U.S. Department of  Health  and  Human Services  
Office of Inspector General  
 
Challenges With  Vaccination  
Data Hinder State and Local 
Immunization Program  Efforts  
To Combat COVID-19  
Ann Maxwell  
Deputy  Inspector General   
   for Evaluation and Inspections   
January  2023, OEI-05-22-00010   U.S.  Department of Health and  Human Services  
Office  of  Inspector  General  
Report in Brief  
January  2023,  OEI-05-22-00010  
Why OIG Did This   Challenges With Vaccination  Data Hinder  State  
Review  
and Local Immunization  Program  Efforts  To 
Successful national vaccination  
campaigns and routine   Combat COVID-19   
vaccination efforts depend on  
complete and timely vaccination  
What OIG Found  
data being available to State and  Key Takeaway  
State and local immunization  programs reported 
local immunization programs.    Many  State  and  local 
experiencing challenges  in obtaining data for their 
The  Centers for Disease Control  
immunization  programs  reported   immunization  databases  both from  Federal agencies  
and Prevention (CDC)  relies on  
having  incomplete  individual - that provide vaccinations  and from  retail pharmacies  
State and local immunization  
level  data  for  the more than  250   that receive vaccines from  CDC  (to which we refer as  
programs  to monitor vaccination  
million  COVID -19  vaccine  doses  retail pharmacy partners).   As of December 2021,  
coverage and to  plan strategies  
administered  by  Federal agencies   nearly all State and local immunization programs  
to increase uptake among 
and  retail pharmacies  that  receive  reported that they were not receiving  individual-level  
communities with low coverage.   
vaccines directly  from  CDC.    data  on vaccinations from at least one of  the  three 
To fulfill this important role,  
These programs  rely  on   Federal agencies  with the largest vaccination  
immunization programs need 
individual -level data  in  their   programs:  the Department of  Veterans  Affairs  (VA),  
complete and accurate  
the  Department of Defense  (DoD), and/or  the  Indian 
individual-level vaccination data  immunization  databases  to  
Health Service  (IHS).   Most  programs  reported that  
from  all providers.    manage  vaccination  campaigns.    
they  received data from retail pharmacy partners,  
Comprehensive data are   but the data were  was often incomplete, inaccurate, or delayed.   Federal agencies and retail  
important for State and local  pharmacy partners are not required to submit vaccination data to immunization programs.  
immunization programs;  
Immunization programs said that without complete individual-level vaccination data, they  
however, two key types of  
struggled to accurately measure vaccination coverage and to  target outreach to  
providers are not required to  
unvaccinated and vulnerable populations.   Because State and local immunization databases  
submit individual-level data to  
contain data on all types of vaccinations, if left unresolved, these challenges will likely hinder  
immunization programs 
the ongoing COVID-19 vaccination campaign,  responses  to  future public health emergencies,  
databases: Federal agencies and 
and routine vaccination campaigns (e.g., flu shots).   
retail  pharmacies that partner 
with the Federal government.    State and local immunization  programs said that  they need  help from CDC to obtain 
Combined, these two types of   comprehensive vaccination  data.  Immunization databases are operated by 64 separate  
providers have already   States, cities, and territories, with varying policies and technological capabilities.   Federal 
administered over 250 million   agencies and retail pharmacy partners  agreed to  submit COVID-19 vaccination data either  to  
COVID-19 vaccine doses.    State and local  immunization  databases or  directly  to CDC.   CDC reported that it was  
determined that Federal agencies would transmit data directly to CDC only, rather than to  
How OIG Did This 
immunization databases,  because of  policy and technical challenges  that could not be  
Review   resolved  in the necessary timeframe.  Retail  pharmacy partners  often do not share these  
In December 2021,  we  challenges,  and CDC  reported  encouraging  them  to  submit  data directly  to immunization 
administered a survey to 56   databases.   The Federal government  set up  systems  outside of State and local immunization  
State and local immunization   databases  to help share  data that CDC receives  with immunization programs,  but the data  it  
programs that have   shares  are aggregated, and  programs reported  that  these aggregate data  were not sufficient 
immunization  databases.  We  to  comprehensively  monitor their vaccination campaigns.  To meet this need  in the long  
asked immunization programs   term,  CDC  established and  is working to set up  the  Immunization Gateway (IZ Gateway) 
whether  they  receive COVID-19  a  data-exchange system intended to connect Federal agencies with immunization  
vaccination data from  Federal  programsbut programs reported that it has been delayed.   Given the complexity of  
agencies and retail pharmacy   collecting and sharing data across the many different stakeholders that make up the  Nations  
partners; whether they   public health system,  CDC has  publicly called for  updated  data authority to  better  address  
experience challenges in   public health concerns.   However, there are steps CDC can take in the interim to  help  address  
obtaining complete and accurate   immunization program  needs.  
data; and how these challenges  
impact their vaccination  
campaigns, if at all.      
What OIG  Recommends and How the Agency Responded  
We recommend that  CDC (1) work with State and local immunization programs,  and retail 
pharmacy partners, to  mitigate  reported data gaps and timeliness  challenges  and (2) provide  
educational outreach to ensure  that  State and local immunization programs  are aware of  
existing  tools to address  vaccination  campaign needs.   CDC nonconcurred with our first 
recommendation and concurred with our second  recommendation.   
   
KEY FINDINGS  
Challenges with data  on  vaccines  administered by Federal vaccination  
providers  hindered  State  and  local immunization programs  efforts to  
comprehensively monitor  COVID-19 vaccination  coverage.  
State and local immunization  programs reported  that  they did not receive 
individual-level data  on vaccines  administered  by  Federal agencies.   
Federal agencies  may submit data either  to  State and local  immunization databases or  
to CDC.   However,  CDC  reported to OIG that it was determined  that Federal agencies  
should  submit data to  CDC  for efficiency related  to policy  and technical  challenges in 
establishing connections  to immunization databases.   CDC shares aggregated Federal  
agency  data with  State and local  immunization programs, but some programs  
reported  that these  aggregate  data were  not sufficient  for individual-level monitoring.  
VA has administered over 7.4  44 of the 56 immunization programs 
million COVID-19 vaccinations  reported not receiving any individual
level vaccination data from VA 
DoD has administered over 7.5  42 of the 56 immunization programs 
million COVID-19 vaccinations  reported not receiving any individual
level vaccination data from DoD 
1l1ti 
    IHS has administered over 2.2  16 of 25 immunization programs 
million COVID-19 vaccinations  reported challenges obtaining 
individual-level vaccination data from 
IHS 
 
Source: CDC  COVID-19 Data Tracker, OIG analysis of survey  results, 2022.1   
State and local immunization programs reported challenges with  data on  
individual-level vaccine administration  received  from pharmacies that  
partner  with  the Federal government.  
While Federal retail pharmacy providers may submit  data either  to  immunization  
databases or to CDC,  CDC  reported to OIG that pharmacies were encouraged  to  
submit vaccination data to immunization databases because many pharmacies  
already have connections established.  
Retail pharmacies partnering with  44 of the 56 immunization programs 
eJll 
the Federal government have  reported not receiving complete, 
administered over 234.9 million  accurate, and timely data from all 
COVI D-19 vaccinations  Federal retail pharmacy providers 
 
Source:  CDC Federal Retail Pharmacy Program, OIG analysis  of survey results, 2022.2  TABLE OF CONTENTS  
 
 
BACKGROUND ................................................................................................................................................  1  
FINDINGS ......................................................................................................................................................... 8  
Most State and local immunization programs did not receive individual-level data on vaccinations  
administered by at least  one Federal agency, and  programs reported challenges with the limited data  
received.........................................................................................................................................................................................  8  
Although most immunization programs received individual-level data on vaccines  administered by  
retail pharmacy partners, many reported challenges with the data .................................................................... 11  
With insufficient vaccination data, some immunization programs reported struggling to monitor  
vaccination campaigns, despite Federal efforts  .......................................................................................................... 12  
CONCLUSION AND RECOMMENDATIONS ...........................................................................................  17  
Work  with State and local immunization programs and retail pharmacy partners to mitigate reported  
data gaps and timeliness challenges ............................................................................................................................... 18  
Provide educational outreach to ensure that State and local immunization programs are aware of  
existing tools to address  vaccination  campaign needs ............................................................................................ 18  
AGENCY COMMENTS AND OIG RESPONSE  .........................................................................................  19  
DETAILED METHODOLOGY ......................................................................................................................  20  
APPENDIX .....................................................................................................................................................  22  
Agency Comments  ................................................................................................................................................................. 22  
ACKNOWLEDGMENTS AND CONTACT  ................................................................................................  25  
Acknowledgments .................................................................................................................................................................. 25  
Contact ........................................................................................................................................................................................ 25  
ABOUT THE OFFICE  OF INSPECTOR GENERAL ....................................................................................  26  
ENDNOTES  .................................................................................................................................................... 27  
 
 
 
 
   
BACKGROUND  
OBJECTIVE  
Identify  the extent to which the immunization databases  of States and local  
immunization programs  receive COVID-19  vaccination data from Federal  
agencies and retail pharmacy  partners.   
 
State  and  Local  Immunization Databases  
State and local health departments rely on Immunization Information Systems  
(IIS)confidential, population-based,  computerized databases  that record  
information on  immunization doses  and are maintained by State and local  
immunization programs  (hereinafter referred to as immunization databases).3   These 
immunization databases  can help vaccination providers determine patient needs  
and assist in  surveillance and program  operations to guide public health.4   
Immunization databases  should combine immunization information from  
participating providers into a single record  for each person residing or receiving  
vaccines in a given jurisdiction.5   Relying  primarily on  CDC funding,  all 50 States, the 
District of Columbia,  5  other  cities, and  8 territories  each operate  an immunization  
database.6   These databases  collectively  are the backbone for monitoring  
vaccinations during  a national mass-vaccination campaign, such as the COVID-19  
vaccination effort.7, 8  
According to the Centers for Disease Control and  Prevention (CDC), these 
immunization databases  play a  critical role in monitoring COVID-19 vaccination 
administration and  coverage estimates.9   As outlined in the COVID-19 Vaccination  
Program  Interim Playbook for Jurisdiction Operations  (the Playbook), CDC  instructed 
State and local immunization programs to use their immunization databases to  
collect required  data on  vaccine  administration  and report those data to  CDC.10   
Required data include elements such as administration date, dose number,  and 
recipient ethnicity.11  
CDC  established  functional standards and guidance for State and local  
immunization programs  to improve immunization databases  so that the  databases  
are capable of  achieving  the vision of easily  accessible real-time, consolidated  
immunization data.12   For example,  one standard states  that databases  should  
support public health response during disease outbreaks.13   Another standard states  
that  databases should  support immunization program activities during a public  
health emergency according to the jurisdictions public health emergency plan.14   
CDC conducts  an annual survey  of  immunization programs  about their  databases,  
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using  these  functional standards  to measure progress, identify areas for 
improvement, set program priorities, and influence policy-level decision making.15   
Although jurisdictions rely primarily on CDC grants for IIS maintenance, operation,  
and enhancement, CDC  does not require grantees to satisfy  all standards as a  
condition of funding.16   Adherence to the functional standards is  encouraged, but  
remains with each IIS program.17  
The 64  immunization  databases are operated by State and local immunization 
programs, and  vary  as to local reporting requirements, data-sharing polices, and  
system capabilities.   For example:   
    Some immunization programs  operate under  State  laws or policies that  
prohibit sharing  personally identifiable  information about residents  with  
the Federal government.18  
    Some immunization databases do not have bidirectional data exchange 
capabilities,  which limits  the ability to share immunization data with  
providers and other immunization database users  who need it.19, 20  
    Some  immunization  programs  do not  require  vaccine providers to  
report  data  for individuals over the age of  19.21  
    Some  immunization programs  do not require all pharmacists to report  
vaccinations administered  to their  immunization  database.22   
CDC  and others have highlighted the need for  increased  investment and  authority  
related to public health data.   CDC called for increased data modernization and 
authority to  address data gaps  created by  receiving data from a variety  of sources in 
inconsistent ways.23   Specifically,  CDC noted that updated data authority  could  
improve CDCs legal ability to access secure public health data in a timely  and  
coordinated way.  Additionally, in  March 2022 former CDC directors  called attention 
to the lack  of funding and legal authority needed  for CDC to  achieve accurate,  
timely, and comprehensive data.24    
Federal  Agencies  and Retail  Pharmacy  Partners   
COVID-19 vaccine  providers may receive their vaccine supply  directly from CDC, 
from their  respective  local health departments, or from  a combination thereof.25   
Two types of vaccination providers who receive some  portion of their  vaccine  supply  
directly from CDC are  (1) Federal agencies that provide vaccines  and (2)  retail 
pharmacies  that partner  with the Federal government as members of  the Federal  
retail pharmacy  partner program.26,  27    
Federal agencies and pharmacies that receive vaccines directly from CDC signed  
agreements  which specified the conditions for receiving COVID-19 vaccines.   These 
agreements state  that Federal retail pharmacy partners  and  Federal agency  
providers  should  transmit  data on vaccine administration either  (1)  to  State and 
Challenges With Vaccination  Data Hinder State and Local Immunization Program Efforts  To  Combat COVID-19  
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local immunization  databases or (2)  to  another system, as  designated  or agreed to  
by  CDC.  CDC  told OIG  that it was determined  that Federal  agencies would  transmit  
data  directly to CDC only,  to allow efficient resolution of policy and technical 
requirements  that could not have been achieved in the necessary timeframe at the 
individual immunization  program level.   However, many retail pharmacies were 
connected to  State and local immunization databases prior to the COVID-19 
vaccination campaign  and  CDC stated  to OIG  that  it  encouraged retail pharmacy  
partners to directly  transmit vaccination data  to  State and local  immunization  
databases.   The signed  agreements  also  outline timeliness  expectations  for 
transmitting vaccination  data, stating that transmission should occur  as soon as 
practicable,  or within  72 hours,  depending on the type of  vaccination provider and  
jurisdictions  immunization database capabilities.    
The number  of these Federal agency and pharmacy partners  providing vaccinations  
varies  amongst immunization programs jurisdictions, but they  are widespread and  
represent a substantial portion of the data that immunization programs need. For  
example,  while all jurisdictions may not have  DoD  facilities,  VA is present in all  
States.  Combined, these two  agencies have administered over 14 million doses to  
veterans, active military,  and other beneficiaries.   All State and local immunization  
programs utilize the Federal retail pharmacy program to help administer  
vaccinations in their areas.28   There are 21 pharmacy partners, representing  41,000  
locations.29   In addition to  including large chain pharmacies (e.g.,  Walgreens, CVS)  
the program includes partners with a small number of stores  and those  which serve 
rural areas.  As of March 2022, pharmacy partners receiving vaccines directly from  
CDC  were responsible for 40 percent of all administered doses of COVID-19  
vaccines.30, 31     
 
 
 
 
 
 
 
 
 
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      Background |  3    
Federal agencies and  pharmacy partners have  administered  over 250  
million COVID-19 vaccinations  nationally.  
the five Federal agencies that provide vaccinations, these three have 
administered the most doses: the Department of Veterans Affairs (VA), the 
Department of Defense (DoD), and the India n Health Service (IHS) . 
1ith 
aii& 
VA has administered  DoD has administered  IHS has administered 
7.4 million  7.5 million  2.2 million 
COVI D-19 vaccinations to  COVID-19 vaccinations to  COVID-19 vaccinations to 
veterans, their spouses,  service members and  American Indians and 
and caregivers  eligible civilians  Alaska Natives 
There are over 41,000 retail pharmacy partners that receive COVID-19 vaccines 
directly from CDC. 
Retail pharmacy partners have administered over 
W1l 
234.9 million 
COVI D-19 vaccinations 
 
Sources:  CDC COVID-19 Data Tracker, CDC Federal Retail Pharmacy  Program.32,  33  
Immunization Gateway  (IZ  Gateway)  
The Immunization  Gateway  (IZ Gateway)  development  began  prior to the pandemic  
as a Health  and Human Services (HHS) pilot project with the focus  of  facilitating  
interstate vaccine administration data exchange.34, 35   In the Playbook, CDC  
described  the IZ Gateway as a tool for  (1) Federal  agencies to share immunization  
data with State and local immunization programs,  and  (2) sharing among different  
State and local  immunization databases.36   CDC  told OIG  that it is  not currently  
planning to  use  the  IZ Gateway  to share data between immunization programs and  
retail pharmacies  because most pharmacies can already exchange data  with State  
and local  immunization databases.   CDC  identified connecting immunization  
databases to the IZ Gateway as an immediate priority in the Playbook.37   However,  
connecting these systems has been a  complex process that encountered setbacks  
during the campaign.38, 39   
Once a  jurisdiction or  Federal agency provider is connected, the IZ  Gateway can  
provide access to  patient-identifiable  vaccination  records,  which is important for  
immunization programs.   For example, once a Federal agency is connected  to the IZ  
Gateway, the agency  can report and query any vaccination data  with multiple State 
and local immunization programs.40   Additionally,  multijurisdictional providers and  
immunization programs  can query the IZ Gateway to obtain an individuals full  
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immunization history  across States and localities.41   Immunization  programs need  
identifiable records to link with existing data in their immunization databases and  
perform functions such as facilitating authorized access to vaccination records by  
individuals and their providers.  
Tiberius  
Tiberius is a platform created specifically  for the COVID-19 pandemic that  pulls data  
from various sources to  display aggregated, deidentified information related to  
manufacturing;  supply chain;  allocation;  and delivery and administration of  vaccines.   
Tiberius was developed  for  Operation Warp Speed (later renamed Countermeasures  
Acceleration Group (CAG)),  the collaboration  of  the  Department  of Defense (DoD)  
and HHS.   When CAG was dissolved  in December  2021, management of Tiberius  
was transitioned to CDC.42   Tiberius provides a zip code view of priority populations  
and provides tools to  assist State and local immunization campaigns in decision  
making.43   Tiberius  integrates  COVID-19 vaccination data from  several systems,  such 
as  data that Federal agencies and retail pharmacy  partners  submit to CDC.    
The Federal government  offered technical assistance and other opportunities  to  
State and local  immunization  programs  to help them  use Tiberius  for their  
vaccination campaigns.44   CDC reported  to OIG  that regular trainings in addition to  
office hours  were offered to  State and local immunization programs.   If  an 
immunization program reported challenges reconciling data  between its  
immunization database and Tiberius,  CDC  offered support  and, in some cases,  a 
contractor.  Additionally,  in June 2022, following  immunization programs feedback  
asking  for increased information about  vaccinations provided by  retail pharmacy  
partners,  CDC informed  jurisdictions that  efforts  to  improve Tiberius and  create a  
more efficient and unified presentation of retail pharmacy partner activity  were 
beginning.  
However,  media outlets  reported  that State and local  immunization  programs  
struggled to leverage Tiberius  for their  COVID-19  vaccination campaigns.   One 
program noted that the  platform  was  complex and required multiple staff  members  
to undergo training.45   A second program  reported that it was  unable to use  
Tiberius to locate  and map all critical populations.46   Unlike  the IZ Gateway,  Tiberius  
does not provide access to  patient-identifiable records.47   
CDC COVID-19  Data Tracker  
CDC publishes  a public online data  dashboard, the COVID-19 Data Tracker,  which 
includes  aggregate  information  about vaccinations administered  (e.g.,  vaccination  
coverage;  vaccines administered  by  race/ethnicity, age, and sex;  and vaccinations by  
county).48   The information  currently  is updated  weekly.49   The tracker includes  
information submitted through State and local immunization databases,  the Vaccine 
Administration Management System (VAMS), and direct data submissions.50   VAMS  
is an online tool to manage vaccine administration available to enrolled  
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jurisdictions, Federal agencies, and organizations  that do not have existing systems  
to report data on COVID-19 vaccine administration.51   CDC does not  share any  
personally identifiable information.52  
Related  Work  
In conjunction with this  work, OIG issued  Early Challenges Highlight Areas for  
Improvement  in  COVID-19 Vaccination Programs  (OEI-04-21-00190),  which provides  
a broader  review of  challenges faced by State and local immunization programs  in  
the early stages  of the COVID-19 vaccination  including (1)  achieving logistical 
efficiency, (2) obtaining  complete vaccine data  from all providers, (3) combating  
vaccine hesitancy  with public health messaging,  and (4) overseeing vaccine  
providers.    
OIG recommended that  CDC (1) update mass vaccination program plans  with  
strategies that address  awardee-reported logistical challenges;  (2) strengthen 
reporting of vaccine allocation and administration data;  (3) clarify roles and  
responsibilities within HHS for vaccine public health messaging during a pandemic;  
and (4) work  with State and local immunization programs to enhance current and  
future capabilities for provider training and oversight.    
Methodology  
To understand how many State and local immunization programs  were receiving  
data, in December  2021 we administered an  online  survey to  56 State and local  
immunization programs  that have immunization databases.   These included  all 50  
States  and the 6  cities  (Chicago,  the  District of Columbia,  Houston, New York  City,  
Philadelphia, and  San Antonio) that operate an immunization database.   We did not 
survey the eight territories with an immunization database.   We asked immunization 
programs whether  they  receive  COVID-19 vaccination data from Federal agencies  
that provide vaccinations  and retail pharmacies  partnered with CDC, and whether  
they  experience challenges obtaining complete and accurate data.  We also asked  
programs how missing or inaccurate data affects local  vaccination  campaigns, if at  
all.   We did not ask  State and local immunization  programs about  their  
immunization database  technical capabilities or reporting requirements.   We did not 
survey Federal agencies  or retail pharmacy partners.   
Limitations  
Our analysis relied  only  on self-reported data from State and local immunization  
programs.  We did not independently verify information received from  
immunization programs.   We followed up with programs to  clarify responses only  
when their survey results were unclear.   
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Standards  
We conducted this study in accordance with the Quality Standards for  Inspection  
and Evaluation  issued by  the Council of the Inspectors General on Integrity  and  
Efficiency.  
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FINDINGS  
Most  State and local immunization programs  did  not receive  
individual-level data on  vaccinations administered by  at least  
one Federal agency,  and  programs reported challenges with the 
limited  data received  
As of December  2021,  52 out of 56  State and local immunization programs  reported  
not  receiving  any  individual-level  vaccination data  from  at least one of the following  
Federal agencies  that provide vaccinations: VA,  DoD, and/or IHS.53   Further,  
immunization programs  reported that  when they did receive vaccination data from  
these Federal agencies, the data were often untimely or incomplete.    
CDC does not require Federal agencies to  submit  individual-level  vaccination data  
directly  to  State  and local immunization  databases.   Federal agencies signed  
agreements  with CDC state that vaccination data  must be transmitted either to State  
and local immunization databases  or  to  another system as agreed upon.   CDC  told 
OIG  that  it was  determined that Federal agencies  would report directly to CDC only,  
due to policy  and technical limitations.   State and local immunization databases are 
designed for individual-level data about  vaccine doses and the residents  who  received  
them.   CDC  provides  aggregated (i.e., zip-code-level) summaries of  COVID-19 vaccine 
doses administered by  the Federal  agencies, but this information cannot be 
integrated directly into  State and local immunization databases.54    
Most  immunization  programs  reported not receiving individual-
level  data on vaccinations  administered  by  Veterans  Affairs  or 
Department  of  Defense  providers  
Forty-four  State and local  immunization programs  reported  not receiving any  
individual-level  data  on COVID-19 vaccinations administered  by  VA,  and 42  reported  
not receiving  this data  from DoD.    
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Pre-existing data-sharing policies may limit  an  of the 56 immunization 
agencys ability to share  data on  vaccine  programs reported not 
administration  with  a State or local  receiving any data from VA 
immunization program.   For example, one  providers 
immunization program reported that VA  
maintained that its patients must consent    
before their data  can go  to the immunization   X  X 
database.   In one State, the governor enacted  
X  X  X  X  X  X  X 
an executive order requiring VA to  transmit  
X  X  X  X  X  X  X 
data to the  States  immunization database.55   
X  X  X  X  X  X  X 
An additional immunization program reported  
X  X  X  X  X  X  X 
being told that VAs current privacy policy  
does not allow the sharing of health data   X  X  X  X  X  X  X 
unless there is a State mandate.     X  X  X  X  X  X  X 
Immunization programs  reported similar   Source: OIG analysis of survey data, 2022.  
challenges with DoD, citing  DoD confidentiality  and privacy concerns.   For example,  
one immunization program reported that  DoD clinics are hesitant to share  data on  
vaccine administration without expressed  approval from leadership although DoD has  
released COVID-19 case data to comply  with the States law.  Further, one program  
specifically  stated that there is no requirement for DoD to share data with  its  local 
immunization database,  and any data obtained is due to local entities building  
relationships with organizations in their  jurisdiction. 
Of the smaller group of  State and local  
42 of the 56 immunization 
immunization programs  that reported receiving  
programs reported not 
some data from VA or DoD,  most reported that 
receiving any data from DoD 
their  immunization databases  do not receive timely  
providers 
transmissions on a regular basis.  Instead, these 
programs sometimes  reported that VA  and DoD  
 
occasionally submitted files for batch upload  or  that 
providers manually entered  data  directly  into the 
X  X  X  X  X  X  X 
immunization database.  For example, one 
X  X  X  X  X  X  X  immunization program reported that  VA only  
X  X  X  X  X  X  X  manually uploads a file upon request  of  the 
X  X  X  X  X  X  X  immunization program.   Similarly,  one  program  
X  X  X  X  X  X  X  reported  relying  on data being  manually entered  
into the local database  by  DoD providers.  
X  X  X  X  X 
VA and DoD data  may be of special importance for  
Source:  OIG analysis of survey  data, 2022.  
those State and local immunization programs  with 
large veteran  and military  populations.   Veterans  comprise more than 10  percent of  
the adult population in Alaska, Virginia,  and Montana.56   Additionally,  North Carolina  
is home to the largest military base in the world and has an estimated  113,000 active 
duty and reserve personnel.57, 58   One immunization program  that reported  having  a 
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large  veteran  population  stated  that  not  having  data  directly  from VA  created  serious  
quality issues  when the immunization program  tried  to create a complete picture of  
vaccination coverage.  
Most  immunization  programs  reported receiving individual-level  
data on  vaccines  administered  by  IHS  providers, but many  
reported  challenges  
In contrast to VA and DoD,  most  immunization  
of the 25 immunization 
programs reported receiving  some  vaccination 
programs reported not 
data from IHS, but many programs also reported   receiving any data from IHS 
that IHS data received  were incomplete.   Of  the 25   providers 
State and local immunization programs with 
documented IHS  facilities,  2 reported not   
receiving  any data  at all, and 14 reported 
 
challenges, such as  with  obtaining data from all 
 
IHS providers.59, 60   Only  nine  of these 
immunization programs reported  receiving  data    
from IHS  and did not report challenges  in  
obtaining all the data needed.   
A 14 programs 
reported challenges 
Some  of  the 14  State and local immunization  
obtaining data 
programs that received data but  reported 
challenges  attributed these challenges  to IHS  
Source:  OIG analysis of survey  data, 2022.  
facilities differing technological capabilities.   
Some facilities may have an electronic health record (EHR)  that  can more easily be 
connected into an immunization database  for automatic submission.  One program  
suggested that this technological difference  was  dependent on whether a  facility is  
IHS- or Tribally operated, noting that Tribal facilities  were  not  always supported by  
compatible  data-exchange systems  and may  have  faced  greater challenges  
establishing connection with the immunization database.  Additionally, immunization  
programs reported that  connecting  IHS facilities to their  database  was  challenging  
because each location must connect to the database  individually,  requiring testing 
and troubleshooting unique to each  facility.    
Although  not all jurisdictions have  IHS facilities,  their immunization  programs may  
need data from  IHS facilities outside of their area.  American Indians and Alaska 
Natives (AI/ANs) may receive care at  any hospital  or clinic.61   For example, one 
immunization program noted that Tribal lands sometimes span multiple States and  
therefore the program  worked  with out-of-State  IHS facilities to ensure full coverage.   
Complete IHS data may  be particularly important for certain jurisdictions  with high 
concentrations of AI/AN  populations or  where a single Tribal land may  cover  multiple  
jurisdictions.  For example, the Navajo  administrative unit alone serves 224,000  
individuals and has facilities in Arizona, New  Mexico, and Utah.62   
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Although most immunization programs received  individual-
level data on vaccines administered by retail pharmacy partners,  
many reported  challenges with the  data  
As of December  2021,  42  State  and local immunization programs reported  that they  
received  at least some  patient-level data  directly from  all of  the pharmacy partners  
offering vaccinations  in their jurisdiction.   However,  14  State and local immunization  
programs reported  not receiving  any  individual-level data from at least one retail  
pharmacy partner active in their area.   One immunization program estimated  that  its  
immunization database  was missing information  on 400,000 doses  from retail 
pharmacy partners at the time of our survey.  Moreover, many immunization 
programs reported quality or timeliness challenges  with the data  they did receive.   
Retail pharmacy partners  signed agreements  with CDC  that state that vaccination data  
must be transmitted  either to State and local immunization databases  or  to another  
system determined by CDC,  and CDC  reported to OIG that it  encouraged  retail 
pharmacy partners  to report to local immunization databases.      
Many  immunization  programs  reported  challenges  with  
vaccination data from pharmacies,  such  as with  timeliness,  
accuracy,  and  completeness  
of the 56 immunization  Thirty  immunization programs reported  challenges  
programs reported not  with  vaccination  data received  from  pharmacy 
receiving any data from at  partners, including  receiving untimely, inaccurate,  
least one retail pharmacy 
or duplicate data,  or not  receiving all vaccination 
partner 
records from a pharmacy that was otherwise  
 submitting data.    
 
Some immunization programs noted that retail  
 pharmacy partners  sometimes simply failed  to  
submit data in a timely fashion.  One program  
 
reported that some doses  were  not reported until  
 
months after the  actual administration date.    
State and local immunization programs also  
X  X  X  X  X  X  X 
sometimes  reported various concerns about the 
X  X  X  X  X  X  X 
accuracy and completeness of data received.   For 
A 30 programs  example, immunization programs reported  that 
~eceived untimely,  they  discovered  patterns  of  deleted  doses, missing  
inaccurate, or 
data  elements, and  duplicate reporting.   One 
incomplete data 
immunization program reported that even after  
Source: OIG analysis of survey data, 2022.   working with the pharmacy partners  in an effort  to  
resolve these challenges, the program may still be left with inaccurate data.    
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Additionally,  some  State  and local immunization programs  reported that retail 
pharmacy partners  sometimes  experienced  interruptions with their  data  
transmissions.  Some immunization programs attributed missing records to delayed  
or interrupted data  transmissions.  One  immunization program stated that when data  
transmissions were interrupted,  it  was  unable to recover  all  data reported during the  
interruption.  Without being able to recover this data, immunization programs  are left  
with  records  missing.  Further, resolving the interruption may require that  
immunization program staff provide technical assistance to pharmacies,  where 
pharmacy staff often did  not know why the transmission was interrupted.  
Some immunization  programs  reported that  missing or  untimely  
pharmacy  vaccination data  may  be related  to  third-party data-
sharing  vendors  
Retail pharmacies sometimes partner  with third-party vendors  to manage  data-
sharing  systems for reporting to State and local immunization programs,  and 
immunization programs  noted that these vendors might  have caused  some data  
challenges.  For example, one immunization program reported that a vendor  is  
responsible for data transmissions but  the vendors  system sometimes  went  down for  
days at  a time.  After the connection issue was  resolved, the immunization program  
said  that it  struggled  to obtain the records  missing  because of  the downtime.   
Another immunization program noted that if  a patient scheduled  an appointment but  
then canceled  and rescheduled, the vendor  might  transmit  both a record for the 
canceled  appointment  and  a record  for the  rescheduled  appointment that occurred,  
resulting in  more records for vaccine administration than a patient received.  Finally,  
one program  attributed inaccurate dates of administration to a vendor  that  used  the 
billing date instead of  the administration date.  
Fourteen  State  and local immunization programs  reported  that many of the data  
challenges experienced  were associated with one common third-party vendor.   
Immunization programs  reported that this vendor works  with some of  the countrys  
largest pharmacy chains.   Given that this vendor works  with these large chains, this  
single vendor is likely responsible for transmitting a great deal of retail pharmacy  
data.    
With insufficient  vaccination  data,  some  immunization  
programs reported struggling to monitor vaccination  
campaigns, despite Federal  efforts  
Without complete and reliable individual-level  data from all Federal agencies and  
pharmacy partners, many immunization programs  reported  facing  challenges  
managing effective vaccination campaigns.   While Federal agencies and  retail 
pharmacy partners are not required to submit data  directly  to immunization  
databases,  State and local immunization programs  reported  that incomplete data  
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hindered  their  efforts to  estimate vaccination coverage rates, effectively plan  strategic  
targeted interventions, and provide vaccination records  to individuals and providers.    
Difficulty estimating  coverage rates  
t
 Some immunization programs reported being unable 
to  accurately estimate vaccination coverage rates  
   without complete and  timely  vaccination data from  
all providers.   Vaccination coverage is the estimated  
Nearly  half of all 
percentage of people in a community  who have 
Americans age  75 or 
received vaccines.64   Monitoring vaccination 
older are veterans.63    
coverage, through data on vaccine administration,  
Many  of these older veterans  
allows immunization programs to track and measure  
are eligible for VA health  care  
the success of their efforts.    
services, including  
vaccinations.  
When data  are  missing or inaccurate, immunization 
  
programs  cannot confidently determine these 
Without VA data, one  
estimates.  For example,  one immunization program  
immunization program said,  
reported that data missing from retail pharmacies  
it could not accurately  
affected  its  total vaccination count and the 
estimate vaccination rates  
for its older populations.    vaccination numbers  it  reported  to the public.   
   Another immunization program reported that  
without data  from Federal  agencies that provide 
vaccinations,  it  had difficulty  accurately estimating  vaccination coverage for counties  
with large military populations.    
Although CDC makes  Federal agency and pharmacy partner data available at the 
aggregate  level  through Tiberius and the public COVID-19  Data Tracker,  some  
immunization programs  noted differences  in  the  aggregate  data and the  programs  
databases.  Some  immunization programs  reported that the vaccination coverage 
estimates in their  databases  were smaller than CDCs estimates.  One immunization 
                program added that CDCs publicly reported estimates may  also have been  larger 
    because a person who received their first dose from a Federal provider and  their  
  second from a non-Federal provider could have been  counted as two different 
individuals  who received  their first doses, not as  a single fully  vaccinated person.   CDC  
commented that a number of factors may  contribute to such  discrepancies  and some  
of them are not solely under Federal control, such as  incomplete or  inaccurate  data  
maintained by State and  local immunization programs.    
 
 
 
 
 
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Challenges  in  targeting outreach to unvaccinated and vulnerable populations  
---
  Some  immunization programs  reported  using  data  
to systematically identify  communities  with low  
vaccination coverage to  plan local pop-up 
 
vaccination clinics, target vaccination marketing  
Most  Americans live  
campaigns, or  conduct other outreach aimed at  
within 5 miles of a  
increasing vaccination rates.   However, without the  
pharmacy.   CDC partnered with   data  needed, some  State and local immunization  
21 retail pharmacies  and their   programs reported struggling to plan and enact  
41,000  retail locations across the  
strategic targeted interventions.    
country  because pharmacies can  
reach people who  cannot access   Some immunization programs reported that  
other providers easily,  such as   incomplete data  limited  their  ability to promote  
rural Americans.65,  66   health equity because the programs could not  
  accurately identify vaccination disparities between  
Rural Americans are at higher risk 
demographic groups.  For example, one 
of death from COVID-19, so  
immunization program reported that without data  
increasing vaccination rates in  
from VA, DoD,  and IHS, it  could not  accurately  
remote areas is key.67   Without  
calculate vaccine rates or provide vaccination 
complete and accurate data from  
records  for special populations, such as  Tribal 
retail pharmacies,  State and local  
members and their families; rural communities; 
immunization databases  are  
potentially missing vaccination   and veterans experiencing homelessness.   
records  for some  Americans   Immunization programs  specifically described  the 
disproportionately  affected  by  importance of  IHS  data  to monitor vaccination  
COVID-19.     coverage of American Indians and Alaska Natives  
  (AI/ANs), a demographic  group at high risk for the  
negative impacts of COVID-19.  AI/ANs have historically experienced a lower life 
expectancy and disproportionate disease burden compared to other Americans,  and  
AI/ANs are  nearly  twice as likely to die from COVID-19 as  are White Americans.68, 69      
Some immunization programs also  conducted  outreach to individual residents, but  
incomplete vaccination records made  it difficult to efficiently and  correctly identify  
unvaccinated or partially  vaccinated residents  who would benefit from reminders.  For  
instance, one immunization program said that  it  sent out reminder letters to all  
unvaccinated  older  residents  using  data  in  its immunization  database, but then it 
received many calls from individuals who informed the program that they  had already  
been vaccinated by Federal agencies.   Similarly, another immunization program  noted  
that incomplete data limit  its  ability to  conduct any outreach about booster needs.  
Inability to provide  up-to-date records to individuals and providers   
Some immunization programs reported not being able to provide records to  
residents when requested because these residents had been vaccinated by Federal  
agency or retail pharmacy providers  that did not report to immunization databases.   
Without complete vaccination  data, immunization programs  cannot  always provide 
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accurate individual vaccination records  when requested by residents and  health care  
providers.   For  example, one immunization program  said  that it received reports of  
residents who requested  a second or third COVID-19 vaccine dose but faced  
challenges  when vaccination providers could not find evidence of earlier doses in the 
immunization databases.   One purpose of  State  and local  immunization  databases  is  
to offer up-to-date vaccination records for  individual residents and health care 
providers, and residents  sometimes inquire about obtaining proof  of  their vaccination 
status.    
Lack of comprehensive  information on  vaccination providers  
Some immunization programs reported not knowing  that lists of all Federal agency  
providers providing vaccinations in the programs jurisdiction  were available.   Without 
comprehensive information about  all providers  operating in their  jurisdiction, State  
and local immunization programs  do not know the extent to which  the program is  
missing vaccination data.   CDC  indicated that it would notify programs of  any Federal  
providers  that enroll directly  with CDC to receive and dispense vaccinations.70   
Additionally, CDC stated that immunization programs can access lists  of enrolled  
providers in Tiberius.    
The Federal  government  is  making  efforts  to  share vaccination 
data  from Federal providers,  but  immunization programs  
reported  that  these efforts had  not  yet  met  program  needs  
CDC and other parts of the Federal government have taken steps to provide 
immunization programs  with data from Federal agencies.   However,  these efforts  did  
not yet offer  all  the data  that immunization programs needed.   
The Federal government made  aggregate  data available,  but  immunization  
programs  reported  that those  data did  not provide sufficient  individual-level  
details to fully meet immunization programs  needs  
The  Tiberius  data  system  provides  State and local immunization  programs with  the 
Federal governments aggregate, deidentified  counts of the total number of vaccines  
administered by Federal  agencies  and  pharmacy partners.71   Tiberius also offers  
aggregate  equity  and social vulnerability  metrics  at the zip-code level.   However,  
some  programs  reported  still being  unable to  confidently estimate vaccination  
coverage because they  could not  compare  this deidentified data  against their own  
individual-level  data  records  to resolve data discrepancies such as doses that were 
accidentally recorded twice.  Aggregate data also  did  not provide the type of detail 
that immunization programs needed  to support  all vaccination-campaign efforts.  For  
example, one immunization program said  that the available aggregate  Federal agency  
data  did not allow  a sufficiently  granular breakdown for use in  small-scale health 
equity promotions.   And  because aggregate  data  cannot be used  to  update records  
for individual residents,  it does not help State and  local immunization programs  
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ensure that they  provide residents and health care providers with accurate vaccination 
records.     
The current  Federal immunization data exchange  solution  will likely  solve  many 
issues  with Federal agency data, but  this  solution was delayed and may have  
outstanding challenges  
Immunization programs  acknowledged that CDC  is  actively  working on setting up the 
IZ Gateway  as a solution to support  the exchange of  vaccination  data between Federal  
agencies and  State and local  immunization databases.   Some immunization programs  
anticipated  that the IZ  Gateway will  help them  obtain  some  or all of the data  needed  
from Federal agencies.    
At the time of our survey in  December 2021, the IZ Gateway was not  yet operational  
for the exchange of immunization data between Federal agencies and  all State and 
local immunization databases, but  the process has since progressed.   Some of these 
immunization programs reported  being  in  the process of setting up agreements with 
VA and CDC to share data through the IZ Gateway in the future.   In May  2022, CDC  
reported  that 1  immunization program  was actively exchanging data  with VA, and  
CDC reported that  as of November 2022,  23  immunization programs  were doing so.   
In addition,  other  immunization programs  expressed concerns  that they  will not be  
able to connect to the IZ  Gateway system  when it is  ready  because of  potential 
technical limitations of  their  immunization databases.   For example,  some  
immunization programs  said that the software company  contracted to build and  
maintain  their  immunization database  systems had  indicated that it may  opt out of  
participating in the IZ Gateway.   Twelve immunization programs  reported using  this  
software  company  for their immunization database  systems.  If this company opts out  
of the IZ Gateway, these immunization programs  may  not be able to  exchange 
immunization data via  the IZ Gateway.   
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CONCLUSION AND RECOMMENDATIONS  
High-quality,  comprehensive  data on  vaccine administration are essential for State 
and local immunization programs to protect the health and well-being of  the 
populations  they  serve.   The COVID-19 pandemic  highlighted  the public health  need  
for this  data.   Immunization  programs need individual-level  vaccination data  to  
estimate  coverage rates,  identify populations in need of vaccines,  and protect  those  at 
higher risk of  negative health  outcomes.   However, nearly all programs reported  
challenges  in  obtaining individual-level data on COVID-19  vaccinations  administered  
by  Federal agencies and retail  pharmacy  partners, with many receiving no individual-
level data at all on vaccinations  administered by Federal  agencies.  
Vaccine data sharing is complex,  as it involves many stakeholders  with different  
policies and technical capabilities.  Prior to the pandemic, CDC recognized  the  need  
for a long-term solution  to facilitate  comprehensive sharing of individual-level vaccine 
data, but that solution  was not  in place when the public health emergency began.   
Federal agencies and retail pharmacy partners  were not required to submit individual-
level COVID-19 vaccination data directly to  immunization databases,  given existing  
policy  and technical limitations.   To  help meet  the immediate need for  immunization  
program oversight of COVID-19 vaccinations, CDC made  available  aggregate data,  
which  can be  helpful but  are not entirely sufficient  for vaccination monitoring.  
CDC is actively  working to set up the IZ Gateway  as a long-term solution to connect  
Federal agencies with State and local immunization databases, and to  connect 
different State and local immunization databases  with one another.   Congress and  
CDC are also  considering changes to immunization databases  and the authorities that  
govern how  public health data  are collected and shared.72, 73   These efforts  to  facilitate  
data sharing  on vaccination administration,  for the COVID-19 vaccination campaign  as 
well as  for  other emerging infectious diseases  and routine vaccinations  (e.g., flu  
vaccines),  may address challenges described  by  State and local immunization  
programs.   Recent  concerns about the threat of  mpoxanother  infectious disease 
with available vaccinesunderscore the urgency  of  improving vaccination data  
sharing.  There are additional steps CDC can take  to  help  meet  immunization  
programs  needs, beyond prioritizing the completion of the IZ Gateway.   We 
recommend  that  CDC:   
 
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Work with  State  and local  immunization programs  and  retail 
pharmacy partners  to mitigate  reported data gaps  and  
timeliness challenges   
CDC should  take action to improve the data  immunization programs receive from  
retail pharmacy partners.   CDC should,  at minimum, facilitate  solutions  to  sizable  gaps  
in reporting from retail pharmacy partners to State and local immunization programs.   
For example, CDC  could  prioritize the 14 immunization programs  that reported  not 
receiving any data from  at least one retail pharmacy partner present in their  
jurisdiction.   CDC could clarify expectations and facilitate better data reporting for the 
COVID-19  vaccination campaign and future vaccination efforts.   To  further  improve 
data  quality and  transmission timeliness, CDC  could also work  with the third-party  
vendors that  contract  with major national pharmacy  chains to  identify  improvements.    
OIGs  companion work,  Early Challenges Highlight Areas for Improvement  in  COVID-19  
Vaccination Programs  (OEI-04-21-00190),  also recommends that CDC  develop 
strategies to improve vaccine administration data.   Specifically, that  recommendation 
states that CDC should define and communicate  data quality standards for providers  
and require that immunization programs develop an approach to provide routine 
data quality feedback to  all providers of  IIS reporting.   Further, that recommendation  
states  that CDC  should  continue to work  with immunization programs on the 
collection of complete and accurate race and ethnicity data.   This  reports findings  
also support that  recommendation.    
Provide educational outreach to  ensure that  State and local  
immunization programs are aware of  existing  tools to address 
vaccination  campaign needs  
CDC should offer updated educational opportunities to  ensure  that immunization  
programs understand  how  existing tools  can assist in their COVID-19 vaccination 
campaigns.   These opportunities could include webinars or publication of  a  
frequently-asked-questions document  about how  to leverage data  sources outside of  
immunization databases,  such as  Tiberius and the COVID-19 Data Tracker,  to address 
gaps reported to OIG.  For instance, CDC could  instruct immunization programs  on 
how  to access  complete lists of Federal agency and retail pharmacy providers through  
Tiberius.   
 
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AGENCY  COMMENTS  AND OIG RESPONSE  
CDC nonconcurred with our first recommendation and concurred with our second  
recommendation.   
In nonconcurring with  our first recommendationthat  CDC should  work  with State and local  
immunization programs  and retail pharmacy partners to mitigate reported data gaps and  
timeliness  challengesCDC  indicated that it does not have the legal authority to standardize  
reporting across all  jurisdictions.   CDC stated that in the absence of a Federal mandate for all  
vaccination events to be reported to IISs,  IIS data  will continue to be inconsistent.   Specifically,  
CDC  noted  that some jurisdictions  lack legal authority  to collect and share pharmacy vaccination 
data,  and that jurisdictions may  not prioritize pharmacy connections  to IISs because some  
pharmacies may  have lower  immunization volume  than do  other providers.  
While OIG recognizes that limits on legal authority impact CDCs ability to  ensure 
comprehensive  vaccination data sharing  across all jurisdictions,  we continue to believe that  CDC  
has opportunities to improve the data immunization programs receive from retail pharmacy  
partners.   Indeed, CDC agreed that additional  work with pharmacies is needed to ensure robust  
immunization  data and  stated  that it  continues to work  with partners to address technological  
issues within IISs  and pharmacy systems.   OIG  supports  these efforts, and  we encourage CDC  to  
focus  on immunization programs that reported the greatest gaps in data  from Federal retail 
pharmacy partners.  
In concurring with our second recommendationthat  CDC should  provide educational  outreach 
to ensure that State and local immunization programs are aware  of existing tools to address 
vaccination campaign needsCDC  stated  that  it provides  immunization  programs with  technical  
assistance;  educational  outreach;  and information on  where  and how to find data.   For example,  
CDC  described  conducting individual outreach  to jurisdictions,  holding  regular office hours  to  
solicit feedback on jurisdictions needs,  hosting webinars on its  data systems, and issuing  weekly  
reports on data quality.   OIG believes that  CDC  could take additional steps  to help 
immunuization programs leverage data sources  outside of immunization databases, such as  
providing instructions  on how to access  complete lists of Federal agency  and retail pharmacy  
providers through Tiberius.   
In technical  comments, CDC also stated that concerns raised in our report regarding an 
immunization database software company  potentially  choosing not to participate in the IZ  
Gateway had been resolved.  
For full text of CDCs  comments, see the Agency  Comments appendix at the end of the report.    
 
 
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DETAILED METHODOLOGY  
For  this data brief,  we conducted a survey among State and local immunization 
programs and analyzed their responses.  
Scope  
We included 56 State and local immunization programs in our review.  This includes  
all 50 States and the 6  cities  (i.e., Chicago,  the District of Columbia, Houston, New  
York City, Philadelphia, and San Antonio) that operate an immunization database. We  
included all States and cities  to ensure that we could provide comprehensive 
information about immunization data received by State and local programs from  
Federal agencies and retail pharmacy partners.   We did not include the eight  U.S.  
territories with  immunization databases  in this review.    
Data Sources and Collection  
In December  2021, OIG sent an online survey to  State and local  staff who  manage 
immunization  programs and  immunization databases.  All 56 States and localities  
responded to our survey.   In February  2022, OIG followed up via email with seven  
immunization  programs to  request more in-depth information regarding unclear  
responses.   
Survey  questions  
We used the survey to ask State and local immunization programs about data  
received  from Federal COVID-19 vaccination providers.  First, we asked  whether  
programs receive data from  (1) Federal  agencies that provide vaccinations  (VA, DoD,  
IHS,  the Bureau of Prisons  (BoP), and the Department of State)  and  (2) retail  
pharmacies  participating in the  Federal  retail pharmacy partner program  (e.g.,  
Walgreens, CVS, Walmart), and how programs use this data in immunization 
campaigns.74, 75   We asked immunization programs to describe how data  are received,  
either through (1) automated  means  (e.g., an electronic health exchange, or an HL7  
system interface) or (2) other methods such as manual entry by providers  or program  
staff,  and any challenges with receiving  data through  either method.  Additionally,  we 
asked how State  and local immunization campaigns  are  limited by incomplete data.   
Finally,  we asked  State and local immunization programs about how CDC  or others  
could assist  with these issues.    
Data analysis  
We analyzed surveys  and followup emails to understand the data State and local  
immunization programs  are receiving from Federal  agencies  and  retail pharmacy  
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partners.   First,  we reviewed survey responses to understand whether State and local  
immunization programs  received any data  from Federal agency providers  or retail  
pharmacy partners.  
After determining whether State and local immunization programs received any data,  
we reviewed surveys to gain greater insight into how the data were received and any  
challenges  with completeness, accuracy, and timeliness of the data.   
We analyzed the surveys  to identify how immunization programs use this  data to  
administer their vaccination campaigns or any limitations their campaigns experience 
because of incomplete, inaccurate, or untimely data. 
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APPENDIX  
Agency Comments  
,:~: --z~  U.S. DEPARTMENT OF HEAL TH AND HUMAN SERVICES  Public Health Service 
Centers for Disease Control 
and Prevention (CDC) 
Atlanta GA 30329-4027 
DATE:  December 6, 2022 
TO:  Ann Maxwell 
DATE:   DecemDbeepur t6y ,I n2s0p2ec2t  or General for Evaluation and Inspections 
TO:   FROM:A  nn MRaoxchwelelell P  . Walensky, MD, MPH 
Director, CDC Centers for Disease Control and Prevention (CDC) 
Deputy  Inspector General for Evaluation and  Inspections  
SUBJECT:  INFORM AT TON ONLY - CDC's response to the Office of the Inspector 
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COVID-19, OEI-05-22-00010" (the Report) 
SUBJECT:   INFORMATION ONLY  CDCs response to the Office of the  Inspector  
KEY INFORMATION 
Generals (OIG) draft report, Challenges With Data From  Federal Vaccination  
This mePmaorrtannedrusm H isi ntod ienrf  oErmff oyrotus  tbhayt  CSDtaCte h aans dre sLpooncdaeld  I mto mtheu Rniezpaotrito bny  dPertoaiglirnagm thse  To Combat  
agency'Cs pOlaVnnIeDd- a1c9ti,o nOs E(TI-A0B5 -A2)2. C-0D0C0 1ap0pr e(ctihaete sR tehpe oorptp)o  rtunity to review and comment on 
this report prior to the final release. 
KEY INFORMATION  
This memorandum is to inform you that CDC has responded to the Report  by detailing the  
agencys planned actions (TAB A). CDC appreciates the opportunity to review and comment on  
this report prior to the final release.  
Attachment 
TAB A:  CDC's planned actions regarding recommendations 
 
_____________________________  
Rochelle P. Walensky, MD, MPH  
Attachment  
TAB A:   CDCs planned actions regarding recommendations  
Challenges With  Vaccination  Data Hinder State and Local Immunization Program Efforts To Combat COVID-19  
OEI-05-22-00010  
  Appendix |  22    Centers  for Disease Control and Prevention (CDC)s planned actions in response to the  
Office of  the Inspector  Generals (OIG) draft  report, Challenges With Data From Federal  
Vaccination Partners Hinder Efforts by State and Local Immunization Programs To  
Combat COVID-19, OEI-05-22-00010 (the Report)  
CDC appreciates  OIGs  ongoing work on the Report and strongly supports state and local  
immunization program efforts to increase vaccination rates and reduce vaccine-preventable  
disease through ongoing  data collection and monitoring using jurisdiction immunization  
information systems (IIS). As described in the OIG report, complete and timely vaccination data  
is important for immunization programs to successfully identify populations at high risk for  
vaccine-preventable diseases and target interventions and resources efficiently. IIS comprise the  
information systems, programs, people, and process associated with the system and is directly  
related to increasing vaccination rates and reducing vaccine-preventable disease. IIS uses  
confidential, population-based, computerized databases that record immunization doses  
administered by participating providers to persons  residing within a given geopolitical area. At  
the point of clinical care, IIS provides consolidated immunization histories for use by a  
vaccination provider in determining appropriate patient vaccinations. IIS provides aggregate data  
on vaccinations for use in surveillance  and program operations, and in guiding public health  
action with the goal of improving vaccination rates and reducing vaccine-preventable diseases. 
CDC plans to continue progress in  IIS performance, standards, and sustainability; and in  
strengthening connections to and within the public health information technology environment. 
OIG Recommendation  (1)  
OIG recommends CDC take action to improve the data immunization programs receive from  
retail pharmacy partners  by:   
o  Facilitating solutions where there are sizeable gaps in reporting from retail pharmacy 
partners to state  and local immunization programs. For example, CDC could prioritize the 
14 immunization programs that reported not receiving any data from  at least one retail 
pharmacy partner present in their jurisdiction. 
o  Clarifying expectations and facilitating data reporting for the coronavirus disease 2019 
(COVID-19) vaccination campaign and future vaccination efforts. 
o  Working with third-party vendors that contract with major national pharmacy chains to 
identify improvements. 
CDC Response: CDC nonconcurs with OIGs recommendation. 
CDC agrees that additional work with pharmacies  is needed to ensure robust reporting of  
immunization data to IIS. CDC continues to work with IIS partners to address technological  
issues within the IIS and/or pharmacy systems. However, the  ecosystem in  which  IIS operate is  
complicated by the web  of policies and regulations that govern  IIS reporting. IIS policies  and  
regulations are  enacted at the state and local levels, and CDC does not have the legal authority to  
standardize  reporting across the nation. IIS policies govern the reporting entities (i.e. who reports  
to the jurisdiction IIS), what data may be  collected, what type of consent is required to collect  
data, and what data may  be shared. Currently, some jurisdictions are limited in their ability to  
collect and share data  from pharmacies because they do not have the legal authority to do so, per  
Challenges With Vaccination Data Hinder State and Local Immunization Program Efforts To Combat COVID-19 
OEI-05-22-00010 
Appendix | 23  state and local regulations. In other cases, jurisdictions may prioritize pharmacies lower in their  
onboarding queues to focus on high-volume providers of routine immunizations. Ensuring  
sustainable and diverse  mechanisms of financial  support, a trained workforce, and  adequate  
reporting authorities would enhance pharmacy data collection and reporting to the IIS. In the  
absence of a federal mandate for  all vaccination events to be reported to the  IIS for population  
health monitoring, IIS data will continue to be inconsistent across the nation. 
OIG Recommendation  (2)  
OIG recommends CDC offer updated educational  opportunities to ensure immunization  
programs understand how existing tools can assist in their COVID-19 vaccination campaigns. 
These could include  webinars or the publication of a frequently asked questions document about  
leveraging data sources outside of immunization databases, such as Tiberius and the COVID-19  
Data Tracker, to address gaps reported to  OIG. For example, CDC could instruct immunization  
programs to access complete lists of federal agency and retail pharmacy providers through  
Tiberius. 
CDC Response: CDC concurs with OIGs  recommendation. 
CDC agrees that ongoing outreach to ensure awareness of existing tools and data is helpful to  
jurisdictions. CDC provides technical  assistance, educational outreach, and information on data  
systems (e.g. where and  how to find data). This includes individual outreach to jurisdictions by  
assigned project officers and subject matter  experts to provide customized technical  assistance, 
regular webinars on data  systems (e.g., HHS-CAG webinars on Tiberius, CDC webinars on the  
Immunization Data Lake, Data Clearinghouse, Immunization Gateway, etc.), available  reports  
(e.g., provider data, partner administration data), resources  and guidance, weekly data quality  
reports to highlight areas  of concern and suggested steps for improvement, and regular office  
hours to answer questions and solicit feedback on  jurisdiction needs. CDC does not own  
jurisdiction, participating partners, or other federal agency systems and must rely on system  
owners to determine the training needs of their users but does provide communications and  
access to training materials, when feasible.  
Challenges With Vaccination Data Hinder State and Local Immunization Program Efforts To Combat COVID-19 
OEI-05-22-00010 
Appendix | 24   
 
ACKNOWLEDGMENTS AND CONTACT  
 
 
ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments  
Jonathan Jones,  Samantha Handel-Meyer, and Kayla Phelps  served as the team  
leaders  for this study.   Others in the Office of Evaluation and Inspections who  
conducted the study include Danielle Noriega  and  Alexandra Roehll.  Office of 
Evaluation and Inspections headquarters staff  who provided support include Kaliane  
Davidson,  Althea Hosein,  Christine Moritz, and Sara Swisher.   
We would  also like to acknowledge the contributions of other Office of Inspector  
General staff, including  Lauren Buss, Evan  Godfrey, Dwayne Grant,  and Rebekah 
Schwartz.   
This report was prepared under the direction of  Laura Kordish, Regional Inspector  
General for  Evaluation and Inspections in the Chicago  regional office;  Adam  Freeman,  
Deputy  Regional Inspector  General;  and Hilary Slover, Assistant Regional Inspector  
General.   
Contact  
To obtain additional information concerning this report, contact the Office of Public  
Affairs at  Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found  
on the OIG website at oig.hhs.gov.  
Office of Inspector General  
U.S. Department of Health and Human Services  
330 Independence Avenue, SW  
Washington, DC 20201  
 
Challenges With  Vaccination  Data Hinder State and Local Immunization Program Efforts To Combat COVID-19  
OEI-05-22-00010  
  Acknowledgments and Contact |  25     
ABOUT THE  OFFICE OF INSPECTOR  GENERAL  
The mission of the Office of Inspector General (OIG), as mandated by  Public Law  
95-452,  as amended, is to protect the integrity of  the Department of Health and  
Human Services (HHS) programs, as  well as the health and welfare of beneficiaries  
served by those programs.  This statutory mission is carried out through a  nationwide 
network of audits, investigations, and inspections  conducted by  the following  
operating components:  
The  Office  of  Audit  Services  (OAS)  provides auditing services for HHS,  
either by conducting  audits with its own audit resources  or by overseeing  audit work  
done by others.  Audits examine the performance of HHS programs  and/or its  
grantees and  contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments  of  HHS programs and operations.   
These audits help reduce waste, abuse, and mismanagement and promote economy  
and efficiency throughout HHS.  
The  Office  of  Evaluation  and Inspections  (OEI)  conducts national  
evaluations to provide HHS, Congress,  and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud,  waste,  
or abuse and promoting  economy, efficiency, and  effectiveness of departmental  
programs.  To promote impact, OEI reports also present practical recommendations 
for improving program operations.  
The Office of  Investigations  (OI)  conducts criminal, civil,  and administrative  
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.   With investigators working in all 50 States and the District of Columbia,  
OI utilizes its resources by actively coordinating  with the Department of Justice and  
other Federal, State, and  local law enforcement  authorities.  The investigative efforts  
of OI often lead to criminal convictions, administrative sanctions,  and/or  civil 
monetary penalties.  
The Office of  Counsel to  the Inspector  General  (OCIG)  provides  
general legal services  to  OIG, rendering advice and opinions on HHS programs and  
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil  and administrative fraud  and abuse cases involving HHS  
programs, including False Claims Act, program exclusion, and  civil monetary penalty  
cases.   In connection with these cases, OCIG also  negotiates and monitors  corporate 
integrity agreements.  OCIG renders  advisory opinions, issues compliance program  
guidance, publishes  fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities. 
Challenges With  Vaccination  Data Hinder State and Local Immunization Program Efforts  To  Combat COVID-19  
OEI-05-22-00010  
  About the Office  of  Inspector General  | 26     
ENDNOTES  
 
1  CDC,  Total Doses Administered Reported to the CDC by State/Territory and for Select Federal  Entities, as  of May 4, 2022.   
Accessed at  CDC COVID Data Tracker: Vaccinations in the US  on May 4,  2022.    
2  CDC,  Total Doses Administered Reported to the CDC by State/Territory and for Select Federal Entities, as of May 4, 2022.   
Accessed at  CDC COVID Data  Tracker: Vaccinations in the US  on May 4, 2022.    
3  CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October 29, 2020, version 2.0, Section 11:  
COVID-19 Requirements for Immunization Information Systems of Other External Systems, page 38.  Accessed at  COVID-19 
Vaccination Program Interim Operational Guidance Jurisdiction Operations (cdc.gov)  on May 14, 2021.  
4  CDC,  About Immunization Information Systems.  Accessed at  About Immunization Information System (IIS) | CDC  on June 9,  
2022.  
5  CDC,  Immunization Information Systems Functional Standards  (IIS), v4.1.   See Essential Infrastructure Functional Standards 1,  
1.1, 1.3,  and 1.4.   Accessed at  IIS Functional Standards v4.1 | CDC  on October 1, 2021.  
6  CDC,  Immunization Information Systems Annual Report (IISAR) Data Overview.  Accessed at  IISAR Annual Report Data  
Overview | CDC  on May 11, 2021.   
7  During the 2009 H1N1 pandemic, IISs  were leveraged  extensively to support mass vaccination efforts.   See American  
Immunization Registry Association (AIRA),  Mass Vaccination Capabilities Summary,  page 5.   Accessed at  Mass Vaccination  
Capabilities Summary (memberclicks.net)  on September 30, 2021.    
8  CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October 29, 2020, version 2.0,  Section 11:  
COVID-19 Requirements for Immunization Information Systems or  Other External Systems, page 38.  Accessed at  COVID-19 
Vaccination Program Interim Operational Guidance Jurisdiction Operations (cdc.gov)  on May 14, 2021.  
9  CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October 29, 2020, version 2.0, page 63,  
Appendix D.  Accessed at  COVID-19 Vaccination Program Interim Operational Guidance Jurisdiction Operations (cdc.gov)  on 
April 27, 2021.  
10  CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October 29, 2020, version 2.0, page 39.   
Accessed at  COVID-19 Vaccination Program Interim Operational Guidance Jurisdiction Operations (cdc.gov)  on April 27, 2021.  
11  CDC,  COVID-19 Vaccination Program Interim Playbook for  Jurisdiction Operations, October 29, 2020, version 2.0, pages 63-
64.   Accessed at  COVID-19 Vaccination Program Interim Operational Guidance Jurisdiction Operations (cdc.gov)  on April 27,  
2021.  
12  CDC,  Immunization Information System (IIS) Strategic Plan.  The 2018-2020 Strategic Plan builds on the prior plan from  
2014-2017.  In addition to population-level goals, the plan supports goals for the point of clinical care that support use by  
vaccination providers in determining appropriate patient vaccinations.  Accessed at  IIS 2018-2020 Strategy Initiative and Plan  
Introduction | CDC  on June 9,  2022.  
13  CDC,  Immunization Information Systems  (IIS)  Functional Standards, v4.1.   See Essential Infrastructure Functional Standard 14.   
Accessed at  IIS Functional Standards v4.1 | CDC  on September 13, 2022.  
14  CDC,  Immunization Information Systems  (IIS)  Functional Standards, v4.1.   See Essential Infrastructure Functional Standard 17.   
Accessed at  IIS Functional Standards v4.1 | CDC  on September 13, 2022.   
15  CDC,  Immunization Information Systems Annual Report  (IISAR) Data Overview.  IISAR data  from 2012-2019 are currently  
publicly available.  Accessed at  IISAR Annual Report Data Overview | CDC  on June 9, 2022.    
16  Congressional Research Service,  Immunization Information Systems: Overview  and Current  Issues, February 1, 2022.   
Accessed at  R47024 (congress.gov)  on September 12, 2022.  
 
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OEI-05-22-00010  
  Endnotes | 27     
 
17  Congressional Research Service,  Immunization Information Systems: Overview  and Current Issues, February 1, 2022.   
Accessed at  R47024 (congress.gov)  on September 12, 2022.  
18  Vermonts State Plan notes that State law only allows  its  IIS  to provide information to the CDC in summary, statistical, or  
other form in which particular individuals are not identified.   See Vermont Department of  Health,  COVID-19 Vaccination 
Plan,  page 31, Section 9 B.   Accessed at  COVID-19 Vaccination Plan (healthvermont.gov)  on June 9, 2022.   In Minnesota,  State  
law prohibits sharing race and ethnicity data.  See Kaiser Health News (KHN),  Huge Gaps in  Vaccine Data Make It Next to  
Impossible to Know Who Got the Shots.   Accessed at  Huge Gaps in Vaccine Data Make It Next to Impossible to Know Who  Got  
the Shots | Kaiser Health News (khn.org)  on June 9, 2022.  
19  Trotter, Andrew B., Abbott, Elizabeth, K.,  et al,  Annals of  Internal  Medicine,  Preparing for COVID-19 Vaccination: Call to  
Action for Clinicians on Immunization Information Systems, February 2, 2021.  Accessed at  Preparing for COVID-19  
Vaccination: A Call to Action for Clinicians on Immunization Information Systems | Annals of  Internal Medicine  
(acpjournals.org)  on April 27, 2021.  
20  The Office of the National Coordinator for Health Information Technology (ONC)  uses its Interoperability Standards  
Advisory (ISA) to identify, assess, and promote interoperability standards and implementation specifications for use by the  
health  care industry.  See What  Is the ISA? on FAQs | Interoperability Standards Advisory (ISA) (healthit.gov).   ISA includes a 
standards/implementation specification for transportation and query/response of immunization  data between CDC,  
electronic health record  (EHR), and IIS.  See Transport for Immunization Submission and Query/Response | Interoperability  
Standards Advisory (ISA) (healthit.gov).  
21  AIRA,  Landscape Analysis: IIS  Adult Vaccination Capture and  Data Utilization, page 16.  Accessed at  Adult Landscape FINAL  
(immregistries.org)  on June 14, 2021.    
22  AIRA,  Landscape Analysis: IIS  Adult Vaccination Capture and  Data Utilization, page 17.  Accessed at  Adult Landscape FINAL  
(immregistries.org)  on June 14, 2021.    
23  CDC,  The Nation Benefits When Public Health Connects.  Accessed at  How Data Authority Improves Public Health | CDC  on 
December 7, 2022.  
24  The Hill,  Former CDC Directors: Coordinating Our Nations Health Data Will Save Lives.  Accessed at  Former CDC directors:  
Coordinating our nations health data will save lives | The Hill  on September 14, 2022.  
25  CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October 29, 2020, version 2.0.  COVID-19  
providers could enroll directly with their jurisdictions immunization program, see page 21.  Federal agency and retail 
pharmacy providers enrolled directly with CDC, see pages  25 and 74.  Accessed at COVID-19 Vaccination Program Interim  
Operational Guidance Jurisdiction Operations (cdc.gov)  on April 27, 2021.  
26  The two other Federal agencies that provide vaccinations are the Bureau of Prisons  (BoP) and the Department of State.  See 
CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October 29, 2020, version 2.0, page 25.   
Accessed at  COVID-19 Vaccination Program Interim Operational Guidance Jurisdiction Operations (cdc.gov)  on March 3,  
2022.    
27  For a partial list of pharmacies in the Federal Retail Pharmacy Program, see CDC,  COVID-19 Vaccination Program Interim  
Playbook for Jurisdiction Operations, October 29, 2020, version 2.0, page 74.  Accessed at  COVID-19 Vaccination Program  
Interim Operational Guidance  Jurisdiction Operations (cdc.gov)  on  March 3, 2022.    
28  CDC,  Federal Retail Pharmacy  Program, Pharmacies Participating in the Federal Retail Pharmacy Program.  Accessed at     
Pharmacies  Participating in COVID-19 Vaccination | CDC  on April 6, 2022.   
29  CDC,  The Federal  Retail Pharmacy Program for COVID-19 Vaccination.  Accessed at  COVID-19 Vaccination Federal Retail 
Pharmacy Partnership Program | CDC  on March 21, 2022.   
30  Federal retail pharmacy partners have administered a substantial portion of the total doses administered.  As of March 17,  
2022,  234.9 doses had been administered by these pharmacies.  CDC,  The  Federal Retail Pharmacy Program for COVID-19 
Vaccination.  Accessed at  COVID-19 Vaccination  Federal Retail Pharmacy Partnership Program | CDC  on March 21, 2022.   
 
Challenges With  Vaccination  Data Hinder State and Local Immunization Program Efforts  To  Combat COVID-19  
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  Endnotes | 28     
 
31  As of April, 7, 2022,  563.4 million total doses had been administered.  CDC,  COVID-19 Vaccinations in the United States. 
Accessed at  CDC COVID Data Tracker: Vaccinations in the US  on April 7, 2022.  
32  CDC,  Total Doses Administered Reported to the CDC by State/Territory and for Select Federal Entities, as of May 4, 2022.   
Accessed at  CDC COVID Data Tracker: Vaccinations in the US  on May 4, 2022.  
33  CDC,  The  Federal  Retail Pharmacy Program  for COVID-19 Vaccination.  Accessed at  COVID-19 Vaccination Federal Retail 
Pharmacy Partnership Program | CDC  on May 10, 2022.  
34  Record of IZ Gateway development appears as early as April 2019.  See CDC,  The Immunization Information System (IIS)  
Landscape.  Accessed at  The Immunization Information System (IIS) Landscape (healthit.gov)  on June 22, 2022.    
35  CDC identifies the COVID-19 pandemic as beginning in December 2019.  CDC,  CDC Museum COVID-19 Timeline.  Accessed  
at  CDC Museum COVID-19 Timeline | David J. Sencer CDC Museum | CDC  on June 22, 2022.  
36  CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October  29, 2020, version 2.0, page 35,  
footnote 7.  Accessed at  COVID-19 Vaccination Program Interim Operational Guidance Jurisdiction Operations (cdc.gov)  on  
July 23, 2021.  
37  CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October 29, 2020, version 2.0, page 38.   
Accessed at  COVID-19 Vaccination Program Interim Operational Guidance Jurisdiction Operations (cdc.gov)  on July 23, 2021.  
38  In June 2020,  an AIRA representative reported that there were still IZ Gateway policy and technical issues that needed to be  
resolved before the Gateway could be leveraged on a national scale.  See  Coronavirus vaccine: State immunization databases  
hold key to success (usatoday.com)  from June 12, 2020.  Accessed on July 17, 2021.  
39  As of late 2019,  the IZ Gateway was only in a proof-of-concept stage and some programs noted not intending to sign the  
memorandum that allowed for cross-jurisdiction querying of registries.  National Governors Association,  Supporting an  
Equitable Distribution of COVID-19 Vaccines:  Key Themes, Strategies,  and Challenges Across State and Territorial COVID-19 
Vaccination Plans, page 19, December 2020.  Accessed at  Supporting-an-Equitable-Distribution-of-COVID-19-Vaccine.pdf  
(nga.org)  on April 6, 2022.    
40  HHS,  Immunization (IZ) Gateway Portfolio Overview,  see page 2.  Accessed at  Immunization (IZ) Gateway Portfolio Overview  
(hhs.gov)  on June 15, 2022.    
41  CDC,  Immunization Gateway Information Sheet.  See Connect: National Provider Organizations to Multiple IISs.  Accessed at  
IZ Gateway Information for COVID-19 Vaccination Reporting | CDC  on June 15, 2022.    
42  Government Accountability Office (GAO),  HHS  and DOD Transitioned Vaccine  Responsibilities to HHS, but Need to Address  
Outstanding Issues,  see page 17.   Accessed at  GAO-22-104453, COVID-19: HHS and DOD Transitioned Vaccine  
Responsibilities to HHS, but Need to Address Outstanding Issues  on September 13, 2022.   
43  U.S. Department of  Defense,  Tiberius Platform Aids COVID-19 Logistics, Delivery.  Accessed  at  Tiberius Platform Aids  
COVID-19 Logistics, Delivery > U.S. Department of  Defense > Defense Department News  on June 11, 2022.    
44  Politico,  States Complain Feds Data System  Is Holding Up Vaccination Effort.   Accessed at  States complain feds' data system  
is holding up vaccination effort  -POLITICO  on June 11, 2022.   
45  Politico,  States Complain Feds Data System  Is Holding Up Vaccination Effort.   Accessed at  States complain feds' data system  
is holding up vaccination effort  -POLITICO  on June 11, 2022.    
46  USA Today, A National System to Prioritize COVID-19 Vaccines Has Largely Failed As Our States Rely On Their Own Systems.   
Accessed at  COVID-19 vaccine: Distribution system fails to live up to promise (usatoday.com)  on June  11, 2022.    
47  GovConWire,  Palantir Helps HHS Develop Tiberius  System to Track COVID-19 Vaccine Production, Distribution.  Accessed  
at  Palantir Helps HHS Develop 'Tiberius' System to Track COVID-19 Vaccine Production, Distribution -GovCon Wire  on June  
17, 2022.  
48  CDC,  COVID-19 Data Tracker   Vaccine Distribution & Coverage.   Accessed at  CDC COVID Data Tracker  on June 23, 2022.    
 
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  Endnotes | 29     
 
49  CDC,  Frequently Asked Questions about COVID-19 Vaccination Data.  See How Often Are COVID-19 Vaccination  Data 
Updated?  Accessed at  Frequently Asked Questions about COVID-19 Vaccination Data | CDC  on June 23, 2022.    
50  CDC,  Frequently Asked Questions about COVID-19 Vaccination Data.   See How Are Vaccine  Administration  Data Reported  
to CDC?  Accessed  at  Frequently Asked Questions about COVID-19 Vaccination Data | CDC  on June 23, 2022.    
51  CDC,  Vaccine Administration Management System (VAMS).   Accessed at  VAMS COVID-19 Vaccination Reporting | CDC  on 
October 19, 2022.   
52  CDC,  Data Definitions for COVID-19 Vaccinations in the United States.   Accessed at  Data Definitions  for  COVID-19 
Vaccinations in the United States (cdc.gov)  on June 23, 2022.    
53  All Federal agencies are not present in all jurisdictions.   Fifty-two out of  56 jurisdictions are not receiving data from VA,  
DoD, and/or IHS where it is  expected or wanted.    
54  CDC stated that availability of DoD vaccine administration data may be more limited due to security concerns.   
55  New York State, Governor Kathy Hochul,  Executive  Order No. 8:  Directing the Department of Veterans Affairs to Transmit  
Immunization Records.   Accessed at  No. 8: Directing the Department of Veterans Affairs to  Transmit Immunization Records | 
Governor Kathy Hochul (ny.gov)  on March 3, 2022.   
56  Newsweek,  Which U.S. States Have the Highest  Concentration of Veterans?,  November 17, 2018.  Accessed at  Which U.S.  
States Have the Highest Concentration of Veterans? (newsweek.com)  on March 3, 2022.  
57  The Soldiers Project,  Top 5 Largest Military Bases in the World by Population and Area, March 1, 2022.  Accessed at Top 5 
Largest Military Bases in the World by Population & Area (thesoldiersproject.org)  on March 3, 2022.  
58  Governing,  Military Active-Duty Personnel, Civilians by State.  Accessed  at  Military Active-Duty Personnel, Civilians by State  
(governing.com)  on May 4, 2022.  
59  Not all State and local immunization programs have  IHS facilities.  25 States have facilities.   IHS,  Find Health Care.  Accessed  
at  Find Health Care | Indian Health Service (IHS)  on March 21, 2022.  
60  IHS may not cover all AI/ANs in a jurisdiction.  The  Playbook  instructed jurisdictions to incorporate a variety of AI/AN  
organizations in their planning process  (e.g.,  State-recognized tribes, unrecognized tribes, Urban Indian Health Centers  
(UIHCs)).   CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October 29, 2020, version 2.0,  
page 9.  Accessed at  COVID-19 Vaccination Program Interim Operational Guidance Jurisdiction Operations (cdc.gov)  on 
March 3, 2022.  
61  IHS,  Frequently  Asked Questions.  Accessed  at  Frequently Asked Questions | for Patients (ihs.gov)  on March 3, 2022.   
62  IHS,  Navajo Area.  Accessed at  https://www.ihs.gov/Navajo/  on March 3, 2022.  
63  Statista,  Percentage of U.S. Population Who Are Veterans in 2019, by Age and  Gender.  Accessed at  Percentage of U.S.  
population who are veterans by age and gender 2019 | Statista  on May 10, 2011.   
64  CDC,  What is Vaccination Coverage  and Why is it Important?   Accessed at  VaxView Vaccination Coverage | CDC  on March 3,  
2022.  
65  CDC,  The Federal  Retail Pharmacy Program for COVID-19 Vaccination.  Accessed at  COVID-19 Vaccination Federal Retail 
Pharmacy Partnership Program | CDC  on May 10, 2022.  
66  GAO,  COVID-19 Federal Efforts to Provide Vaccines to Racial  and Ethnic Groups, February  2022.   Accessed at  GAO-22-
105079, Accessible Version, covid-19: Federal Efforts to Provide Vaccines to Racial and Ethnic Groups  on  May 10, 2022.  
67  Murthy Patel, Bhavini, Sterrett, Natalie, et al.,  Disparities in COVID-19 Vaccination Coverage Between Urban  and Rural  
Counties    United States, December 14, 2020   April 10, 2021, MMWR  Morb Mortal Wkly Rep 2020;71:335340.  Accessed at 
MMWR, Disparities in COVID-19 Vaccination Coverage Between Urban and Rural Counties   United States, December 14,  
2020April 10, 2021 (cdc.gov)  on May 9, 2022.   
68  IHS,  Disparities,  October 2019.  Accessed at Disparities | Fact  Sheets (ihs.gov)  on March 3, 2022.    
 
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69  Arrazola,  Jessica, Masiello,  Matthew  M., Joshi,  Sujata, et al.,  COVID-19 Mortality Among American Indian and Alaska Native  
Persons   14 States, JanuaryJune 2020,  MMWR Morb Mortal Wkly Rep  2020;69:18531856.   Accessed at  COVID-19 Mortality  
Among American Indian and Alaska Native Persons   14 States, JanuaryJune 2020 | MMWR (cdc.gov)  on March 3, 2022.   
70  CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October 29, 2020, version 2.0, Role of  
Commercial and Federal Partners, page 25.  Accessed at   COVID-19 Vaccination Program Interim Operational Guidance  
Jurisdiction Operations (cdc.gov)  on February 24, 2022.   
71  Federal COVID-19 data platforms available to immunization  programs include HHS Tiberius dashboard for vaccine  
distribution and CDCs public COVID-19 Data Tracker.   See CDC, COVID-19 Vaccination Program Interim Playbook for  
Jurisdiction Operations, October 29, 2020, version 2.0, page 49,  for description of Tiberius.  Accessed at   COVID-19 Vaccination 
Program Interim Operational Guidance Jurisdiction Operations (cdc.gov)  on March 3, 2022.   Also see CDCs public COVID-19 
data tracker accessed at  CDC COVID  Data Tracker: Vaccinations in the US  and CDC  COVID Data Tracker: County View  on April 
8, 2022.   
72  The Immunization Infrastructure Modernization Act of 2021 directs HHS to improve data sharing and other aspects of IISs.   
Accessed at  H.R.550  -117th Congress (2021-2022): Immunization Infrastructure Modernization Act of 2021 | Congress.gov |  
Library of Congress  on September 15, 2022.  
73  The PREVENT Pandemics Act  considers  revisions on authories of HHS to support preparedness, including the collection of  
public heath data.  Accessed at  S.3799 -117th Congress (2021-2022): PREVENT Pandemics Act | Congress.gov | Library of  
Congress  on September 15, 2022.  
74  Some  multijurisdictional vaccination providers receive COVID-19 vaccine allocation directly from CDC.  These providers  
include Federal agencies (i.e., BoP, DoD,  DoS,  VA, and IHS) and select pharmacy partners (e.g., Walgreens, CVS, Walmart, Rite  
Aid Corp).  CDC,  COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations, October 29, 2020, version 2.0,  
pages 25 and 74.  Accessed at   COVID-19 Vaccination Program Interim Operational Guidance Jurisdiction Operations  
(cdc.gov)  on February 14, 2022.  
75  We did not ask respondents to differentiate between data received from  Federally  run and Tribally  run IHS facilities.   
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