring of national vaccination programmes and support interventions intended to establish herd immunity [[1]Derrough T. Olsson K. Gianfredi V. Simondon F. Heijbel H. Danielsson N. et al.Immunisation information systems—useful tools for monitoring vaccination programmes in EU/EEA countries.Euro Surveill. 2016; 2017: 30519Google Scholar,[12]Lopalco P.L. The role of surveillance in assuring mutual protection for vaccine-preventable diseases.Clin Microbiol Infect. 2016; 22: S85-S88Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. Israel's immunization registry has been planned to facilitate vaccination coverage monitoring [[6]Stein-Zamir C. Zentner G. Tallen-Gozani E. Grotto I. The Israel national immunization registry.Isr Med Assoc J. 2010; 12: 296-300PubMed Google Scholar]. The overall national immunization coverage rates are high; however, in recent years, vaccine-preventable diseases outbreaks emerged in specific communities (e.g. Arab Bedouin and Jewish ultraorthodox communities). Susceptibility to outbreaks increased even with a moderate decline in vaccination coverage rates or within undervaccinated pockets [[8]Stein-Zamir C. Israeli A. Timeliness and completeness of routine childhood vaccinations in young children residing in a district with recurrent vaccine-preventable disease outbreaks.Jerusalem Isr Euro Surveill. 2019; 24: 1800004Google Scholar,[10]Ben-Chetrit E. Oster Y. Jarjou’i A. Megged O. Lachish T. Cohen M.J. et al.Measles-related hospitalizations and associated complications in Jerusalem.2018–2019 Clin Microbiol Infect. 2020; 26: 637-642Scopus (6) Google Scholar,[11]Stein-Zamir C. Abramson N. Shoob H. Notes from the field: large measles outbreak in Orthodox Jewish communities—Jerusalem District, Israel, 2018–2019.MMWR Morb Mortal Wkly Rep. 2020; 69: 562-563Crossref PubMed Scopus (4) Google Scholar]. Furthermore, childhood vaccinations delays are prevalent and are associated with difficulties in preventive services utilization, organizational constrains and insufficient vaccine-relevant knowledge among parents [[5]Rubin L. Belmaker I. Somekh E. Urkin J. Rudolf M. Honovich M. et al.Maternal and child health in Israel: building lives.Lancet. 2017; 389: 2514-2530Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar,[8]Stein-Zamir C. Israeli A. Timeliness and completeness of routine childhood vaccinations in young children residing in a district with recurrent vaccine-preventable disease outbreaks.Jerusalem Isr Euro Surveill. 2019; 24: 1800004Google Scholar]. The role of an immunization registry was demonstrated in the recent New York measles outbreak of 2018–19 (after virus was imported from Israel), with 649 confirmed cases, mainly occurring in unvaccinated children in the orthodox Jewish community, 81% of whom were younger than 18. The New York Citywide Immunization Registry (established in 1996) was utilized to provide high-quality data on immunization coverage rates and to assess the vaccination campaign [[13]Zucker J.R. Rosen J.B. Iwamoto M. Arciuolo R.J. Langdon-Embry M. Vora N.M. et al.Consequences of undervaccination—measles outbreak, New York City, 2018–2019.N Engl J Med. 2020; 382: 1009-1017Crossref PubMed Scopus (22) Google Scholar]. Israel's immunization registry has progressively turned into a useful digital tool. Future challenges include linking the preventive and primary care health records to improve continuity of care. The child's immunization history would be available without depending on paper records. Electronic health record linkage would provide health professionals (in various facilities) and consumers with personalized, updated immunization data. As a public health strategy, the Ministry of Health should issue regular vaccination coverage rate reports that are based on registry data. Reports should be published on a national level and by age groups; in addition, reports should focus on population groups according to geographic area, socioeconomic status and so on. These data will support planning and evaluation of appropriate interventions in areas and groups with low vaccination coverage rates. In conclusion, ongoing vaccination coverage monitoring by an immunization registry in regular circumstances lays the ground for its utilization in emergencies. The focus of surveillance and monitoring should be on provision of continuous support to the national vaccination programmes' long-term sustainability. All authors report no conflicts of interest relevant to this article. The authors wish to acknowledge Nesia Cohen (Computing Division, Ministry of Health, Jerusalem, Israel) and Ilana Stolerman (Public Health Services, Ministry of Health, Jerusalem, Israel). The authors also acknowledge the dedicated public health nurses in Israel's mother-and-child health clinics.