Research Article Developing the Evidence for Public Health Systems to Battle Vaccine Preventable Disease at the Local Level: Data Challenges and Strategies for Advancing Research Betty Bekemeier, PhD, MPH, FAAN; Athena Pantazis, MPH, MA; Michelle Pui-Yan Yip, MHA, MN; Tao Kwan-Gett, MD, MPH ABSTRACT Context: Generally decreasing local health department (LHD) resources devoted to immunization programs and changes in LHD roles in immunization services represent major shifts in a core LHD service. Objective: Within a rapidly changing immunization landscape and emerging vaccine preventable disease outbreaks, our objective was to examine how LHD immunization expenditures are related to county-level immunization coverage and pertussis rates. Design: We used a practice-based approach in which we collaborated with practice partners and uniquely detailed LHD immunization expenditure data. Our analyses modeled the ecologic relationship between LHD immunization expenditures and LHD system performance and health outcomes. Setting: This study was launched through a consortium of public health Practice-Based Research Network states as part of a suite of studies examining the relationship between various LHD service-related expenditures and health outcomes. Participants: We investigated and sought to include all LHDs in the states of Florida, New York (except New York City’s LHD), and Washington. Outcome Measures: With LHD immunization expenditures as our independent variable, our outcomes were 1 year of jurisdiction-level rates of toddler immunization completeness, to measure immunization system performance, and 11 years of annual jurisdiction-level numbers of pertussis cases per 100 000 population, to measure related health outcomes. Results: Immunization completeness and pertussis rates varied greatly, but our models did not produce signifcant results despite numerous analytic approaches and while controlling for other factors. Conclusion: While our study was part of a suite of studies using similar methods and producing signifcant results, this study was instead challenged by serious data limitations and highlighted the gap in consistent, standardized data that can support critically needed evidence regarding immunization rates and disease. With LHDs at the epicenter of reducing vac- cine preventable disease, it is vital to utilize emerging opportunities to understand the nature of their efforts in immunization coverage and disease prevention. KEY WORDS: immunizations, Practice-Based Research Networks, public health expenditures, public health systems, vaccine preventable disease R ecent large national outbreaks of vaccine pre- ventable diseases (VPDs) such as measles 1 and pertussis 2 demonstrate that despite Author Affliations: Department of Psychosocial and Community Health, University of Washington School of Nursing, Seattle, Washington (Dr Bekemeier and Ms Yip); University of Washington School of Public Health, Seattle, Washington (Drs Bekemeier and Kwan-Gett); and Department of Sociology, University of Washington, Seattle, Washington (Ms Pantazis). The authors declare no conficts of interest. Correspondence: Betty Bekemeier, PhD, MPH, FAAN, Department of Psychosocial and Community Health, University of Washington School of Nursing, 1959 NE Pacifc St., Box 357263, Seattle, WA 98195-7263 (bettybek@uw.edu). Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHH.0000000000000411 successes in immunization coverage in the United States over the last century, 3 more effort is needed. Local health departments (LHDs) play a critical role in protecting communities against communicable dis- eases. LHD immunization services include direct vac- cination of individuals, coordination of vaccine deliv- ery among local providers, and disease surveillance. 4 Yet even before the economic recession of 2008 and major cuts to local public health systems that fol- lowed, Guyer and colleagues described the nation’s public health infrastructure supporting our immu- nization systems as “fragile and unstable.” 5 Immunization services provided by LHDs have been decreasing in recent years. 6-8 The National Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. March/April 2017 • Volume 23, Number 2 www.JPHMP.com 131