**Chapter 10.** **Population Assessment**

**Overview**

Goals for immunization programs have been set on many levels and serve
to keep programs focused and operating at their potential as well as to
improve the health status of the population. Continual evaluation of
national, state, and local immunization goals (in particular, Healthy
People 2010 objectives) is necessary for managing effective immunization
programs. At a minimum, grantees must report immunization assessment
measures requested by the grantee Annual Progress Report. This enables
managers to set objectives, plan strategies and direct limited program
resources rationally and effectively.

Several sources of data are available for determining progress in
various aspects of immunization. The National Immunization Survey (NIS)
provides immunization coverage data on children ages 19--35 months for
the 50 state and six city immunization grantees, and for other selected
city/county areas. Starting in 2006 the NIS was expanded to assess
adolescent vaccination with a national sample of children ages 13 to 17
years. An expansion of the NIS/Teen survey to provide grantee-level
estimates is under consideration. The Behavioral Risk Factor
Surveillance System (BRFSS) provides influenza and pneumococcal
vaccination data for adults age 18 years and older for all 50 states,
the District of Columbia, and Puerto Rico. Assessments of children
entering school (kindergarten and middle school) and child care centers
provide additional population data points, even though the ultimate
purpose of these surveys is to assure compliance with state vaccination
laws. Data collected for AFIX visits, and from immunization information
systems (IIS) may also provide useful vaccination coverage data. Data
from Medicaid, Medicare, and other health insurance plans may also be
available.

Some states have recently added immunization entry requirements for
middle school, junior high school, and high school grade levels. If
these grades are surveyed, the resulting data may be useful to generate
rough estimates of vaccine coverage among adolescents. Nationally, the
validity of these estimates will increase as more states add middle
school entry requirements.

The NIS, school and child care center--based surveys, and BRFSS provide
measures of progress toward national and state-specific *Healthy People
2010* immunization objectives. Achieving and maintaining 90% coverage
for each of the ACIP-recommended pediatric vaccines by the second
birthday remains the highest priority nationally. However, substantial
vaccine-preventable disease (VPD) morbidity is occurring in adolescent
and adult populations. Also, the VFC program has been expanded to cover
vaccines recently recommended for routine use in children ages 11-12
years (e.g., human papillomavirus vaccine; meningococcal conjugate
vaccine; tetanus, diphtheria and acellular pertussis vaccine).
Therefore, implementing programmatic interventions to increase
immunization levels among adolescents and adults in high risk groups is
important in order to reach the *Healthy People 2010* objectives for
these groups.

Independent surveys conducted by state and local public health agencies
may be beneficial to estimate coverage in smaller geographic areas or
special subpopulations such as certain racial or ethnic minorities,
Women, Infants, and Children (WIC) enrollees, adolescents, healthcare
workers, adults aged 65 years and older, and persons with medical
conditions that put them at high risk for VPDs for whom ACIP recommends
vaccination. Independent surveys can also be used for comparison to NIS,
BRFSS, and IIS data. In addition to estimating coverage directly,
programs can identify geographic areas with low vaccination coverage by
examining sociodemographic factors known to be associated with
under-immunization. Factors such as poverty, large family size, and low
maternal educational achievement often are associated with low
vaccination coverage.

**References**

-   NIS reports are available at <http://www.cdc.gov/nis/reports.htm>.
    Reports are also published periodically in the Morbidity and
    Mortality Weekly Report (MMWR). NIS public use data sets can be
    obtained at <http://www.cdc.gov/nis/datafiles.htm>.

-   BRFSS information and data are available at
    <http://www.cdc.gov/brfss/>.

-   Data from the Centers for Medicare and Medicaid Services (CMS)
    Minimum Data Set for long term care facilities are available at
    <http://www.medicare.gov/NHCompare/Home.asp>

-   US Department of Health and Human Services. Healthy People 2010. 2nd
    edition. With understanding and improving health and objectives for
    improving health (2 vols). Washington, DC: US Government Printing
    Office, 2000.

-   Healthy People 2010 Midcourse Review:
    <http://www.healthypeople.gov/data/midcourse/html/focusareas/FA14TOC.htm>

-   Technical Support for conducting school and child care center
    immunization surveys are available at
    <http://www.cdc.gov/nip/coverage/schoolsurv/overview.htm>.

-   Childcare and School Immunization Requirements 2005-2006.
    Immunization Services Division, National Center for Immunization and
    Respiratory Diseases, Centers for Disease Control and Prevention.
    April, 2007.

-   2008-2012 Immunization Program Operations Manual (IPOM) Chapters 1,
    3, 6, and 7

**Program Requirements**

**10.1 Identify and monitor groups of under-immunized children,
adolescents, and adults at higher risk for VPDs using immunization
coverage estimates (e.g., NIS data, retrospective analysis of school
immunization surveys, provider coverage assessments, IIS data, Medicare
billing data, BRFSS, and cluster surveys).**

> [Required activities]{.underline}
>
> 10.1a. Pre-school Children (children aged \<5 years)

-   Annually review trends in vaccination coverage for individual
    vaccines and vaccine series from the NIS.

-   Consider at least one other data source to annually identify trends
    in coverage and subgroups of under-immunized children (e.g.,
    retrospective analysis of school vaccination surveys to assess
    coverage at age 2 years, provider coverage assessments, IIS,
    Medicaid billing data, conduct household cluster survey, conduct
    cohort follow-up study using birth certificates or IIS population as
    the sampling frame; request use of grant funds for NIS oversampling
    of specific geographic areas within your jurisdiction). Ask your
    project officer for help in obtaining technical support for these
    kinds of projects.

> 10.1b. School-aged Children

-   See 10.2

> 10.1c. Adolescents/Teenagers

-   Consider at least one data source to monitor trends in coverage and
    subsets of under-immunized adolescents and teenagers (e.g., analysis
    of middle school vaccination surveys, provider coverage assessments,
    juvenile detention centers, STD clinics, IIS, Medicaid billing data,
    conduct household cluster survey, conduct cohort follow-up study
    using IIS population as the sampling frame).

> 10.1d. Adults

-   Annually review trends in influenza and pneumococcal vaccination
    coverage from the BRFSS, in adults aged ≥65 years, adults ages 50-64
    years, and adults aged \<65 years with selected high risk conditions
    (e.g., asthma, diabetes, heart disease, pregnancy).

-   Develop and maintain a relationship with the state BRFSS
    coordinator, provide feedback to the BRFSS coordinator and to CDC on
    CDC-proposed vaccination-related modules, and discuss how to
    implement BRFSS enhancements with the BRFSS coordinator (e.g., use
    of optional modules, state-added questions, and oversampling in an
    area of interest).

-   At least annually, review measures of influenza and pneumococcal
    vaccination for long-term care facilities in your jurisdictions,
    using results from the Minimum Data Set (MDS) available online or
    from tables provided by the CDC. Work with the Centers for Medicare
    and Medicaid Services (CMS) Quality Improvement Organization (QIO)
    serving your jurisdiction to identify and follow-up with facilities
    having low vaccination rates.

> *Performance Measure:* Percentage of children, adolescents,
> non-institutionalized adults, or institutionalized adults who have
> received specific vaccines or vaccine series, as specified by Healthy
> People 2010 objectives.
>
> *Target:* As specified by Healthy People 2010 objectives
>
> [Recommended activities]{.underline}
>
> 10.1e. Pre-school Children (children aged \<5 years)

-   Consider proposals to sample areas of interest in the NIS. At least
    two months prior to submitting the grant application, the CDC will
    need to assess the feasibility of the area proposed for NIS sampling
    and provide a cost estimate.

-   Consider pooling several years of NIS public use files to assess
    coverage in sociodemographic subgroups of interest within your
    jurisdiction.

-   Estimate program-wide immunization coverage of children who turn age
    2 years during a 1-year period, using a CDC-approved follow-back
    survey method (e.g., school retrospective survey collecting dates of
    vaccination, sampling based on birth certificates or children in an
    IIS).

-   Assess coverage rates among WIC, Medicaid and State Children's
    Health Insurance Program (SCHIP) populations.

-   Use existing coverage data and vaccine purchase information to
    monitor uptake of new and recently introduced vaccines, and take
    steps necessary to increase uptake within the context of the total
    immunization program.

-   Routinely obtain immunization coverage reports from managed care
    organizations (Medicaid and commercial) for age 2 years.

-   Use census data at the zip code or county level to identify
    geographic regions within your jurisdiction likely to have low
    vaccination coverage.

-   Measure immunization coverage and sociologic factors associated with
    non-immunization, using a community-based household cluster survey
    or telephone survey with a provider record check component. Cluster
    and telephone surveys are resource intensive and should be
    undertaken only in response to critical need (e.g., low or
    persistent declines in other indicators of immunization coverage;
    household cluster survey in areas without adequate telephone
    coverage).

-   Consider use of provider-based data collected for AFIX to assess
    coverage or identify under-immunized areas or population subgroups.
    Work with your CDC project officer to get support in selecting a
    representative sample for this project.

> 10.1f. School-aged Children

-   See 10.2

> 10.1g. Adolescents/Teenagers

-   Conduct a survey to determine the number of colleges and
    universities that require entering students to have MMR2, hepatitis
    B series, a Tdap booster, varicella vaccine, and meningococcal
    vaccine, and the number that offer HPV vaccine.

-   Routinely obtain immunization coverage reports from managed care
    organizations (Medicaid and commercial) for children ages 13-18
    years

> 10.1h. Adults

-   Consider use of CDC-sponsored optional modules (e.g., place where
    influenza vaccination received, month and year of most recent flu
    shot, high risk and healthcare worker status) on the BRFSS.

-   Consider including state-added questions of local interest to the
    BRFSS.

-   Consider oversampling in an area of interest using the BRFSS.

-   Consider surveys of long term care facilities to assess influenza
    vaccination of workers.

-   Consider surveys of healthcare facilities to assess influenza
    vaccination of workers.

-   Consider surveys of child care centers to assess influenza
    vaccination of workers.

-   Assess hepatitis B and HPV coverage rates at STD, HIV, correctional
    and other clinics, and facilities serving high risk populations.

-   Assess hepatitis B coverage rates among at-risk immigrant
    Asian-Pacific populations as appropriate.

-   Conduct a survey to determine the number of colleges and
    universities that require entering students to have MMR2, hepatitis
    B series, a Tdap booster, varicella vaccine and meningococcal
    vaccine.

-   Measure influenza vaccination coverage among women who were pregnant
    during the influenza season, using data on currently pregnant women
    from BRFSS, managed care databases, or WIC participants. In states
    participating in the Pregnancy Risk Assessment Monitoring System
    (PRAMS), work with the state PRAMS coordinator to include standard,
    CDC-developed influenza vaccination questions on the survey.

-   Routinely obtain immunization coverage reports from managed care
    organizations (Medicaid and commercial) for adults aged ≥65 years,
    and/or high risk subpopulations (e.g., persons with diabetes or
    chronic pulmonary diseases).

**10.2 Use a CDC-approved survey methodology to annually estimate
program-wide immunization coverage and exemption rates among children
entering kindergarten; report data and assessment methods to CDC
annually by April 30.  These data will be used to monitor progress
toward Healthy People objective 14.23, and will be available annually on
CDC\'s website and published periodically in the MMWR. Refer to "School
and Child Care Center Assessments: Instructions for Data Collection and
Reporting" and "Requirements for Using CDC Sampling Program" supporting
documents at the end of this chapter.**

> [Required activities]{.underline}
>
> 10.2a. Kindergarten Assessments

-   Assess vaccination status of each child on the day of entry into
    kindergarten. Use an approved survey methodology by following the
    procedure described in the guidance at the end of this chapter or by
    consulting with CDC staff for acceptable alternatives. If you are
    sampling rather than doing a census, use an approved sampling
    technique or ask for CDC to draw your sample. Submit your report
    each year by the deadline\--April 30.

> *Performance measure:* Percentage of children entering school who have
> received all recommended vaccines
>
> *Target:* At least 95% of all children entering kindergarten are
> up-to-date
>
> [Recommended activities]{.underline}
>
> 10.2b. Middle School Assessments

-   Assess vaccination status of each child on the day of entry into
    middle school. Use an approved survey methodology. If you are
    sampling rather than doing a census, use an approved sampling
    technique or ask for CDC to draw your sample. Submit your report
    each year by April 30.

> *Performance measure:* Percentage of children entering school who have
> received all recommended vaccines
>
> *Target:* At least 95% of children entering middle school are
> up-to-date
>
> 10.2c. Child Care Center Assessments

-   Assess vaccination status of each child on the day of the
    assessment. Use an approved survey methodology. If you are sampling
    rather than doing a census, use an approved sampling technique or
    ask for CDC to draw your sample. Submit your report each year by
    April 30.

> *Performance measure:* Percentage of child care facility enrollees who
> are age-appropriately immunized
>
> *Target:* \>95% are up-to-date
>
> 10.2d. School and Child Care Center Assessments - Other

-   Consider validating the completeness of immunization records from
    schools by confirming the immunization status of a subset of the
    schools and children within each school by comparing immunization
    histories held at the school with immunization histories at the
    child's medical provider.

-   For areas where IIS are available, consider integrating school and
    child care center vaccination data with the IIS.

**10.3 Monitor changes to state immunization requirements for child care
centers and schools. Include updated information on state immunization
requirements as part of the annual report to CDC on school data and
assessment methods.  This information will be available annually on
CDC\'s website and published periodically. **

> [Required activities]{.underline}
>
> 10.3a. Complete the section of the annual report that deals with state
> immunization requirements. Ensure that the information on state
> requirements is updated annually. This report is due by April 30 each
> year.

**10.4 Additional Activities**

> [Recommended activities]{.underline}
>
> 10.4a. Conduct a retrospective analysis. Expand your assessment data
> collection for a portion of your sample to include vaccination dates.
> Analyze the data to determine the vaccination status of kindergarten
> children when they were age 2 years.

**School and Child Care Center Assessments**

**Instructions for Data Collection and Reporting**

The annual school coverage report should include kindergarten. Inclusion
of middle school and child care center data is recommended but not
required.

[Monitoring vaccinations]{.underline}. Monitor vaccines based on ACIP
recommendations, not just state law. If an ACIP-recommended vaccine is
not required in your state but it is recorded in the vaccination record
at the school, monitor and report on that vaccine. For example, if your
state does not require a vaccination for mumps but the record notes that
the child received MMR, monitor and report on mumps coverage in your
state based on the MMR coverage.

-   In your annual report, you will be asked to report coverage based on
    ACIP recommendations. For example, 3+ polio vaccinations are
    required for children aged 19 months and older. You need to monitor
    and count 3+ polio as up-to-date (UTD) and less than that as not
    UTD.

-   For child care center children aged 19 months and older, UTD will
    consist of the following:

    -   4+ Diphtheria

    -   4+ Tetanus

    -   4+ Pertussis

    -   3+ Polio

    -   1 Measles

    -   1 Mumps

    -   1 Rubella

    -   3+ Hib

    -   3+ HepB

    -   1+ Varicella

    -   4+ PCV

> \*Grantees have 2 years from the date of changes in dosing
> recommendations to adjust their assessment practices to reflect the
> change.
>
> For child care center children aged 19 months and younger, UTD status
> should be calculated based on age.

-   For kindergarten, UTD will consist of the following:

    -   4+ Diphtheria

    -   4+ Tetanus

    -   4+ Pertussis

    -   3+ Polio

    -   1 Measles

    -   1 Mumps

    -   1 Rubella

    -   2nd MMR or 2nd dose measles

    -   3+ HepB

    -   2 Varicella

    -   4+ PCV

> \*Grantees have 2 years from the date of changes in dosing
> recommendations to adjust their assessment practices to reflect the
> change.

-   For middle school, UTD will consist of the following:

    -   Tdap/Td

    -   3 HepB

    -   2 MMR

    -   1+ Varicella (2 Varicella in 2008\*)

    -   1 Meningococcal Conjugate Vaccine

> \*Grantees have 2 years from the date of changes in dosing
> recommendations to adjust their assessment practices to reflect the
> change.
>
> [Timing of the assessment of immunization status]{.underline}. You can
> do your assessment any time before the due date (April 30); however,
> the data that you report should be based on the child's immunization
> status at school entry for kindergarten and middle school. The data
> for child care centers should reflect immunization status at the time
> of the assessment.

[Data collection]{.underline}:

-   Collect information on the number of doses of each vaccine received,
    not merely on UTD status as defined by state law or regulation. If
    this has not been your policy in the past, CDC will assist you in
    developing a new methodology that will work within the available
    resources.

-   For validation audits and for follow-up with children not UTD, dates
    of vaccination should be collected if possible.

-   Data for kindergarten and middle school should reflect vaccination
    status **at entry** and before follow-up by health departments. This
    will provide assessment of coverage at entry and a baseline for
    evaluation of follow-up efforts.

-   The Family Educational Rights and Privacy Act (FERPA) (20 USC
    §1232g, 34 CFR Part 99) is a federal law that protects the privacy
    of school education records. With very limited exceptions, FERPA
    requires written parental consent (or the consent of an adult aged
    18 years or older or attending an institution of postsecondary
    education) for the disclosure of any personally identifiable
    information from the education record. The law applies to all
    schools that receive U.S. Department of Education funds.
    Immunization information is considered part of the education record.

    -   Unless the disclosure falls under one of the specified
        exceptions, signed and dated written consent must: (1) specify
        the records that may be disclosed; (2) state the purpose of the
        disclosure; and (3) identify the party or class of party to whom
        the disclosure may be made. (34 CFR 99.30)

    -   More information on FERPA is available on the U.S. Department of
        Education website at
        <http://www.ed.gov/policy/gen/guid/fpco/ferpa/index.html>

-   Since FERPA generally requires consent for the disclosure of
    identifiable information from the education record, there are two
    options for compliance:

    -   Obtain written consent: Develop a FERPA compliant consent form
        that includes the information specified above. Discuss the
        logistics for obtaining consent with the school and develop a
        mutually acceptable plan. Note that consent is only required
        when obtaining personally identifiable information; it is not
        required for aggregate data.

    -   Obtain information that does not identify an individual: Ask the
        school to remove any information that would identify a specific
        child before public health has access to the record. Until we
        receive more guidance from the U.S. Department of Education, CDC
        recommends requesting that only the child's month and year of
        birth and immunization history be shared. If the Department of
        Education provides additional guidance on this issue, grantees
        will be notified, and the information will be incorporated in
        the revised IPOM. For validation audits that assess
        age-appropriateness and valid spacing of vaccine doses, or
        include follow-up for children in need of additional
        vaccinations, the month, day and year of birth would be needed
        for the most accurate assessment.

> [Report Scope]{.underline}. Report the scope of the survey for all
> grade levels---preschool, kindergarten, middle school. That will
> include:

-   Type of sample

-   Types of schools surveyed

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-   Report on the details of the data collection

    -   Who collected the data?

    -   Is the child care center/school immunization record signed by a
        provider (doctor, nurse, clinic, health department, physician's
        assistant)?

    -   How many child care centers/kindergartens and middle schools are
        in the state?

    -   How many of the child care centers/schools did you survey?

    -   How many children in child care centers/kindergartens and middle
        schools did you survey?

    -   How many children did not have immunization records?

    -   How many children were excluded from child care centers,
        kindergartens and middle schools because they were not UTD?

    -   How many children had medical, religious, philosophical, or
        temporary exemptions?

    -   Is each child care center, kindergarten, and middle school
        immunization record signed by a provider (doctor, nurse,
        physician's assistant, clinic or health department)?

-   Report on coverage of new ACIP recommendations

    -   2 years after a recommendation is added, coverage on the new
        vaccine will be required for your report to CDC.

**Requirements for Using CDC Sampling Program**

If you would like CDC to help you select a two-stage sample (random
sample of schools/child care centers, random sample of children within
the schools), we need the following information from you:

-   What is your estimated coverage rate for the vaccine that you think
    has the lowest coverage? Use the results of previous surveys to
    estimate this coverage.

-   How precise do you want your coverage estimate to be? Many states
    select ±5%, but you can choose ±7% or ±10%. The more precision you
    want, the larger your sample will need to be.

-   How many records do you want to review (or have reviewed by trained
    staff) in each school? The recommended number is 30 (or all students
    if the class size is less than 30).

-   We need you to send us an Excel file with the school/facility name
    and estimated enrollment or capacity. Include in that file anything
    you would like to have in the electronic report to you. For
    instance, you might like the school address, contact, or phone
    number to be in the final report.