Measure: CMS117
Childhood Immunization Status
Measure Versions
| eMeasure Code |
Measure Year |
Full Version Number |
Title |
| CMS117v12 |
2024 |
12.0.000 |
Childhood Immunization Status |
| CMS117v11 |
2023 |
11 |
Childhood Immunization Status |
| CMS117v10 |
2022 |
10.0.000 |
Childhood Immunization Status |
| CMS117v9 |
2021 |
9.2.000 |
Childhood Immunization Status |
| CMS117v8 |
2020 |
8.3.000 |
Childhood Immunization Status |
| CMS117v7 |
2019 |
7.2.000 |
Childhood Immunization Status |
| CMS117v6 |
2018 |
6.2.000 |
Childhood Immunization Status |
| CMS117v5 |
2017 |
5.1.000 |
Childhood Immunization Status |
Description
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 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
Guidance
For the MMR, hepatitis B, VZV and hepatitis A vaccines, numerator inclusion criteria include: evidence of receipt of the recommended vaccine; documented history of the illness; or, a seropositive test result for the antigen. For the DTaP, IPV, HiB, pneumococcal conjugate, rotavirus, and influenza vaccines, numerator inclusion criteria include only evidence of receipt of the recommended vaccine.
Patients may be included in the numerator for a particular antigen if they had an anaphylactic reaction to the vaccine. Patients may be included in the numerator for the DTaP vaccine if they have encephalopathy. Patients may be included in the numerator for the IPV vaccine if they have had an anaphylactic reaction to streptomycin, polymyxin B, or neomycin. Patients may be included in the numerator for the influenza, MMR, or VZV vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have Immunodefiency, or have HIV. Patients may be included in the numerator for the hepatitis B vaccine if they have had an anaphylactic reaction to common baker's yeast.
The measure allows a grace period by measuring compliance with these recommendations between birth and age two.
Patient Group Definitions
| Group |
Description |
Instructions Links |
| Initial Population | Children who turn 2 years of age during the measurement period and who have a visit during the measurement period | Webchart Instructions |
| Denominator | Equals Initial Population | Webchart Instructions |
| Denominator Exclusions | Exclude patients whose hospice care overlaps the measurement period | Webchart Instructions |
| Numerator | 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 | Webchart Instructions |
| Numerator Exclusions | Not Applicable | Webchart Instructions |
| Denominator Exceptions | None | |
Details
| Full eMeasure Code |
eMeasure Identifier |
Measure Year |
Version |
NQF # |
GUID |
| CMS117v7 |
117 |
2019 |
7.2.000 |
0038 |
B2802B7A-3580-4BE8-9458-921AEA62B78C |
| Steward |
Developer |
Endorsed By |
| National Committee for Quality Assurance |
National Committee for Quality Assurance |
National Quality Forum |
| Scoring Method |
Measure Type |
Stratification |
Risk Adjustment |
| Proportion |
PROCESS |
None |
None |
Rate Aggregation
None
Improvement Notation
Higher score equals better quality
Rationale
Infants and toddlers are particularly vulnerable to infectious diseases because their immune systems have not built up the necessary defenses to fight infection (Centers for Disease Control and Prevention 2017a). Most childhood vaccines are between 90 and 99 percent effective in preventing diseases (HealthyChildren 2015). Vaccination of each U.S. birth cohort with the current childhood immunization schedule prevents approximately 42,000 deaths and 20 million cases of disease, and saves nearly $14 billion in direct costs and $69 billion in societal costs each year (Zhou 2014).
Immunizing a child not only protects that child's health but also the health of the community, especially for those who are not immunized or are unable to be immunized due to other health complications (Centers for Disease Control and Prevention 2017b). When the majority of the community is immunized against a disease, other members of the community are also protected because herd immunity shields them. (National Institute of Allergy and Infectious Diseases 2014).
Clinical Recommendation Statement
Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2017 (Centers for Disease Control and Prevention 2017c)
Hepatitis B (HepB)
"Minimum age: birth"
"At birth:
-- Administer monovalent HepB vaccine to all newborns
within 24 hours of birth.
-- For infants born to hepatitis B surface antigen (HBsAg)-positive mothers, administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. These infants should be tested for HBsAg and antibody to HBsAg (anti-HBs) at age 9 through 12 months (preferably at the next well-child visit) or 1 to 2 months after completion of the HepB series if the series was delayed.
-- If mother's HBsAg status is unknown, within 12 hours of birth, administer HepB vaccine regardless of birth weight. For infants weighing less than 2,000 grams, administer HBIG in addition to HepB vaccine within 12 hours of birth. Determine mother's HBsAg status as soon as possible and, if mother is HBsAg-positive, also administer HBIG to infants weighing 2,000 grams or more as soon as possible, but no later than age 7 days.
Doses following the birth dose:
-- The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be used for doses administered before age 6 weeks.
-- Infants who did not receive a birth dose should receive 3 doses of a HepB-containing vaccine on a schedule of 0, 1 to 2 months, and 6 months, starting as soon as feasible (see figure 2).
-- Administer the second dose 1 to 2 months after the first dose (minimum interval of 4 weeks); administer the third dose at least 8 weeks after the second dose AND at least 16 weeks after the first dose. The final (third or fourth) dose in the HepB vaccine series should be administered no earlier than age 24 weeks.
-- Administration of a total of 4 doses of HepB vaccine is
permitted when a combination vaccine containing HepB
is administered after the birth dose."
Diptheria, tetanus, acellular pertussis vaccinations (DTap)
"Minimum age: 6 weeks. Exception: DTaPIPV [Kinrix, Quadracel]: 4 years"
"Routine vaccination:
-- Administer a 5-dose series of DTaP vaccine at ages 2, 4, 6 15 through 18 months, and 4 through 6 years. The fourth dose may be administered as early as age 12 months, provided at least 6 months have elapsed since the third dose.
-- Inadvertent administration of fourth DTaP dose early: If the fourth dose of DTaP was administered at least 4 months after the third dose of DTaP and the child was 12 months of age or older, it does not need to be repeated."
Hib (Haemophilus influenzae type b)
"Minimum age: 6 weeks for PRP-T [ActHIB, DTaP-IPV/Hib (Pentacel), Hiberix, and Hib-MenCY (MenHibrix)], PRPOMP [PedvaxHIB]"
"Routine vaccination:
-- Administer a 2- or 3-dose Hib vaccine primary series and a booster dose (dose 3 or 4, depending on vaccine used in primary series) at age 12 through 15 months to complete a full Hib vaccine series.
-- The primary series with ActHIB, MenHibrix, Hiberix, or Pentacel consists of 3 doses and should be administered at ages 2, 4, and 6 months. The primary series with PedvaxHIB consists of 2 doses and should be administered at ages 2 and 4 months; a dose at age 6 months is not indicated.
-- One booster dose (dose 3 or 4, depending on vaccine used in primary series) of any Hib vaccine should be administered at age 12 through 15 months."
Polio (IPV)
"Minimum age: 6 weeks"
"Routine vaccination:
-- Administer a 4-dose series of IPV at ages 2, 4, 6 through 18 months, and 4 through 6 years. The final dose in the series should be administered on or after the fourth birthday and at least 6 months after the previous dose."
Measles, mumps, rubella (MMR)
"Minimum age: 12 months for routine vaccination"
"Routine vaccination:
-- Administer a 2-dose series of MMR vaccine at ages 12 through 15 months and 4 through 6 years. The second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose.
-- Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United States for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months (12 months if the child remains in an area where disease risk is high), and the second dose at least 4 weeks later.
-- Administer 2 doses of MMR vaccine to children aged 12 months and older before departure from the United States for international travel. The first dose should be administered on or after age 12 months and the second dose at least 4 weeks later."
Pneumococcal conjugate (PCV13)
"Minimum age: 6 weeks for PCV13"
"Routine vaccination with PCV13:
-- Administer a 4-dose series of PCV13 at ages 2, 4, and 6
months and at age 12 through 15 months."
Varicella (Var)
"Minimum age: 12 months"
"Routine vaccination:
-- Administer a 2-dose series of VAR vaccine at ages 12 through 15 months and 4 through 6 years. The second dose may be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid"
Hepatitis A (HepA)
"Minimum age: 12 months"
"Routine vaccination:
-- Initiate the 2-dose HepA vaccine series at ages 12 through 23 months; separate the 2 doses by 6 to 18 months.
-- Children who have received 1 dose of HepA vaccine before age 24 months should receive a second dose 6 to 18 months after the first dose.
-- For any person aged 2 years and older who has not already received the HepA vaccine series, 2 doses of HepA vaccine separated by 6 to 18 months may be administered if immunity against hepatitis A virus infection is desired."
Rotavirus (RV)
"Minimum age: 6 weeks for both RV1 [Rotarix] and RV5 [RotaTeq]"
"Routine vaccination:
-- Administer a series of RV vaccine to all infants as follows:
1. If Rotarix is used, administer a 2-dose series at ages 2 and 4 months.
2. If RotaTeq is used, administer a 3-dose series at ages 2, 4, and 6 months.
3. If any dose in the series was RotaTeq or vaccine product
is unknown for any dose in the series, a total of 3 doses
of RV vaccine should be administered."
Influenza (inactivated influenza vaccine (IIV)
"Minimum age: 6 months for inactivated influenza vaccine [IIV]"
"Routine vaccination:
-- Administer influenza vaccine annually to all children beginning at age 6 months. For the 2016-17 season, use of live attenuated influenza vaccine (LAIV) is not recommended."
Definition
Recommended vaccines: Vaccines and the schedule of vaccines as recommended by the Advisory Committee on Immunization Practices (ACIP) for children two years of age. The measure may differ slightly from the ACIP recommendations because the measure focuses on immunizations that are appropriate by age 2. Also, there may be small differences when there are shortages for a particular vaccine.
Transmission Format
TBD
Applicable Value Sets
| Category |
Value Set |
OID |
| Diagnosis |
Anaphylactic Reaction to Common Baker's Yeast |
2.16.840.1.113883.3.464.1003.199.12.1032 |
| Diagnosis |
Anaphylactic Reaction to DTaP Vaccine |
2.16.840.1.113883.3.464.1003.199.12.1031 |
| Diagnosis |
Anaphylactic Reaction to Hepatitis A Vaccine |
2.16.840.1.113883.3.464.1003.199.12.1026 |
| Diagnosis |
Disorders of the Immune System |
2.16.840.1.113883.3.464.1003.120.12.1001 |
| Diagnosis |
Encephalopathy due to Childhood Vaccination |
2.16.840.1.113883.3.464.1003.114.12.1007 |
| Diagnosis |
Hepatitis A |
2.16.840.1.113883.3.464.1003.110.12.1024 |
| Diagnosis |
Hepatitis B |
2.16.840.1.113883.3.464.1003.110.12.1025 |
| Diagnosis |
HIV |
2.16.840.1.113883.3.464.1003.120.12.1003 |
| Diagnosis |
Intussusception |
2.16.840.1.113883.3.464.1003.199.12.1056 |
| Diagnosis |
Malignant Neoplasm of Lymphatic and Hematopoietic Tissue |
2.16.840.1.113883.3.464.1003.108.12.1009 |
| Diagnosis |
Measles |
2.16.840.1.113883.3.464.1003.110.12.1053 |
| Diagnosis |
Mumps |
2.16.840.1.113883.3.464.1003.110.12.1032 |
| Diagnosis |
Rubella |
2.16.840.1.113883.3.464.1003.110.12.1037 |
| Diagnosis |
Severe Combined Immunodeficiency |
2.16.840.1.113883.3.464.1003.120.12.1007 |
| Diagnosis |
Varicella Zoster |
2.16.840.1.113883.3.464.1003.110.12.1039 |
| Encounter, Performed |
Encounter Inpatient |
2.16.840.1.113883.3.666.5.307 |
| Encounter, Performed |
Home Healthcare Services |
2.16.840.1.113883.3.464.1003.101.12.1016 |
| Encounter, Performed |
Office Visit |
2.16.840.1.113883.3.464.1003.101.12.1001 |
| Encounter, Performed |
Preventive Care - Established Office Visit, 0 to 17 |
2.16.840.1.113883.3.464.1003.101.12.1024 |
| Encounter, Performed |
Preventive Care- Initial Office Visit, 0 to 17 |
2.16.840.1.113883.3.464.1003.101.12.1022 |
| Intervention, Order |
Hospice care ambulatory |
2.16.840.1.113762.1.4.1108.15 |
| Intervention, Performed |
Hospice care ambulatory |
2.16.840.1.113762.1.4.1108.15 |
| Laboratory Test, Performed |
Anti Hepatitis B Virus Surface Ab |
2.16.840.1.113883.3.464.1003.198.12.1073 |
| Laboratory Test, Performed |
Hepatitis A Antigen Test |
2.16.840.1.113883.3.464.1003.198.12.1033 |
| Laboratory Test, Performed |
Measles Antibody Test (IgG Antibody presence) |
2.16.840.1.113883.3.464.1003.198.12.1060 |
| Laboratory Test, Performed |
Measles Antibody Test (IgG Antibody Titer) |
2.16.840.1.113883.3.464.1003.198.12.1059 |
| Laboratory Test, Performed |
Mumps Antibody Test (IgG Antibody presence) |
2.16.840.1.113883.3.464.1003.198.12.1062 |
| Laboratory Test, Performed |
Mumps Antibody Test (IgG Antibody Titer) |
2.16.840.1.113883.3.464.1003.198.12.1061 |
| Laboratory Test, Performed |
Rubella Antibody Test (IgG Antibody presence) |
2.16.840.1.113883.3.464.1003.198.12.1064 |
| Laboratory Test, Performed |
Rubella Antibody Test (IgG Antibody Titer) |
2.16.840.1.113883.3.464.1003.198.12.1063 |
| Laboratory Test, Performed |
Varicella Zoster Antibody Test (IgG Antibody Presence) |
2.16.840.1.113883.3.464.1003.198.12.1067 |
| Laboratory Test, Performed |
Varicella Zoster Antibody Test (IgG Antibody Titer) |
2.16.840.1.113883.3.464.1003.198.12.1066 |
| Patient Characteristic Ethnicity |
Ethnicity |
2.16.840.1.114222.4.11.837 |
| Patient Characteristic Payer |
Payer |
2.16.840.1.114222.4.11.3591 |
| Patient Characteristic Race |
Race |
2.16.840.1.114222.4.11.836 |
| Patient Characteristic Sex |
ONC Administrative Sex |
2.16.840.1.113762.1.4.1 |
| Procedure, Performed |
DTaP Vaccine Administered |
2.16.840.1.113883.3.464.1003.110.12.1022 |
| Procedure, Performed |
Haemophilus Influenzae Type B (HiB) Vaccine Administered |
2.16.840.1.113883.3.464.1003.110.12.1043 |
| Procedure, Performed |
Hepatitis A Vaccine Administered |
2.16.840.1.113883.3.464.1003.110.12.1041 |
| Procedure, Performed |
Hepatitis B Vaccine Administered |
2.16.840.1.113883.3.464.1003.110.12.1042 |
| Procedure, Performed |
Inactivated Polio Vaccine (IPV) Administered |
2.16.840.1.113883.3.464.1003.110.12.1045 |
| Procedure, Performed |
Influenza Vaccine Administered |
2.16.840.1.113883.3.464.1003.110.12.1044 |
| Procedure, Performed |
Measles, Mumps and Rubella (MMR) Vaccine Administered |
2.16.840.1.113883.3.464.1003.110.12.1031 |
| Procedure, Performed |
Pneumococcal Conjugate Vaccine Administered |
2.16.840.1.113883.3.464.1003.110.12.1046 |
| Procedure, Performed |
Varicella Zoster Vaccine (VZV) Administered |
2.16.840.1.113883.3.464.1003.110.12.1040 |
References
Centers for Disease Control and Prevention. 2017a. "Infant Immunizations FAQs" https://www.cdc.gov/vaccines/parents/parent-questions.html
HealthyChildren. 2015. "Safety & Prevention: Why Immunize Your Child." https://www.healthychildren.org/english/safety-prevention/immunizations/Pages/Why-Immunize-Your-Child.aspxhttps
Zhou, F., A. Shefer, J. Wenger, et al. 2014. "Economic Evaluation of the Routine Childhood Immunization Program in the United States, 2009." Pediatrics "133(4). doi:10.1542/peds.2013-0698d.
National Institute of Allergy and Infectious Diseases. 2014. " Vaccine Benefits" https://www.niaid.nih.gov/research/vaccine-benefits
Centers for Disease Control and Prevention. 2017c. "Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States, 2017." https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf
Centers for Disease Control and Prevention. 2017b. "Vaccines & Immunizations: Why Are Childhood Vaccines So Important?" https://www.cdc.gov/vaccines/vac-gen/howvpd.htm
Disclaimer
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Source:
https://ecqi.healthit.gov/ecqm/measures/cms117v7