Implications of the COVID-19 Pandemic on IIS Operations, Performance, and Future Readiness: Not the New Normal
Year: 2024
Type: article
Abstract: The COVID-19 pandemic dramatically increased demands on state and local immunization information systems (IIS) to provide near real-time information about the immunization status of large populations and individuals. We believe that continued expectations for near real-time access to IIS data in an ongoing manner post-pandemic are potentially incompatible with ensuring the accuracy of IIS data. IIS were initially developed in the United States with 2 goals: to assist providers with tracking immunization administrations in their practices, especially when records were scattered across multiple provider sites, and to track all dose administrations within jurisdictions primarily for surveillance purposes. In doing so, IIS furnished an integrated perspective, which was previously lacking at a population level, and provided a detailed base of information for conducting state and local immunization surveillance. IIS are often used to produce demographic or geographic-based immunization rates for populations or subpopulations within their jurisdictions. This type of analysis is commonly used for a limited set of age ranges reflecting key immunization milestones, such as the primary vaccination series given by 2 years of age. Most, but not all IIS, routinely calculate population-based immunization rates for ages beyond early childhood, including rates for adolescent immunizations (eg, tetanus, diphtheria, pertussis [Tdap], human papillomavirus [HPV], and meningococcal ACWY). A smaller number prior to the COVID-19 pandemic also assessed adult immunization rates, such as for seasonal influenza. On the provider support side, all IIS are also used by public health and primary care providers to identify individuals eligible or overdue for recommended vaccinations. A third type of typical IIS usage is to support public health responses to periodic outbreaks of vaccine-preventable disease identifying undervaccinated groups in affected geographic areas. IIS Respond to the Pandemic With the onset of the COVID-19 pandemic and ensuing public health emergency, priorities quickly changed for public health officials, particularly those charged with managing IIS. With the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines becoming widely available early in 2021,1 most IIS were inundated with unprecedented volumes of new immunization data as large populations were immunized, often in mass vaccination settings. Many of those immunized against COVID-19 did not have prior IIS records in their jurisdictions, particularly among young and middle-aged adults. Prior to the pandemic, the majority of IIS had focused on collecting and assessing child immunization records rather than adult records. The IIS scalability needs became profound as IIS were faced with dramatic increases not only in the number of requests for immunization information but also in their scope. These requests often required immediate attention, as consumers needed real-time access to their records and pandemic responders typically wanted daily or weekly updates. Many jurisdictions accommodated the increased demand for rapid immunization information through the use of dashboarding, both for public health management of the response and public-facing resources for broader community use.2–7 IIS data were integral to these and other dashboards of SARS-CoV-2 vaccine uptake, some of which were refreshed on a weekly, daily, or even a continuous basis.2 These demands for IIS data quickly revealed limits of aging IIS technology and capacity. The pandemic-born demand for rapid and comprehensive information exposed a growing number of IIS data quality issues that had emerged due in part to reporting lags, incompleteness, and deduplication problems of both patients and vaccine doses. In some jurisdictions, these issues were coupled with problems stemming from inaccurate or incomplete data across age, race, and geographic categories. IIS had regular processes established to assess data quality and address data cleaning needs; these had often taken place over a period of months and became increasingly at odds with an emphasis on the rapid provision of data. Meeting requirements for geocoded data to support mapping for pandemic epidemiologic assessments was often hampered by missing or incorrect client IDs, administration dates, or locations of vaccine administrations as well as numerous other issues tied to mass vaccination reporting problems.2,8,9 IIS also grappled with needs for reporting out-of-state SARS-CoV-2 vaccine administrations, as doses were often administered in jurisdictions other than the patient's primary residence. At the same time, new issues arose as IIS-to-IIS interoperability came online, which had previously not been available.10 The pandemic uncovered numerous IIS record matching/linkage issues, which impeded important initiatives supporting disease surveillance, vital records, vaccine inventory distribution, Medicaid program operations, and other activities.11–13 Increased connectivity to a wider variety of systems drove an increased demand for accurate, urgent record linking/matching even beyond that which IIS typically handled. Creating accurate vaccine histories for clients, either across SARS-CoV-2 immunizations or to other types of immunizations, was hampered by the absence of common unique person identifiers; IIS typically had to merge records based only on client name, date of birth, and sex, especially for newly acquired adult records. Consequently, a level of uncertainty had to be accepted with some IIS data, such as understanding whether uneven SARS-CoV-2 vaccine availability and uptake was driving vaccine administration inequity issues across demographic groups.8,14 At the same time, politics became an even greater part of IIS operations as the accuracy of data itself at times became politically charged given its prominence in a pandemic response impacted by a growing wave of COVID-era misinformation.15–18 Opportunities to Move Forward The collective experiences of jurisdictions throughout the pandemic response have left a lasting impression on the post-pandemic IIS environment and provide a framework for potential improvement moving forward. One of the more pressing issues will be how best to be responsive to requests for data with rapid turnaround yet still provide accurate and complete information. A looming concern is that the role of IIS during the pandemic has fueled new expectations that IIS can provide near real-time data for all types of vaccines, spanning all age groups, races, and varying levels of geographic granularity. The success of the federal government in tracking COVID immunizations on a national scale may also support calls for an overarching, national immunization registry. The Centers for Disease Control and Prevention (CDC) has a goal of collecting all immunization data from all jurisdictional IIS to create a deidentified national data set.19–21 Such a federal role is likely to address a perceived need for near real-time immunization surveillance across the United States, while leaving the clinical support role to state and local IIS. Some IIS are already participating in this federal initiative; while most IIS have statutory or rule-based language that allows for sharing data outside of their jurisdictions, data sharing barriers may exist for others.22 The timeliness of vaccine dose reporting will continue to be fostered by the expansion of electronic interoperability between vaccination providers and IIS. However, the value of instituting near real-time surveillance processes to monitor nonpandemic vaccination rates is not evident. For example, it is unclear how often routine immunization dashboards should be updated and how much lag time should be allowed to accommodate quality assurance processes. Without dramatic changes in the underlying population or service delivery environment, the establishment of near real-time surveillance for routine vaccinations may not be warranted. Data quality trade-offs notwithstanding, we question whether the preference and expectation of near real-time access to IIS data as shown during the pandemic is useful in a time of limited resources and public retrenchment from public health pandemic management. It is unclear how future mandates for near real-time reporting of vaccinations from IIS will come about, whether it be for the next pandemic event or otherwise. The recent reductions in federal funding to state and local IIS are likely to create barriers to participation in any such initiatives, potentially impacting future readiness to furnish accurate data in near real time.23 Looking ahead, the lessons learned by IIS during the COVID-19 pandemic should be applied toward readiness for future pandemics and will serve as a blueprint where rapid, large population data assessments are needed. The challenge will be finding a balance between these new lessons and the ongoing need for quality support of routine immunizations. For now, data quality needs and the IIS processes for ensuring data quality should be considered a priority above processes that focus on reporting IIS contents on a day-to-day basis. Intelligent planning for IIS data usage should include data quality needs as well as a consideration of what IIS population data are actually useful for long-term public health planning. Frequent and rapid reporting may have little utility in comparison to purpose-driven, and slower, reporting of meaningful immunization data on a population level for routine immunizations. IIS saw a massive injection of resources during the pandemic, although postpandemic budgets and staffing are rapidly declining.23 We believe that ensuring the continuation of nonpandemic IIS operations through sustained funding is imperative and is certainly a higher priority than efforts focused on supporting pandemic-response data sets on a national scale. The core of IIS value is to support the work of providers and public health officials, ensuring immunization protection for all vaccine-preventable disease, not restricted to pandemic diseases. IIS sustainability will require ongoing, consistent funding to enable the development and scaling necessary to meet increasing needs for data. Recent CDC cuts to state IIS funding are worrisome and short-sighted; these reductions in funding will likely have impacts on ongoing IIS operations to support routine vaccinations as well as jurisdictions' readiness to effectively respond to the next pandemic.
Institutions: University of Michigan, Oregon Health Authority
Language: English
Subfield: Health
Field: Social Sciences
Domain: Social Sciences
Open Access status: hybrid
OpenAlex ID: W4391242667