Increasing Coverage of Appropriate Vaccinations: A Community Guide Systematic Economic Review

Opportunities for HPV vaccine education in school-based immunization programs in British Columbia, Canada: A qualitative study

Despite the availability of school-based immunization programs (SBIPs) in Canada, human papillomavirus (HPV) vaccine uptake remains suboptimal. Vaccine education may improve vaccine uptake among adolescents. The objective of this qualitative study was to identify opportunities for HPV vaccine education in British Columbia, Canada, by exploring the perspectives of students, parents, school staff, and public health nurses on the current SBIP. Individual semi-structured interviews were conducted with adult participants and focus groups were conducted with grade 6 students between November 2019 and May 2020. The interviews and focus groups were transcribed and then analyzed using reflexive thematic analysis. Opportunities for HPV vaccine education were identified in three themes: 1) making SBIPs student-centered; 2) adopting a collaborative and interdisciplinary approach to vaccine education; and 3) actualizing parent education opportunities. Broad support existed for a formal, collaborative HPV grade 6 vaccine curriculum delivered by teachers and public health nurses to provide evidence-based health information. Participants voiced that the curriculum should integrate students' perspectives on topics of interest and address needle associated pain and anxiety. Parents were identified as the primary vaccine decisionmakers, therefore, participants stated it was crucial to also provide parent-directed vaccine education as part of SBIP. Our findings support the development of a collaborative HPV vaccine curriculum directed to and informed by students and parents to buttress current SBIPs in British Columbia.

Completion of multidose vaccine series in early childhood: current challenges and opportunities

PURPOSE OF REVIEW

Completion of all doses in multidose vaccine series provides optimal protection against preventable infectious diseases. In this review, we describe clinical and public health implications of multidose vaccine series noncompletion, including current challenges to ensuring children receive all recommended vaccinations. We then highlight actionable steps toward achieving early childhood immunization goals.

RECENT FINDINGS

Although coverage levels are high for most early childhood vaccinations, rates of completion are lower for vaccinations that require multiple doses. Recent research has shown that lower family socioeconomic status, a lack of health insurance coverage, having multiple children in the household, and moving across state lines are associated with children failing to complete multidose vaccine series. These findings provide contextual evidence to support that practical challenges to accessing immunization services are impediments to completion of multidose series. Strategies, including reminder/recall, use of centralized immunization information systems, and clinician prompts, have been shown to increase immunization rates. Re-investing in these effective interventions and modernizing the public health infrastructure can facilitate multidose vaccine series completion.

SUMMARY

Completion of multidose vaccine series is a challenge for immunization service delivery. Increased efforts are needed to address remaining barriers and improve vaccination coverage in the United States.

HPV vaccine standing orders and communication in primary care: A qualitative study

BACKGROUND

Standing orders may improve HPV vaccination rates, but clinical staff's readiness to use them has not been well-explored. We sought to explore benefits and challenges to using HPV vaccine standing orders for adolescents ages 9 to 12, understand clinical staff roles in communication about HPV vaccine, and how standing orders can reduce barriers contributing to vaccine disparities among racial and ethnic marginalized groups.

METHODS

Participants were a sample of 16 U.S. nurses, medical assistants, and healthcare providers working in primary care, recruited from June to September 2022. Trained staff conducted virtual, semi-structured qualitative interviews. We analyzed the resulting data using reflexive thematic analysis.

RESULTS

Themes reflected benefits and challenges to using HPV vaccine standing orders and strategies to address clinic barriers to improve vaccine access and HPV vaccine communication. Benefits included faster and efficient clinic flow; fewer missed vaccine opportunities and promotion of early vaccination; and normalization of HPV vaccination as routine care. Challenges included possible exacerbation of existing HPV vaccine communication and recommendation barriers; and how the complexity of the vaccine administration schedule lessens nurses' and medical assistants' confidence to use standing orders. Strategies to address vaccine access barriers included using nurse-only visits to empower nurse autonomy and catch up on HPV vaccination; engaging clinical staff to follow up with overdue children; and educating parents on HPV vaccine before their child is vaccine eligible.

CONCLUSION

Using HPV vaccine standing orders can promote autonomy for nurses and medical assistants and address vaccine access barriers. Clinical staff engagement and clinic support to mitigate existing vaccine communication barriers are needed to empower staff to use of HPV vaccine standing orders.

Delays in Hepatitis A vaccination in people with HIV in Houston, Texas between 2010 and 2018

Background

Studies have demonstrated low hepatitis A virus (HAV) vaccination rates among persons with HIV (PWH).

Methods

We conducted a retrospective study of persons entering HIV care at two clinics in Houston, Texas between 2010 and 2018. We defined those eligible for HAV vaccination as those who had no history of HAV vaccination and had a negative anti-HAV IgG at entry to care. Kaplan-Meier curves summarized time to receipt of HAV vaccines. The proportions of patients who received 1 and 2 HAV vaccines at 6, 12, and 24 months were estimated. Cox proportional hazards regression evaluated associations between patient characteristics and vaccination. Significant factors were included in a multivariable Cox proportional hazards model.

Results

Of 6,515 patients, 1372 were eligible for HAV vaccination. Of eligible patients, 29.2 % received 1 HAV vaccination at 6 months, 37.1 % at 12 months, and 47.8 % at 24 months. At 6 months, 10 % received 2 HAV vaccinations, 21.1 % at 12 months, and 33.4 % at 24 months. In multivariable analysis, men who have sex with men (adjusted HR 1.35, 95 % CI 1.06, 1.73) or those who had CD4 count ≥ 200 cells/µl (adjusted HR 2.52, 95 % CI 1.89, 3.37) had their second vaccination sooner than those who were not men who have sex with men or who had CD4 counts < 200 cells/µl, respectively. Patients > 50 years of age had their second vaccination sooner than those aged 30-50 years (adjusted HR 1.47, 95 % CI 1.08, 1.99). Those with active substance history had a longer time to second vaccination compared to those with no substance use history (adjusted HR 0.57, 95 % CI 0.40, 0.82).

Conclusions

HAV vaccination rates were low and highlight the need for effective solutions to address HAV immunization gaps in PWH, especially among young patients, those with active substance use disorders, and those with significant immunocompromise.

Interventions to increase vaccination against COVID-19, influenza and pertussis during pregnancy: a systematic review and meta-analysis

BACKGROUND

Pregnant women and their babies face significant risks from three vaccine-preventable diseases: COVID-19, influenza and pertussis. However, despite these vaccines' proven safety and effectiveness, uptake during pregnancy remains low.

METHODS

We conducted a systematic review (PROSPERO CRD42023399488; January 2012-December 2022 following PRISMA guidelines) of interventions to increase COVID-19/influenza/pertussis vaccination in pregnancy. We searched nine databases, including grey literature. Two independent investigators extracted data; discrepancies were resolved by consensus. Meta-analyses were conducted using random-effects models to estimate pooled effect sizes. Heterogeneity was assessed using the I2 statistics.

RESULTS

From 2681 articles, we identified 39 relevant studies (n = 168 262 participants) across nine countries. Fifteen studies (39%) were randomized controlled trials (RCTs); the remainder were observational cohort, quality-improvement or cross-sectional studies. The quality of 18% (7/39) was strong. Pooled results of interventions to increase influenza vaccine uptake (18 effect estimates from 12 RCTs) showed the interventions were effective but had a small effect (risk ratio = 1.07, 95% CI 1.03, 1.13). However, pooled results of interventions to increase pertussis vaccine uptake (10 effect estimates from six RCTs) showed no clear benefit (risk ratio = 0.98, 95% CI 0.94, 1.03). There were no relevant RCTs for COVID-19. Interventions addressed the 'three Ps': patient-, provider- and policy-level strategies. At the patient level, clear recommendations from healthcare professionals backed by text reminders/written information were strongly associated with increased vaccine uptake, especially tailored face-to-face interventions, which addressed women's concerns, dispelled myths and highlighted benefits. Provider-level interventions included educating healthcare professionals about vaccines' safety and effectiveness and reminders to offer vaccinations routinely. Policy-level interventions included financial incentives, mandatory vaccination data fields in electronic health records and ensuring easy availability of vaccinations.

CONCLUSIONS

Interventions had a small effect on increasing influenza vaccination. Training healthcare providers to promote vaccinations during pregnancy is crucial and could be enhanced by utilizing mobile health technologies.

Effect of immunization registry-based provider reminder to initiate HPV vaccination at age 9, Washington state

Human papillomavirus (HPV) vaccination rates are lower than Tetanus-diphtheria-pertussis (Tdap) and Meningococcal conjugate (MenACWY) rates, although the Advisory Committee on Immunization Practices recommends all three vaccines be given routinely at age 11-12. Evidence is mounting that children who initiate HPV vaccination starting at age 9 are more likely to complete the series on time. Washington state implemented a provider reminder through its immunization information system (WAIIS) in January 2023 to increase HPV vaccine initiation at 9-years-old by updating the forecasted recommended age for HPV from age 11 to 9. The effectiveness of provider reminders when implemented via an immunization information system (IIS) is poorly understood. We evaluated the impact of this forecast update using a seasonally adjusted interrupted time series regression of weekly HPV initiations at 9-years-old before and after implementation. We also examined time series trends of vaccine administration between 2018 and 2023 for HPV initiation at age 9, as well as Tdap, MenACWY and HPV initiation at age 11. The WAIIS forecast update doubled the weekly rate of HPV initiation among 9-year-olds in Washington state, although the weekly count of initiation at 9 remains far lower than initiations at 11. Jurisdictions wanting to increase HPV vaccine initiation at earlier ages should consider updating their forecast algorithm and investing in complementary evidence-based strategies such as provider and parent education, and clinic-based quality improvement efforts. The reach of IIS forecaster updates may be enhanced by working with administrators of electronic medical record systems to ensure parity of provider prompts with IIS.

Surveying a Sample of the Spanish Ophthalmologic Community about Vaccination against Herpes Zoster

There are currently two authorized vaccines against herpes zoster (HZ) that have been shown to be safe and effective in its prevention: Zostavax, a zoster vaccine live (ZVL), and Shingrix, a recombinant zoster Vaccine (RZV). Because ophthalmologists work with vision-threatening complications of zoster, such as herpes zoster ophthalmicus (HZO), they are in a good position to advocate for vaccination. Our aim was to determine the current knowledge among Spanish ophthalmologists about the effectiveness of the available vaccines against HZ. A Google Forms questionnaire was created and used as the survey platform for this study. It was an anonymous online survey of 16 questions, which was shared among Spanish ophthalmologists in-training and consultants from 27 April 2022 to 25 May 2022. The survey was completed by a total of 206 ophthalmologists of all subspecialties. We obtained responses from 17 of the 19 regions of Spain. Fifty-five percent of the respondents agreed that HZ is a frequent cause of vision loss. However, 27% of the professionals were unaware of the existence of vaccines against HZ and 71% of them did not know in which cases it could be indicated. Only nine ophthalmologists (4%) had ever suggested vaccination against HZ to their patients. Despite this, 93% considered it important to recommend vaccination against HZ if it proved to be safe and effective. Considering the sequelae, complications, and the existence of safe and effective vaccines against HZ, vaccination of the target population could be considered an important public health measure. We are convinced that it is time for ophthalmologists to take an active role in HZO prevention.

Pertussis and influenza immunization: perceived attitude and decision of postpartum patients

BACKGROUND

Vaccination of pregnant patients with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) and influenza vaccine during influenza season can reduce maternal and fetal morbidity and mortality; nevertheless, vaccination rates remain suboptimal in this patient population. To investigate the effect of a brief educational counseling session on maternal Tdap and influenza vaccination and determine factors influencing women's decision in regards to receiving Tdap and or influenza vaccine during their pregnancy.

METHODS

A face-to-face semi-structured cross-sectional survey was administered to postpartum patients on their anticipated day of discharge (June 11-August 21, 2018). A brief educational counseling session about maternal pertussis and Tdap vaccine was provided to interested patients after which the Tdap vaccine was offered to eligible patients who did not receive it during their pregnancy or upon hospital admission. Medical records were reviewed to determine if surveyed patients were vaccinated prior to discharge.

RESULTS

Two hundred postpartum patients were surveyed on their day of anticipated discharge. Of those who were surveyed, 103 (51.5%) had received Tdap and 80 (40.0%) had received influenza vaccinations prior to hospitalization. Among immunized patients, the common facilitators were doctor's recommendation (Tdap: 68, 54.4%; influenza: 3, 6.0%), to protect their baby (Tdap: 57, 45.6%; influenza: 17, 34.0%) and for self-protection (Tdap: 17, 13.6%; Influenza: 17, 34.0%). Of the 119 participants who had not received either Tdap or influenza vaccine prior to the survey, the barriers cited were that the vaccine was not offered by the provider (Tdap: 36, 52.2%; influenza: 29, 27.6%), belief that vaccination was unnecessary (Tdap: 5, 7.2%; influenza: 9, 8.5%), safety concerns for baby (Tdap: 4, 5.8%; influenza: 2, 1.9%). Of 97 patients who were not immunized with Tdap prior to admission but were eligible to receive vaccine, 24 (25%) were vaccinated prior to survey as part of routine hospital-based screening and vaccination program, 29 (38.2%) after our survey.

CONCLUSION

Interventions to educate pregnant patients about the benefits of vaccination for their baby, addressing patient safety concerns, and vaccine administration in obstetricians' offices may significantly improve maternal vaccination rates.

Healthcare workers' attitudes on mandates, incentives, and strategies to improve COVID-19 vaccine uptake: A mixed methods study

Healthcare workers are a trusted health information source and are uniquely positioned to reduce the burden of the COVID-19 pandemic. The purpose of this sequential exploratory mixed methods study was to understand attitudes of healthcare workers working in Massachusetts during the COVID-19 pandemic regarding strategies to improve COVID-19 vaccine utilization, including vaccine mandates and incentives. Fifty-two individuals completed one-on-one interviews between April 22^nd and September 7th, 2021. The survey was developed based on findings from the interviews; 209 individuals completed the online survey between February 17^th and March 23^rd, 2022. Both the interview and survey asked about attitudes toward COVID-19 vaccine and booster mandates, incentives, and strategies to improve vaccination rates. Most participants were female (79%-interview, 81%-survey), Caucasian (56%, 73%), and worked as physicians (37%, 34%) or nurses (10%, 18%). Overall, nuanced attitudes regarding vaccine and booster mandates were expressed; many supported mandates to protect their patients' health, others emphasized personal autonomy, while some were against mandates if job termination was the consequence of declining vaccines. Similarly, views regarding vaccine incentives differed; some considered incentives helpful, yet many viewed them as coercive. Strategies believed to be most effective to encourage vaccination included improving accessibility to vaccination sites, addressing misinformation, discussing vaccine safety, tailored community outreach via trusted messengers, and one-on-one conversations between patients and healthcare workers. Healthcare workers' experiences with strategies to improve utilization of COVID-19 vaccines and boosters have implications for public health policies. Generally, efforts to improve access and education were viewed more favorably than incentives and mandates.

Information nudges for influenza vaccination: Evidence from a large-scale cluster-randomized controlled trial in Finland

BACKGROUND

Vaccination is the most effective means of preventing the spread of infectious diseases. Despite the proven benefits of vaccination, vaccine hesitancy keeps many people from getting vaccinated.

METHODS AND FINDINGS

We conducted a large-scale cluster randomized controlled trial in Finland to test the effectiveness of centralized written reminders (distributed via mail) on influenza vaccination coverage. The study included the entire older adult population (aged 65 years and above) in 2 culturally and geographically distinct regions with historically low (31.8%, n = 7,398, mean age 75.5 years) and high (57.7%, n = 40,727, mean age 74.0 years) influenza vaccination coverage. The study population was randomized into 3 treatments: (i) no reminder (only in the region with low vaccination coverage); (ii) an individual-benefits reminder, informing recipients about the individual benefits of vaccination; and (iii) an individual- and social-benefits reminder, informing recipients about the additional social benefits of vaccination in the form of herd immunity. There was no control treatment group in the region with high vaccination coverage as general reminders had been sent in previous years. The primary endpoint was a record of influenza vaccination in the Finnish National Vaccination Register during a 5-month follow-up period (from October 18, 2018 to March 18, 2019). Vaccination coverage after the intervention in the region with historically low coverage was 41.8% in the individual-benefits treatment, 38.9% in the individual- and social-benefits treatment and 34.0% in the control treatment group. Vaccination coverage after the intervention in the region with historically high coverage was 59.0% in the individual-benefits treatment and 59.2% in the individual- and social-benefits treatment. The effect of receiving any type of reminder letter in comparison to control treatment group (no reminder) was 6.4 percentage points (95% CI: 3.6 to 9.1, p < 0.001). The effect of reminders was particularly large among individuals with no prior influenza vaccination (8.8 pp, 95% CI: 6.5 to 11.1, p < 0.001). There was a substantial positive effect (5.3 pp, 95% CI: 2.8 to 7.8, p < 0.001) among the most consistently unvaccinated individuals who had not received any type of vaccine during the 9 years prior to the study. There was no difference in influenza vaccination coverage between the individual-benefit reminder and the individual- and social-benefit reminder (region with low vaccination coverage: 2.9 pp, 95% CI: -0.4 to 6.1, p = 0.087, region with high vaccination coverage: 0.2 pp, 95% CI: -1.0 to 1.3, p = 0.724). Study limitations included potential contamination between the treatments due to information spillovers and the lack of control treatment group in the region with high vaccination coverage.

CONCLUSIONS

In this study, we found that sending reminders was an effective and scalable intervention strategy to increase vaccination coverage in an older adult population with low vaccination coverage. Communicating the social benefits of vaccinations, in addition to individual benefits, did not enhance vaccination coverage. The effectiveness of letter reminders about the benefits of vaccination to improve influenza vaccination coverage may depend on the prior vaccination history of the population.

TRIAL REGISTRATION

AEA RCT registry AEARCTR-0003520 and ClinicalTrials.gov NCT03748160.

Evaluating the effects of vaccine messaging on immunization intentions and behavior: Evidence from two randomized controlled trials in Vermont

The effectiveness of vaccines in reducing child morbidity and mortality worldwide relies on public acceptance. However, relatively little is known about the effects of vaccine communication on vaccine attitudes and immunization behavior. Previous research suggests that common communication approaches may be ineffective or even counterproductive, especially among vaccine-hesitant parents. However, these studies typically rely on observational data or self-reported measures of vaccination intention. Using novel research designs, we tested the attitudinal and behavioral effects of messages encouraging vaccination in both a survey experiment conducted among a large sample of parents in Vermont who expressed hesitancy about childhood immunizations and a field experiment among parents whose children were overdue for vaccines. We find that neither a message promoting immunization as a social norm nor a message correcting common misperceptions about vaccines was measurably more effective than a standard public health message at improving parents' attitudes toward vaccines, intention to vaccinate their children, or compliance with the recommended vaccine schedule. Our results highlight the need for more research on approaches to successfully reducing vaccine hesitancy among parents.

The Contribution of Reminder-Recall to Vaccine Delivery Efforts: A Narrative Review

Reminders, alerting patients to the need for vaccines that will be due in the future, and recall messages, informing patients about vaccines that are overdue, have been shown to improve immunization rates for children and adolescents in numerous systematic reviews. Therefore, reminder and recall interventions (R/R) are recommended by the Task Force on Community Preventive Services for increasing immunization rates on the basis of strong evidence. R/R messages can be delivered by mail (letter or postcard), via personal or auto-dialer phone calls, by text or e-mail or via patient-portals and can simply be alerts to action or can include educational material with the aim of motivating patients to seek vaccination. R/R has also been shown to be a relatively low-cost intervention with high cost-effectiveness compared with other recommended strategies. However, although R/R as a strategy is consistently effective and cost-effective overall, there is wide variation in the impact of R/R by 1) modality of how it is delivered, 2) the targeted vaccine, 3) the age group, and 4) whether the R/R is conducted centrally by a health system or Immunization Information System or by individual practices. This narrative review summarizes the literature about effectiveness of R/R within each of these categories. We also discuss limitations of R/R, with a focus on the potential impact of parental vaccine hesitancy in blunting its effectiveness and problems with data integrity, on which R/R relies. We also discuss challenges to sustaining R/R efforts, including potential methods of funding for R/R efforts.

Costs of Interventions to Increase Vaccination Coverage Among Children in the United States: A Systematic Review

BACKGROUND

The Community Preventive Services Task Force (CPSTF) has recommended several interventions that have been demonstrated to be effective at increasing vaccination coverage.

OBJECTIVE

Conduct a systematic review to examine the costs of interventions designed to increase vaccination coverage among children and adolescents in the United States.

DATA SOURCES

PubMed, EconLit, Embase, and Cochrane.

STUDY ELIGIBILITY, PARTICIPANTS, AND INTERVENTIONS

Peer-reviewed articles from January 1, 2009 to August 31, 2019.

APPRAISAL AND SYNTHESIS METHODS

Studies were identified with systematic searches of the literature, reviewed for inclusion criteria, abstracted for data on intervention, target population, costs, and risk of bias. Cost measures were reported as costs per child in the target population, costs per vaccinated child, incremental costs per vaccinated child, and costs per vaccine dose administered. Results were stratified by intervention type, vaccine, and age group.

RESULTS

Thirty-seven studies were identified for full-text review. Across all interventions and age groups, the cost per child ranged from $0.10 to $537.38, and the incremental cost per vaccinated child ranged from $6.52 to $5,098.57. Provider assessment and feedback interventions had the lowest (median) cost per child ($0.17) and a healthcare system-based combined intervention with multiple components had the lowest (median) incremental cost per vaccinated child ($26.65). A community-based combined intervention with multiple components had the highest median cost per child ($537.38) and the highest median incremental cost per vaccinated child ($5,098.57).

LIMITATIONS

A small number of included intervention types and inconsistent cost definition.

CONCLUSIONS

There is substantial variability in the costs of CPSTF-recommended interventions.

Influenza Vaccination Rates Among Patients With a History of Cancer: Analysis of the National Health Interview Survey

Background

Annual influenza vaccination is recommended for all patients with cancer, but vaccine uptake data by cancer type and time since diagnosis are limited. We sought to estimate vaccination rates across different cancer types in the United States and determine whether rates vary over time since diagnosis.

Methods

Vaccination rates in individuals with solid tumor and hematological malignancies were estimated using data from 59 917 individuals obtained by the 2016 and 2017 National Health Interview Survey conducted by the Centers for Disease Control and Prevention.

Results

An average of 64% of the 5053 individuals with self-reported cancer received the influenza vaccine. Vaccination rates in men and women with solid tumors (66.6% and 60.3%, respectively) and hematological malignancies (58.1% and 59.2%, respectively) were significantly higher compared to those without cancer (38.9% and 46.8%, respectively). Lower rates were seen in uninsured patients, those younger than 45 years of age, and in African Americans with hematological malignancies but not with solid tumors. Vaccine uptake was similar regardless of time since cancer diagnosis.

Conclusions

Influenza vaccination rates are higher in men and women with cancer but remain suboptimal, highlighting the need for additional measures to improve vaccine compliance and prevent complications from influenza across all cancer types.

Improving adolescent human papillomavirus (HPV) immunization uptake in school-based health centers through awareness campaigns

PURPOSE

The aim of this study was to measure the effect of a multicomponent human papillomavirus (HPV) vaccine promotion campaign on adolescent HPV vaccine uptake at school-based health centers (SBHCs) in Seattle, WA.

METHODS

Youth-led HPV vaccine promotion campaigns were introduced in 2016 in 13 schools with SBHCs in Seattle. Five other schools with SBHCs served as controls. Vaccination records for students were obtained from the Washington Immunization Information System from September 2012 to August 2018. We compared increase in HPV vaccine uptake in SBHCs between 1) intervention and control schools, and 2) pre- and post-intervention periods in intervention schools using generalized estimating equations.

RESULTS

HPV vaccine uptake was high at baseline among students that use SBHCs for vaccines and has steadily increased between 2012 and 2018. Implementing the promotion campaign resulted in 14% higher (95% Confidence Interval (CI): 1%, 30%) HPV vaccine uptake in intervention SBHCs compared to control SBHCs, adjusting for time and confounders. Comparing pre-and post-intervention periods in intervention SBHCs, HPV vaccine uptake was 14% higher (95% CI: -4%, 35%) in the post-intervention period. SBHCs that received more active intervention activities saw 9% higher (95% CI: 1%, 21%) vaccine uptake compared to those that received passive intervention.

CONCLUSION

The vaccination promotion program implemented in a school-based setting resulted in higher HPV vaccine uptake in the post-intervention period compared to pre-intervention period, but this increase was not statistically significant. Even so, schools that received more intervention activities for longer periods of time had higher HPV vaccine uptake.

Impact of video-led educational intervention on the uptake of influenza vaccine among adults aged 60 years and above in China: a study protocol for a randomized controlled trial

Background

Influenza is a global health threat to older adults, and the influenza vaccine is the most effective approach to prevent influenza infection. However, influenza vaccination coverage among Chinese older adults is far less than in developed countries such as the United States (4.0% vs. 64.9%). This study aims to increase influenza vaccination coverage in Chinese adults ≥60 years using a video-led educational intervention conducted by medical students.

Methods

A cluster randomized controlled trial will be conducted in 4 districts of Xi’an city, Shaanxi Province, China, using a stratified sampling approach. Adults aged ≥60 years will be recruited from 8 community hospitals. A self-administered questionnaire of knowledge, attitudes, and practices (KAP) will be employed to record the KAP score. During the 6-month interventional period, participants in the intervention group will receive educational videos focused on influenza and influenza vaccination, coupled with a group discussion conducted by the medical students. For those in the control group, no intervention will be provided. The outcomes measured in both groups will be the influenza vaccination coverage and the KAP scores of all participants.

Discussion

Medical students are more likely to educate older adults about scientific knowledge of influenza and its vaccine compared to clinical practitioners, who, most of the time, remain over-occupied due to the extensive workload. Video-led counseling and education could be a useful option to optimize older adults’ understanding of influenza and influenza vaccination. This eventually could improve the uptake of influenza vaccine among Chinese older adults.

Trial registration

Chinese Clinical Trial Registry; ChiCTR2000034330; Registered 3rd July 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10220-1.

Strengthening Vaccine Confidence and Acceptance in the Pediatric Provider Office

Although vaccine acceptance and uptake are overall high among children in the United States, vaccine delays or refusals are a growing concern. Vaccine hesitancy is a challenge for the pediatric provider, given the diverse factors associated with hesitancy and the limited evidence on effective strategies for addressing vaccine hesitancy in the provider office. In this article, we review available evidence and approaches for vaccine communication, including the importance of using a whole-team approach, building trust, starting the conversation early, using a presumptive approach for vaccine recommendations, motivational interviewing with parents who have concerns for vaccines, and additional techniques for responding to parent questions. We also review organizational strategies to help create a culture of immunization in the practice, including evidence-based approaches for increasing vaccine uptake and efficiency. Although these communication approaches and organizational strategies are intended to reassure parents who are vaccine hesitant that all routine, universally recommended vaccines are safe and effective, they likely will take on increased significance as the development, implementation, and evaluation of coronavirus disease 2019 vaccines continue to unfold. [Pediatr Ann. 2020;49(12):e523-e531.].

Cost-effectiveness of Interventions to Increase HPV Vaccine Uptake

OBJECTIVES

We sought to prioritize interventions for increasing human papillomavirus (HPV) vaccination coverage based on cost-effectiveness from a US state perspective to inform decisions by policy makers.

METHODS

We developed a dynamic simulation model of HPV transmission and progression scaled to a medium-sized US state (5 million individuals). We modeled outcomes over 50 years comparing no intervention to a one-year implementation of centralized reminder and recall for HPV vaccination, school-located HPV vaccination, or quality improvement (QI) visits to primary care clinics. We used probabilistic sensitivity analysis to assess a range of plausible outcomes associated with each intervention. Cost-effectiveness was evaluated relative to a conservative willingness-to-pay threshold; $50 000 per quality-adjusted life-year (QALY) .

RESULTS

All interventions were cost-effective, relative to no intervention. QI visits had the lowest cost and cost per QALY gained ($1538 versus no intervention). Statewide implementation of centralized reminder and recall cost $28 289 per QALY gained versus QI visits. School-located vaccination had the highest cost but was cost-effective at $18 337 per QALY gained versus QI visits. Scaling to the US population, interventions could avert 3000 to 14 000 future HPV cancers. When varying intervention cost and impact over feasible ranges, interventions were typically preferred to no intervention, but cost-effectiveness varied between intervention strategies.

CONCLUSIONS

Three interventions for increasing HPV vaccine coverage were cost-effective and offered substantial health benefits. Policy makers seeking to increase HPV vaccination should, at minimum, dedicate additional funding for QI visits, which are consistently effective at low cost and may additionally consider more resource-intensive interventions (reminder and recall or school-located vaccination).

Technological approaches to streamline vaccination schedules, progressing towards single-dose vaccines

Vaccines represent the most successful medical intervention in history, with billions of lives saved. Although multiple doses of the same vaccine are typically required to reach an adequate level of protection, it would be advantageous to develop vaccines that induce protective immunity with fewer doses, ideally just one. Single-dose vaccines would be ideal to maximize vaccination coverage, help stakeholders to greatly reduce the costs associated with vaccination, and improve patient convenience. Here we describe past attempts to develop potent single dose vaccines and explore the reasons they failed. Then, we review key immunological mechanisms of the vaccine-specific immune responses, and how innovative technologies and approaches are guiding the preclinical and clinical development of potent single-dose vaccines. By modulating the spatio-temporal delivery of the vaccine components, by providing the appropriate stimuli to the innate immunity, and by designing better antigens, the new technologies and approaches leverage our current knowledge of the immune system and may synergize to enable the rational design of next-generation vaccination strategies. This review provides a rational perspective on the possible development of future single-dose vaccines.

Trends in Childhood Influenza Vaccination Coverage, United States, 2012-2019

OBJECTIVE

The objective was to compare estimates of childhood influenza vaccination across 7 consecutive influenza seasons based on 2 survey systems.

METHODS

We analyzed data from the National Health Interview Survey (NHIS) and the National Immunization Survey-Flu (NIS-Flu) using Kaplan-Meier survival analysis to estimate receipt, based on parental report, of at least 1 dose of influenza vaccine among children aged 6 months to 17 years.

RESULTS

We found no significant increasing trend in influenza vaccination coverage among children overall from 2012 to 2018 based on the NHIS or from 2012 to 2019 based on the NIS-Flu. We found 4 seasons with a significant increase in influenza vaccination coverage compared with the previous season (2012-2013 [NHIS, NIS-Flu], 2013-2014 [NIS-Flu], 2017-2018 [NHIS], and 2018-2019 [NIS-Flu]). As of the 2018-2019 season, based on NIS-Flu, influenza vaccination coverage was only 62.6%. Children with health conditions that put them at increased risk for complications from influenza had higher influenza vaccination coverage than children without these health conditions for all the seasons studied except 2014-2015. For all seasons studied, influenza vaccination coverage estimates for children were higher based on NIS-Flu data compared with NHIS data. Trends across seasons and differences in vaccination coverage between age groups were similar between the 2 surveys.

CONCLUSIONS

Influenza vaccination coverage among children appears to have plateaued. Only about half of the children in the United States were vaccinated against influenza. Improvements in measurement of influenza vaccination and development and review of strategies to increase childhood influenza vaccination coverage are needed.

Determinants of low uptake of vaccination against influenza, measles, and hepatitis B among healthcare professionals in Greece: a multicenter cross-sectional study

Vaccination is recommended for healthcare professionals (HCPs) to protect them against vaccine-preventable diseases (VPDs); however, uptake rates are low. This study aimed to evaluate HCPs' influenza, hepatitis B, and measles vaccine uptake in all healthcare levels in Crete, Greece. We conducted a questionnaire-based, cross-sectional multicenter study in 2018, including HCPs employed at 18 primary care centers and 3 hospitals. Overall, 2,246 HCPs responded (57.2% of the target population). The influenza vaccine uptake rate was 36.1% (810/2,246), with the annual vaccination rate at 14.8% (332/2,246) over the previous 5 years. Concurrently, the hepatitis B 3-dose vaccine uptake rate was 60.3% (1,316/2,181). Among the participating HCPs, 70.7% (1,457/2,061) had measles immunity due to previous illness (959/2,061, 46.5%), a 2-dose vaccination scheme (461/2,061, 22.4%), or serological confirmation (37/2,061, 1.8%). Vaccine uptake rates differed between groups depending on age, profession, and workplace setting. Logistic regression analysis revealed that risk factors for no influenza vaccine uptake during the previous season were younger age (≤45 years; odds ratio [OR] 1.35, 95% confidence interval [CI]: 1.08-1.66), profession other than physician (OR 2.94, 95%CI: 2.09-4.12), and working in hospitals (OR 1.39, 95%CI 1.02-1.89). Older age (>45 years) was an independent risk factor for not receiving a measles (OR 26.74, 95%CI: 17.41-41.06) or hepatitis B vaccine (OR 1.36, 95%CI 1.09-1.7). Working in primary care was an independent risk factor for not getting a hepatitis B vaccine (OR 1.52, 95%CI: 1.15-2.1). Our findings indicate that individualized and targeted interventions should be implemented to increase vaccine uptake among HCPs.

Use of Standing Orders for Vaccination Among Pediatricians

OBJECTIVES

Standing orders are an effective way to increase vaccination rates, yet little is known about how pediatricians use this strategy for childhood immunizations. We assessed current use of, barriers to using, and factors associated with use of standing orders for vaccination among pediatricians.

METHODS

Internet and mail survey from June 2017 to September 2017 among a nationally representative sample of pediatricians. In the principal component analysis of barrier items, we identified 2 factors: physician responsibility and concerns about office processes. A multivariable analysis that included barrier scales and physician and/or practice characteristics was used to identify factors associated with use of standing orders.

RESULTS

The response rate was 79% (372 of 471); 59% of respondents reported using standing orders. The most commonly identified barriers among nonusers were concern that patients may mistakenly receive the wrong vaccine (68%), concern that patients prefer to speak with the physician about a vaccine before receiving it (62%), and belief that it is important for the physician to be the person who recommends a vaccine to patients (57%). These 3 items also made up the physician responsibility barrier factor. Respondents with higher physician responsibility scores were less likely to use standing orders (risk ratio: 0.59 [95% confidence interval: 0.53-0.66] per point increase). System-level decision-making about vaccines, suburban or rural location, and lower concerns about office processes scores were each associated with use of standing orders in the bivariate, but not the multivariable, analysis.

CONCLUSIONS

Among pediatricians, use of standing orders for vaccination is far from universal. Interventions to increase use of standing orders should address physicians' attitudinal barriers as well as organizational factors.

Strengthening vaccination programmes and health systems in the European Union: A framework for action

Vaccination is one of the most cost-effective public health interventions. However, the EU is facing increasing outbreaks of vaccine preventable diseases, with some fatal cases of measles. This paper reviews the main factors influencing vaccination uptake, and assesses measures expected to improve vaccination coverage. Obstacles to vaccination include concerns about vaccine safety and side effects, lack of trust, social norms, exposure to rumours and myths, and access barriers. Responses fall into three broad categories. Regulation, including the introduction of mandatory vaccination, can be justified but it is important to be sure that it is an appropriate solution to the existing problem and does not risk unintended consequences. Facilitation involves ensuring that there is an effective vaccination programme, comprehensive in nature, and reducing the many barriers, in terms of cost, distance, and time, to achieving high levels of uptake, especially for marginalised or vulnerable populations. Information is crucial, but whether in the form of public information campaigns or interactions between health workers and target populations, must be designed very carefully to avoid the risk of backfire. There is no universal solution to achieving high levels of vaccine uptake but rather a range or combinations of options. The choice of which to adopt in each country will depend on a detailed understanding of the problem, including which groups are most affected.

Evidence-based strategies to increase vaccination uptake: a review

PURPOSE OF REVIEW

To summarize evidence-based strategies for improving pediatric immunization rates including physician behaviors, clinic and public health processes, community-based and parent-focused interventions, and legal and policy approaches RECENT FINDINGS: Studies continue to show the effectiveness of audit and feedback, provider reminders, standing orders, and reminder/recall to increase immunization rates. Provider communication strategies may improve immunization rates including use of a presumptive approach and motivational interviewing. Centralized reminder/recall (using a state Immunization Information System) is more effective and cost-effective compared to a practice-based approach. Recent work shows the success of text messages for reminder/recall for vaccination. Web-based interventions, including informational vaccine websites with interactive social media components, have shown effectiveness at increasing uptake of pediatric and maternal immunizations. Vaccination requirements for school attendance continue to be effective policy interventions for increasing pediatric and adolescent vaccination rates. Allowance for and ease of obtaining exemptions to vaccine requirements are associated with increased exemption rates.

SUMMARY

Strategies to increase vaccination rates include interventions that directly impact physician behavior, clinic and public health processes, patient behaviors, and policy. Combining multiple strategies to work across different settings and addressing different barriers may offer the best approach to optimize immunization coverage.

Seasonal influenza vaccination among primary health care workers in Southwestern Saudi Arabia

Background: Vaccination of primary healthcare workers (PHCWs) help to prevent the spread of influenza among at-risk patients.Objectives: To assesses seasonal influenza vaccination (SIV) coverage and the factors affecting SIV's utilization among PHCWs in Abha city, southwestern Saudi Arabia.Methods: A cross-sectional survey was carried out between June 2018 and August 2018 in all primary healthcare centers in Abha city. It targeted physicians, nurses, technicians, and pharmacists. A self-administered questionnaire was used to collect data regarding SIV status during the 2017-2018 season, obtain knowledge regarding SIV and influenza disease, and identify potential motivators for and barriers to SIV.Results: Of 312 PHCWs, the SIV coverage rate was 45.5% in the 2017-2018 vaccination season. A multivariable logistic regression model showed that the risk groups for non-vaccination were PHCWs less than 40 years old (adjusted Odds Ratio (aOR) = 4.07, 95% CI: 1.50-11.03), technicians (aOR = 3.73, 95% CI: 1.20-11.54), single PHCWs (aOR = 2.36, 95% CI:1.20-4.62), and PHCWs lacking adequate influenza vaccine knowledge (aOR = 4.22, 95% CI: 2.13-8.35). Approximately 23% and 32% of PHCWs were found to have inadequate knowledge about SIV and influenza disease, respectively. PHCWs' awareness about their risk of infection and their need for protection was found to be the most common motivator (77.5%), and a fear of side effects was found to be the most frequent barrier (40%).Conclusion: SIV coverage rate is suboptimal. Knowledge gaps and misconceptions about the influenza vaccine are the main barriers to an adequate coverage.

Defining hard-to-reach populations for vaccination

Extending the benefits of vaccination to everyone who is eligible requires an understanding of which populations current vaccination efforts have struggled to reach. A clear definition of "hard-to-reach" populations - also known as high-risk or marginalized populations, or reaching the last mile - is essential for estimating the size of target groups, sharing lessons learned based on consistent definitions, and allocating resources appropriately. A literature review was conducted to determine what formal definitions of hard-to-reach populations exist and how they are being used, and to propose definitions to consider for future use. Overall, we found that (1) there is a need to distinguish populations that are hard to reach versus hard to vaccinate, and (2) the existing literature poorly defined these populations and clear criteria or thresholds for classifying them were missing. Based on this review, we propose that hard-to-reach populations be defined as those facing supply-side barriers to vaccination due to geography by distance or terrain, transient or nomadic movement, healthcare provider discrimination, lack of healthcare provider recommendations, inadequate vaccination systems, war and conflict, home births or other home-bound mobility limitations, or legal restrictions. Although multiple mechanisms may apply to the same population, supply-side barriers should be distinguished from demand-side barriers. Hard-to-vaccinate populations are defined as those who are reachable but difficult to vaccinate due to distrust, religious beliefs, lack of awareness of vaccine benefits and recommendations, poverty or low socioeconomic status, lack of time to access available vaccination services, or gender-based discrimination. Further work is needed to better define hard-to-reach populations and delineate them from populations that may be hard to vaccinate due to complex refusal reasons, improve measurement of the size and importance of their impact, and examine interventions related to overcoming barriers for each mechanism. This will enable policy makers, governments, donors, and the vaccine community to better plan interventions and allocate necessary resources to remove existing barriers to vaccination.

Impact of school vaccination mandates on pediatric vaccination coverage: a systematic review

BACKGROUND

Mandated vaccination for school attendance is a growing strategy internationally. Our aim was to investigate the effects of implementing school vaccination mandates on pediatric population vaccine coverage.

METHODS

In this systematic review, we searched MEDLINE, Embase, CINAHL, the Education Resources Information Center (ERIC) and the PAIS Index for empirical studies of implementation of a primary or secondary school vaccination requirement published in any language through March 2019 with vaccination rates as an outcome. We sought additional studies by consulting experts, reference lists and grey literature sources. Included studies were too heterogeneous for meta-analysis; thus, we extracted data using a standardized rubric and synthesized the results narratively.

RESULTS

Among the 4232 citations obtained, 20 studies met the inclusion criteria. Eighteen were conducted with US data, 1 with Italian data, and 1 with Australian data. Four studies examined school-entry mandates, and 16 examined adolescent requirements. An uncontrolled before-after design was used in 10 studies, cross-sectional analysis in 7, a retrospective cohort design in 2, and a prospective cohort in 1. In many cases, increased documentation of coverage followed the addition of new requirements. The exception to this was human papillomavirus vaccination mandates, which were highly controversial, in the United States. The studies contained notable risks of bias, with cointerventions rarely acknowledged or accounted for, and subpopulations often excluded. A substantial risk of ecological fallacy existed for most studies.

INTERPRETATION

Vaccination mandates appear largely associated with increased vaccination coverage, but it is not possible to attribute causality to the mandate in most studies. High-quality implementation research that uses whole-population coverage data and takes into consideration cointerventions, confounders, clustering of unvaccinated populations and context is required.

Coaching primary care clinics for HPV vaccination quality improvement: Comparing in-person and webinar implementation

State health departments commonly use quality improvement coaching as an implementation strategy for improving low human papillomavirus (HPV) vaccination coverage, but such coaching can be resource intensive. To explore opportunities for improving efficiency, we compared in-person and webinar delivery of coaching sessions on implementation outcomes, including reach, acceptability, and delivery cost. In 2015, we randomly assigned 148 high-volume primary care clinics in Illinois, Michigan, and Washington State to receive either in-person or webinar coaching. Coaching sessions lasted about 1 hr and used our Immunization Report Card to facilitate assessment and feedback. Clinics served over 213,000 patients ages 11-17. We used provider surveys and delivery cost assessment to collect implementation data. This report is focused exclusively on the implementation aspects of the intervention. More providers attended in-person than webinar coaching sessions (mean 9 vs. 5 providers per clinic, respectively, p = .004). More providers shared the Immunization Report Card at clinic staff meetings in the in-person than webinar arm (49% vs. 20%; p = .029). In both arms, providers' belief that their clinics' HPV vaccination coverage was too low increased, as did their self-efficacy to help their clinics improve (p < .05). Providers rated coaching sessions in the two arms equally highly on acceptability. Delivery cost per clinic was $733 for in-person coaching versus $461 for webinar coaching. In-person and webinar coaching were well received and yielded improvements in provider beliefs and self-efficacy regarding HPV vaccine quality improvement. In summary, in-person coaching cost more than webinar coaching per clinic reached, but reached more providers. Further implementation research is needed to understand how and for whom webinar coaching may be appropriate.

Influenza Vaccination Documentation Rates During the First Year After Diagnosis of Diffuse Large B Cell Lymphoma

INTRODUCTION

Influenza infection causes significant morbidity and mortality in patients with cancer, and annual influenza vaccination for individuals with cancer is recommended. We sought to examine the documentation rate of influenza vaccine administration, refusal, or counseling in the first year after diagnosis of diffuse large B cell lymphoma (DLBCL) for patients across 3 hospitals in 2 health care systems.

PATIENTS AND METHODS

Documentation of vaccine administration, refusal, or counseling by physicians, advanced practice providers, or nursing staff during the first period of influenza vaccine availability after diagnosis (August to April) was assessed in medical records of patients diagnosed with DLBCL between February 2015 and October 2017 who presented to Emory St. Joseph Hospital (community hospital), Winship Cancer Institute of Emory University (academic medical center), or Grady Memorial Hospital (county hospital).

RESULTS

Of the 57% (61/107) of newly diagnosed patients with DLBCL who had vaccine-related documentation, 43% refused vaccination. Counseling was not documented for any patient. Inpatient nursing performed 75% of all documentation. Primary oncologists documented vaccination in 4% of all cases.

CONCLUSION

Despite the limited immunization documentation and high refusal rates observed in this study, the influenza vaccine refusal rate was lower than the average for the United States, the state of Georgia, and the previous studies of patients with cancer. Although routine outpatient vaccination occurs, improvements in screening, strategies for sharing patient vaccine-related information, and counseling of patients who refuse the vaccine are needed. Further work is also needed to determine the effectiveness of influenza vaccination in patients receiving anti-cancer therapy.

Letters designed with behavioural science increase influenza vaccination in Medicare beneficiaries

The influenza ('flu') vaccination is low cost¹ and effective, typically reducing the likelihood of infection by 50-60%². It is recommended for nearly everyone older than 6 months of age³; yet, only 40% of Americans are immunized each year. Vaccination rates are higher among at-risk groups, such as those ≥65 years of age, but still only 6 in 10 receive it⁴. There have been numerous attempts to improve vaccination rates using strategies such as school-based programmes, financial incentives and reminders, but these have generally had limited success^5-7. Of the attempts that are successful, most are expensive-limiting scalability-and have not been evaluated in the elderly⁸. Conversely, lower-cost interventions, such as mailed information, hold promise for a scalable solution, but their limited effectiveness may result from how they have been designed. We randomly assigned 228,000 individuals ≥66 years of age to one of five versions of letters intended to motivate vaccination, including versions with an implementation intention prompt and an enhanced active choice implementation prompt. We found that a single mailed letter significantly increased influenza vaccination rates compared with no letter. However, there was no difference in vaccination rates across the four different letters tailored with behavioural science techniques.

Offering the Influenza Vaccine in a Pediatric Hand Surgery Clinic Increases Vaccination Rates

PURPOSE

The purpose of this study was to evaluate the utility of providing immediate access to the influenza vaccination for patients seen in a pediatric hand surgery clinic. Our hypothesis was that providing access would increase the rate of vaccination.

METHODS

This pilot study was a randomized, controlled, prospective clinical trial that included all patients seen by a single surgeon, on a single day each week, in a hospital-based pediatric hand surgery practice clinic from October 18, 2016, to March 14, 2017. All patients between 6 months and 18 years of age seen during their initial visit during the study period were included. All patients were questioned on their vaccine status. For the intervention group, the influenza vaccine was offered. If requested, after providing educational materials, written consent from the parent or guardian was obtained. The vaccine was given by the registered nurse ordinarily assigned to the clinic. Demographic information and vaccine status for both groups at the end of clinic, including the date of receiving the vaccine, were recorded.

RESULTS

Similar proportions of patients in each group had received the vaccine prior to being seen in the clinic. In the intervention group, 80 children (67%) had received the vaccine by the end of clinic, compared with 29 (25%) in the control group. Patients who were offered the vaccine had a statistically significant higher vaccination rate. Of the 80 patients in the intervention group who received the vaccine, 47 (59%) received it in the hand clinic.

CONCLUSIONS

This project demonstrated that offering the influenza vaccine in a nontraditional setting, an outpatient hand surgery clinic, increased the proportion of patients receiving the vaccine.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Linking Time-Use Data to Explore Health Outcomes: Choosing to Vaccinate Against Influenza

To inform public health and medical decision makers concerning vaccination interventions, a methodology for merging and analyzing detailed activity data and health outcomes is presented. The objective is to investigate relationships between individual's activity choices and their decision to receive an influenza vaccination. Data from the Behavioral Risk Factor Surveillance System (BRFSS) are used to predict vaccination rates in the American Time Use Survey (ATUS) data between 2003 and 2013 by using combined socioeconomic and demographic characteristics. The correlations between the extensive (do or not do) and intensive (how much) decisions to perform activities and influenza vaccination are further explored. Significant positive and negative correlations were found between several activities and vaccination. For some activities, the sign of the correlation flips when considering either the intensive or the extensive decision. This flip occurs with highly studied activities, like smoking. Correlations between activities and vaccination can provide an additional metric for targeting those least likely to vaccinate. The methodology outlined in this paper can be replicated to explore correlation among actions and other health outcomes.

Caregiver and adolescent factors associated with delayed completion of the three-dose human papillomavirus vaccination series

BACKGROUND

Delayed completion of human papillomavirus vaccination (4vHPV) series is common. We sought to identify factors associated with delay.

METHODS

This substudy was part of a large prospective, multi-site study recruiting 9-17 year old girls at the time of their third 4vHPV dose to assess immunogenicity associated with prolonged dosing intervals. At participating sites, parents/legal guardians (caregivers) of all enrolled girls (9-17 years old) and enrolled girls aged 14-17 years were approached for participation. Caregivers completed a questionnaire measuring adolescent and caregiver sociodemographic characteristics, caregiver attitudes and beliefs about on-schedule HPV vaccination and HPV vaccine safety, adolescent's health behaviors, barriers to accessing health care, provider office vaccination practices and a Rapid Estimate of Adult Literacy in Medicine (REALM). Participating girls completed a separate questionnaire measuring their attitudes and beliefs about on-schedule HPV vaccination and HPV vaccine safety. Delay was defined as receiving the third 4vHPV dose >12 months after the first. Bivariate, multinomial logistic regression and multivariate logistic regression analyses were used to identify factors predicting delayed completion.

RESULTS

Questionnaires were completed by 482 caregivers and 386 adolescents; 422 caregivers completed a REALM. Delayed 4vHPV dosing occurred in most adolescents (67%). In multivariate analyses, predictors of delayed completion included caregiver demographic factors (self-reported black vs. white race and high school or less education vs. college or more) and an interaction between caregiver's inability to get an immunization appointment as soon as needed and adolescent's type of insurance.

CONCLUSIONS

Caregiver's race and educational level, accessibility of immunization appointments, and adolescent's insurance type were found to be related to delays in completion of 4vHPV, but caregiver or adolescent attitudes and beliefs about on-schedule HPV vaccination or HPV vaccine safety were not. Therefore, interventions to improve adherence to recommended vaccination schedules could benefit from a focus on improving access to immunizations. ClinicalTrials.gov (NCT01030562).

Cost of a measles outbreak in a remote island economy: 2014 Federated States of Micronesia measles outbreak

After 20years with no reported measles cases, on May 15, 2014 the Centers for Disease Control and Prevention (CDC) was notified of two cases testing positive for measles-specific immunoglobulin M (IgM) antibodies in the Federated States of Micronesia (FSM). Under the Compact of Free Association, FSM receives immunization funding and technical support from the United States (US) domestic vaccination program managed by the Centers for Disease Control and Prevention (CDC). In a collaborative effort, public health officials and volunteers from FSM and the US government worked to respond and contain the measles outbreak through an emergency mass vaccination campaign, contact tracing, and other outbreak investigation activities. Contributions were also made by United Nations Children's Emergency Fund (UNICEF) and World Health Organization (WHO). Total costs incurred as a result of the outbreak were nearly $4,000,000; approximately $10,000 per case. Direct medical costs (≈$141,000) were incurred in the treatment of those individuals infected, as well as lost productivity of the infected and informal caregivers (≈$250,000) and costs to contain the outbreak (≈$3.5 million). We assessed the economic burden of the 2014 measles outbreak to FSM, as well as the economic responsibilities of the US. Although the US paid the majority of total costs of the outbreak (≈67%), examining each country's costs relative to their respective economy illustrates a far greater burden to FSM. We demonstrate that while FSM was heavily assisted by the US in responding to the 2014 Measles Outbreak, the outbreak significantly impacted their economy. FSM's economic burden from the outbreak is approximately equivalent to their entire 2016 Fiscal Year budget dedicated to education.

Impact of patient education on influenza vaccine uptake among community-dwelling elderly: a randomized controlled trial

This randomized controlled trial aimed to test the effectiveness of brief face-to-face patient education in increasing influenza vaccination rate among elderly in the community. Recruitment and intervention were conducted at two general outpatient clinics in Hong Kong. 529 eligible patients were randomly assigned to intervention or control group with 1:1 allocation ratio. Patients in the intervention group received 3-min one-on-one verbal education by medical students and a pamphlet regarding influenza vaccination. Neither verbal health education nor pamphlet was given to the control group. Intention-to-treat analysis showed significantly higher vaccination rate in the intervention group compared with the control group (33.6 versus 25.0%) and the adjusted relative risk was 1.34 (95% CI 1.04-1.72; P = 0.021). Hence, brief face-to-face patient education was effective in increasing influenza vaccine uptake rate of community-dwelling elderly patients. Participants who were undecided whether to receive vaccination seemed to demonstrate larger beneficial effect (RR = 7.84; 95% CI 1.06-57.76) compared with patients who were certain of either receiving (RR = 1.16; 95% CI 0.90-1.48) or not receiving (RR = 2.18; 95% CI 0.68-6.99) the vaccine. The study also revealed that patients' intention for vaccination may not translate into action, reasons for which should be explored in future research.

Vaccine exemptions and the kindergarten vaccination coverage gap

BACKGROUND

Vaccination requirements for kindergarten entry vary by state, but all states require 2 doses of measles containing vaccine (MCV) at kindergarten entry.

OBJECTIVE

To assess (i) national MCV vaccination coverage for children who had attended kindergarten; (ii) the extent to which undervaccination after kindergarten entry is attributable to parents' requests for an exemption; (iii) the extent to which undervaccinated children had missed opportunities to be administered missing vaccine doses among children whose parent did not request an exemption; and (iv) the vaccination coverage gap between the "highest achievable" MCV coverage and actual MCV coverage among children who had attended kindergarten.

METHODS

A national survey of 1465 parents of 5-7year-old children was conducted during October 2013 through March 2014. Vaccination coverage estimates are based provider-reported vaccination histories. Children have a "missed opportunity" for MCV if they were not up-to-date and if there were dates on which other vaccines were administered but not MCV. The "highest achievable" MCV vaccination coverage rate is 100% minus the sum of the percentages of (i) undervaccinated children with parents who requested an exemption; and (ii) undervaccinated children with parents who did not request an exemption and whose vaccination statuses were assessed during a kindergarten grace period or period when they were provisionally enrolled in kindergarten.

RESULTS

Among all children undervaccinated for MCV, 2.7% were attributable to having a parent who requested an exemption. Among children who were undervaccinated for MCV and whose parent did not request an exemption, 41.6% had a missed opportunity for MCV. The highest achievable MCV coverage was 98.6%, actual MCV coverage was 90.9%, and the kindergarten vaccination gap was 7.7%.

CONCLUSION

Vaccination coverage may be increased by schools fully implementing state kindergarten vaccination laws, and by providers assessing children's vaccination status at every clinic visit, and administering missed vaccine doses.

Tennessee's 3-Star Report: Using Available Data Systems to Reduce Missed Opportunities to Vaccinate Preteens

All preteens should receive tetanus–diphtheria–pertussis vaccine (Tdap), quadrivalent meningococcal vaccine (Men-ACWY), and the human papillomavirus (HPV) cancer vaccine series. In Tennessee, HPV vaccination rates have stagnated at low levels for a decade. Three fundamental strategies to reduce missed opportunities for immunization include administering all recommended vaccines at the same visit, making strong recommendations for vaccines, and auditing and feedback. In Tennessee, during each summer, a surge of preteens visit local health departments (LHDs) to receive a required Tdap vaccine before entering seventh grade, presenting an opportunity to administer Men-ACWY and HPV. The Tennessee Immunization Program (TIP) coined the term “3-Star visit” for such encounters and developed a monthly report to track them using data from the Patient Tracking Billing Management Information System (PTBMIS) used by LHDs across Tennessee. Implementation of this quality improvement report has correlated with a substantial increase in 3-Star visits from 2013 to 2016, particularly during the summer months.