Challenges With Vaccination Data Hinder State and Local Immunization Program Efforts To Combat COVID-19, OEI-05-22-00010
- Issuer
- Office of Inspector General
- Document type
- Brief
Summary
A report in brief from the U.S. Department of Health and Human Services Office of Inspector General, OEI-05-22-00010, dated January 2023, on COVID-19 vaccination data received by State and local immunization programs. Based on a December 2021 survey of 56 immunization programs, OIG reports that 44 of the 56 programs received no individual-level vaccination data from VA and 42 of the 56 received none from DoD. It reports that 44 of the 56 programs said they did not receive complete, accurate and timely data from all Federal retail pharmacy providers, and that programs struggled to measure coverage and target outreach. OIG recommends that CDC work with programs and pharmacy partners to mitigate data gaps and provide educational outreach on existing tools. CDC nonconcurred with the first recommendation and concurred with the second.
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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
Successful national vaccination
and Local Immunization Program Efforts To
campaigns and routine Combat COVID-19
vaccination efforts depend on
complete and timely vaccination
Key Takeaway What OIG Found
data being available to State and
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
immunization databases to the Department of Defense (DoD), and/or the Indian
individual-level vaccination data
manage vaccination campaigns. Health Service (IHS). Most programs reported that
from all providers.
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 programs—but 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 Nation’s
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
million COVID-19 vaccinations
16 of 25 immunization programs
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
administered over 234.9 million
COVI D-19 vaccinations
reported not receiving complete,
accurate, and timely data from all
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 jurisdiction’s public health emergency plan. 14
CDC conducts an annual survey of immunization programs about their databases,
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Background | 1
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 CDC’s 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
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Background | 2
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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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 Indian Health Service (IHS) .
VA has administered
•
aii&
DoD has administered
1ith
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 individual’s full
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Background | 4
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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Background | 5
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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Findings | 8
Pre-existing data-sharing policies may limit an of the 56 immunization
agency’s 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
data to the State’s 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 VA’s current privacy policy X X X X X X X
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 State’s 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
their immunization databases do not receive timely
receiving any data from DoD
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
X X X X X
into the local database by DoD providers.
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.
14 programs
Some of the 14 State and local immunization
programs that received data but reported
challenges attributed these challenges to IHS
A reported challenges
obtaining data
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
30 programs example, immunization programs reported that
A ~eceived untimely,
inaccurate, or
incomplete data
they discovered patterns of deleted doses, missing
data elements, and duplicate reporting. One
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 vendor’s 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 country’s
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
Challenges With Vaccination Data Hinder State and Local Immunization Program Efforts To Combat COVID-19
OEI-05-22-00010
Findings | 12
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
Some immunization programs reported being unable
t® 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,
it could not accurately reported that data missing from retail pharmacies
estimate vaccination rates affected its total vaccination count and the
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 CDC’s estimates. One immunization
program added that CDC’s 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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Findings | 13
Challenges in targeting outreach to unvaccinated and vulnerable populations
Some immunization programs reported using data
---
•••
Most Americans live
within 5 miles of a
to systematically identify communities with low
vaccination coverage to plan local pop-up
vaccination clinics, target vaccination marketing
campaigns, or conduct other outreach aimed at
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
retail pharmacies, State and local records for special populations, such as Tribal
immunization databases are members and their families; rural communities;
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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Findings | 14
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 government’s 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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OEI-05-22-00010
Findings | 15
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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Findings | 16
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 mpox—another infectious disease
with available vaccines—underscore 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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Conclusion and Recommendations | 17
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.
OIG’s 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 report’s 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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OEI-05-22-00010
Conclusion and Recommendations | 18
AGENCY COMMENTS AND OIG RESPONSE
CDC nonconcurred with our first recommendation and concurred with our second
recommendation.
In nonconcurring with our first recommendation—that CDC should work with State and local
immunization programs and retail pharmacy partners to mitigate reported data gaps and
timeliness challenges—CDC 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 CDC’s 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 recommendation—that CDC should provide educational outreach
to ensure that State and local immunization programs are aware of existing tools to address
vaccination campaign needs—CDC 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 CDC’s comments, see the Agency Comments appendix at the end of the report.
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OEI-05-22-00010
Agency Comments and OIG Response | 19
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
Challenges With Vaccination Data Hinder State and Local Immunization Program Efforts To Combat COVID-19
OEI-05-22-00010
Detailed Methodology | 20
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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Detailed Methodology | 21
APPENDIX
Agency Comments
~ U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service
,::--z~ Centers for Disease Control
and Prevention (CDC)
Atlanta GA 30329-4027
DATE: December 6, 2022
TO: Ann Maxwell
DATE: December 6, 2022
Deputy Inspector General for Evaluation and Inspections
TO: Rochelle P. Walensky, MD, MPH
FROM:Ann Maxwell
Director, CDC Centers for Disease Control and Prevention (CDC)
Deputy Inspector General for Evaluation and Inspections
SUBJECT: INFORM ATTON ONLY - CDC's response to the Office of the Inspector
FROM: Rochelle P. (OTG)
Walensky,
General's draftMD, MPH
report, "Challenges With Data From Federal Vaccination
Partners Hinder Efforts by
Director, CDC Centers for DiseaseState andControl
Local Immunization Programs
and Prevention To Combat
(CDC)
COVID-1 9, OEI-05-22-00010" (the Report)
SUBJECT: INFORMATION ONLY – CDC’s response to the Office of the Inspector
KEY INFORMATION
General’s (OIG) draft report, “Challenges With Data From Federal Vaccination
Partners Hinder
This memorandum Efforts
is to inform by State
you that andresponded
CDC has Local Immunization Programs
to the Report by detailing theTo Combat
agency'sCOVID-19,
planned actions (TAB A). CDC appreciates
OEI-05-22-00010” (the Report) the opportunity 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
agency’s 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: CDC’s 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 General’s (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 OIG’s 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 OIG’s 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 OIG’s 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.
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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
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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 OIG’s 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.
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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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17 Congressional Research Service, Immunization Information Systems: Overview and Current Issues, February 1, 2022.
Accessed at R47024 (congress.gov) on September 12, 2022.
18 Vermont’s 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 Nation’s Health Data Will Save Lives. Accessed at Former CDC directors:
Coordinating our nation’s 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.
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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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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,
2020–April 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, January–June 2020, MMWR Morb Mortal Wkly Rep 2020;69:18531856. Accessed at COVID-19 Mortality
Among American Indian and Alaska Native Persons — 14 States, January–June 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 CDC’s 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 CDC’s 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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