Pharmacist-led Tdap vaccination of close contacts of neonates in a women's hospital

The impact of pharmacist involvement on immunization uptake and other outcomes: An updated systematic review and meta-analysis

Background

The underutilization of immunization services remains a big public health concern. Pharmacists can address this concern by playing an active role in immunization administration.

Objective

We performed a systematic review and meta-analysis to assess the impact of pharmacist-involved interventions on immunization rates and other outcomes indirectly related to vaccine uptake.

Methods

A systematic literature search was conducted using MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases from inception to February 2022 to identify randomized controlled trials (RCTs) and observational studies in which pharmacists were involved in the immunization process. Studies were excluded if no comparator was reported. Two reviewers independently completed data extraction and bias assessments using standardized forms. Meta-analyses were performed using a random-effects model.

Results

A total of 14 RCTs and 79 observational studies were included. Several types of immunizations were provided, including influenza, pneumococcal, herpes zoster, Tdap, and others in a variety of settings (community pharmacy, hospital, clinic, others). Pooled analyses from RCTs indicated that a pharmacist as immunizer (risk ratio 1.14 [95% CI 1.12–1.15]), advocator (1.31 [1.17–1.48]), or both (1.14 [1.12–1.15]) significantly increased immunization rates compared with usual care or non–pharmacist-involved interventions. The quality of evidence was assessed as moderate or low for those meta-analyses. Evidence from observational studies was consistent with the results found in the analysis of the RCTs.

Conclusion

Pharmacist involvement as immunizer, advocator, or both roles has favorable effects on immunization uptake, especially with influenza vaccines in the United States and some high-income countries. As the practice of pharmacists in immunization has been expanded globally, further research on investigating the impact of pharmacist involvement in immunization in other countries, especially developing ones, is warranted.

Increasing Uptake of Maternal Pertussis Vaccinations through Funded Administration in Community Pharmacies

Although maternal pertussis vaccination is recommended, uptake is suboptimal in New Zealand (NZ), despite full funding in general practice and hospitals. We determined whether funding maternal pertussis vaccination in community pharmacy increases its uptake. Pertussis vaccination during pregnancy was compared between non-contiguous, demographically similar regions of NZ. The pertussis vaccine was funded at pharmacies from Nov 2016 in one NZ region (Waikato), but not in comparator regions (Northland, Hawkes Bay). Vaccinations during pregnancy were determined from the National Immunisation Register, general practice and pharmacy claims data, and a maternity database. Comparisons were made using adjusted odds ratios (OR) and 95% confidence intervals (CI) for Nov 2015 to Oct 2016 versus Nov 2016 to Oct 2019. The odds of pregnancy pertussis vaccination increased in the post-intervention versus pre-intervention period with this increase being larger (p = 0.0014) in the intervention (35% versus 21%, OR = 2.07, 95% CI 1.89–2.27) versus the control regions (38% versus 26%, OR = 1.67, 95% CI 1.52–1.84). Coverage was lower for Māori versus non-Māori, but increased more for Māori in the intervention versus control regions (117% versus 38% increase). It was found that funding maternal pertussis vaccination in pharmacy increases uptake, particularly for Māori women. Measures to increase coverage should include reducing barriers to vaccines being offered by non-traditional providers, including pharmacies.

Improving vaccination rates in older adults and at-risk groups: focus on pertussis

Despite the implementation of effective paediatric vaccination programmes, pertussis remains a global health problem. Disease epidemiology has changed over time, shifting towards the adolescent and adult populations. In adults, the true burden of pertussis is greatly underestimated and pertussis vaccine coverage rates are suboptimal, including individuals with chronic conditions. Here, we report the outcomes of a virtual international scientific workshop to assess the evidence on the burden of pertussis in older adults and identify potential solutions to improve uptake of pertussis vaccines. In adults, pertussis is underdiagnosed in part due to atypical or milder clinical presentation and the lack of testing and case confirmation. However, contemporary epidemiological data denoted an increase in the burden of pertussis among adolescents and adults. This might be related to a variety of reasons including the waning of immunity over time, the lack of booster vaccination, and the improved diagnostic methods that led to increased recognition of the disease in adults. Pertussis sequelae can be severe in older adults, particularly those with existing chronic medical conditions, and the vulnerability of these groups is further enhanced by low pertussis vaccine coverage. Possible measures to increase vaccine uptake include strengthening and harmonisation of immunisation guidelines, healthcare professionals taking a more active role in recommending pertussis vaccination, involvement of vaccination centres and pharmacies in the vaccination process, and improving knowledge of pertussis burden and vaccine efficacy among the general population.

Strategies to increase uptake of maternal pertussis vaccination

INTRODUCTION

Pertussis is a highly contagious respiratory disease that results in disproportionate morbidity and mortality in infants who have yet to receive the primary diphtheria-tetanus-pertussis vaccine series. In the preceding decades numerous countries began to pursue either prenatal vaccination of pregnant women or postpartum vaccination of caregivers to protect infants. Despite proven benefit, maternal uptake of pertussis vaccine continues to remain suboptimal.

AREAS COVERED

Many studies have been conducted to address the suboptimal uptake of maternal pertussis vaccination. This systematic review was undertaken to systematically identify those studies, highlight the most successful strategies and find the knowledge gaps that need to be filled over the coming years to improve vaccine uptake. Twenty-five studies were identified from six different databases.

EXPERT OPINION

Five different interventions were shown to be successful in promoting uptake of pertussis vaccination: (1) standing orders, (2) opt-in orders, (3) provider education, (4) on-site vaccination and (5) interactive patient education. Three major knowledge gaps were also identified that need to be filled over the coming years: (1) lack of studies in low- and middle-income countries, (2) lack of studies targeting midwives and/or home birth and (3) lack of studies on the process of vaccine communication.

Exploring beliefs about pneumococcal vaccination in a predominantly older African American population: the Pharmacists' Pneumonia Prevention Program (PPPP)

Objectives: To assess the association of the Pharmacists' Pneumonia Prevention Program (PPPP) with changes in beliefs related to pneumonia vaccination (PV) in a predominately older African American population.Methods: PPPP was an educational intervention delivered using a senior center model of care consisting of a formal pharmacist presentation, live skit, small group action planning, and optional PV. A 15-item instrument assessed participants' beliefs at baseline, post-test, and three months across four domains: pharmacists and pharmacies, vaccination, pneumococcal disease, and physicians. Friedman tests and pairwise Wilcoxon signed rank tests were used to determine the statistical significance of the mean change in belief responses across timepoints.Results: 190 older adults participated; the sample was majority female (76.3%) and African American (80.5%), and had a mean age of 74.3 years. Statistically significant improvements in beliefs at post-test were observed in the following domains: pharmacists and pharmacies, vaccination, and the pneumococcal disease; however, some of these gains were incompletely sustained at three months.Conclusion: PPPP positively impacted beliefs post-program regarding the pneumococcal disease, pharmacists and pharmacies, and vaccination; however, sustained efforts may be needed to reinforce these gains.Policy implications: Support for pharmacist educational services in senior centers should be considered.

Effect of educational and financial incentive-based interventions on immunization attitudes, beliefs, intentions and receipt among close contacts of pregnant women

INTRODUCTION

Cocooning, the vaccination of close contacts of a newborn, is a strategy to limit the risk of pertussis and influenza infection among vulnerable infants.

METHODS

Pregnant women in Colorado and Georgia referred close contacts to an app that provided tailored educational videos about vaccines along with a small pharmacy-based financial incentive for vaccine receipt. The primary objective of this study was to determine the feasibility of implementing this app-based cocooning intervention.

RESULTS

Two hundred seventy seven contacts were enrolled in this study. Of those who received the educational videos, 96% found them interesting, 100% found them clear to understand, 97% found them helpful, and 99% trusted them. Completion of the videos led to significant increases in influenza vaccine knowledge (p = 0.025), Tdap vaccine knowledge (p < 0.001), and intention to receive these vaccines (p = 0.046). Of the 136 participants who reported receiving influenza vaccine, 41 (30%) reported receiving it at a pharmacy, and of the 66 who reported receiving Tdap vaccine, 15 (23%) reported receiving it at a pharmacy. Of all participants, 80% reported being comfortable receiving vaccines at a pharmacy instead of a doctor's office. The provision of small pharmacy-based financial incentives combined with individually-tailored educational videos about vaccines led to 6.97 (95%CI: 2.25-21.64) times higher odds of self-reported receipt of influenza vaccine than providing small pharmacy-based financial incentives without these videos. No significant difference was found for Tdap vaccine.

CONCLUSIONS

Tailored vaccine education can positively impact vaccine knowledge and intentions among adults. An app-based referral program providing education and financial incentives for cocooning vaccination at pharmacies is feasible.

The Role of Intern Pharmacists in Implementing Innovative and Sustainable Practices to Enhance Rates of Non-influenza Immunizations

Background Intern pharmacists are likely an underutilized resource for addressing immunization barriers and improving immunization rates. Studies have addressed methods that pharmacists use to improve immunization rates, but few have focused on the role of intern pharmacists, with particular emphasis on non-influenza immunizations. Methods An online survey was distributed through email listservs associated with California pharmacy schools and organizations. Data collected included title (“pharmacist” or “intern pharmacist”), practice setting, perceptions of the intern pharmacists’ role in improving immunization rates (strongly agree to strongly disagree using a 5-point Likert scale), and opinions regarding potential implementations. Immunization barriers were assessed using a 9-point scale, from least to most feasible to be addressed. Statistical comparisons between intern pharmacist and pharmacist responses were made using chi-square or Fisher’s exact tests. Results A total of 133 respondents completed the survey. The immunization barrier most likely to be successfully overcome by intern pharmacists was lack of patient awareness. There was strong support in favor of intern pharmacists having greater involvement in programs that increase patient non-influenza immunization rates. The two most feasible implementations by intern pharmacists were determined to be intern-led college/university campus clinics providing free non-influenza immunizations and educational booths/outreaches that raise awareness about immunizations. Conclusion Identification of immunization barriers capable of being addressed by intern pharmacists and effective intern pharmacist-led initiatives may contribute to enhanced immunization outcomes. Future steps include the implementation of intern pharmacist-led activities and further evaluation of whether these intern pharmacist-specific initiatives contribute to increasing non-influenza immunizations.

A Qualitative Study of Views and Experiences of Women and Health Care Professionals about Free Maternal Vaccinations Administered at Community Pharmacies

Background: A policy to extend funding of maternal pregnancy influenza and pertussis vaccinations to community pharmacies could address low pregnancy vaccine uptake. The policy has been implemented in one region in New Zealand. This study explored the views and experiences of women eligible for the vaccines and health care professionals regarding funded maternal vaccinations in pharmacy. Methods: Women in late pregnancy or with an infant, and midwives, pharmacists, and general practice staff were selected purposively and interviewed regarding maternal vaccinations and the new policy, including their awareness and views of the funded vaccinations in pharmacies, and how this policy worked in practice. Enablers and barriers to vaccination by pharmacists were explored. Interviews were transcribed and analysed using a framework approach. Results: Fifty-three interviews were conducted. Most women and health care professionals viewed funded maternal vaccinations in pharmacies positively with respect to increasing awareness and providing delivery options. Many women received messages from pharmacies. Most pharmacies used posters, leaflets and/or verbal explanation to pregnant women to raise awareness of the vaccinations. Not all pharmacies provided these vaccinations, and frontline staff could help to raise awareness. Conclusion: Funded maternal vaccinations in pharmacies are generally well accepted and provide an opportunity to increase uptake and prevent disease.

Pharmacists' Attitudes and Practices Regarding Tetanus, Diphtheria and Pertussis (Tdap) Vaccination in Pregnancy and Surrounding Newborns

Background: Bordetella pertussis or whooping cough is a serious and vaccine-preventable illness. Despite widespread vaccination in the pediatric population, pertussis still infects approximately 100,000 infants each year in the United States. The purpose of this study was to determine gaps in pharmacists’ understanding, attitudes, practices, and barriers surrounding the tetanus, diphtheria, and pertussis (Tdap) vaccination recommendation for patients who are pregnant or planning to come in close contact with infants. Methods: This study was a descriptive, exploratory electronic survey. The survey assessed three major areas; the role of the pharmacist in Tdap vaccination, perceived barriers to vaccination, and understanding the recommendations. Results: A total of 225 pharmacists responded to the survey. Pharmacists who responded to this survey agreed that pharmacists should have a role vaccinating the public and individuals expecting to come into contact with a newborn, (88.5% and 86.9%) respectively, but fewer agreed that pharmacists should have a role vaccinating pregnant women against tetanus, diphtheria, and pertussis (77%, p < 0.001). Based on the responses to case scenarios, only 22.5% and 30.6% of respondents understood the recommendations. Numerous barriers to vaccinating pregnant women were identified. Conclusion: While most pharmacists surveyed felt they should have a role in vaccinating pregnant women and those expecting to come in contact with a newborn, there are barriers to implementing this practice. Future efforts should focus on further evaluating identified gaps and developing programs for pharmacists that emphasize the significance of vaccinating these patients to reduce the burden of pertussis in infants.

Community pharmacists as vaccine providers

Purpose

The purpose of this paper is to describe the history of pharmacist involvement as vaccine providers in the USA and discuss examples of growing interests in other parts of the world.

Design/methodology/approach

Literature searches were performed in PubMed as well as pharmacy-related journals.

Findings

Pharmacists have been involved with the storage and management of vaccines for more than a century. Based on the unmet needs in meeting national goals for vaccination rates among adults in the USA, efforts led to training and recognizing pharmacists as vaccine providers which is now within the scope of practice for a pharmacist in all US states and territories. Pharmacists complete a comprehensive training program in vaccine sciences, regulatory considerations, as well as demonstration of skills in administering vaccines. Over 300,000 pharmacists have been trained in vaccine delivery and this represents the majority of the pharmacist workforce in the USA. There are examples of the beneficial impact of pharmacist involvement as vaccine providers in community pharmacy settings.

Research limitations/implications

This review is based on a thorough review of the literature but was not conducted in a systematic fashion.

Originality/value

This review provides a historical perspective and evidence of the benefit of pharmacists as vaccine providers.

The impact of pharmacist immunization programs on adult immunization rates: A systematic review and meta-analysis

OBJECTIVES

To estimate the impact that pharmacist immunization programs have on immunization rates.

DATA SOURCES

Pubmed, Ovid/Medline, and Google Scholar were searched. References were checked and citation searches using identified studies conducted.

STUDY SELECTION

Studies were eligible for the systematic review and meta-analysis if the study compared pharmacist as immunizer versus usual care. Any study design that involved a comparison group was acceptable.

DATA EXTRACTION

Data were extracted by 2 investigators independently with the use of a standardized data extraction form; any differences were resolved by consensus.

RESULTS

A total of 8 studies with 11 study arms met inclusion criteria. A wide variety of immunizations were provided, including influenza, herpes zoster, pneumococcal, Tdap, hepatitis A and B, MMR, varicella, meningococcal, and human papillomavirus. Immunizations were provided in a variety of settings, including hospitals, single community sites, multiple sites, and a university. The overall risk ratio (RR) for immunizations was 2.95 (P <0.001) but varied substantially based on type of vaccine administered (heterogeneity: I(2) = 93.28%). For influenza, the RR was 2.23 (P <0.001), for herpes RR was 4.78 (P <0.001), and for other vaccines RR was 3.44 (P <0.001). The RR for comparisons by type of vaccine and sample size was significant (P = 0.010 and P <0.001, respectively).

CONCLUSION

Pharmacist immunization programs can have a substantial impact on immunization rates, but the impact varied widely. Widespread implementation of pharmacist immunization programs that include an advocacy component could help in the reaching of Healthy People 2020 immunization goals.

A National Assessment of Medication Adherence to Statins by the Racial Composition of Neighborhoods

Adherence to statins is lower in black and Hispanic patients and is linked to racial/ethnic disparities in cardiovascular mortality. Poverty, education, and prescription coverage differentials are typically invoked to explain adherence disparities, but analyses at the level of neighborhoods and their pharmacies may provide additional insights. Among individuals filling new statin prescriptions in a national pharmacy chain (N = 326,171), we compared adherence for patients residing in mostly minority neighborhoods to those living in mainly white areas. In analyses adjusting for patient-level factors associated with poor adherence, including age, insurance, payer, prescription cost, and convenience, patients residing in black and Hispanic neighborhoods had 2-3 weeks less statin therapy over 1 year, a pattern not seen in Asian areas. In black and Hispanic neighborhoods, good adherence was associated with co-pays under $10, the use of 90-day refills, and payers other than Medicaid. Efforts to improve medication adherence for vulnerable populations may benefit from interventions at the level of local pharmacies, as well as medication benefit redesign.

Impact of pharmacists as immunizers on vaccination rates: A systematic review and meta-analysis

BACKGROUND

Underutilization of vaccination programs remains a significant public health concern. Pharmacists serve as educators, facilitators, and in some jurisdictions, as administrators of vaccines. Though pharmacists have been involved with immunizations in various ways for many years, there has yet to be a systematic review assessing the impact of pharmacists as immunizers in these three roles.

OBJECTIVE

To complete a systematic review of the literature on the impact of pharmacists as educators, facilitators, and administrators of vaccines on immunization rates.

METHODS

We identified 2825 articles searching the following databases from inception until October 2015: PubMed, EMBASE, Cochrane Libraries, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, Google Scholar. Grey literature was identified through use of the Canadian Agency for Drugs and Technology in Health "Grey Matters" search tool. Content from relevant journals and references of included studies were also searched. Inclusion criteria were clinical or epidemiologic studies in which pharmacists were involved in the immunization process. Studies were excluded if no comparator was reported. Two reviewers independently completed data extraction and bias assessments using standardized forms.

RESULTS

Thirty-six studies were included in the review, 22 assessed the role of pharmacists as educators and/or facilitators and 14 assessed their role as administrators of vaccines. All studies reviewed found an increase in vaccine coverage when pharmacists were involved in the immunization process, regardless of role (educator, facilitator, administrator) or vaccine administered (e.g., influenza, pneumococcal), when compared to vaccine provision by traditional providers without pharmacist involvement. Limitations of the results include the large number of non-randomized trials and the heterogeneity between study designs.

CONCLUSIONS

Pharmacist involvement in immunization, whether as educators, facilitators, or administrators of vaccines, resulted in increased uptake of immunizations. PROSPERO Registration: CRD42013005067.

A global perspective of the roles of the pharmacist in the NICU

Objectives

To describe pharmacist practice and roles performed in the neonatal intensive care unit (NICU) worldwide and to map these findings along the medicines management pathway (MMP).

Method

Quasi-systematic review.

Search Strategy

Google Scholar, Medline/PubMed and Embase were searched utilising the selected MeSH terms.

Results

Thirty sources of information were reviewed. Overall, pharmacist practice in the NICU involves a wide-range of roles, with the most commonly reported involving patient medication chart review, therapeutic drug monitoring and the provision of medication information. Studies highlight that pharmacist contribution to total parenteral nutrition (TPN) regimens and patient medication chart review is beneficial to patient outcomes. Roles beyond the regular scope of practice included involvement in immunisation programmes and research. Most of the data were collected from the USA (13 of 30), followed by the UK (6 of 30) and reports from other countries. The American, British, South African and Australian articles have reported very similar roles, with a pharmacist firmly integrated into the overall structure of the NICU team.

Conclusion

The literature identifies that there is insufficient evidence to describe what roles are currently performed in NICUs worldwide. This is due to the lack of recently published articles leading to a large gap in knowledge in understanding what contemporary pharmaceutical services in the NICU comprise. Further research is required to address these gaps in knowledge, and identify the impact of the pharmacist's role on neonatal patient outcomes as well as to determine how to better resource NICUs to access pharmacy services.

Evaluation of the impact of a pertussis cocooning program on infant pertussis infection

BACKGROUND

Tetanus, diphtheria and acellular pertussis immunization of infant contacts (cocooning) is recommended by the Centers for Disease Control and Prevention to prevent infant pertussis. We determined whether implementing a cocooning program at Ben Taub General Hospital, Houston, reduced severe pertussis in young infants.

METHODS

Infants ≤6 months of age, diagnosed with pertussis (determined by International Classification of Diseases, Ninth Revision codes and microbiology records) at 4 hospitals, and born at times when only postpartum women (January 2008 through May 2009) and all infant contacts (June 2009 through August 2011) were offered tetanus, diphtheria and acellular pertussis vaccine at Ben Taub General Hospital were compared with infants born preintervention (May 2004 through December 2007).

RESULTS

One hundred ninety-six (49%) infants with pertussis were born preintervention, 140 (35%) during maternal postpartum (PP) and 64 (16%) during cocooning (C) periods. Infants were similar in age at diagnosis (81.2 vs. 71.3 [PP] vs. 72.5 [C] days; P 0.07), sex (male 59% vs. 51% [PP] vs. 48% [C]; P 0.17), hospitalization (68% vs. 71% [PP] vs. 78% [C]; P 0.27) and outcome (2 deaths in the PP period; P 0.15), but more were admitted to intensive care units during cocooning (24% vs. 35% [PP] vs. 68% [C]; P < 0.001). Similar proportions of infants were born at Ben Taub General Hospital throughout the study (8% vs. 9% [PP] vs. 5% [C]; P 0.53).

CONCLUSIONS

Postpartum immunization and cocooning did not reduce pertussis illness in infants ≤6 months of age. Efforts should be directed toward increasing tetanus, diphtheria and acellular pertussis immunization during pregnancy, combined with cocooning, to reduce life-threatening young infant pertussis.

Prevention of pertussis through adult vaccination

Pertussis is a vaccine preventable respiratory infection. Young infants are at high risk of developing severe complications from infection. Despite high rates of pediatric vaccine uptake, there continues to be increases in pertussis cases, likely due to waning immunity from childhood vaccine and increased transmission through adults. Currently, pertussis booster vaccine (Tdap) is recommended for unimmunized adults and for women in the third trimester of each pregnancy; yet adult Tdap coverage remains low. Administering Tdap vaccine at non-traditional vaccination clinics and at sites where adults are accessing care for their children are effective in improving adult Tdap uptake. While most are willing to receive vaccine when recommended by their provider, lack of provider recommendation is a major obstacle to immunization. Future studies to understand barriers to provider vaccine recommendations need to be undertaken to develop interventions to improve adult Tdap vaccine uptake and reduce pertussis infection in the susceptible population.

Management and prevention of pertussis infection in neonates

Despite the fact that universal immunization against pertussis led to a dramatic decrease in the incidence and mortality in high-income countries, it has left a window of vulnerability for newborns. Although specific guidelines concerning management of neonatal whooping cough have not yet been developed, the present review summarizes the main available recommendations on diagnostic work-up and treatment of neonatal pertussis. Additionally, new prevention strategies are explored, including the use of an additional booster dose of vaccine to adolescents and adults, vaccination of healthcare workers, immunization of household contacts and caregivers (cocooning strategy), vaccination of pregnant women and, finally, neonatal immunization with novel vaccines. These strategies are analyzed and discussed in terms of efficacy, safety and cost-effectiveness.

Acceptability of immunization in adult contacts of infants: possibility of expanding platforms to increase adult vaccine uptake

OBJECTIVE

Adult vaccination coverage is low and current strategies are unlikely to achieve Healthy People 2020 targets. We determined the attitude of adult infant contacts toward recommended adult vaccines and their willingness to receive vaccines should they be available during hospital visits or prenatal or infant clinic appointments.

METHODS

Survey of predominantly Hispanic, underinsured and medically underserved infant contacts at a county hospital in Houston, Texas where a pertussis cocooning program is offered.

RESULTS

Two hundred and eighty-five contacts (mean age 32.8 years [18-73]; 94.8% Hispanic) participated. Most were fathers (58.2%), followed by aunts (19%), and grandparents (12.3%). Participants used many health information sources. 221 (77.5%) considered healthcare providers the most influential on their decisions but only 51.6% reported healthcare visits within the prior year. Forty-one (14.4%) discussed family vaccinations during prenatal visits. Preferred locations for adult vaccination were hospital or clinic-based (96.5%). Lack of knowledge (22.8%), fear of pain/needles (14.7%), work commitments (14%), lack of transport (11.2%), cost (10.2%) and fear of side effects (5.3%) were barriers to vaccination. More males than females reported fear of pain/needles and work commitments (P 0.01 and P 0.02, respectively), and more females lack of transport (P<0.001) as barriers. Most planned to (76.1%) or had received (7%) pertussis vaccine; if available, 73.3%, 53.3% and 50.5% expressed willingness to receive vaccines against influenza, pneumonia and meningitis, respectively. Age, ethnicity or education was not associated with willingness to be vaccinated. Vaccine acceptance was higher in females than males for pertussis (P 0.04), influenza (P 0.008), pneumonia (P 0.04), and meningitis (P 0.006) vaccines by multiple regression analysis.

CONCLUSIONS

Most adults were willing to be vaccinated if offered during hospital visits or clinic appointments for mother or infant. Development and expansion of recommended immunization platforms, such as the cocooning platform, offers the opportunity to increase adult vaccination coverage.