The precipitous decline in vaccine preventable diseases (VPDs) over the past century underscores the significance of vaccinations as one of the most important public health interventions of our time. A review of the early decades of the 1900s reminds us that VPD cases were once widespread and often lethal. In those days, it was not unusual to have more than 100 000 cases of pertussis resulting in thousands of deaths annually, until the introduction of pertussis vaccines in the 1940s.1,2 Remarkably similar patterns preceded the introduction of vaccines for additional VPDs, including diphtheria, polio, measles, mumps, rubella, influenza, and others.3

Although untold numbers of VPD cases are prevented today by a growing number of vaccines, the delivery of vaccinations to children and adults is a challenging endeavor. Vaccine procurement and inventory management are complicated, involving substantial administrative effort by public and private immunization providers alike.4 In fact, the entire vaccination clinical workflow can be considerably challenging, often involving numerous administrative and clinical staff members. Patient scheduling, check-in, assessment of vaccination status, vaccine administration, and subsequent documentation all necessitate close coordination among administrative and clinical teams.4-6

In the not-so-distant past, this was largely a manual process that typically relied upon checklists and paper chart documentation. Given the increasing complexity and size of the pediatric vaccination schedule,7 whether a child may be due for one or more vaccines at any point in time can no longer reliably be assessed manually. Consequently, today's busy practice settings increasingly rely on information technology to support the entire vaccination workflow, with paper medical charts and clipboards increasingly giving way to electronic health records (EHRs).8

Through bidirectional interoperability, EHRs can exchange information with a jurisdiction's immunization information system (IIS) in real time to accurately assess a patient's vaccination needs based on a comprehensive view of their vaccination history from present and past providers. The value of this is particularly noteworthy among adults who may see numerous health care providers and commonly obtain vaccinations in settings such as retail pharmacies. Furthermore, this information is directly integrated into the clinical workflow so that accurate vaccination decision making can occur within the patient encounter, as well as to support subsequent communication and outreach through patient portals or other mechanisms.8-10

This issue of the Journal of Public Health Management and Practice includes several articles that detail ongoing challenges in the prevention of VPDs. Together, these articles clearly illustrate the complexity in mounting and sustaining effective vaccination strategies to address VPDs. The 2016-2017 mumps outbreaks across the United States provide an important reminder of the burden of VPD response efforts. In "CDC Guidance for Use of a Third Dose of MMR Vaccine During Mumps Outbreaks," a framework is presented for use by public health jurisdictions to identify priority groups for a third MMR dose in response to a mumps outbreak. The basis for that guidance is provided from data collected in a national survey and summarized in "Health Departments' Experience With Mumps Outbreak Response and Use of a Third Dose of Measles, Mumps, and Rubella Vaccine."

VPD outbreaks of all types can take a toll on our health system; in "Cost of Responding to the 2017 University of Washington Mumps Outbreak: A Prospective Analysis," Pike and colleagues portray the financial burdens of one mumps outbreak. Another perspective of this burden is provided by "Responding to a Mumps Outbreak Impacting Immigrants and Low-English Proficiency Populations," in which the costs and challenges associated with a 2018 Pennsylvania mumps outbreak are described. This VPD outbreak challenged a community largely comprising immigrants who may have been undocumented and spoke little or no English. In "Vaccination Capability Inventory of Community, Migrant, and Homeless Health Centers: A Survey Report," Lewis and colleagues characterize the infrastructure and services in place at community health centers, a mainstay for adult vaccinations among the vulnerable populations they serve.

Adherence to vaccination recommendations is essential for effective prevention of VPDs. The article "Factors Associated With Childhood Vaccination Adherence in Kindergartens of the Houston Independent School District" explores one method to assess the characteristics of groups associated with lower vaccination rates, which could serve as the basis for development of effective outreach strategies. Effective prevention of VPDs requires successful communication and outreach strategies aimed at groups that are eligible for vaccination. In "Use of Person Locator Service to Facilitate Immunization Information System-Based Adolescent Reminder Project," Kuramoto and colleagues illustrate the benefits of using a commercial address checking service to validate and correct postal mailing addresses maintained by the Minnesota's IIS, thereby minimizing undeliverable reminder/recall notifications. Another perspective on VPD prevention is provided by "Using the North Dakota IIS to Assess the Response of Health Care Providers to the ACIP recommendation for Tdap Vaccination During Pregnancy," demonstrating how IIS can serve an important role in policy evaluation.

As we look forward, a fundamental challenge of VPDs is that effective protection requires continuous vigilance on the part of public health and primary care practitioners. Communities or subgroups with poor vaccination adherence, combined with imported VPD cases from global travelers, are an ever-present risk. As population-based IIS become increasingly interoperable with EHRs, the tools to meet these challenges have never been better.

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