Brief Description of Measure:
​CMS117: Childhood Immunization Status:
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (Hib); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.

Description of Issue:
Currently, the measure includes robust immunization criteria in the clinical recommendation statement, while the numerator statement is ambiguous. The measure developer received feedback that the lack of detail in the numerator statement is confusing, and additional detail is desired.
 
The measure developer proposes adding information from the clinical recommendation statements to the numerator to reduce ambiguity and confusion for implementers, which will also align with the language in the parent HEDIS MY2022 specification and updated the logic. 

Proposed Solution:
Current Clinical Recommendation Statement:
Recommended Child and Adolescent Immunization Schedule
for ages 18 years or younger, United States 2020 (Centers for Disease Control and Prevention, 2020)
Hepatitis B vaccination
(minimum age: birth)
"Routine series
– 3-dose series at 0, 1–2, 6–18 months (use monovalent HepB vaccine for doses administered before age 6 weeks)
– Infants who did not receive a birth dose should begin the series as soon as feasible (see Table 2).
– Administration of 4 doses is permitted when a combination vaccine containing HepB is used after the birth dose.
– Minimum age for the final (3rd or 4th ) dose: 24 weeks
– Minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to
dose 3: 8 weeks / dose 1 to dose 3: 16 weeks (when 4 doses are administered, substitute "dose 4" for "dose 3" in these calculations) "
Diphtheria, tetanus, and pertussis (DTaP) vaccination (minimum age: 6 weeks [4 years for Kinrix or Quadracel])
"Routine vaccination
– 5-dose series at 2, 4, 6, 15–18 months, 4–6 years

• Prospectively: Dose 4 may be administered as early as age 12 months if at least 6 months have elapsed since dose 3.
• Retrospectively: A 4th dose that was inadvertently administered as early as 12 months may be counted if at least 4 months have elapsed since dose 3. "
  Haemophilus influenzae type b vaccination
  (minimum age: 6 weeks)
  "Routine vaccination
  • ActHIB, Hiberix, or Pentacel: 4-dose series at 2, 4, 6, 12–
    15 months
  • PedvaxHIB: 3-dose series at 2, 4, 12–15 months"
    Pneumococcal vaccination
    (minimum age: 6 weeks [PCV13], 2 years [PPSV23])
    "Routine vaccination with PCV13
  • 4-dose series at 2, 4, 6, 12–15 months"
    Poliovirus vaccination
    (minimum age: 6 weeks)
    "Routine vaccination
  • 4-dose series at ages 2, 4, 6–18 months, 4–6 years; administer the final dose at or after age 4 years and at least 6 months after the previous dose.
  • 4 or more doses of IPV can be administered before age 4 years when a combination vaccine containing IPV is used. However, a dose is still recommended at or after age 4 years and at least 6 months after the previous dose"
    Measles, mumps, and rubella vaccination
    (minimum age: 12 months for routine vaccination)
    "Routine vaccination
  • 2-dose series at 12–15 months, 4–6 years
  • Dose 2 may be administered as early as 4 weeks after dose 1."
    Varicella vaccination
    (minimum age: 12 months)
    "Routine vaccination
  • 2-dose series at 12–15 months, 4–6 years
  • Dose 2 may be administered as early as 3 months after dose 1 (a dose administered after a 4-week interval may be counted)."
    Hepatitis A vaccination
    (minimum age: 12 months for routine vaccination)
    "Routine vaccination
  • 2-dose series (minimum interval: 6 months) beginning at age 12 months"
    Rotavirus vaccination
    (minimum age: 6 weeks)
    "Routine vaccination
  • Rotarix: 2-dose series at 2 and 4 months
  • RotaTeq: 3-dose series at 2, 4, and 6 months
  • If any dose in the series is either RotaTeq or unknown, default to 3-dose series"
    Influenza vaccination
    (minimum age: 6 months [IIV], 2 years [LAIV],
    18 years [recombinant influenza vaccine, RIV])
    "Routine vaccination
  • Use any influenza vaccine appropriate for age and health status annually:
• 2 doses, separated by at least 4 weeks, for children age 6
  months–8 years who have received fewer than 2 influenza
  vaccine doses before July 1, 2019, or whose influenza vaccination history is unknown (administer dose 2 even if the child turns 9 between receipt of dose 1 and dose 2)
• 1 dose for children age 6 months–8 years who have received at least 2 influenza vaccine doses before July 1, 2019
• 1 dose for all persons age 9 years and older
  • For the 2020–21 season, see the 2020–21 ACIP influenza vaccine recommendations."

Updated Clinical Recommendation Statement:

This measure looks for childhood vaccinations that should be completed by age 2, in accordance with the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) recommended child and adolescent immunization schedule (ACIP 2021). For the 2021–22 influenza season, see the 2021–22 ACIP influenza vaccine recommendations.

Current Numerator Statement:
Children who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday

Updated Numerator Statement:

DTaP
Children with any of the following on or before the child’s second birthday meet criteria:
·          At least four DTaP vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth.
·          Anaphylaxis due to the diphtheria, tetanus or pertussis vaccine.
·          Encephalitis due to the diphtheria, tetanus or pertussis vaccine.
 
IPV
At least three IPV vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
 
MMR
Children with either of the following meet criteria:
·          At least one MMR vaccination on or between the child’s first and second birthdays.
·          All of the following anytime on or before the child’s second birthday (on the same or different date of service):
o    History of measles.
o    History of mumps.
o    History of rubella.
 
HiB
Children with either of the following on or before the child’s second birthday meet criteria:
·          At least three HiB vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth.
·          Anaphylaxis due to the HiB vaccine.
 
Hepatitis B
Children with any of the following on or before the child’s second birthday meet criteria:
·          At least three hepatitis B vaccinations, with different dates of service.
o    One of the three vaccinations can be a newborn hepatitis B vaccination during the eight-day period that begins on the date of birth and ends seven days after the date of birth. For example, if the member’s date of birth is December 1, the newborn hepatitis B vaccination must be on or between December 1 and December 8.
·          Anaphylaxis due to the hepatitis B vaccine.
·          History of hepatitis B illness.
 
VZV
Children with either of the following meet criteria:
·          At least one VZV vaccination, with a date of service on or between the child’s first and second birthdays.
·          History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday.
 
Pneumococcal Conjugate
At least four pneumococcal conjugate vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
 
Hepatitis A
Children with either of the following meet criteria:
·          At least one hepatitis A vaccination, with a date of service on or between the child’s first and second birthdays.
·          History of hepatitis A illness on or before the child’s second birthday.
 
Rotavirus
Children with any of the following meet criteria:
·          At least two doses of the two-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
·          At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
·          At least one dose of the two-dose rotavirus vaccine and at least two doses of the three-dose rotavirus vaccine, all on different dates of service, on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth.
·          Anaphylaxis due to the rotavirus vaccine on or before the child’s second birthday.
 
Influenza
At least two influenza vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 6 months (180 days) after birth.
·          One of the two vaccinations can be an LAIV vaccination administered on the child’s second birthday. Do not count an LAIV vaccination administered before the child’s second birthday.

//Numerator logic before:
Numerator
( exists ( "Four DTaP Vaccinations" )
    or exists ( "DTaP Numerator Inclusion Conditions" )
)
  and ( exists ( "Three Polio Vaccinations" )
      or exists ( "Polio Numerator Inclusion Conditions" )
  )
  and ( exists ( "One MMR Vaccination" )
      or exists ( "MMR Numerator Inclusion Conditions" )
      or ( exists ( "Measles Indicators" )
          and exists ( "Mumps Indicators" )
          and exists ( "Rubella Indicators" )
      )
  )
  and ( "Has Appropriate Number of Hib Immunizations"
      or exists ( "Hib Numerator Inclusion Conditions" )
  )
  and ( exists ( "Three Hepatitis B Vaccinations" )
      or exists ( "Hepatitis B Numerator Inclusion Conditions" )
  )
  and ( exists ( "One Chicken Pox Vaccination" )
      or exists ( "Varicella Zoster Numerator Inclusion Conditions" )
  )
  and ( exists ( "Four Pneumococcal Conjugate Vaccinations" )
      or exists ( "Pneumococcal Conjugate Numerator Inclusion Conditions" )
  )
  and ( exists ( "One Hepatitis A Vaccinations" )
      or exists ( "Hepatitis A Numerator Inclusion Conditions" )
  )
  and ( "Has Appropriate Number of Rotavirus Immunizations"
      or exists ( "Rotavirus Numerator Inclusion Conditions" )
  )
  and ( exists ( "Two Influenza Vaccinations" )
      or ( "Two Influenza Vaccinations Including One LAIV Vaccination" )
      or exists ( "Influenza Numerator Inclusion Conditions" )
  )

//Numerator logic after:

Numerator
( exists ( "Four DTaP Vaccinations" )
    or exists ( "DTaP Numerator Inclusion Conditions" )
)
  and ( exists ( "Three Polio Vaccinations" )
  and ( exists ( "One MMR Vaccination" ) 
      or ( exists ( "Measles Indicators" )
          and exists ( "Mumps Indicators" )
          and exists ( "Rubella Indicators" )
      )
  )
  and ( "Has Appropriate Number of Hib Immunizations"
      or exists ( "Hib Numerator Inclusion Conditions" )
  )
  and ( exists ( "Three Hepatitis B Vaccinations" )
or ( exists ( "Meets HepB Vaccination Requirement")

      or exists ( "Hepatitis B Numerator Inclusion Conditions" )
  )
) 
  and ( exists ( "One Chicken Pox Vaccination" )
      or exists ( "Varicella Zoster Numerator Inclusion Conditions" )
  )
  and ( exists ( "Four Pneumococcal Conjugate Vaccinations" )
  )
  and ( exists ( "One Hepatitis A Vaccinations" )
      or exists ( "Hepatitis A Numerator Inclusion Conditions" )
  )
  and ( "Has Appropriate Number of Rotavirus Immunizations"
      or exists ( "Rotavirus Numerator Inclusion Conditions" )
  )
  and ( exists ( "Two Influenza Vaccinations" )
      or ( "Two Influenza Vaccinations Including One LAIV Vaccination" )
  )

//adding this definition to align with Hep B vaccine criteria
define "Meets HepB Vaccination Requirement":
  "Three Hepatitis B Vaccinations" HepatitisBRequirement 
 where HepatitisBRequirement.relevantDatetime during day of Interval[Patient.birthDatetime, Patient.birthDatetime + 7 days]  

Rationale for Change:
Including more detail in the numerator statement to describe the intent will ease confusion amongst implementers.