Approaches to immunization data collection employed across Canada during the pandemic (H1N1) 2009 influenza vaccination campaign.

Heidebrecht, Christine L. ; Pereira, Jennifer A. ; Quach, Susan 等

As part of the public health response to the 2009 influenza A (H1N1) pandemic, and in accordance with federal and international pandemic plans, Canadian health jurisdictions carried out a universal immunization campaign between October 2009 and January 2010. A critical component of this campaign was the collection of immunization data at the point of care. To meet reporting requirements, ensure timely availability of coverage information for assessment of the response, and to monitor adverse event rates, a wide range of data collection approaches were used across Canada, including many new or modified information systems.

To explore these approaches from a systems perspective, an observational study was carried out during the immunization campaign. Study sites included public health mass immunization clinics and occupational health clinics operating in hospitals. We describe and categorize the data collection approaches that were observed at immunization clinics across Canada.

In addition to an awareness of the capabilities that various types of data repositories possess, an understanding of how data are obtained and processed at the point of care is critical for vaccine providers and/or policy-makers who are considering alternative approaches to immunization data collection. Many information systems and registries that capture immunization data are described in the literature, imparting valuable information about systems' capacity, performance and validity. Examples of these include childhood registries, (1-3) health provider records, (4) and population health information systems or immunization databases. (5-9) There is a paucity of in-depth information available regarding how data collection is incorporated into clinic processes, however, and this is the first study to examine and illustrate the range of data collection practices employed in Canadian mass influenza vaccination settings.

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METHODS

This study was conducted in the context of a three-stage evaluation, integrating time and motion methodology, user perception surveys, and passive observation. The present paper describes the passive observation evaluation. Full study methods have been described previously. (10)

To ensure that participant sites reflected variation in data collection methods, geographic diversity and a range of clinic settings across Canada, this study's sampling frame included public health organizations in every province and territory. Participant sites were recruited through email; invitations were sent to all public health organizations across the country, as well as a convenience sample of acute care hospitals. A maximum number of study sites was not set. Ethics approval was obtained from the University of Toronto's Health Sciences Research Ethics Board, as well as from the ethics review boards of participating jurisdictions, as required.

Three clinic days were spent at each participating site, during which one member of the research team spent several hours collecting data. To supplement time observations and survey data, this team member observed clinic processes, focusing particularly on tasks related to data collection. These tasks included client registration, collection and review of medical history, vaccine recordkeeping (lot number, date of administration, etc.), proof of vaccination preparation, and post-vaccination data entry (Figure 1). An observation guide* outlining questions regarding the clinic environment, equipment and overall clinic processes, as well as a checklist of data elements, directed the documentation of this information in detailed field notes. Client information forms obtained from each organization identified the data elements that were recorded on paper and captured electronically. Field notes were analyzed in order to understand the data collection mechanisms that comprised each information system as a whole; our interpretations of these system characteristics were summarized and sent to each organization for validation.

RESULTS

Seventy-nine clinic sites in thirty-eight organizations were observed across nine provinces and territories between October 27th and December 17th, 2009, representing 23% of the 165 organizations invited to participate. Due to logistical constraints, we were unable to visit a small number (n=5) of interested organizations. The characteristics of participating sites are described in Table 1.

Data collection approaches varied extensively among and often within provinces and territories, but could be grouped into two broad categories. Electronic systems captured all data electronically on a computer prior to or at the point of immunization; hybrid systems comprised both electronic and manual data collection components. Within these classifications, we have described systems according to the nature of the infostructure (information infrastructure) in which the data were ultimately housed. Table 2 illustrates the processes followed within each of the systems described below.

Electronic systems

Two fully electronic systems were observed in this study.

In one organization, client immunization data were captured in a regional electronic health record (EHR) that incorporated a telephone booking system (System A). Appointments were made over the phone and directly entered into each individual's electronic record by a clerk; if no file existed for a caller, a new client record was created when the appointment was made. On arrival at an immunization clinic, each client was directed to an immunizing nurse who selected his/her electronic record from a list of registered individuals. Medical history and vaccine details (dose, site, lot number) were entered electronically into the client's record through a series of check-boxes and drop-down menus. All of these data were retained within each individual's health record in the regional registry, and transferred daily to a secondary server to facilitate reporting. Immunized clients were provided with a handwritten proof of vaccination card for their records.

The second electronic system, employed in eight observed organizations, was a system developed specifically to capture influenza immunization data (System B). Upon arrival at a clinic, clients were registered by clerks equipped with laptops connected to a networked database. Demographic information was retrieved by swiping a health insurance card or driver's licence, ** or captured through manual data entry when necessary. Responses to medical history questions posed by the registration clerk were also entered into the client's record. Clients then proceeded to an immunization nurse, also equipped with a laptop, who retrieved each individual's electronic record and reviewed the client's medical history before administering the vaccine. Following immunization, vaccine details were entered into the client's record through check-boxes and by selecting pre-populated vaccine information. Printed directly from the system, a proof of vaccination record was provided to each client. The individual vaccine records created at each immunization clinic were uploaded daily into a centralized, regional database.

Hybrid systems: Electronic client registration

Hybrid systems integrated both electronic and paper elements into their data collection approaches. In several hybrid systems, electronic immunization records were created for each client at registration, and in six organizations the following process was observed: upon arrival at the clinic, clients provided their name, health card number, and, if necessary, demographic information to a registration clerk for entry into an electronic database. This was either a) pre-populated with residents' individual-level data from regional or provincial records (System C), or b) a stand-alone database into which all information was manually entered as new records at the time of registration (System D). Following registration, a paper immunization form was printed and taken to an immunization nurse for medical history review and immunization documentation. The additional information recorded on these forms was later manually entered into each client's electronic immunization record. Varying by clinic, clients' proof of vaccination documentation consisted of pre-filled cards printed at registration or a form signed and dated by the immunizer; in some cases, no proof was provided.

In another organization, software and swipe technology similar to those described as System B were incorporated into a hybrid data collection process (System E). Upon clinic arrival, clients completed a paper immunization form and presented it to a clerk at the time of registration. Together with demographic information from a health card or driver's licence, the information on this form was used to create an electronic immunization record in a new standalone influenza database. The paper form was returned to the client and used by the nurse as a reference for medical history review and, once updated with immunization documentation, was retained by the organization operating the clinic. No additional information was entered into the electronic system after registration. Nurses completed a proof of vaccination form for each client.

Hybrid systems: Manual data collection at the point of care

Twenty-two organizations shared a common data collection approach, in which all data collection tasks at the point of care were performed manually using paper forms; the primary differences lay in the mechanisms used to transfer data from paper records into an electronic form. Demographic and medical history fields were completed on paper consent forms by either clients or registration staff. These forms were brought to the immunizing nurse who reviewed the medical information and completed all required vaccine administration details (in some jurisdictions, date stamps and/or lot number stickers were used to expedite recordkeeping). Proof of vaccination consisted of either a carbonless copy of the immunization form or an immunization card--pre-printed in some organizations and requiring handwritten documentation in others.

In some jurisdictions, data were transferred from paper forms into provincial immunization registries (System F). In one province, in which seven organizations were observed, this registry contained client-level records for all individuals registered for health coverage, reflecting most immunizations administered over the past several years. Data were transferred from paper forms into the registry by data entry clerks. In another province in which three organizations were observed, the provincial registry previously used exclusively to capture childhood immunizations was expanded to incorporate adult immunizations in advance of the pandemic H1N1 immunization campaign. Using paper forms, data entry staff updated existing client records in the internet-based registry and created new records for all individuals (adults and children) who did not have a previous record in this registry.

In three other organizations, the individual-level data entered into provincial or regional registries were limited to certain subgroups. Immunization data for children nine years of age and younger were entered into childhood immunization registries (system G), in order to track immunization doses received at the individual level, as initially it was expected that all children under the age of ten years would require two doses of the pandemic H1N1 vaccine (this directive was later modified). Data for the remaining population were retained electronically as aggregate counts of vaccinees by age- and risk-group.

Specialized influenza interfaces were developed by some organizations to expedite data entry (System H). In one organization, an influenza immunization registry created from health insurance data was pre-populated with individual-level demographic information for all residents of the jurisdiction. Data entry involved retrieving each client's profile using a unique identifier and completing fields from the paper form. Another organization used an immunization interface to enter vaccine data into each employee's human resources record. Again, individual records were retrieved during the data entry process and vaccine data were entered into a series of prompted fields.

Seven organizations observed in one province created new influenza databases into which individual-level data from immunization forms were entered by data entry staff (System I). Since these databases were not integrated with previously-established registries, as was done in other organizations, new records were required for all clients.

Data elements

We observed substantial variability in the data elements captured by or entered into electronic information systems. Certain core demographic and clinical elements were collected by all organizations, while supplementary data retained electronically in individual immunization records varied extensively across participating jurisdictions. Table 3 describes the key data elements collected, the proportion by information system type, and the proportion of observed organizations that retained these elements within individual electronic records.

DISCUSSION

The observed approaches used to capture and store pandemic H1N1 immunization data varied considerably across Canada. In some instances, the use of pre-existing health records, pre-populated databases, pre-entered lot and expiry information, or magnetic card reader technology reduced manual data entry, improving data collection efficiency, (11) and potentially data quality (although this was not assessed in the present study). Further, systems that allowed electronic immunization records to be created or accessed at the point of registration/immunization and updated electronically made information readily available for evaluation and analysis.

The nature of an information storage system and the data collection methods employed, as well as the data elements retained in the system, have important implications for when, how, and which data can be analyzed and used. Fully electronic systems and individual electronic records that are updated shortly after each clinic day allow a range of functions to be performed during the immunization campaign in a highly automated and consistent fashion. These include dose and date monitoring for individuals who require multiple doses, and lot number tracking in the case of adverse events. Through the collection of a comprehensive set of medical and demographic data, and provided that these data are rapidly available for analysis, vaccine uptake among vulnerable populations can be assessed throughout the immunization campaign and addressed through public health outreach initiatives as necessary. Though check-boxes make these data straightforward to collect either on paper or in electronic form, our observations indicate that organizations employing electronic systems captured a greater number of data elements. We were not able to ascertain the reasons for this in the context of the current study but the fact that a greater number of elements can be collected without lengthening paper consent forms, coupled with the potential to use the data immediately rather than relying on data entry, are likely significant factors. Electronic immunization data collected over a number of influenza seasons can enhance longer-term policy-making, program planning and evaluations by allowing trends in uptake across a range of client and clinic characteristics to be observed. From a clinical perspective, electronic registries allow rapid access to vaccine information for both care providers and clients, who may require vaccination confirmation for employee or personal records. Further, robust research and evaluation regarding the safety and impact of a vaccine are dependent on system characteristics and data elements collected. The inclusion of unique identifiers in immunization records allows these data to be linked with other health information for program evaluation and research purposes, including safety and effectiveness assessments, and also minimizes possible duplication of client records in the system. Capturing clinic data directly in an EHR, within which a range of other individual personal and medical information is stored, ensures that immunization history is part of a client's comprehensive clinical profile.

The specific approach to data collection that is most appropriate for an organization is highly dependent on several factors. In addition to the information needs and size of the population being served, the financial and technical resources available are also critical considerations. (12) While electronic components may hasten data collection tasks, their implementation requires the purchase of hardware and software and requires staff with appropriate expertise to install and maintain these elements. The capacity of an organization to preserve data security, in order to ensure that privacy and confidentiality legislation is upheld, is another important factor to consider when personal health information is collected and stored electronically. In addition to database architecture that is suitable from an operational perspective, jurisdictions employing electronic systems must have the appropriate infrastructure and standards in place to maintain the integrity of any identifiable information that is collected.

Collecting and electronically maintaining a broad range of immunization data is a considerable yet worthwhile investment if these systems are used to their full capacity, but if they are not, time and resources could be more appropriately spent elsewhere. Recognition of the value of fully electronic systems is essential for these investments to be made. This exploration was not within the scope of this study; an important next step is to understand how immunization data are being applied, at which organizational levels, and by whom.

A key limitation of this study is its emphasis primarily on mass immunization clinics managed by public health organizations. Hospital settings were included in our sampling frame but because recruitment coincided with the beginning of the pandemic's second wave and health care workers were identified as a priority group and quickly vaccinated, it was only possible to obtain consent to observe a small number of hospitals while their immunization campaigns were still operating. Physician offices and other settings were excluded from this study due to complexities related to recruitment within a very short time period. Further, because it was not possible to recruit sites in all public health jurisdictions, nor all provinces and territories, there may have been other approaches to data collection used within Canada that are not described in this paper.

Public health organizations and hospitals across Canada employed a wide range of immunization data collection approaches during the pandemic (H1N1) 2009 influenza vaccination campaign, several of which were newly developed or modified. System characteristics can have important implications for on-site efficiency and organization of vaccine services as well as longer-term planning and program evaluation. The systems observed have been described in detail with the intention that vaccine providers and program planners will be able to learn from what has been done elsewhere. Further studies examining systems' data quality, user acceptability and ease of integration with clinic operations will be valuable in moving toward provincial/territorial, if not national, consensus on optimal approaches for collecting immunization information. It is hoped that an in-depth understanding of the system features and characteristics that facilitate the collection of high-quality data with greater usability will be incorporated into Panorama, the proposed pan-Canadian public health surveillance system, as well as other information systems as they continue to be developed and implemented across Canada.

Acknowledgements: PCIRN Vaccine Coverage Theme Group members are: David Allison, Julie Bettinger, Nicole Boulianne, Stephanie Brien, David Buckeridge, Larry Chambers, Natasha Crowcroft, Shelley Deeks, Michael Finkelstein, Julie Foisy, Effie Gournis, Maryse Guay, Jemila Hamid, Christine Heidebrecht, Donna Kalailieff, Faron Kolbe, Jeff Kwong, Allison McGeer, Jane Nassif, Jennifer Pereira, Susan Quach, Sherman Quan, Beate Sander, Chris Sikora, and Don Willison.

This study was supported by an operating grant from the Public Health Agency of Canada and the Canadian Institutes of Health Research. The Canadian Association for Immunization Research and Evaluation provided networking assistance. We are grateful for the contributions and support of the organizations across Canada that participated in this study.

Conflict of Interest: Maryse Guay received a research grant from Hoffman-Laroche in 2006, and honoraria from Merck Frosst Canada for lectures delivered between 2007-2009. Jennifer Pereira is engaged in consultancy work for GlaxoSmithKline in areas unrelated to influenza vaccine. No other authors have conflicts of interest.

Received: October 15, 2010

Accepted: April 14, 2011

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(9.) Luhm KR, Cardoso MR, Waldman EA. Vaccination coverage among children under two years of age based on electronic immunization registry in Southern Brazil. Rev Saude Publica 2011;45(1):90-98.

(10.) Pereira JA, Quach S, Heidebrecht CL, Foisy J, Quan S, Finkelstein MS, et al. Pan-Canadian assessment of pandemic immunization data collection: Study methodology. BMC Med Res Methodol 2010;10:51.

(11.) Quach S, Hamid JS, Pereira JA, Heidebrecht CL, Foisy J, Bettinger JA, et al. Time and motion study to compare electronic and hybrid data collection systems during the pandemic (H1N1) 2009 influenza vaccination campaign. Vaccine 2011;29(10):1997-2003.

(12.) Heidebrecht CL, Foisy J, Pereira JA, Quan SD, Willison DJ, Deeks SL, et al. Perceptions of immunization information systems for collecting pandemic H1N1 immunization data within Canada's public health community: A qualitative study. BMC Public Health 2010;10:523.

(13.) Statistics Canada. Postal Code Conversion File, Reference Guide, 2005. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/Statcan/92F0153GIE/ 92F0153GIE2005001.pdf (Accessed June 10, 2010).

* This unpublished guide was developed by colleagues within our research network and is available upon request.

** In some Canadian provinces and territories, demographic information is embedded within health insurance cards and/or driver's licences and is automatically scanned and uploaded when the card is swiped through a magnetic reader.

Christine L. Heidebrecht, MSc, [1] Jennifer A. Pereira, PhD, [1] Susan Quach, MSc, [1] Julie Foisy, MPH, [1] Sherman D. Quan, BSc, [2] Michael Finkelstein, MD, MHSc, [3,4] Shelley L. Deeks, MD, MHSc, [1,4] Maryse Guay, MD, MSc, [5-8] Julie A. Bettinger, PhD, mph, [9] Faron Kolbe, MSc, [3] Natasha S. Crowcroft, MD(Cantab), FFPH, [1,4,10] Christopher A. Sikora, MD, MPH, [11] David L. Buckeridge, MD, PhD, [6,12,13] Jeffrey C. Kwong, MD, MSc, [1,4,14,15] for the Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network (PCIRN) Vaccine Coverage Theme Group

Author Affiliations

[1.] Surveillance and Epidemiology, Public Health Ontario, Toronto, ON

[2.] University Health Network, Toronto, ON

[3.] Toronto Public Health, Toronto, ON

[4.] Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[5.] Departement des sciences de la sante communautaire, Universite de Sherbrooke, Longueuil, QC

[6.] Institut national de sante publique du Quebec, Montreal, QC

[7.] Agence de la sante et des services sociaux de la Monteregie, Longueuil, QC

[8.] Centre de recherche de l'Hopital Charles LeMoyne, Longueuil, QC

[9.] Vaccine Evaluation Center, University of British Columbia, Vancouver, BC

[10.] Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON

[11.] School of Public Health, University of Alberta, Edmonton, AB

[12.] Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC

[13.] Agence de la sante et des services sociaux de Montreal, Montreal, QC

[14.] Institute for Clinical Evaluative Sciences, Toronto, ON

[15.] Department of Family and Community Medicine, University of Toronto, Toronto, ON

Correspondence: Dr. Jeff Kwong, Institute for Clinical Evaluative Sciences, G1-06, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Tel: 416-480-4055, ext. 7665, Fax: 416-480-6048, E-mail: jeff.kwong@utoronto.ca

Table 1. Site Characteristics

                                 Number of Sites (%)

Province/Territory

Alberta                           8 (10.1)
British Columbia                  5 (6.3)
Manitoba                         14 (17.7)
Newfoundland and Labrador         6 (7.6)
Nova Scotia                      15 (19.0)
Nunavut                           2 (2.5)
Ontario                          15 (19.0)
Quebec                            6 (7.6)
Saskatchewan                      8 (10.1)
Organization Type
Public Health                    74 (93.7)
Hospital                          5 (6.3)
Data Collection Approach
Electronic                       14 (17.7)
Hybrid                           65 (82.3)
Clinic Location *
Rural                            27 (34.2)
Urban                            52 (65.8)

* Classified according to postal code; the number in the second
position of the postal code indicates whether the forward
sortation area is urban or rural. (13)

Table 2. Data Collection Tasks by System

                                 Electronic
                                 Systems (# of    Hybrid Systems
                                 organizations)   (# of organizations)

                                 A      B         C      D      E

                                 (1)    (8)       (5)    (1)    (1)

Registration
  Clerk calls up client record                    (a)
    in pre-populated registry
  Card swiped to populate               (a)                     (a)
    demographics in a new
    client record
  Prior to clinic visit, over    (a)
    the phone; entered into
    electronic patient record
  Client or clerk completes
    paper immunization form
  Clerk manually creates new                             (a)
    client record within
    database
Medical History
  Reviewed and entered into      (a)
    electronic system by nurse
  Entered into electronic               (a)       (a)    (a)
    system by clerk; reviewed
    by nurse
  Completed on paper by client                    (a)           (a)
    or clerk; reviewed by
    nurse
Vaccine Record-keeping
  Entered into electronic        (a)    (a)
    system by nurse
  Completed on paper by nurse                     (a)    (a)    (a)
Proof of Vaccination
  Immunization card or form;     (a)              (a)    (a)    (a)
    handwritten, pre-printed,
    carbonless copy, or no
    proof *
  Printed from client record            (a)
Immunization Data Entry
  All immunization data are      (a)    (a)
    captured electronically at
    the point of care
  Manually entered into                           (a)    (a)
    influenza immunization
    database
  Immunization information not                                  (a)
    captured electronically
  Manually entered into
    provincial immunization
    registry
  Majority retained as
    aggregate counts;
    remaining in immunization
    registry
  Entered into influenza
    immunization database
    using specialized
    interface

                                   Hybrid Systems
                                  (# of organizations)

                                 F      G      H      I

                                 (10)   (3)    (2)    (7)

Registration
  Clerk calls up client record
    in pre-populated registry
  Card swiped to populate
    demographics in a new
    client record
  Prior to clinic visit, over
    the phone; entered into
    electronic patient record
  Client or clerk completes      (a)    (a)    (a)    (a)
    paper immunization form
  Clerk manually creates new
    client record within
    database
Medical History
  Reviewed and entered into
    electronic system by nurse
  Entered into electronic
    system by clerk; reviewed
    by nurse
  Completed on paper by client   (a)    (a)    (a)    (a)
    or clerk; reviewed by
    nurse
Vaccine Record-keeping
  Entered into electronic
    system by nurse
  Completed on paper by nurse    (a)    (a)    (a)    (a)
Proof of Vaccination
  Immunization card or form;     (a)    (a)    (a)    (a)
    handwritten, pre-printed,
    carbonless copy, or no
    proof *
  Printed from client record
Immunization Data Entry
  All immunization data are
    captured electronically at
    the point of care
  Manually entered into                               (a)
    influenza immunization
    database
  Immunization information not
    captured electronically
  Manually entered into          (a)
    provincial immunization
    registry
  Majority retained as                  (a)
    aggregate counts;
    remaining in immunization
    registry
  Entered into influenza                       (a)
    immunization database
    using specialized
    interface

(a) This varied by clinic and organization, not necessarily by system.

Table 3. Data Elements Captured at the Time of H1N1 Immunization *

                                          Element collected
                                          in electronic
                                          organizations (%)
                                          n=9

Personal and Demographic Information
  Name                                         9 (100)
  Unique identifier (health insurance          9 (100)
    or employee number)
  Sex                                          9 (100)
  Date of birth                                9 (100)
  Ethnicity                                    8 (88.9)
  Aboriginal status                            9 (100)
  Full address                                 9 (100)
  Postal code                                  9 (100)
Priority Status and Medical Information
([section])
  Chronic medical conditions                   9 (100)
  Details of chronic conditions (type          9 (100)
    and/or meds)
  Pregnancy status ([parallel])                9 (100)
  Health care worker ([parallel])              9 (100)
  Care provider or household contact of        9 (100)
    high-risk individual
  From remote community                        9 (100)
  Allergies                                    9 (100)
  Overall health status on the day of          9 (100)
    immunization--feeling well,
    fever, etc.
Vaccination Details
  Vaccination date                             9 (100)
  Prior receipt of 08/09 or 09/10 seasonal     9 (100)
    vaccine ([aragraph])
  Vaccinator name/initials/identification      9 (100)
  Lot number                                   9 (100)

                                          Element collected
                                          in hybrid
                                          organizations (%)
                                          n=29

Personal and Demographic Information
  Name                                        29 (100)
  Unique identifier (health insurance         29 (100)
    or employee number)
  Sex                                         29 (100)
  Date of birth                               29 (100)
  Ethnicity                                    2 (6.9)
  Aboriginal status                           20 (69.0)
  Full address                                19 (65.5)
  Postal code                                 28 (96.6)
Priority Status and Medical Information
([section])
  Chronic medical conditions                  29 (100)
  Details of chronic conditions (type         12 (41.4)
    and/or meds)
  Pregnancy status ([parallel])               28 (96.6)
  Health care worker ([parallel])             29 (100)
  Care provider or household contact of       12 (41.4)
    high-risk individual
  From remote community                        2 (6.9)
  Allergies                                   18 (62.1)
  Overall health status on the day of         19 (65.5)
    immunization--feeling well,
    fever, etc.
Vaccination Details
  Vaccination date                            29 (100)
  Prior receipt of 08/09 or 09/10 seasonal    15 (51.7)
    vaccine ([aragraph])
  Vaccinator name/initials/identification     29 (100)
  Lot number                                  29 (100)

                                          Total organizations
                                          retaining element
                                          electronically
                                          ([dagger]),
                                          ([double dagger]) (%)
                                          n=38

Personal and Demographic Information
  Name                                        38 (100)
  Unique identifier (health insurance         38 (100)
    or employee number)
  Sex                                         38 (100)
  Date of birth                               38 (100)
  Ethnicity                                   10 (26.3)
  Aboriginal status                           27 (71.1)
  Full address                                27 (71.1)
  Postal code                                 37 (97.4)
Priority Status and Medical Information
([section])
  Chronic medical conditions                  36 (94.7)
  Details of chronic conditions (type          9 (23.7)
    and/or meds)
  Pregnancy status ([parallel])               34 (89.5)
  Health care worker ([parallel])             35 (92.1)
  Care provider or household contact of       20 (52.6)
    high-risk individual
  From remote community                       11 (28.9)
  Allergies                                   13 (34.2)
  Overall health status on the day of         10 (26.3)
    immunization--feeling well,
    fever, etc.
Vaccination Details
  Vaccination date                            38 (100)
  Prior receipt of 08/09 or 09/10 seasonal    22 (57.9)
    vaccine ([aragraph])
  Vaccinator name/initials/identification     21 (55.3)
  Lot number                                  30 (78.9)

* In some settings, depending on organizational discretion, not all
of the fields on the client information form or computer interface
were completed for all clients.

([dagger]) In three organizations, data were only captured
electronically for children 9 years of age and younger.

([double dagger]) Some of these elements were already contained in
client records and thus were not collected at the time of
immunization but were retained and accessible electronically.

([section]) In some organizations, only one risk category was
recorded as the reason for immunization, although an individual may
fall into two or more of these groups.

([parallel]) Not applicable for three organizations in which
information was only captured electronically for children 9 years
of age and younger.

([paragraph]) In one organization, information regarding prior
immunizations was only captured for some individuals.