Compliance with vaccination recommendations for U.S. children

Temporal Trends in Undervaccination: A Population-Based Cohort Study

INTRODUCTION

Monitoring the trends in undervaccination, including that because of parental vaccine refusal or delay, can inform public health responses directed at improving vaccine confidence and vaccination coverage.

METHODS

A retrospective cohort study was conducted in the Vaccine Safety Datalink. The cohort included all children born in 2004-2017 with ≥3 well-child visits between ages 2 and 23 months. Using electronic health record-based vaccination data, the average days undervaccinated was calculated for each child. Undervaccination patterns were assessed through age 23 months. Temporal trends were inspected for inflection points and were analyzed using linear regression. Nested within the cohort study, a survey was conducted to compare parent reports of vaccine refusal or delay with observed vaccination patterns. Data were analyzed in 2020.

RESULTS

The study cohort consisted of 808,170 children. The percentage of children with average days undervaccinated=0 (fully vaccinated, no delays) rose from a nadir of 47.1% for the birth year 2008 to 68.4% for the birth year 2017 (p_trend<0.001). The percentage with no vaccines rose from 0.35% for the birth year 2004 to 1.28% for the birth year 2017 (p_trend<0.001). Consistent vaccine limiting was observed in 2.04% for the birth year 2017. Omission of measles, mumps, and rubella vaccine peaked at 4.76% in the birth year 2007 and declined thereafter (p_trend<0.001). On the parent survey (response rate 60.2%), a high proportion of parents of the most undervaccinated children reported refusing or delaying vaccines.

CONCLUSIONS

In a 14-year cohort study, vaccination timeliness has improved. However, the small but increasing number of children who received no vaccines by age 23 months warrants additional attention.

Factors Associating Vaccination Delay among Jordanian Children under Two Years of Age

PURPOSE

This study examines the association between selected socio-demographic factors (gender, birth order, parents' educational levels, and parents' employment status) and reasons for vaccination delay among Jordanian children under two years of age.

DESIGN & METHODS

A cross-sectional, prospective study was conducted in the three comprehensive public health centres in Amman Governorate in Jordan from January-June, 2019. The electronic vaccination record was designed to collect socio- demographic information and reasons for vaccination delay in children. This data was collected from the medical records of those children.

RESULTS

The findings revealed that 150 (8.3%) children under two years of age were registered as vaccination-delayed cases. The factors associated with vaccination delay were age (Chi-square test [χ²] [6150] = 15.02, p-value [p] < 0.01), birth order (χ² [6150] = 15.02, p < 0.01), mother's educational level (χ² [2150] = 9.27, p < 0.05), and father's and mother's employment (χ² [2150] = 7.89, p < 0.05; χ² [2150] = 10.54, p < 0.01, respectively).

CONCLUSION

Timeliness of vaccination should be promoted to prevent illness outbreaks and provide specific protection for children, taking into consideration the significance of age and birth order.

PRACTICE IMPLICATIONS

Interventions and strategies need to implementation to reduce vaccination delay and improve timeliness.

Adherence to Timely Vaccinations in the United States

OBJECTIVES

To estimate (1) the proportion of children not adhering to the Advisory Committee on Immunization Practices (ACIP) recommended early childhood immunization schedule and (2) associations between schedule adherence, sociodemographic characteristics, and up-to-date immunization status by 19 to 35 months of age.

METHODS

We used 2014 National Immunization Survey provider-verified vaccination data to classify vaccination patterns as "recommended" (ie, in line with ACIP dose- and age-specific recommendations), "alternate" (ie, in line with either limiting the number of shots per visit or skipping at least 1 vaccine series), or "unknown or unclassifiable" (ie, not in line with ACIP recommendations or clearly limiting shots per visit or vaccine series). We evaluated the association between vaccination patterns and up-to-date status for all ACIP-recommended vaccinations (including rotavirus and hepatitis A vaccines) using Poisson regression.

RESULTS

The majority of children's patterns were classified as "recommended" (63%), with 23% and 14% following alternate or unknown or unclassifiable patterns, respectively; 58% of children were up-to-date with all ACIP-recommended immunizations by 19 to 35 months. Not being up-to-date was associated with alternate (prevalence ratio = 4.2, 95% confidence interval: 3.9-4.5) and unknown or unclassifiable (prevalence ratio = 2.4, 95% confidence interval: 2.2-2.7) patterns.

CONCLUSIONS

High vaccine coverage by 19 to 35 months of age may miss nonadherence to the recommended immunization schedule in the first 18 months of life, leaving children vulnerable to preventable diseases. With more than one-third of US children not following the ACIP schedule, targeted interventions are needed to minimize vaccine delays and disease susceptibility.

Different Reasons for Not Completing Routine Vaccinations Among Jewish and Arab Children in Israel

Minority communities are at high risk for low childhood vaccination coverage rates. This paper compared the rate of children not fully vaccinated and the reasons for that between Jewish (majority) and Arab (minority) children in Israel. This cross-sectional study screened the medical files of 14,232 children (12,360 Jewish and 1872 Arab), registered at Mother-Child Health Clinics in two large geographical area, to identify children who did not complete the last dose of hepatitis B and DTaP or first dose of MMR vaccines. We compared the reasons for not completing the vaccine schedule registered by the nurses between Jewish and Arab children. We identified 1052 children who did not complete at least one of the vaccines: 975 Jewish children and 77 Arab children. Four causal categories were identified: medical reasons, parental decision, parental behaviour, and organizational reasons. Multinomial logistic regression analysis was performed to analyze the reasons for not completing the vaccination protocol. Arab children compared to Jewish children were more likely not to complete the vaccination protocol due to medical reasons (OR 3.81, CI 1.53-9.49) and less likely due to the reason parental decision (OR 0.35, CI 0.13-0.96). Therefore, patterns of reasons for not completing vaccinations vary, depending on population. Interventions to reduce the number of children not fully vaccinated should be tailored to the specific population.

Vaccine coverage for Lebanese citizens and Syrian refugees in Lebanon

Article History

Following the refugee crisis in Lebanon, the on-going inflow of Syrian refugees presented new challenges to optimal immunization coverage for all the children living in the country. Healthcare facilities have been overburdened during this period and the country witnessed outbreaks of many infectious diseases. Thus, the evaluation of vaccine compliance for mandatory and non-mandatory vaccines as well as the factors affecting the vaccination rate among Lebanese residents and Syrian refugees is fundamental.

Background

Since 2012, Lebanon has hosted around 1.2 million Syrian refugees, a high number in a country whose population does not exceed 4.4 million. Healthcare facilities have been overburdened during this period, which has led to the spread of many infectious diseases, including outbreaks of measles, mumps and hepatitis. At the appearance of such outbreaks, it becomes essential to evaluate vaccine compliance and the factors influencing the vaccination rate among Lebanese residents and Syrian refugees in infants and children up to 15 y of age.

Methods

A total of 571 infants and children were recruited in Beirut and Mount Lebanon, two governorates that together host half of the Lebanese population.

Results

A very high rate of vaccine compliance was seen for mandatory vaccines, whereas an intermediate to very low rate of compliance was found for non-mandatory vaccines. Both bivariate and multiple regression analyses indicated that age group and regular consultation of a pediatrician were independently associated with immunization coverage. Bivariate analysis indicated that parental age, occupational and educational status of parents, family size and vaccine price were also independently associated with immunization coverage. Incomplete vaccination coverage was associated with socioeconomic factors.

Conclusions

From these results, it becomes apparent that it may be necessary to reassess vaccination priorities considering the current socioeconomic situation.

Risk factors for pertussis among hospitalized children in a high HIV prevalence setting, South Africa

BACKGROUND

In low- and middle-income countries, including South Africa, the epidemiology of pertussis in relation to immunization, nutritional, and HIV status is poorly described. This article reports on risk factors in South African children hospitalized with pertussis.

METHODS

A prospective, hospital-based, sentinel surveillance programme for pertussis was conducted in Gauteng Province, South Africa. Hospitalized children (≤10 years) meeting the surveillance criteria for clinically suspected pertussis were screened and enrolled. Nasopharyngeal specimens were collected for real-time multiplex PCR and culture of Bordetella species.

RESULTS

Bordetella pertussis was detected in 6.2% (61/992) of children. Pertussis was significantly more prevalent in infants younger than 3 months (9.8%; 38/392) and in young children between the ages of 5 and 9 years (12%; 4/34) (p=0.0013). Of the 61 confirmed pertussis cases, 17 were too young for vaccination. Of the remaining 44 infants, vaccination DTP1 was administered in 73% (32/44) of pertussis-confirmed patients who were eligible, DTP2 in 50% (16/32), DTP3 in 54% (14/26), and DTP4 in 56% (5/9) of vaccine-eligible cases at 18 months of age. B. pertussis infection was less likely in children immunized at least once (5%, 32/692) than in unvaccinated children (10%, 24/230) (p=0.0001). HIV exposure and infection status were determined in 978 (99%) patients: 69% (678/978) were HIV-unexposed and uninfected and 31% (300/978) were HIV-exposed. Of these HIV-exposed patients, 218 (22%) were proven HIV-exposed and uninfected and 82 patients were HIV-infected (8.4%, 82/978). HIV prevalence was similar in pertussis-positive (6%, 5/82) and pertussis-negative (6%, 55/896) children (p=0.90). B. pertussis infection was unrelated to poor nutritional status.

CONCLUSIONS

In South Africa, B. pertussis poses a greater risk to infants who are too young for the first vaccine dose, those who are not vaccinated in a timely manner, and those who do not receive all three primary doses. HIV infection and HIV exposure were not associated with pertussis infection.

Frequency and Cost of Vaccinations Administered Outside Minimum and Maximum Recommended Ages-2014 Data From 6 Sentinel Sites of Immunization Information Systems

OBJECTIVE

To quantify vaccinations administered outside minimum and maximum recommended ages and to determine attendant costs of revaccination by analyzing immunization information system (IIS) records.

STUDY DESIGN

We analyzed deidentified records of doses administered during 2014 to persons aged <18 years within 6 IIS sentinel sites (10% of the US population). We quantified doses administered outside of recommended ages according to the Advisory Committee on Immunization Practices childhood immunization schedule and prescribing information in package inserts, and calculated revaccination costs. To minimize misreporting bias, we analyzed publicly funded doses for which reported lot numbers and vaccine types were consistent.

RESULTS

Among 3 394 047 doses with maximum age recommendations, 9755 (0.3%) were given after the maximum age. One type of maximum age violation required revaccination: 1344 (0.7%) of 194 934 doses of the 0.25-mL prefilled syringe formulation of quadrivalent inactivated influenza vaccine (Fluzone Quadrivalent, Sanofi Pasteur, Swiftwater, PA) were administered at age ≥36 months (revaccination cost, $111 964). We identified a total of 7 529 165 childhood, adolescent, and lifespan doses with minimum age recommendations, 9542 of which (0.1%) were administered before the minimum age. The most common among these violations were quadrivalent injectable influenza vaccines (3835, or 0.7% of 526 110 doses administered before age 36 months) and Kinrix (GlaxoSmithKline Biologicals, Rixensart, Belgium; DTaP-IPV) (2509, or 1.2% of 208 218 doses administered before age 48 months). The cost of revaccination for minimum age violations (where recommended) was $179 179.

CONCLUSION

Administration of vaccines outside recommended minimum and maximum ages is rare, reflecting a general adherence to recommendations. Error rates were higher for several vaccines, some requiring revaccination. Vaccine schedule complexity and confusion among similar products might contribute to errors. Minimization of errors reduces wastage, excess cost, and inconvenience for parents and patients.

Geographic and demographic correlates of autism-related anti-vaccine beliefs on Twitter, 2009-15

This study examines temporal trends, geographic distribution, and demographic correlates of anti-vaccine beliefs on Twitter, 2009-2015. A total of 549,972 tweets were downloaded and coded for the presence of anti-vaccine beliefs through a machine learning algorithm. Tweets with self-disclosed geographic information were resolved and United States Census data were collected for corresponding areas at the micropolitan/metropolitan level. Trends in number of anti-vaccine tweets were examined at the national and state levels over time. A least absolute shrinkage and selection operator regression model was used to determine census variables that were correlated with anti-vaccination tweet volume. Fifty percent of our sample of 549,972 tweets collected between 2009 and 2015 contained anti-vaccine beliefs. Anti-vaccine tweet volume increased after vaccine-related news coverage. California, Connecticut, Massachusetts, New York, and Pennsylvania had anti-vaccination tweet volume that deviated from the national average. Demographic characteristics explained 67% of variance in geographic clustering of anti-vaccine tweets, which were associated with a larger population and higher concentrations of women who recently gave birth, households with high income levels, men aged 40 to 44, and men with minimal college education. Monitoring anti-vaccination beliefs on Twitter can uncover vaccine-related concerns and misconceptions, serve as an indicator of shifts in public opinion, and equip pediatricians to refute anti-vaccine arguments. Real-time interventions are needed to counter anti-vaccination beliefs online. Identifying clusters of anti-vaccination beliefs can help public health professionals disseminate targeted/tailored interventions to geographic locations and demographic sectors of the population.

Comparison of homologous and heterologous prime-boost vaccine approaches using Modified Vaccinia Ankara and soluble protein to induce neutralizing antibodies by the human cytomegalovirus pentamer complex in mice

Since neutralizing antibodies (NAb) targeting the human cytomegalovirus (HCMV) pentamer complex (PC) potently block HCMV host cell entry, anti-PC NAb induction is thought to be important for a vaccine formulation to prevent HCMV infection. By developing a vaccine strategy based on soluble PC protein and using a previously generated Modified Vaccinia Ankara vector co-expressing all five PC subunits (MVA-PC), we compared HCMV NAb induction by homologous immunization using prime-boost vaccine regimen employing only PC protein or MVA-PC and heterologous immunization using prime-boost combinations of PC protein and MVA-PC. Utilizing a recently isolated anti-PC NAb, we produced highly pure soluble PC protein that displayed conformational and linear neutralizing epitopes, interfered with HCMV entry, and was recognized by antibodies induced by HCMV during natural infection. Mice vaccinated by different immunization routes with the purified PC protein in combination with a clinically approved adjuvant formulation elicited high-titer and durable HCMV NAb. While MVA-PC and soluble PC protein either alone or in combination elicited robust HCMV NAb, significantly different potencies of these vaccine approaches were observed in dependence on immunization schedule. Using only two immunizations, vaccination with MVA-PC alone or prime-boost combinations of MVA-PC and PC protein was significantly more effective in stimulating HCMV NAb than immunization with PC protein alone. In contrast, with three immunizations, NAb induced by soluble PC protein either alone or combined with two boosts of MVA-PC increased to levels that exceeded NAb titer stimulated by MVA-PC alone. These results provide insights into the potency of soluble protein and MVA to elicit NAb by the HCMV PC via homologous and heterologous prime-boost immunization, which may contribute to develop clinically deployable vaccine strategies to prevent HCMV infection.

Determining the Optimal Vaccination Schedule for Herpes Zoster: a Cost-Effectiveness Analysis

BACKGROUND

The Advisory Committee on Immunization Practices recommends a single dose of herpes zoster (HZ) vaccine in persons aged 60 years or older, but the efficacy decreases to zero after approximately 10 years. A booster dose administered after 10 years might extend protection, but the cost-effectiveness of a booster strategy has not been examined.

OBJECTIVE

We aimed to determine the optimal schedule for HZ vaccine DESIGN: We built a Markov model to follow patients over their lifetime. From the societal perspective, we compared costs and quality-adjusted life years (QALYs) saved of 11 strategies to start and repeat HZ vaccine at different ages.

SUBJECTS

Adults aged 60 years.

INTERVENTION

HZ vaccine.

MAIN MEASURES

Costs, quality-adjusted life years (QALYs), and incremental costs per QALY saved.

KEY RESULTS

At a $100,000/QALY threshold, "vaccination at 70 plus one booster" was the most cost-effective strategy, with an incremental cost-effectiveness ratio (ICER) of $36,648/QALY. "Vaccination at 60 plus two boosters" was more effective, but had an ICER of $153,734/QALY. In deterministic sensitivity analysis, "vaccination at 60 plus two boosters" cost < $100,000/QALY if compliance rate was > 67 % or vaccine cost was < $156 per dose. In probabilistic sensitivity analysis, "vaccination at 70 plus one booster" was preferred at a willingness-to-pay of up to $135,000/QALY.

CONCLUSIONS

Under current assumptions, initiating HZ vaccine at age 70 years with one booster dose 10 years later appears optimal. Future data regarding compliance with or efficacy of a booster could affect these conclusions.

Increasing Immunization Compliance by Reducing Provisional Admittance

Students in Vermont with incomplete or undocumented immunization status are provisionally admitted to schools and historically had a calendar year to resolve their immunization status. The process of resolving these students’ immunization status was challenging for school nurses. We conducted a school-based quality improvement effort to increase student compliance with Vermont immunization regulations using a collaborative learning approach with public health school liaisons and school nurses from public schools to reduce provisional admittance in 2011–2012. Strategies included using a tracking system, accessing the immunization registry, promoting immunization importance, tracking immunization plans, and working with medical homes to update records. Participating school nurses observed decreases in the number of provisionally admitted students, although this reduction was not significantly different than matched comparison schools. We also found the number of provisionally admitted students fluctuated throughout the year and resolving the immunization status of New Americans and exchange students required special attention. Our approach supports the coordinated school health model and demonstrates the critical role school nurses play in improving population health outcomes.

Effective and sustainable advice line promotes safe vaccine practices

AIM

The SHOT LINE Telephone Assistance Resource provides consistent and timely education to healthcare providers ensuring safe delivery of immunizations.

BACKGROUND

A local health district created and implemented an advice line to assist healthcare personnel with immunization storage or administration questions. Healthcare workers with varying levels of education call with requests for information including vaccine administration, storage and handling, scheduling, contraindications, and timing.

METHODS

Ten years of call data to the SHOT LINE were analyzed through categorizing type of calls, personnel calling, facility type, information needed, and education provided.

RESULTS

There were 3032 calls received from various job types. The most frequent inquiries were vaccine-specific calls, timing, and vaccine schedules. Medical assistants from family medicine clinics called the most. Five percent of the calls included reports of immunization errors. Healthcare personnel reported errors and self-disclosed making errors; 7% of all calls were errors in the first 2 years, but decreased to 5.4% in the last 8 years.

CONCLUSION

The SHOT LINE telephone assistance provides timely education to healthcare personnel whose primary responsibilities are immunization practice management, administration, and handling. The findings reveal a significant need for timely advice in immunization practice management. Error reporting was an unexpected outcome of this advice line. Call categories of vaccine-specific information, vaccine timing, and schedules were similar across all groups of callers. The advice line has grown to include parents, school nurses, childcare providers, and emergency personnel. In summary, the SHOT LINE prevents errors, increases accuracy of vaccine management, and provides 'just in time' education.

Shortened Intervals during Heterologous Boosting Preserve Memory CD8 T Cell Function but Compromise Longevity

Developing vaccine strategies to generate high numbers of Ag-specific CD8 T cells may be necessary for protection against recalcitrant pathogens. Heterologous prime-boost-boost immunization has been shown to result in large quantities of functional memory CD8 T cells with protective capacities and long-term stability. Completing the serial immunization steps for heterologous prime-boost-boost can be lengthy, leaving the host vulnerable for an extensive period of time during the vaccination process. We show in this study that shortening the intervals between boosting events to 2 wk results in high numbers of functional and protective Ag-specific CD8 T cells. This protection is comparable to that achieved with long-term boosting intervals. Short-boosted Ag-specific CD8 T cells display a canonical memory T cell signature associated with long-lived memory and have identical proliferative potential to long-boosted T cells Both populations robustly respond to antigenic re-exposure. Despite this, short-boosted Ag-specific CD8 T cells continue to contract gradually over time, which correlates to metabolic differences between short- and long-boosted CD8 T cells at early memory time points. Our studies indicate that shortening the interval between boosts can yield abundant, functional Ag-specific CD8 T cells that are poised for immediate protection; however, this is at the expense of forming stable long-term memory.

Translating laboratory anti-aging biotechnology into applied clinical practice: Problems and obstacles

Although the use of biomedical technologies against ageing (rejuvenation biotechnologies) is considered by many as an effective way of controlling all age-related degeneration, in reality this belief cannot be justified. The human body is notoriously resistant to external perturbations and can respond in unpredictable or undesirable ways. Basic concepts of science, evolution and disease must also be considered. In this paper, I discuss some relevant problems associated with the application of any putative rejuvenation biotechnologies such as stem cell therapies, genetic engineering, tissue manipulation, as well as pharmacological approaches. I conclude that these and other biotechnologies will not be applicable to humans in the community. This is due to a wide spectrum of problems and obstacles, such as unpredictable therapeutic results, unrealistic expectations, lack of infrastructure, cellular network disruption, and many more. Even if some such technologies are developed, the totality of the problems, issues and side effects will prove an insurmountable final hurdle, rendering the development of such therapies, essentially and practically useless.

Immunizations against respiratory infections in children in primary health care in poland: coverage and delays

Pneumococcal infections, pertussis, and influenza are vaccine-preventable diseases. The aim of this study was to determine vaccine coverage and compliance with the dosage regimen among children in Poland. We performed a retrospective chart analysis of 1,356 children in a large primary healthcare establishment. The complete primary pertussis vaccination, 3 doses in the first year of life, was administered to 1,310/1,356 patients (96.6 %). The self-paid combined acellular vaccine was given in 55.2 % of children. The first dose of the pertussis vaccine was administered in a timely manner to 67.1 % of children. The self-paid pneumococcal vaccine was administered in 499/1,356 (36.8 %) children. In 46.1 % of them immunization started within the first 6 months of life; in 12.6 % aged 7-11 months, in 12.6 % aged 12-23 months, and in 28.7 % aged over 24 months. The dosage regimen was compliant in 49.2 % of patients. Only 3.5 % of patients were immunized against both pneumococci and influenza. Compliance with the Polish immunization program should be increased by reducing the number of injections and the cost of vaccines. Education is essential to facilitate simultaneous administration of vaccines during one visit and to prepare the parents for judicious decision-making when it comes to vaccinations.

Vaccination Coverage and Compliance with Three Recommended Schedules of 10-Valent Pneumococcal Conjugate Vaccine during the First Year of Its Introduction in Brazil: A Cross-Sectional Study

Pneumococcal 10-valent conjugate vaccine (PCV10) was introduced to Brazil's National Immunization Program (NIP) in 2010. During the first year of vaccine introduction three schedules were used to deal with age at initiation of PCV for catch-up purposes: 3 primary doses + 1 booster (for children aged ≤6 months), a catch-up schedule of 2 doses + 1 booster (7-11 months), and a catch-up schedule of a single dose (12-15 months). The purpose of this study was to assess the magnitude and associated risk factors for under-vaccination or lack of on time vaccination six to eight months after PCV10 introduction. A household survey was conducted in the municipality of Goiania with 1,237 children, who were retroactively classified into one of three age groups, as a factor of the child's age relatively to 30 days after PCV10 introduction. Socioeconomic characteristics and vaccination dates were obtained during home interviews. Vaccination coverage was defined as the percentage of children who completed the recommended number of doses. Compliance with recommended schedules was defined as the percentage of children who received all valid doses at the NIP recommended time interval. Adjusted prevalence ratios (PR) of variables independently associated with coverage and compliance were estimated by log binomial regression. Coverage of DTP-Hib was used for comparison purposes. Overall, vaccination coverage was 54.6% (95% CI 52.1-57.7%), lower than DTP-Hib coverage (93.0%; 95% CI 91.5-94.3%). Compliance with recommended schedules was 16.8% (95% CI: 14.7-18.6%). Children 7-11 months old had lower coverage (40.7%) and compliance (6.3%) compared to children aged 12-15 months (coverage: 88.8%; compliance: 35.6%) and ≤6 months old (coverage: 54%; compliance: 18.8%). Having private health insurance was associated with higher PCV10 coverage (PR=1.25; 95% CI: 1.06-1.47, p=0.007), and compliance (PR=1.09; 95% CI: 1.02-1.16, p=0.015). Although PCV10 coverage rapidly increased shortly after vaccination introduction, it was not matched by compliance with recommended schedules. Public initiatives should target compliance of PCV10 because of the burden of pneumococcal diseases on childhood morbidity and mortality.

Experiences, perceptions and preferences of mothers towards childhood immunization reminder/recall in Ibadan, Nigeria: a cross-sectional study

INTRODUCTION

Immunization reminder/recall system is proven as one of the effective ways of improving immunization rates. Prior to the development and implementation of an immunization reminder/recall system intervention, we explored the experiences, preferences and perceptions towards childhood immunization reminder/recall among 614 mothers of infants in Ibadan, Nigeria.

METHODS

A cross-sectional health facility-based survey utilizing a semi-structured questionnaire was conducted in four Primary Health Care centers. Descriptive statistics were computed using SPSS. Logistic models were used to investigate the relationships with specific outcomes.

RESULTS

Only 3.9% had ever heard of immunization reminder/recall and 1.5% had ever received one. However, 97.9% were willing to record their cellphone numbers in the clinics for immunization reminder/recall and 95.1% were willing to receive. Their preferred communication modes were cell phone calls (57.6%) or text messages/SMS (35.6%). Only 2.2% preferred home-visits and 0.4%, e-mails. About 4% were not willing to receive any form of immunization reminder/recall. Mothers with post-secondary education were more likely to prefer SMS than other mothers (OR 2.3, 95% CI 1.7-3.3, p.

CONCLUSION

This study provided critical baseline data for designing a reminder/recall intervention for routine childhood immunization in the study communities. The findings may serve as a guide for public health professionals in designing reminder/recall strategies to improve childhood immunization.

Vaccinating my way--use of alternative vaccination schedules in New York State

OBJECTIVE

To identify children vaccinated following an alternative vaccine schedule using immunization information system data and determine the impact of alternative schedule use on vaccine coverage.

STUDY DESIGN

Children born in New York State, outside New York City, between January 1, 2009 and August 14, 2011 were assessed for vaccination patterns consistent with use of an alternative schedule. Children who by 9 months of age had at least 3 vaccination visits recorded in the statewide mandatory immunization information system after 41 days of age were classified as either attempting to conform to the Centers for Disease Control and Prevention published recommended vaccination schedule or an alternative schedule. The number of vaccination visits and up-to-date status at age 9 months were compared between groups.

RESULTS

Of the 222 628 children studied, the proportion of children following an alternative schedule was 25%. These children were significantly less likely to be up-to-date at age 9 months (15%) compared with those conforming to the routine schedule (90%, P < .05). Children following an alternative schedule on average had about 2 extra vaccine visits compared with children following a routine schedule (P < .05).

CONCLUSIONS

Almost 1 in 4 children in this study appear to be intentionally deviating from the routine schedule. Intentional deviation leads to poor vaccination coverage leaving children vulnerable to infection and increasing the potential for vaccine-preventable disease outbreaks.

Patterns of rotavirus vaccine uptake and use in privately-insured US infants, 2006-2010

Rotavirus vaccines are highly effective at preventing gastroenteritis in young children and are now universally recommended for infants in the US. We studied patterns of use of rotavirus vaccines among US infants with commercial insurance. We identified a large cohort of infants in the MarketScan Research Databases, 2006-2010. The analysis was restricted to infants residing in states without state-funded rotavirus vaccination programs. We computed summary statistics and used multivariable regression to assess the association between patient-, provider-, and ecologic-level variables of rotavirus vaccine receipt and series completion. Approximately 69% of 594,117 eligible infants received at least one dose of rotavirus vaccine from 2006-2010. Most infants received the rotavirus vaccines at the recommended ages, but more infants completed the series for monovalent rotavirus vaccine than pentavalent rotavirus vaccine or a mix of the vaccines (87% versus 79% versus 73%, P<0.001). In multivariable analyses, the strongest predictors of rotavirus vaccine series initiation and completion were receipt of the diphtheria, tetanus and acellular pertussis vaccine (Initiation: RR = 7.91, 95% CI = 7.69-8.13; Completion: RR = 1.26, 95% CI = 1.23-1.29), visiting a pediatrician versus family physician (Initiation: RR = 1.51, 95% CI = 1.49-1.52; Completion: RR = 1.13, 95% CI = 1.11-1.14), and living in a large metropolitan versus smaller metropolitan, urban, or rural area. We observed rapid diffusion of the rotavirus vaccine in routine practice; however, approximately one-fifth of infants did not receive at least one dose of vaccine as recently as 2010. Interventions to increase rotavirus vaccine coverage should consider targeting family physicians and encouraging completion of the vaccine series.

Managing scientific uncertainty in medical decision making: the case of the advisory committee on immunization practices

This article explores the question of how scientific uncertainty can be managed in medical decision making using the Advisory Committee on Immunization Practices as a case study. It concludes that where a high degree of technical consensus exists about the evidence and data, decision makers act according to a clear decision rule. If a high degree of technical consensus does not exist and uncertainty abounds, the decision will be based on a variety of criteria, including readily available resources, decision-process constraints, and the available knowledge base, among other things. Decision makers employ a variety of heuristic devices and techniques, thereby employing a pragmatic approach to uncertainty in medical decision making. The article concludes with recommendations for managing scientific uncertainty in medical decision making.

Pricing of new vaccines

New vaccine pricing is a complicated process that could have substantial long-standing scientific, medical, and public health ramifications. Pricing can have a considerable impact on new vaccine adoption and, thereby, either culminate or thwart years of research and development and public health efforts. Typically, pricing strategy consists of the following ten components: 1. Conduct a target population analysis; 2. Map potential competitors and alternatives; 3. Construct a vaccine target product profile (TPP) and compare it to projected or actual TPPs of competing vaccines; 4. Quantify the incremental value of the new vaccine's characteristics; 5. Determine vaccine positioning in the marketplace; 6. Estimate the vaccine price-demand curve; 7. Calculate vaccine costs (including those of manufacturing, distribution, and research and development); 8. Account for various legal, regulatory, third party payer, and competitor factors; 9. Consider the overall product portfolio; 10. Set pricing objectives; 11. Select pricing and pricing structure. While the biomedical literature contains some studies that have addressed these components, there is still considerable room for more extensive evaluation of this important area.

Extra-immunization as a clinical indicator for fragmentation of care

OBJECTIVES

We assessed whether extra-immunization can serve as a clinical indicator for fragmentation of care.

METHODS

Using public-use files of the 1999-2003 National Immunization Survey, we classified children 19-35 months of age by their vaccination providers for the degree of fragmentation of care as ordered from lowest with one vaccine provider, to increasing fragmentation with multiple providers in one facility type, to multiple providers in more than one facility type. Extra-immunization was defined conservatively based on the year-specific recommendations of the Advisory Committee on Immunization Practices (ACIP) for immunizations due before 18 months of age. Of note, 1999-2003 transitioned from oral to inactivated poliovirus vaccines.

RESULTS

The rate for extra-immunization was 9.4% (95% confidence interval [CI] 9.2, 9.7). Of single vaccines, the rate for polio vaccine was highest (5.7%, 95% CI 5.5, 6.0). Extra-immunization was lowest for the 69% of children with only one vaccination provider (6.4%, 95% CI 6.1, 6.7), was higher in children who had more than one vaccination provider with one vaccination facility type (13.9%, 95% CI 13.2, 14.6), and highest with more than one facility type (24.1%, 95% CI 22.5, 25.6). Logistic regression (including race/ethnicity, language, provider type, survey year, and a parent-held immunization record) confirmed that multiple providers (adjusted odds ratio [AOR] = 2.30), multipl facility types (AOR = 4.67), Spanish language (AOR = 1.29), and race/ethnicity (black AOR = 1.16, Hispanic AOR = 1.31) were each associated with extra-immunization. Excluding poliovirus vaccine from the analysis, AORs for multiple providers and multiple facility types increased to 3.64 and 8.95, respectively.

CONCLUSIONS

Extra-immunization is associated with receiving immunizations from multiple providers and multiple facility types.

Pediatric vaccination and vaccine-preventable disease acquisition: associations with care by complementary and alternative medicine providers

This study investigated provider-based complementary/alternative medicine use and its association with receipt of recommended vaccinations by children aged 1-2 years and with acquisition of vaccine-preventable disease by children aged 1-17 years. Results were based on logistic regression analysis of insurance claims for pediatric enrollees covered by two insurance companies in Washington State during 2000-2003. Primary exposures were use of chiropractic, naturopathy, acupuncture, or massage practitioner services by pediatric enrollees or members of their immediate families. Outcomes included receipt by children aged 1-2 years of four vaccine combinations (or their component vaccines) covering seven diseases, and acquisition of vaccine-preventable diseases by enrollees aged 1-17 years. Children were significantly less likely to receive each of the four recommended vaccinations if they saw a naturopathic physician. Children who saw chiropractors were significantly less likely to receive each of three of the recommended vaccinations. Children aged 1-17 years were significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care. Use of provider-based complementary/alternative medicine by other family members was not independently associated with early childhood vaccination status or disease acquisition. Pediatric use of complementary/alternative medicine in Washington State was significantly associated with reduced adherence to recommended pediatric vaccination schedules and with acquisition of vaccine-preventable disease. Interventions enlisting the participation of complementary/alternative medicine providers in immunization awareness and promotional activities could improve adherence rates and assist in efforts to improve public health.

Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases

Vaccines are among the most effective prevention tools available to clinicians. However, the success of an immunization program depends on high rates of acceptance and coverage. There is evidence of an increase in vaccine refusal in the United States and of geographic clustering of refusals that results in outbreaks. Children with exemptions from school immunization requirements (a measure of vaccine refusal) are at increased risk for measles and pertussis and can infect others who are too young to be vaccinated, cannot be vaccinated for medical reasons, or were vaccinated but did not have a sufficient immunologic response. Clinicians can play a crucial role in parental decision making. Health care providers are cited as the most frequent source of immunization information by parents, including parents of unvaccinated children. Although some clinicians have discontinued or have considered discontinuing their provider relationship with patients who refuse vaccines, the American Academy of Pediatrics Committee on Bioethics advises against this and recommends that clinicians address vaccine refusal by respectfully listening to parental concerns and discussing the risks of nonvaccination.