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Romano CJ, Burrell M, Bukowinski AT, Hall C, Gumbs GR, Conlin AMS, Ramchandar N. Vaccine Completion and Timeliness Among Children in the Military Health System: 2010-2019. Pediatrics 2024; 154:e2023064965. [PMID: 39295511 DOI: 10.1542/peds.2023-064965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 09/21/2024] Open
Abstract
OBJECTIVE Few studies have evaluated pediatric vaccination coverage in the Military Health System, although some evidence suggests lower than ideal coverage. This study assessed vaccine completion and timeliness among military dependents through age 24 months. METHODS Children born at military hospitals from 2010 through 2019 were identified using Department of Defense Birth and Infant Health Research program data. Vaccine completion and timeliness were assessed for diphtheria, tetanus, and pertussis; polio; measles, mumps, and rubella; hepatitis B; Haemophilus influenzae type b; varicella; and pneumococcal conjugate individually and as a combined 7-vaccine series; rotavirus was assessed separately. Modified Poisson regression models were used to calculate risk ratios (RRs) and 95% confidence intervals (CIs) for noncompletion and delays, adjusting for demographic characteristics. RESULTS Of 275 967 children, 74.4% completed the combined 7-vaccine series, and 36.2% of those who completed the series had delays. Completion peaked at 78.7% among children born in 2016 and 2017. Among all vaccines, completion was lowest for rotavirus (77.5%), diphtheria, tetanus, and pertussis (83.1%), Haemophilus influenzae type b (86.6%), and pneumococcal conjugate (88.4%). Risk for noncompletion was higher among children born to younger pregnant parents (adjusted RR = 1.33; 95% CI = 1.27-1.40) and with a well-child care location change (adjusted RR = 1.10; 95% CI = 1.09-1.12). Risk for delays paralleled that for noncompletion. CONCLUSIONS Vaccine completion and timeliness generally improved among military children, but greater noncompletion of vaccine series with more versus fewer doses and disparities for younger and mobile service members suggest system barriers remain.
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Affiliation(s)
- Celeste J Romano
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc., San Diego, California
| | - Monica Burrell
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc., San Diego, California
| | - Anna T Bukowinski
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc., San Diego, California
| | - Clinton Hall
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc., San Diego, California
| | - Gia R Gumbs
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc., San Diego, California
| | - Ava Marie S Conlin
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
| | - Nanda Ramchandar
- Department of Pediatrics, Naval Medical Center San Diego, San Diego, California
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Newcomer SR, Graham J, Irish K, Freeman RE, Leary CS, Wehner BK, Daley MF. Identification of Spatial Clusters of Undervaccination Patterns Among Children Aged <24 Months Using Immunization Information System Data, Montana, 2015-2019. Public Health Rep 2024; 139:360-368. [PMID: 37503702 PMCID: PMC11037227 DOI: 10.1177/00333549231186603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
OBJECTIVE Spatial clustering of undervaccination leads to increased risk of vaccine-preventable diseases. We identified spatial clustering of undervaccination patterns among children aged <24 months in Montana. METHODS We used Montana's immunization information system data to analyze deidentified vaccination records of children aged <24 months born from January 2015 through November 2017. We measured 3 outcomes that were not mutually exclusive: not completing the combined 7-vaccine series by age 24 months, having an undervaccination pattern indicative of parental hesitancy, and having an undervaccination pattern indicative of structural barriers to timely vaccination. Using geomasked residential addresses, we conducted separate Bernoulli spatial scans with a randomization P < .01 to identify spatial clusters consisting of ≥100 children for each outcome and calculated the relative risk of having the undervaccination pattern inside versus outside the cluster. RESULTS Of 31 201 children aged <24 months included in our study, 11 712 (37.5%) had not completed the combined 7-vaccine series by age 24 months, and we identified 5 spatial clusters of this outcome across Montana. We identified 4 clusters of undervaccination patterns indicative of parental vaccine hesitancy, all in western Montana. The cluster with the largest relative risk (2.3) had a radius of 23.7 kilometers (n = 762 children, P < .001). We also identified 4 clusters of undervaccination patterns indicative of structural barriers, with 3 of the largest clusters in eastern Montana. CONCLUSION In Montana, different strategies to increase routine and timely childhood vaccination are needed in distinct areas of this large and predominantly rural state. Immunization information system data can pinpoint areas where interventions to increase vaccination uptake are needed.
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Affiliation(s)
- Sophia R. Newcomer
- School of Public and Community Health Sciences and Center for Population Health Research, University of Montana, Missoula, MT, USA
| | - Jon Graham
- Department of Mathematical Sciences and Center for Population Health Research, University of Montana, Missoula, MT, USA
| | - Kayla Irish
- Center for Population Health Research, University of Montana, Missoula, MT, USA
| | - Rain E. Freeman
- Center for Population Health Research, University of Montana, Missoula, MT, USA
| | - Cindy S. Leary
- Center for Population Health Research, University of Montana, Missoula, MT, USA
| | - Bekki K. Wehner
- Communicable Disease Bureau, Montana Department of Public Health and Human Services, Helena, MT, USA
| | - Matthew F. Daley
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA
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Novilla MLB, Goates MC, Redelfs AH, Quenzer M, Novilla LKB, Leffler T, Holt CA, Doria RB, Dang MT, Hewitt M, Lind E, Prickett E, Aldridge K. Why Parents Say No to Having Their Children Vaccinated against Measles: A Systematic Review of the Social Determinants of Parental Perceptions on MMR Vaccine Hesitancy. Vaccines (Basel) 2023; 11:926. [PMID: 37243030 PMCID: PMC10224336 DOI: 10.3390/vaccines11050926] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023] Open
Abstract
Ongoing outbreaks of measles threaten its elimination status in the United States. Its resurgence points to lower parental vaccine confidence and local pockets of unvaccinated and undervaccinated individuals. The geographic clustering of hesitancy to MMR indicates the presence of social drivers that shape parental perceptions and decisions on immunization. Through a qualitative systematic review of published literature (n = 115 articles; 7 databases), we determined major themes regarding parental reasons for MMR vaccine hesitancy, social context of MMR vaccine hesitancy, and trustworthy vaccine information sources. Fear of autism was the most cited reason for MMR hesitancy. The social drivers of vaccine hesitancy included primary care/healthcare, education, economy, and government/policy factors. Social factors, such as income and education, exerted a bidirectional influence, which facilitated or hindered vaccine compliance depending on how the social determinant was experienced. Fear of autism was the most cited reason for MMR hesitancy. Vaccine hesitancy to MMR and other childhood vaccines clustered in middle- to high-income areas among mothers with a college-level education or higher who preferred internet/social media narratives over physician-based vaccine information. They had low parental trust, low perceived disease susceptibility, and were skeptical of vaccine safety and benefits. Combating MMR vaccine misinformation and hesitancy requires intersectoral and multifaceted approaches at various socioecological levels to address the social drivers of vaccine behavior.
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Affiliation(s)
| | - Michael C. Goates
- Harold B. Lee Library, Brigham Young University, Provo, UT 84602, USA
| | - Alisha H. Redelfs
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Mallory Quenzer
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | | | - Tyler Leffler
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Christian A. Holt
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Russell B. Doria
- School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, USA
| | - Michael T. Dang
- School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, USA
| | - Melissa Hewitt
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Emma Lind
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Elizabeth Prickett
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Katelyn Aldridge
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
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4
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Nguyen KH, Zhao R, Mullins C, Corlin L, Beninger P, Bednarczyk RA. Trends in vaccination schedules and up-to-date status of children 19-35 months, United States, 2015-2020. Vaccine 2023; 41:467-475. [PMID: 36481107 DOI: 10.1016/j.vaccine.2022.11.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To estimate trends in, and factors associated with, vaccination patterns and up-to-date immunization status of U.S. children by 19 to 35 months of age. METHODS Data from the 2015 to 2020 National Immunization Surveys were used to assess trends in vaccination patterns, up-to-date status, and zero vaccination status of U.S. children by 19-35 months. Vaccination patterns were categorized as: 1) recommended, 2) alternate, or 3) unknown or unclassifiable. Multivariable analyses were conducted to examine factors associated with each vaccination pattern and up-to-date status for all recommended vaccines. RESULTS From 2015 to 2020, the proportion of U.S. children completing the recommended schedule increased from 62.5% to 69.4%, alternative schedule decreased from 21.6% to 16.2%, and unknown or unclassifiable schedules decreased from 15.9% to 14.3%. In addition, being not up-to-date decreased from 39.7% to 35.6%. There was no change in the percentage of children receiving zero vaccinations from 2015 to 2020 (0.9% to 0.9%). Respondents with lower household income or who were uninsured were more likely to follow an alternate or unknown/unclassifiable schedule, or not be up-to-date with vaccines. CONCLUSION Following any schedule other than the recommended schedule was associated with not being up-to-date on immunizations. Increased efforts to catch up on recommended vaccines is important for protecting children's health. Further efforts should be made to improve timely adherence to recommended vaccination schedules, particularly among populations with the largest disparities in coverage through a tailored approach to increase confidence in and access to vaccines.
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Affiliation(s)
- Kimberly H Nguyen
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - Ruitong Zhao
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Corey Mullins
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Laura Corlin
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA; Department of Civil and Environmental Engineering, Tufts University School of Engineering, Medford, MA, USA
| | - Paul Beninger
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Robert A Bednarczyk
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA; Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA; Emory Vaccine Center, Emory University, Atlanta, GA, USA
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5
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Newcomer SR, Glanz JM, Daley MF. Beyond Vaccination Coverage: Population-Based Measurement of Early Childhood Immunization Schedule Adherence. Acad Pediatr 2023; 23:24-34. [PMID: 35995410 PMCID: PMC10253042 DOI: 10.1016/j.acap.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 07/13/2022] [Accepted: 08/05/2022] [Indexed: 01/19/2023]
Abstract
The immunization schedule recommended by the U.S. Advisory Committee on Immunization Practices (ACIP) provides a structure for how 10 different vaccine series should be administered to children in the first 18 months of life. Progress toward US early childhood immunization goals has largely focused on measuring vaccination coverage at age 24 months. However, standard vaccination coverage measures do not reflect whether children received vaccine doses by recommended ages, or whether vaccines were given concomitantly, per the schedule. In this paper, we describe innovations in population-level measurement of immunization schedule adherence through quantifying vaccination timeliness and undervaccination patterns. Measuring vaccination timeliness involves comparing when children received vaccine doses relative to ACIP age recommendations. To assess undervaccination patterns, children's vaccination histories are analyzed to determine whether they were vaccinated consistent with the ACIP schedule. Some patterns, such as spreading out vaccines across visits, are indicative of parental hesitancy. Other patterns, such as starting all recommended series but missing doses, are largely indicative of other immunization services delivery challenges. Since 2003, at least 12 studies have used National Immunization Survey-Child, immunization information system, or integrated health plan data to measure vaccination timeliness or undervaccination patterns at national or state levels. Moving forward, these novel measures can be leveraged for population-based surveillance of vaccine confidence, and for distinguishing undervaccination due to parental vaccine hesitancy from undervaccination due to other causes. Broader adoption of these measures can facilitate identification of targeted strategies for improving timely and routine early childhood vaccination uptake across the United States.
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Affiliation(s)
- Sophia R Newcomer
- University of Montana School of Public and Community Health Sciences (SR Newcomer), Missoula, Mont; University of Montana Center for Population Health Research (SR Newcomer), Missoula, Mont.
| | - Jason M Glanz
- Kaiser Permanente Colorado, Institute for Health Research (JM Glanz, MF Daley), Aurora, Colo; University of Colorado, Colorado School of Public Health, Department of Epidemiology (JM Glanz), Aurora, Colo
| | - Matthew F Daley
- Kaiser Permanente Colorado, Institute for Health Research (JM Glanz, MF Daley), Aurora, Colo; University of Colorado, School of Medicine, Department of Pediatrics (MF Daley), Aurora, Colo
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Daley MF, Reifler LM, Glanz JM, Hambidge SJ, Getahun D, Irving SA, Nordin JD, McClure DL, Klein NP, Jackson ML, Kamidani S, Duffy J, DeStefano F. Association Between Aluminum Exposure From Vaccines Before Age 24 Months and Persistent Asthma at Age 24 to 59 Months. Acad Pediatr 2023; 23:37-46. [PMID: 36180331 PMCID: PMC10109516 DOI: 10.1016/j.acap.2022.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/20/2022] [Accepted: 08/13/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the association between cumulative aluminum exposure from vaccines before age 24 months and persistent asthma at age 24 to 59 months. METHODS A retrospective cohort study was conducted in the Vaccine Safety Datalink (VSD). Vaccination histories were used to calculate cumulative vaccine-associated aluminum in milligrams (mg). The persistent asthma definition required one inpatient or 2 outpatient asthma encounters, and ≥2 long-term asthma control medication dispenses. Cox proportional hazard models were used to evaluate the association between aluminum exposure and asthma incidence, stratified by eczema presence/absence. Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) per 1 mg increase in aluminum exposure were calculated, adjusted for birth month/year, sex, race/ethnicity, VSD site, prematurity, medical complexity, food allergy, severe bronchiolitis, and health care utilization. RESULTS The cohort comprised 326,991 children, among whom 14,337 (4.4%) had eczema. For children with and without eczema, the mean (standard deviation [SD]) vaccine-associated aluminum exposure was 4.07 mg (SD 0.60) and 3.98 mg (SD 0.72), respectively. Among children with and without eczema, 6.0% and 2.1%, respectively, developed persistent asthma. Among children with eczema, vaccine-associated aluminum was positively associated with persistent asthma (aHR 1.26 per 1 mg increase in aluminum, 95% CI 1.07, 1.49); a positive association was also detected among children without eczema (aHR 1.19, 95% CI 1.14, 1.25). CONCLUSION In a large observational study, a positive association was found between vaccine-related aluminum exposure and persistent asthma. While recognizing the small effect sizes identified and the potential for residual confounding, additional investigation of this hypothesis appears warranted.
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Affiliation(s)
- Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado (MF Daley, LM Reifler, and JM Glanz), Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine (MF Daley and SJ Hambidge), Aurora, Colo.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado (MF Daley, LM Reifler, and JM Glanz), Aurora, Colo
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado (MF Daley, LM Reifler, and JM Glanz), Aurora, Colo; Colorado School of Public Health (JM Glanz), Aurora, Colo
| | - Simon J Hambidge
- Department of Pediatrics, University of Colorado School of Medicine (MF Daley and SJ Hambidge), Aurora, Colo; Community Health Services, Denver Health (SJ Hambidge), Denver, Colo
| | - Darios Getahun
- Department of Research and Evaluation, Kaiser Permanente Southern California (D Getahun), Pasadena, Calif; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine (D Getahun), Pasadena, Calif
| | - Stephanie A Irving
- Center for Health Research, Kaiser Permanente Northwest (SA Irving), Portland, Ore
| | | | - David L McClure
- Marshfield Clinic Research Institute (DL McClure), Marshfield, Wis
| | - Nicola P Klein
- Kaiser Permanente Vaccine Study Center, Kaiser Permanente Northern California (NP Klein), Oakland, Calif
| | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute (ML Jackson), Seattle, Wash
| | - Satoshi Kamidani
- Center for Childhood Infections and Vaccines of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine (S Kamidani), Atlanta, Ga; Immunization Safety Office, Centers for Disease Control and Prevention (S Kamidani, J Duffy, and F DeStefano), Atlanta, Ga
| | - Jonathan Duffy
- Immunization Safety Office, Centers for Disease Control and Prevention (S Kamidani, J Duffy, and F DeStefano), Atlanta, Ga
| | - Frank DeStefano
- Immunization Safety Office, Centers for Disease Control and Prevention (S Kamidani, J Duffy, and F DeStefano), Atlanta, Ga
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Kamidani S, Panagiotakopoulos L, Licata C, Daley MF, Yih WK, Zerbo O, Tseng HF, DeSilva MB, Nelson JC, Groom HC, Williams JT, Hambidge SJ, Donahue JG, Belay ED, Weintraub ES. Kawasaki Disease Following the 13-valent Pneumococcal Conjugate Vaccine and Rotavirus Vaccines. Pediatrics 2022; 150:e2022058789. [PMID: 36349537 PMCID: PMC9724171 DOI: 10.1542/peds.2022-058789] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Temporal associations between Kawasaki disease (KD) and childhood vaccines have been reported. Limited data on KD following 13-valent pneumococcal conjugate (PCV13) and rotavirus vaccines are available. METHODS We conducted a self-controlled risk interval study using Vaccine Safety Datalink electronic health record data to investigate the risk of KD following PCV13 and rotavirus vaccines in children <2 years of age who were born from 2006 to 2017. All hospitalized KD cases identified by International Classification of Diseases diagnosis codes that fell within predefined risk (days 1-28 postvaccination) and control (days 29-56 for doses 1 and 2, and days 43-70 for doses 3 and 4) intervals were confirmed by manual chart review. RESULTS During the study period, 655 cases of KD were identified by International Classification of Diseases codes. Of these, 97 chart-confirmed cases were within risk or control intervals. In analyses, the age-adjusted relative risk for KD following any dose of PCV13 was 0.75 (95% confidence interval, 0.47-1.21). Similarly, the age-adjusted relative risk for KD following any dose of rotavirus vaccine was 0.66 (95% CI, 0.40-1.09). Overall, there was no evidence of an elevated risk of KD following PCV13 or rotavirus vaccines by dose. In addition, no statistically significant temporal clustering of KD cases was identified during days 1 to 70 postvaccination. CONCLUSIONS PCV13 and rotavirus vaccination were not associated with an increased risk of KD in children <2 years of age. Our findings provide additional evidence for the overall safety of PCV13 and rotavirus vaccines.
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Affiliation(s)
- Satoshi Kamidani
- The Center for Childhood Infections and Vaccines of Children’s Healthcare of Atlanta and the Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Charles Licata
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew F. Daley
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - W. Katherine Yih
- The Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Ousseny Zerbo
- Kaiser Permanente Northern California, Vaccine Study Center, Oakland, California
| | - Hung Fu Tseng
- Kaiser Permanente Southern California, Pasadena, California
| | | | - Jennifer C. Nelson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Holly C. Groom
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | | | | | - Ermias D. Belay
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric S. Weintraub
- Immunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia
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Jamison KC, Ahmed AH, Spoerner DA, Kinney D. Best shot: A motivational interviewing approach to address vaccine hesitancy in pediatric outpatient settings. J Pediatr Nurs 2022; 67:124-131. [PMID: 36108393 DOI: 10.1016/j.pedn.2022.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 08/01/2022] [Accepted: 08/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Vaccine hesitancy in parents and childhood vaccine refusal is increasing. A standard of care to address this problem has not been identified. PURPOSE To identify if the use of motivational interviewing by pediatric providers during routine well child visits, when compared to standard of care, would increase vaccine rates in children 0-12 months of age. Factors associated with vaccine hesitancy were also investigated. METHODS A quasi-experimental study was completed on a convenience sample of pediatric providers (N = 6) and caregivers of children 0-12 months of age (N = 66). Four providers were trained to use motivational interviewing. During the well child visit the Parent Attitudes About Childhood Vaccines survey was completed, and the motivational interviewing intervention was implemented. Clinic's data were compared with other clinic data of non-trained providers. FINDINGS Vaccine refusal/delays rate was 11.4% among caregivers. Vaccine refusal rate decreased after the intervention (9.00% pre-intervention and 6.40% post-intervention). An ordinal regression identified caregivers with higher vaccine hesitancy scores and more children were more likely to delay or refuse vaccines, while caregivers ≥30 years or with high income were less likely to delay/refuse vaccines. A difference in difference analysis identified that an additional 2.6% of children received vaccines when seen by trained providers compared to non-trained (β = -0.330, OR = 0.719, p = 0.470). DISCUSSION Findings indicate a condensed motivational interviewing education session may be clinically significant in decreasing vaccine hesitancy among this population. APPLICATIONS TO PRACTICE A more robust study to confirm these findings is recommended prior to practice implementation.
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Affiliation(s)
- Kristin C Jamison
- Advanced Practice Nursing, Beacon Medical Group, Indiana, United States; Purdue University School of Nursing, 502 North University Street, West Lafayette, IN 47907, United States.
| | - Azza H Ahmed
- Purdue University School of Nursing, 502 North University Street, West Lafayette, IN 47907, United States.
| | - Deborah A Spoerner
- Purdue University School of Nursing, 502 North University Street, West Lafayette, IN 47907, United States.
| | - Daniel Kinney
- Pediatrician, Beacon Medical Group, 1815 E Ireland Rd, South Bend, Indiana, United States.
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9
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Michels SY, Freeman RE, Williams E, Albers AN, Wehner BK, Rechlin A, Newcomer SR. Evaluating vaccination coverage and timeliness in American Indian/Alaska Native and non-Hispanic White children using state immunization information system data, 2015-2017. Prev Med Rep 2022; 27:101817. [PMID: 35656223 PMCID: PMC9152883 DOI: 10.1016/j.pmedr.2022.101817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/22/2022] [Accepted: 04/30/2022] [Indexed: 11/29/2022] Open
Abstract
Comprehensive estimates of vaccination coverage and timeliness of vaccine receipt among American Indian/Alaska Native (AI/AN) children in the United States are lacking. This study’s objectives were to quantify vaccination coverage and timeliness, as well as the proportion of children with specific undervaccination patterns, among AI/AN and non-Hispanic White (NHW) children ages 0–24 months in Montana, a large and primarily rural U.S. state. Data from Montana’s immunization information system (IIS) for children born 2015–2017 were used to calculate days undervaccinated for all doses of seven recommended vaccine series. After stratifying by race/ethnicity, up-to-date coverage at key milestone ages and the proportion of children demonstrating specific patterns of undervaccination were reported. Among n = 3,630 AI/AN children, only 23.1% received all recommended vaccine doses on-time (i.e., zero days undervaccinated), compared to 40.4% of n = 18,022 NHW children (chi-square p < 0.001). A greater proportion of AI/AN children were delayed at each milestone age, resulting in lower overall combined 7-vaccine series completion, by age 24 months (AI/AN: 56.6%, NHW: 64.3%, chi-square p < 0.001). As compared with NHW children, a higher proportion of AI/AN children had undervaccination patterns suggestive of structural barriers to accessing immunization services and delayed starts to vaccination. More than three out of four AI/AN children experienced delays in vaccination or were missing doses needed to complete recommended vaccine series. Interventions to ensure on-time initiation of vaccine series at age 2 months, as well initiatives to encourage completion of multi-dose vaccine series, are needed to reduce immunization disparities and increase vaccination coverage among AI/AN children in Montana.
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Affiliation(s)
- Sarah Y. Michels
- Yale School of Public Health, New Haven, CT, United States
- University of Montana, Center for Population Health Research, Missoula, MT, United States
- Corresponding author at: University of Montana, Center for Population Health Research, 32 Campus Drive, Skaggs 173, Missoula, MT 59804, United States.
| | - Rain E. Freeman
- University of Montana, Center for Population Health Research, Missoula, MT, United States
- University of Montana, School of Public and Community Health Sciences, Missoula, MT, United States
| | - Elizabeth Williams
- University of Montana, Center for Population Health Research, Missoula, MT, United States
- University of Montana, School of Public and Community Health Sciences, Missoula, MT, United States
- All Nations Health Center, Missoula, MT, United States
| | - Alexandria N. Albers
- University of Montana, Center for Population Health Research, Missoula, MT, United States
- University of Montana, School of Public and Community Health Sciences, Missoula, MT, United States
| | - Bekki K. Wehner
- Montana Department of Public Health and Human Services, Immunization Section, Helena, MT, United States
| | - Annie Rechlin
- Montana Department of Public Health and Human Services, Immunization Section, Helena, MT, United States
| | - Sophia R. Newcomer
- University of Montana, Center for Population Health Research, Missoula, MT, United States
- University of Montana, School of Public and Community Health Sciences, Missoula, MT, United States
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10
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Lai LY, Arshad F, Areia C, Alshammari TM, Alghoul H, Casajust P, Li X, Dawoud D, Nyberg F, Pratt N, Hripcsak G, Suchard MA, Prieto-Alhambra D, Ryan P, Schuemie MJ. Current Approaches to Vaccine Safety Using Observational Data: A Rationale for the EUMAEUS (Evaluating Use of Methods for Adverse Events Under Surveillance-for Vaccines) Study Design. Front Pharmacol 2022; 13:837632. [PMID: 35392566 PMCID: PMC8980923 DOI: 10.3389/fphar.2022.837632] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/08/2022] [Indexed: 12/28/2022] Open
Abstract
Post-marketing vaccine safety surveillance aims to detect adverse events following immunization in a population. Whether certain methods of surveillance are more precise and unbiased in generating safety signals is unclear. Here, we synthesized information from existing literature to provide an overview of the strengths, weaknesses, and clinical applications of epidemiologic and analytical methods used in vaccine monitoring, focusing on cohort, case-control and self-controlled designs. These designs are proposed to be evaluated in the EUMAEUS (Evaluating Use of Methods for Adverse Event Under Surveillance-for vaccines) study because of their widespread use and potential utility. Over the past decades, there have been an increasing number of epidemiological study designs used for vaccine safety surveillance. While traditional cohort and case-control study designs remain widely used, newer, novel designs such as the self-controlled case series and self-controlled risk intervals have been developed. Each study design comes with its strengths and limitations, and the most appropriate study design will depend on availability of resources, access to records, number and distribution of cases, and availability of population coverage data. Several assumptions have to be made while using the various study designs, and while the goal is to mitigate any biases, violations of these assumptions are often still present to varying degrees. In our review, we discussed some of the potential biases (i.e., selection bias, misclassification bias and confounding bias), and ways to mitigate them. While the types of epidemiological study designs are well established, a comprehensive comparison of the analytical aspects (including method evaluation and performance metrics) of these study designs are relatively less well studied. We summarized the literature, reporting on two simulation studies, which compared the detection time, empirical power, error rate and risk estimate bias across the above-mentioned study designs. While these simulation studies provided insights on the analytic performance of each of the study designs, its applicability to real-world data remains unclear. To bridge that gap, we provided the rationale of the EUMAEUS study, with a brief description of the study design; and how the use of real-world multi-database networks can provide insights into better methods evaluation and vaccine safety surveillance.
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Affiliation(s)
- Lana Yh Lai
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, United Kingdom
| | - Faaizah Arshad
- Department of Biostatistics, University of California, Los Angeles, Los Angeles, CA, United States
| | - Carlos Areia
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Thamir M Alshammari
- Medication Safety Research Chair, King Saud University, Riyadh, Saudi Arabia
| | - Heba Alghoul
- Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine
| | - Paula Casajust
- Real-World Evidence, Trial Form Support, Barcelona, Spain
| | - Xintong Li
- Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, United Kingdom
| | - Dalia Dawoud
- Faculty of Pharmacy, Cairo University, Giza, Egypt
| | - Fredrik Nyberg
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nicole Pratt
- Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Marc A Suchard
- Department of Biostatistics, University of California, Los Angeles, Los Angeles, CA, United States.,Department of Human Genetics, University of California, Los Angeles, Los Angeles, CA, United States
| | - Dani Prieto-Alhambra
- Centre for Statistics in Medicine, NDORMS, University of Oxford, Oxford, United Kingdom.,Health Data Sciences, Medical Informatics, Erasmus Medical Center University, Rotterdam, Netherlands
| | - Patrick Ryan
- Department of Biomedical Informatics, Columbia University, New York, NY, United States.,Observational Health Data Analytics, Janssen R&D, Titusville, NJ, United States
| | - Martijn J Schuemie
- Department of Biostatistics, University of California, Los Angeles, Los Angeles, CA, United States.,Observational Health Data Analytics, Janssen R&D, Titusville, NJ, United States
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11
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Freeman RE, Thaker J, Daley MF, Glanz JM, Newcomer SR. Vaccine timeliness and prevalence of undervaccination patterns in children ages 0-19 months, U.S., National Immunization Survey-Child 2017. Vaccine 2022; 40:765-773. [PMID: 34961632 PMCID: PMC8856130 DOI: 10.1016/j.vaccine.2021.12.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 12/08/2021] [Accepted: 12/14/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Typically, early childhood vaccination coverage in the U.S. is measured as the proportion of children by age 24 months who completed recommended vaccine series. However, these measures do not reflect whether vaccine doses were received at the ages recommended by the U.S. Advisory Committee on Immunization Practices, or whether children received vaccines concomitantly, per the ACIP recommended schedule. This study's objective was to quantify vaccine timeliness and prevalence of specific patterns of undervaccination in U.S. children ages 0-19 months. METHODS Using 2017 National Immunization Survey-Child data, we calculated days undervaccinated for the combined 7-vaccine series and distinguished undervaccination patterns indicative of parental vaccine hesitancy, such as spreading out vaccines across visits ("shot-limiting") or starting some but not all recommended vaccine series ("selective vaccination"), from other non-hesitancy patterns, such as missing final vaccine doses or receiving all doses, with some or all late. We measured associations between demographic, socioeconomic and other characteristics with undervaccination patterns using multivariable log-linked binomial regression. Analyses accounted for the complex survey design. RESULTS Among n = 15,333 U.S. children, only 41.2% received all recommended vaccine doses on-time by age 19 months. Approximately 20.9% of children had an undervaccination pattern suggestive of parental vaccine hesitancy, and 36.2% had other undervaccination non-hesitancy patterns. Uninsured children and those with lower levels of maternal education were more likely to exhibit undervaccination patterns suggestive of parental hesitancy. Lower levels of maternal education were also associated with other non-hesitancy undervaccination patterns. CONCLUSIONS More than half of children in the U.S. are undervaccinated at some point by 19 months of age. Ongoing assessment of vaccine timeliness and immunization schedule adherence could facilitate timely and targeted public health interventions in populations with high levels of undervaccination.
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Affiliation(s)
- Rain E. Freeman
- School of Public and Community Health Sciences, University of Montana, Missoula, MT
| | - Juthika Thaker
- School of Public and Community Health Sciences, University of Montana, Missoula, MT
| | - Matthew F. Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO;,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Jason M. Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO;,Department of Epidemiology, University of Colorado School of Public Health, Aurora, CO
| | - Sophia R. Newcomer
- School of Public and Community Health Sciences, University of Montana, Missoula, MT
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12
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Ni XF, Yang CS, Bai YM, Hu ZX, Zhang LL. Drug-Related Problems of Patients in Primary Health Care Institutions: A Systematic Review. Front Pharmacol 2021; 12:698907. [PMID: 34489695 PMCID: PMC8418140 DOI: 10.3389/fphar.2021.698907] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/02/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction: Drug-related problems (DRPs) are not only detrimental to patients' physical health and quality of life but also lead to a serious waste of health care resources. The condition of DRPs might be more severe for patients in primary health care institutions. Objective: This systematic review aims to comprehensively review the characteristics of DRPs for patients in primary health care institutions, which might help find effective strategies to identify, prevent, and intervene with DRPs in the future. Methods: We searched three English databases (Embase, The Cochrane Library, and PubMed) and four Chinese databases (CNKI, CBM, VIP, and Wanfang). Two of the researchers independently conducted literature screening, quality evaluation, and data extraction. Qualitative and quantitative methods were combined to analyze the data. Results: From the 3,368 articles screened, 27 met the inclusion criteria and were included in this review. The median (inter-quartile range, IQR) of the incidences of DRPs was 70.04% (59%), and the median (IQR) of the average number of DRPs per patient was 3.4 (2.8). The most common type of DRPs was “treatment safety.” The causes of DRPs were mainly in the prescribing section, including “drug selection” and “dose selection”, while patients' poor adherence in the use section was also an important cause of DRPs. Risk factors such as the number of medicines, age, and disease condition were positively associated with the occurrence of DRPs. In addition, the medians (IQR) of the rate of accepted interventions, implemented interventions, and solved DRPs were 78.8% (22.3%), 64.15% (16.85%), and 76.99% (26.09%), respectively. Conclusion: This systematic review showed that the condition of DRPs in primary health care institutions was serious. In pharmaceutical practice, the patients with risk factors of DRPs should be monitored more closely. Pharmacists could play important roles in the identification and intervention of DRPs, and more effective intervention strategies need to be established in the future.
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Affiliation(s)
- Xiao-Feng Ni
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.,Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Chun-Song Yang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.,Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China
| | - Yu-Mei Bai
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Zi-Xian Hu
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Ling-Li Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China.,Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education (Sichuan University), Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
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13
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Abstract
BACKGROUND Important questions exist regarding the comparative effectiveness of alternative childhood vaccine schedules; however, optimal approaches to studying this complex issue are unclear. METHODS We applied methods for studying dynamic treatment regimens to estimate the comparative effectiveness of different rotavirus vaccine (RV) schedules for preventing acute gastroenteritis-related emergency department (ED) visits or hospitalization. We studied the effectiveness of six separate protocols: one- and two-dose monovalent rotavirus vaccine (RV1); one-, two-, and three-dose pentavalent rotavirus vaccine (RV5); and no RV vaccine. We used data on all infants to estimate the counterfactual cumulative risk for each protocol. Infants were censored when vaccine receipt deviated from the protocol. Inverse probability of censoring-weighted estimation addressed potentially informative censoring by protocol deviations. A nonparametric group-based bootstrap procedure provided statistical inference. RESULTS The method yielded similar 2-year effectiveness estimates for the full-series protocols; weighted risk difference estimates comparing unvaccinated children to those adherent to either full-series (two-dose RV1, three-dose RV5) corresponded to four fewer hospitalizations and 12 fewer ED visits over the 2-year period per 1,000 children. We observed dose-response relationships, such that additional doses further reduced risk of acute gastroenteritis. Under a theoretical intervention to fully vaccinate all children, the 2-year risk differences comparing full to observed adherence were 0.04% (95% CI = 0.03%, 0.05%) for hospitalizations and 0.17% (95% CI = 0.14%, 0.19%) for ED visits. CONCLUSIONS The proposed approach can generate important evidence about the consequences of delaying or skipping vaccine doses, and the impact of interventions to improve vaccine schedule adherence.
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Affiliation(s)
- Anne M. Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | | | - John M. Sahrmann
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - M. Alan Brookhart
- NoviSci, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
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14
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Newcomer SR, Freeman RE, Wehner BK, Anderson SL, Daley MF. Timeliness of Early Childhood Vaccinations and Undervaccination Patterns in Montana. Am J Prev Med 2021; 61:e21-e29. [PMID: 33975767 PMCID: PMC8217328 DOI: 10.1016/j.amepre.2021.01.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/08/2021] [Accepted: 01/13/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Early childhood vaccination rates are lower in rural areas than those in urban areas of the U.S. This study's objective is to quantify vaccine timeliness and the prevalence of undervaccination patterns in Montana and to measure the associations between timeliness and series completion by age 24 months. METHODS Using records from January 2015 to November 2019 in Montana's centralized immunization information system, days undervaccinated were calculated for the combined 7-vaccine series. Undervaccination patterns indicative of certain barriers to vaccination, including parental vaccine hesitancy, were identified. Using multivariable log-linked binomial regression, the association between timing of vaccine delay and not completing the combined 7-vaccine series by age 24 months was assessed. Analyses were conducted in March 2020-August 2020. RESULTS Among 31,422 children, 38.0% received all vaccine doses on time; 24.3% received all doses, but some were received late; and 37.7% had not completed the combined 7-vaccine series. Approximately 18.7% had an undervaccination pattern suggestive of parental vaccine hesitancy, and 19.7% started all series but were missing doses needed for multidose series completion. Although falling behind on vaccinations at any age was associated with failing to complete the combined 7-vaccine series, being late at age 12-15 months had the strongest association (adjusted prevalence ratio=3.73, 95% CI=3.56, 3.91) compared with being on time at age 12-15 months. CONCLUSIONS Fewer than 2 in 5 Montana children were fully vaccinated on time for the combined 7-vaccine series. To increase vaccination rates, initiatives to increase vaccine confidence and remind parents to complete vaccine series are needed.
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Affiliation(s)
- Sophia R Newcomer
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana.
| | - Rain E Freeman
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana
| | - Bekki K Wehner
- Immunization Section, Montana Department of Public Health and Human Services, Helena, Montana
| | - Stacey L Anderson
- Communicable Disease Epidemiology Section, Montana Department of Public Health and Human Services, Helena, Montana
| | - Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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15
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Dodd C, Andrews N, Petousis-Harris H, Sturkenboom M, Omer SB, Black S. Methodological frontiers in vaccine safety: qualifying available evidence for rare events, use of distributed data networks to monitor vaccine safety issues, and monitoring the safety of pregnancy interventions. BMJ Glob Health 2021; 6:bmjgh-2020-003540. [PMID: 34011501 PMCID: PMC8137251 DOI: 10.1136/bmjgh-2020-003540] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 01/28/2023] Open
Abstract
While vaccines are rigorously tested for safety and efficacy in clinical trials, these trials do not include enough subjects to detect rare adverse events, and they generally exclude special populations such as pregnant women. It is therefore necessary to conduct postmarketing vaccine safety assessments using observational data sources. The study of rare events has been enabled in through large linked databases and distributed data networks, in combination with development of case-centred methods. Distributed data networks necessitate common protocols, definitions, data models and analytics and the processes of developing and employing these tools are rapidly evolving. Assessment of vaccine safety in pregnancy is complicated by physiological changes, the challenges of mother-child linkage and the need for long-term infant follow-up. Potential sources of bias including differential access to and utilisation of antenatal care, immortal time bias, seasonal timing of pregnancy and unmeasured determinants of pregnancy outcomes have yet to be fully explored. Available tools for assessment of evidence generated in postmarketing studies may downgrade evidence from observational data and prioritise evidence from randomised controlled trials. However, real-world evidence based on real-world data is increasingly being used for safety assessments, and new tools for evaluating real-world evidence have been developed. The future of vaccine safety surveillance, particularly for rare events and in special populations, comprises the use of big data in single countries as well as in collaborative networks. This move towards the use of real-world data requires continued development of methodologies to generate and assess real world evidence.
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Affiliation(s)
- Caitlin Dodd
- Julius Center, UMC Utrecht, Utrecht, The Netherlands
| | - Nick Andrews
- Statistics Modelling and Economics Department, Public Health England, London, UK
| | - Helen Petousis-Harris
- Department of General Practice and Primary Health Care, The University of Auckland, Auckland, New Zealand
| | | | - Saad B Omer
- Institute for Global Health, Yale University, New Haven, Connecticut, USA
| | - Steven Black
- Global Vaccine Data Network, Berkeley, California, USA
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16
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Liles E, Irving SA, Dandamudi P, Belongia EA, Daley MF, DeStefano F, Jackson LA, Jacobsen SJ, Kharbanda E, Klein NP, Weintraub E, Naleway AL. Incidence of pediatric inflammatory bowel disease within the Vaccine Safety Datalink network and evaluation of association with rotavirus vaccination. Vaccine 2021; 39:3614-3620. [PMID: 34052066 DOI: 10.1016/j.vaccine.2021.05.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 04/15/2021] [Accepted: 05/11/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recent studies have reported an increase in Inflammatory bowel disease (IBD) incidence in young children, highlighting the need to better understand risk factors for the development of IBD. Licensed for use in infants in 2006, the oral, live-attenuated rotavirus vaccine has biologic plausibility for instigating inflammation of the gut mucosa as a pathway to immune dysregulation. METHODS Over a ten-year period, we evaluated incidence of IBD within a cohort of children under the age of ten, enrolled in seven integrated healthcare delivery systems. We conducted a nested case-control study to evaluate the association between rotavirus vaccination and IBD using conditional logistic regression. Cases were confirmed via medical record review and matched to non-IBD controls on date of birth, sex, and study site. RESULTS Among 2.4 million children under the age of 10 years, 333 cases of IBD were identified with onset between 2007 and 2016. The crude incidence of IBD increased slightly over the study period (p-value for trend = 0.046). Of the 333 cases, 227 (68%) were born prior to 2007. Forty-two cases born in 2007 or later, with continuous enrollment since birth were included in the case-control study and matched to 210 controls. The adjusted odds ratio for any rotavirus vaccination in IBD cases, compared to matched controls, was 0.72 (95% confidence interval 0.19-2.65). CONCLUSIONS Data from this large pediatric cohort demonstrate a small overall increase in IBD incidence in young children over a ten-year period. The data suggest that rotavirus vaccination is not associated with development of IBD.
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Affiliation(s)
- Elizabeth Liles
- Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227, United States.
| | - Stephanie A Irving
- Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227, United States.
| | - Padma Dandamudi
- Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227, United States.
| | - Edward A Belongia
- Marshfield Clinic Research Institute, 1000 North Oak Avenue (ML2), Marshfield, WI 54449, United States.
| | - Matthew F Daley
- Kaiser Permanente of Colorado Institute for Health Research, 2550 South Parker Road, Suite 200, Aurora, CO 80014, United States.
| | - Frank DeStefano
- Immunization Safety Office, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS V18-4, Atlanta, GA 30333, United States.
| | - Lisa A Jackson
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101, United States.
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles Avenue, Pasadena, CA 91101, United States
| | - Elyse Kharbanda
- HealthPartners Institute for Education and Research, 8170 33(rd) Avenue South, MS 23301A, Bloomington, MN 55425, United States.
| | - Nicola P Klein
- Vaccine Study Center, Kaiser Permanente Division of Research, 1 Kaiser Plaza, 16(th) Floor, Oakland, CA 94612, United States.
| | - Eric Weintraub
- Immunization Safety Office, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS V18-4, Atlanta, GA 30333, United States.
| | - Allison L Naleway
- Kaiser Permanente Center for Health Research, 3800 North Interstate Avenue, Portland, OR 97227, United States.
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17
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Newcomer SR, Xu S, Kulldorff M, Daley MF, Fireman B, Glanz JM. A primer on quantitative bias analysis with positive predictive values in research using electronic health data. J Am Med Inform Assoc 2021; 26:1664-1674. [PMID: 31365086 DOI: 10.1093/jamia/ocz094] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/12/2019] [Accepted: 05/17/2019] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE In health informatics, there have been concerns with reuse of electronic health data for research, including potential bias from incorrect or incomplete outcome ascertainment. In this tutorial, we provide a concise review of predictive value-based quantitative bias analysis (QBA), which comprises epidemiologic methods that use estimates of data quality accuracy to quantify the bias caused by outcome misclassification. TARGET AUDIENCE Health informaticians and investigators reusing large, electronic health data sources for research. SCOPE When electronic health data are reused for research, validation of outcome case definitions is recommended, and positive predictive values (PPVs) are the most commonly reported measure. Typically, case definitions with high PPVs are considered to be appropriate for use in research. However, in some studies, even small amounts of misclassification can cause bias. In this tutorial, we introduce methods for quantifying this bias that use predictive values as inputs. Using epidemiologic principles and examples, we first describe how multiple factors influence misclassification bias, including outcome misclassification levels, outcome prevalence, and whether outcome misclassification levels are the same or different by exposure. We then review 2 predictive value-based QBA methods and why outcome PPVs should be stratified by exposure for bias assessment. Using simulations, we apply and evaluate the methods in hypothetical electronic health record-based immunization schedule safety studies. By providing an overview of predictive value-based QBA, we hope to bridge the disciplines of health informatics and epidemiology to inform how the impact of data quality issues can be quantified in research using electronic health data sources.
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Affiliation(s)
- Sophia R Newcomer
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Stan Xu
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Martin Kulldorff
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA.,Department of Pediatrics, School of Medicine, University of Colorado Denver, Aurora, Colorado, USA
| | - Bruce Fireman
- Division of Research, Vaccine Study Center, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA.,Department of Epidemiology, School of Public Health, University of Colorado Denver, Aurora, Colorado, USA
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18
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Relative Incidence of Office Visits and Cumulative Rates of Billed Diagnoses Along the Axis of Vaccination. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228674. [PMID: 33266457 PMCID: PMC7709050 DOI: 10.3390/ijerph17228674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 12/16/2022]
Abstract
We performed a retrospective analysis spanning ten years of pediatric practice focused on patients with variable vaccination born into a practice, presenting a unique opportunity to study the effects of variable vaccination on outcomes. The average total incidence of billed office visits per outcome related to the outcomes were compared across groups (Relative Incidence of Office Visit (RIOV)). RIOV is shown to be more powerful than odds ratio of diagnoses. Full cohort, cumulative incidence analyses, matched for days of care, and matched for family history analyses were conducted across quantiles of vaccine uptake. Increased office visits related to many diagnoses were robust to days-of-care-matched analyses, family history, gender block, age block, and false discovery risk. Many outcomes had high RIOV odds ratios after matching for days-of-care (e.g., anemia (6.334), asthma (3.496), allergic rhinitis (6.479), and sinusitis (3.529), all significant under the Z-test). Developmental disorders were determined to be difficult to study due to extremely low prevalence in the practice, potentially attributable to high rates of vaccine cessation upon adverse events and family history of autoimmunity. Remarkably, zero of the 561 unvaccinated patients in the study had attention deficit hyperactivity disorder (ADHD) compared to 0.063% of the (partially and fully) vaccinated. The implications of these results for the net public health effects of whole-population vaccination and with respect for informed consent on human health are compelling. Our results give agency to calls for research conducted by individuals who are independent of any funding sources related to the vaccine industry. While the low rates of developmental disorders prevented sufficiently powered hypothesis testing, it is notable that the overall rate of autism spectrum disorder (0.84%) in the cohort is half that of the US national rate (1.69%). The practice-wide rate of ADHD was roughly half of the national rate. The data indicate that unvaccinated children in the practice are not unhealthier than the vaccinated and indeed the overall results may indicate that the unvaccinated pediatric patients in this practice are healthier overall than the vaccinated.
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19
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Order of Live and Inactivated Vaccines and Risk of Non-vaccine-targeted Infections in US Children 11-23 Months of Age. Pediatr Infect Dis J 2020; 39:247-253. [PMID: 32032310 DOI: 10.1097/inf.0000000000002550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Some findings from observational studies have suggested that recent receipt of live vaccines may be associated with decreased non-vaccine-targeted infection risk and mortality. Our objective was to estimate risk of non-vaccine-targeted infections based on most recent vaccine type (live vaccines only, inactivated vaccines only or both concurrently) received in US children 11-23 months of age. METHODS We conducted a retrospective cohort study within the Vaccine Safety Datalink. We examined electronic health record and immunization data from children born in 2003-2013 who received 3 diphtheria-tetanus-acellular pertussis vaccines before their first birthday. We modeled vaccine type as a time-varying exposure and estimated risk of non-vaccine-targeted infections identified in emergency department and inpatient settings, adjusting for multiple confounders. RESULTS Among 428,608 children, 48.9% were female, 4.9% had ≥1 immunization visit with live vaccines only and 10.3% had a non-vaccine-targeted infection. In males, lower risk of non-vaccine-targeted infections was observed following last receipt of live vaccines only or live and inactivated vaccines concurrently as compared with last receipt of inactivated vaccines only [live vaccines-only adjusted hazard ratio (aHR) = 0.83, 95% confidence interval (CI): 0.72-0.94; live and inactivated vaccines concurrently aHR: 0.91, 95% CI: 0.88-0.94]. Among females, last receipt of live and inactivated vaccines concurrently was significantly associated with non-vaccine-targeted infection risk (aHR = 0.94, 95% CI: 0.91-0.97 vs. last receipt of inactivated vaccines only). CONCLUSIONS We observed modest associations between live vaccine receipt and non-vaccine-targeted infections. In this observational study, multiple factors, including healthcare-seeking behavior, may have influenced results.
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Hargreaves AL, Nowak G, Frew P, Hinman AR, Orenstein WA, Mendel J, Aikin A, Nadeau JA, McNutt LA, Chamberlain AT, Omer SB, Randall LA, Bednarczyk RA. Adherence to Timely Vaccinations in the United States. Pediatrics 2020; 145:peds.2019-0783. [PMID: 32086389 DOI: 10.1542/peds.2019-0783] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To estimate (1) the proportion of children not adhering to the Advisory Committee on Immunization Practices (ACIP) recommended early childhood immunization schedule and (2) associations between schedule adherence, sociodemographic characteristics, and up-to-date immunization status by 19 to 35 months of age. METHODS We used 2014 National Immunization Survey provider-verified vaccination data to classify vaccination patterns as "recommended" (ie, in line with ACIP dose- and age-specific recommendations), "alternate" (ie, in line with either limiting the number of shots per visit or skipping at least 1 vaccine series), or "unknown or unclassifiable" (ie, not in line with ACIP recommendations or clearly limiting shots per visit or vaccine series). We evaluated the association between vaccination patterns and up-to-date status for all ACIP-recommended vaccinations (including rotavirus and hepatitis A vaccines) using Poisson regression. RESULTS The majority of children's patterns were classified as "recommended" (63%), with 23% and 14% following alternate or unknown or unclassifiable patterns, respectively; 58% of children were up-to-date with all ACIP-recommended immunizations by 19 to 35 months. Not being up-to-date was associated with alternate (prevalence ratio = 4.2, 95% confidence interval: 3.9-4.5) and unknown or unclassifiable (prevalence ratio = 2.4, 95% confidence interval: 2.2-2.7) patterns. CONCLUSIONS High vaccine coverage by 19 to 35 months of age may miss nonadherence to the recommended immunization schedule in the first 18 months of life, leaving children vulnerable to preventable diseases. With more than one-third of US children not following the ACIP schedule, targeted interventions are needed to minimize vaccine delays and disease susceptibility.
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Affiliation(s)
- Allison L Hargreaves
- Hubert Department of Global Health and.,Division of Infectious Diseases, Department of Medicine, School of Medicine, and
| | - Glen Nowak
- Grady College of Journalism and Mass Communication, University of Georgia, Athens, Georgia
| | - Paula Frew
- Hubert Department of Global Health and.,Division of Infectious Diseases, Department of Medicine, School of Medicine, and
| | | | - Walter A Orenstein
- Division of Infectious Diseases, Department of Medicine, School of Medicine, and.,Emory Vaccine Center, Emory University, Atlanta, Georgia
| | - Judith Mendel
- National Vaccine Program Office, Department of Health and Human Services, Washington, DC; and
| | - Ann Aikin
- National Vaccine Program Office, Department of Health and Human Services, Washington, DC; and
| | - Jessica A Nadeau
- Institute for Health and the Environment, School of Public Health, State University of New York-University at Albany, Rensselaer, New York
| | - Louise-Anne McNutt
- Institute for Health and the Environment, School of Public Health, State University of New York-University at Albany, Rensselaer, New York
| | | | - Saad B Omer
- Hubert Department of Global Health and.,Emory Vaccine Center, Emory University, Atlanta, Georgia.,Department of Epidemiology, Rollins School of Public Health
| | - Laura A Randall
- Hubert Department of Global Health and.,Division of Infectious Diseases, Department of Medicine, School of Medicine, and
| | - Robert A Bednarczyk
- Hubert Department of Global Health and .,Emory Vaccine Center, Emory University, Atlanta, Georgia.,Department of Epidemiology, Rollins School of Public Health
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21
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The science of vaccine safety: Summary of meeting at Wellcome Trust. Vaccine 2020; 38:1869-1880. [PMID: 31987690 DOI: 10.1016/j.vaccine.2020.01.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/18/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
Abstract
Vaccines are everywhere hugely successful but are also under attack. The reason for the latter is the perception by some people that vaccines are unsafe. However that may be, vaccine safety, life any other scientific subject, must be constantly studied. It was from this point of view that a meeting was organized at the Wellcome Trust in London in May 2019 to assess some aspects of vaccine safety as subjects for scientific study. The objective of the meeting was to assess what is known beyond reasonable doubt and conversely what areas need additional studies. Although the meeting could not cover all aspects of vaccine safety science, many of the most important issues were addressed by a group of about 30 experts to determine what is already known and what additional studies are merited to assess the safety of the vaccines currently in use. The meeting began with reviews of the current situation in different parts of the world, followed by reviews of specific controversial areas, including the incidence of certain conditions after vaccination and the safety of certain vaccine components. Lastly, information about the human papillomavirus vaccine was considered because its safety has been particularly challenged by vaccine opponents. The following is a summary of the meeting findings. In addition to this summary, the meeting organizers will explore opportunities to perform studies that would enlarge knowledge of vaccine safety.
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22
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Moro PL, Haber P, McNeil MM. Challenges in evaluating post-licensure vaccine safety: observations from the Centers for Disease Control and Prevention. Expert Rev Vaccines 2019; 18:1091-1101. [PMID: 31580725 DOI: 10.1080/14760584.2019.1676154] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Vaccination is one of the most successful and cost-effective public health interventions. Although vaccines undergo extensive safety and efficacy evaluations prior to licensure, vaccine safety assessment post-licensure is essential for detecting rare and longer-term adverse events (AEs) and maintaining public confidence in vaccines and recommended immunization programs. Despite the proven effect of vaccines to save lives and prevent disease and overwhelming evidence of vaccines' safety and societal benefit, like any drug, no vaccine can be considered as completely safe and completely effective. New vaccines continue to be introduced and require rapid safety assessment post-licensure through pharmacovigilance reports as well as epidemiologic studies to investigate any potential safety signals.Areas covered: We discuss selected challenges for conducting pharmacovigilance and epidemiologic studies of AEs after vaccination in the United States using the post-licensure safety surveillance infrastructure of the Centers for Disease Control and Prevention (CDC).Expert opinion: The availability of specific post-licensure surveillance systems to monitor and study AEs after vaccination, such as the Vaccine Adverse Event Reporting System, the Vaccine Safety Datalink, and the Clinical Immunization Safety Assessment Project, each with its unique set of strengths and limitations, provide a harmonized and supportive approach to meet several of these barriers.
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Affiliation(s)
- Pedro L Moro
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Penina Haber
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Michael M McNeil
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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23
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Zheng C, Yu W, Xie F, Chen W, Mercado C, Sy LS, Qian L, Glenn S, Lee G, Tseng HF, Duffy J, Jackson LA, Daley MF, Crane B, McLean HQ, Jacobsen SJ. The use of natural language processing to identify Tdap-related local reactions at five health care systems in the Vaccine Safety Datalink. Int J Med Inform 2019; 127:27-34. [PMID: 31128829 PMCID: PMC6645678 DOI: 10.1016/j.ijmedinf.2019.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/31/2019] [Accepted: 04/12/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Local reactions are the most common vaccine-related adverse event. There is no specific diagnosis code for local reaction due to vaccination. Previous vaccine safety studies used non-specific diagnosis codes to identify potential local reaction cases and confirmed the cases through manual chart review. In this study, a natural language processing (NLP) algorithm was developed to identify local reaction associated with tetanus-diphtheria-acellular pertussis (Tdap) vaccine in the Vaccine Safety Datalink. METHODS Presumptive cases of local reactions were identified among members ≥ 11 years of age using ICD-9-CM codes in all care settings in the 1-6 days following a Tdap vaccination between 2012 and 2014. The clinical notes were searched for signs and symptoms consistent with local reaction. Information on the timing and the location of a sign or symptom was also extracted to help determine whether or not the sign or symptom was vaccine related. Reactions triggered by causes other than Tdap vaccination were excluded. The NLP algorithm was developed at the lead study site and validated on a stratified random sample of 500 patients from five institutions. RESULTS The NLP algorithm achieved an overall weighted sensitivity of 87.9%, specificity of 92.8%, positive predictive value of 82.7%, and negative predictive value of 95.1%. In addition, using data at one site, the NLP algorithm identified 3326 potential Tdap-related local reactions that were not identified through diagnosis codes. CONCLUSION The NLP algorithm achieved high accuracy, and demonstrated the potential of NLP to reduce the efforts of manual chart review in vaccine safety studies.
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Affiliation(s)
- Chengyi Zheng
- Kaiser Permanente Southern California, Pasadena, CA, USA.
| | - Wei Yu
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Fagen Xie
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Wansu Chen
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Cheryl Mercado
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Lina S Sy
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Lei Qian
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Gina Lee
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Hung Fu Tseng
- Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jonathan Duffy
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Brad Crane
- Kaiser Permanente Northwest, Portland, OR, USA
| | - Huong Q McLean
- Marshfield Clinic Research Institute, Marshfield, WI, USA
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24
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Use of three summary measures of pediatric vaccination for studying the safety of the childhood immunization schedule. Vaccine 2019; 37:1325-1331. [PMID: 30709727 DOI: 10.1016/j.vaccine.2019.01.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 01/10/2019] [Accepted: 01/14/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Summary measures such as number of vaccine antigens, number of vaccines, and vaccine aluminum exposure by the 2nd birth day are directly related to parents' concerns that children receive too many vaccines over a brief period. High correlation among summary measures could cause problems in regression models that examine their associations with outcomes. OBJECTIVES To evaluate the performance of multiple regression models using summary measures as risk factors to simulated binary outcomes. METHODS We calculated summary measures for a cohort of 232,627 children born between 1/1/2003 and 9/31/2013. Correlation and variance inflation factors (VIFs) were calculated. We conducted simulations (1) to examine the extent to which an association can be detected using a summary measure other than the true risk factor; (2) to evaluate the performance of multiple regression models including true and redundant risk factors; (3) to evaluate the performance of multiple regression models when all three were risk factors; (4) to examine the performance of multiple regression models with incorrect relationship between risk factors and outcome. RESULTS These summary measures were highly correlated. VIFs were 7.14, 6.25 and 2.17 for number of vaccine antigens, number of vaccines, and vaccine aluminum exposure, respectively. In simulations, an association would be detected if a summary measure other than the true risk factor was used. The power to detect the association between the true risk factor and outcome significantly decreased if redundant risk factors were included. When all three were risk factors, multiple regression model was appropriate to detect the stronger risk factor. Correctly specifying the relationship between risk factors and the outcome was crucial. CONCLUSIONS Multiple regression models can be used to examine the association between summary measures and outcome despite of high correlation among summary measures. It is important to correctly specify the relationship between risk factors and outcome.
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25
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Kochhar S, Excler JL, Bok K, Gurwith M, McNeil MM, Seligman SJ, Khuri-Bulos N, Klug B, Laderoute M, Robertson JS, Singh V, Chen RT. Defining the interval for monitoring potential adverse events following immunization (AEFIs) after receipt of live viral vectored vaccines. Vaccine 2018; 37:5796-5802. [PMID: 30497831 PMCID: PMC6535369 DOI: 10.1016/j.vaccine.2018.08.085] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/27/2018] [Indexed: 12/13/2022]
Abstract
Live viral vectors that express heterologous antigens of the target pathogen are being investigated in the development of novel vaccines against serious infectious agents like HIV and Ebola. As some live recombinant vectored vaccines may be replication-competent, a key challenge is defining the length of time for monitoring potential adverse events following immunization (AEFI) in clinical trials and epidemiologic studies. This time period must be chosen with care and based on considerations of pre-clinical and clinical trials data, biological plausibility and practical feasibility. The available options include: (1) adapting from the current relevant regulatory guidelines; (2) convening a panel of experts to review the evidence from a systematic literature search to narrow down a list of likely potential or known AEFI and establish the optimal risk window(s); and (3) conducting "near real-time" prospective monitoring for unknown clustering's of AEFI in validated large linked vaccine safety databases using Rapid Cycle Analysis for pre-specified adverse events of special interest (AESI) and Treescan to identify previously unsuspected outcomes. The risk window established by any of these options could be used along with (4) establishing a registry of clinically validated pre-specified AESI to include in case-control studies. Depending on the infrastructure, human resources and databases available in different countries, the appropriate option or combination of options can be determined by regulatory agencies and investigators.
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Affiliation(s)
- Sonali Kochhar
- Global Healthcare Consulting, New Delhi, India; Erasmus MC, University Medical Center, Rotterdam, the Netherlands; University of Washington, Seattle, USA
| | | | - Karin Bok
- National Vaccine Program Office, Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington DC, USA
| | | | - Michael M McNeil
- Immunization Safety Office, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Stephen J Seligman
- Department of Microbiology and Immunology, New York Medical College, NY, USA; St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller University, New York, NY, USA
| | - Najwa Khuri-Bulos
- Division of Infectious Disease, Jordan University Hospital, Amman, Jordan
| | - Bettina Klug
- Division Immunology, Paul-Ehrlich-Institut, Langen, Germany
| | | | - James S Robertson
- Independent Adviser (formerly of National Institute for Biological Standards and Control), Potters Bar, UK
| | - Vidisha Singh
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), USA
| | - Robert T Chen
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), USA; Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
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26
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Daley MF, Shoup JA, Newcomer SR, Jackson ML, Groom HC, Jacobsen SJ, McLean HQ, Klein NP, Weintraub ES, McNeil MM, Glanz JM. Assessing Potential Confounding and Misclassification Bias When Studying the Safety of the Childhood Immunization Schedule. Acad Pediatr 2018; 18:754-762. [PMID: 29604461 PMCID: PMC6445249 DOI: 10.1016/j.acap.2018.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/13/2018] [Accepted: 03/17/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Some parents are concerned the childhood immunization schedule could increase risk for allergic disorders, including asthma. To inform future safety studies of this speculated association, a parent survey was conducted to examine the risk of misclassification of vaccination status in electronic health record data, and to assess the potential for confounding if asthma risk factors varied by vaccination status. METHODS A survey was conducted among parents of children 19 to 35 months old at 6 medical organizations within the Vaccine Safety Datalink. Parents of children in 4 vaccination groups were surveyed: 1) no vaccines by 12 months of age and a diagnosis of parental vaccine refusal; 2) consistent vaccine limiting (≤2 vaccines per visit); 3) not consistently vaccine limiting but otherwise undervaccinated with a vaccine refusal diagnosis; and 4) fully vaccinated with no delays and no vaccine refusal. Parents were surveyed about their child's vaccination status and whether asthma risk factors existed. RESULTS Among a survey sample of 2043 parents, 1209 responded (59.2%). For receiving no vaccines, the observed agreement between parent report and electronic health record data was 94.0% (κ = 0.79); for receiving all vaccines with no delays, the observed agreement was 87.3% (κ = 0.73). Although most asthma risk factors (allergic rhinitis, eczema, food allergies, family asthma history) reported by parents did not differ significantly between children in the vaccination groups studied, several factors (aeroallergen sensitivity, breastfeeding) differed significantly between groups. CONCLUSIONS Measurement and control of disease risk factors should be carefully considered in observational studies of the safety of the immunization schedule.
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Affiliation(s)
- Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colo
| | - Sophia R Newcomer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colo
| | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Wash
| | | | | | | | | | - Eric S Weintraub
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
| | - Michael M McNeil
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colo
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27
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Xu S, Clarke CL, Newcomer SR, Daley MF, Glanz JM. Analyzing self-controlled case series data when case confirmation rates are estimated from an internal validation sample. Biom J 2018; 60:748-760. [PMID: 29768667 DOI: 10.1002/bimj.201700088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 01/10/2023]
Abstract
Vaccine safety studies are often electronic health record (EHR)-based observational studies. These studies often face significant methodological challenges, including confounding and misclassification of adverse event. Vaccine safety researchers use self-controlled case series (SCCS) study design to handle confounding effect and employ medical chart review to ascertain cases that are identified using EHR data. However, for common adverse events, limited resources often make it impossible to adjudicate all adverse events observed in electronic data. In this paper, we considered four approaches for analyzing SCCS data with confirmation rates estimated from an internal validation sample: (1) observed cases, (2) confirmed cases only, (3) known confirmation rate, and (4) multiple imputation (MI). We conducted a simulation study to evaluate these four approaches using type I error rates, percent bias, and empirical power. Our simulation results suggest that when misclassification of adverse events is present, approaches such as observed cases, confirmed case only, and known confirmation rate may inflate the type I error, yield biased point estimates, and affect statistical power. The multiple imputation approach considers the uncertainty of estimated confirmation rates from an internal validation sample, yields a proper type I error rate, largely unbiased point estimate, proper variance estimate, and statistical power.
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Affiliation(s)
- Stanley Xu
- The Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, 80231, USA.,School of Public Health, University of Colorado, Aurora, CO, 80045, USA
| | - Christina L Clarke
- The Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, 80231, USA
| | - Sophia R Newcomer
- The Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, 80231, USA.,School of Public Health, University of Colorado, Aurora, CO, 80045, USA
| | - Matthew F Daley
- The Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, 80231, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, 80045, USA
| | - Jason M Glanz
- The Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, 80231, USA.,School of Public Health, University of Colorado, Aurora, CO, 80045, USA
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28
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Wang SV, Abdurrob A, Spoendlin J, Lewis E, Newcomer SR, Fireman B, Daley MF, Glanz JM, Duffy J, Weintraub ES, Kulldorff M. Methods for addressing "innocent bystanders" when evaluating safety of concomitant vaccines. Pharmacoepidemiol Drug Saf 2018; 27:405-412. [PMID: 29441647 DOI: 10.1002/pds.4399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 12/04/2017] [Accepted: 01/03/2018] [Indexed: 11/07/2022]
Abstract
PURPOSE The need to develop methods for studying the safety of childhood immunization schedules has been recognized by the Institute of Medicine and Department of Health and Human Services. The recommended childhood immunization schedule includes multiple vaccines in a visit. A key concern is safety of concomitant (same day) versus separate day vaccination. This paper addresses a methodological challenge for observational studies using a self-controlled design to investigate the safety of concomitant vaccination. METHODS We propose a process for distinguishing which of several concomitantly administered vaccines is responsible for increased risk of an adverse event while adjusting for confounding due to relationships between effect modifying risk factors and concomitant vaccine combinations. We illustrate the approach by re-examining the known increase in risk of seizure 7 to 10 days after measles-mumps-rubella (MMR) vaccination and evaluating potential independent or modifying effects of other vaccines. RESULTS Initial analyses suggested that DTaP had both an independent and potentiating effect on seizure. After accounting for the relationship between age at vaccination and vaccine combination, there was little evidence for increased risk of seizure with same day administration of DTaP and MMR; incidence rate ratio, 95% confidence interval 1.2 (0.9-1.6), P value = θ.226. CONCLUSION We have shown that when using a self-controlled design to investigate safety of concomitant vaccination, it can be critically important to adjust for time-invariant effect modifying risk factors, such as age at time of vaccination, which are structurally related to vaccination patterns due to recommended immunization schedules.
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Affiliation(s)
- Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Abdurrahman Abdurrob
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Julia Spoendlin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Edwin Lewis
- Kaiser Permanente Vaccine Study Center, Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Sophia R Newcomer
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Bruce Fireman
- Kaiser Permanente Vaccine Study Center, Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
| | - Jonathan Duffy
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Martin Kulldorff
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital; Department of Medicine, Harvard Medical School, Boston, MA, USA
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29
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Newcomer SR, Kulldorff M, Xu S, Daley MF, Fireman B, Lewis E, Glanz JM. Bias from outcome misclassification in immunization schedule safety research. Pharmacoepidemiol Drug Saf 2018; 27:221-228. [PMID: 29292551 DOI: 10.1002/pds.4374] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/18/2017] [Accepted: 11/20/2017] [Indexed: 11/11/2022]
Abstract
PURPOSE The Institute of Medicine recommended conducting observational studies of childhood immunization schedule safety. Such studies could be biased by outcome misclassification, leading to incorrect inferences. Using simulations, we evaluated (1) outcome positive predictive values (PPVs) as indicators of bias of an exposure-outcome association, and (2) quantitative bias analyses (QBA) for bias correction. METHODS Simulations were conducted based on proposed or ongoing Vaccine Safety Datalink studies. We simulated 4 studies of 2 exposure groups (children with no vaccines or on alternative schedules) and 2 baseline outcome levels (100 and 1000/100 000 person-years), with 3 relative risk (RR) levels (RR = 0.50, 1.00, and 2.00), across 1000 replications using probabilistic modeling. We quantified bias from non-differential and differential outcome misclassification, based on levels previously measured in database research (sensitivity > 95%; specificity > 99%). We calculated median outcome PPVs, median observed RRs, Type 1 error, and bias-corrected RRs following QBA. RESULTS We observed PPVs from 34% to 98%. With non-differential misclassification and true RR = 2.00, median bias was toward the null, with severe bias (median observed RR = 1.33) with PPV = 34% and modest bias (median observed RR = 1.83) with PPV = 83%. With differential misclassification, PPVs did not reflect median bias, and there was Type 1 error of 100% with PPV = 90%. QBA was generally effective in correcting misclassification bias. CONCLUSIONS In immunization schedule studies, outcome misclassification may be non-differential or differential to exposure. Overall outcome PPVs do not reflect the distribution of false positives by exposure and are poor indicators of bias in individual studies. Our results support QBA for immunization schedule safety research.
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Affiliation(s)
- Sophia R Newcomer
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, USA.,Colorado School of Public Health, Anschutz Medical Campus, Department of Epidemiology, Denver, CO, USA
| | - Martin Kulldorff
- Brigham and Women's Hospital and Harvard Medical School, Division of Pharmacoepidemiology and Pharmacoeconomics, Boston, MA, USA
| | - Stan Xu
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, USA
| | - Matthew F Daley
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, USA.,University of Colorado Denver, School of Medicine, Department of Pediatrics, Denver, CO, USA
| | - Bruce Fireman
- Kaiser Permanente Northern California, Division of Research, Vaccine Study Center, Oakland, CA, USA
| | - Edwin Lewis
- Kaiser Permanente Northern California, Division of Research, Vaccine Study Center, Oakland, CA, USA
| | - Jason M Glanz
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, USA.,Colorado School of Public Health, Anschutz Medical Campus, Department of Epidemiology, Denver, CO, USA
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30
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McCarthy NL, Sukumaran L, Newcomer S, Glanz J, Daley MF, McClure D, Klein NP, Irving S, Jackson ML, Lewin B, Weintraub E. Patterns of childhood immunization and all-cause mortality. Vaccine 2017; 35:6643-6648. [PMID: 29061349 PMCID: PMC6506838 DOI: 10.1016/j.vaccine.2017.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/04/2017] [Accepted: 10/12/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Evidence supports the safety of the recommended childhood immunization schedule as a whole. However, additional research is warranted as parents' refusing or delaying vaccinations has increased in recent years. All-cause mortality has been identified as a priority outcome to study in the context of the recommended immunization schedule. METHODS We included children born January 1, 2004 through December 31, 2009, enrolled in the Vaccine Safety Datalink (VSD) from birth through 18 months of age. We examined vaccination patterns during the first 18 months of life among 8 vaccines, and identified deaths occurring between 19 and 48 months of age. We excluded children with complex chronic conditions, contraindications to vaccination, and deaths due to injuries, congenital anomalies, or diseases with onset prior to 19 months of age. We calculated mortality rates among children with different patterns of immunization, and incidence rate ratios (IRR) using the Cox proportional hazards model for children vaccinated according to the schedule versus undervaccinated children, adjusting for outpatient healthcare utilization, influenza vaccination, sex, and VSD site. RESULTS Among 312,388 children in the study, 199,661 (64%) were vaccinated according to the schedule, and 112,727 (36%) were delayed or not vaccinated for at least one vaccine dose. Of 18 deaths eligible for analysis, 11 occurred in children following the schedule (2.28 per 100,000 person-years), and seven occurred in undervaccinated children (2.57 per 100,000 person-years). Mortality rates among children following the schedule were not significantly different from those of undervaccinated children when excluding deaths with unknown causes (IRR = 1.29, 95% CI = 0.33-4.99), as well as when including deaths with unknown causes (IRR = 0.84, 95% CI = 0.32-2.99). CONCLUSION Although there were few deaths, our results do not indicate a difference in risk of all-cause mortality among fully vaccinated versus undervaccinated children. Our findings support the safety of the currently recommended immunization schedule with regard to all-cause mortality.
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Affiliation(s)
- Natalie L McCarthy
- Immunization Safety Office (VSD), Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Lakshmi Sukumaran
- Immunization Safety Office (VSD), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sophia Newcomer
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States
| | - Jason Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States
| | - Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States
| | - David McClure
- Marshfield Clinic Research Foundation, Marshfield, WI, United States
| | - Nicola P Klein
- Kaiser Permanente Division of Research, Kaiser Permanente of Northern California, Oakland, CA, United States
| | - Stephanie Irving
- Kaiser Permanente Center for Health Research, Northwest Kaiser Permanente, Portland, OR, United States
| | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, United States
| | - Bruno Lewin
- Kaiser Permanente Department of Research and Evaluation, Kaiser Permanente of Southern California, Pasadena, CA, United States
| | - Eric Weintraub
- Immunization Safety Office (VSD), Centers for Disease Control and Prevention, Atlanta, Georgia
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Vaccination counselling: The meeting point is possible. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Daley MF, Glanz JM, Newcomer SR, Jackson ML, Groom HC, Lugg MM, McLean HQ, Klein NP, Weintraub ES, McNeil MM. Assessing misclassification of vaccination status: Implications for studies of the safety of the childhood immunization schedule. Vaccine 2017; 35:1873-1878. [PMID: 28285983 PMCID: PMC6445250 DOI: 10.1016/j.vaccine.2017.02.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/03/2017] [Accepted: 02/24/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND To address public concern about the safety of the childhood immunization schedule, the Institute of Medicine recommended observational studies comparing adverse health outcomes of fully vaccinated children to children under-vaccinated due to parental choice. Misclassification of vaccination status could bias such studies. OBJECTIVE To assess risk of misclassification of vaccination status within the Vaccine Safety Datalink (VSD). DESIGN/METHODS A retrospective cohort study was conducted in three phases. In phase 1, electronic health record (EHR) data were used to identify patterns of under-vaccination during the first 24months of life potentially due to parental choice. In phase 2, a random sample of records of under-vaccinated children was manually reviewed. In phase 3, a separate sample of parents were surveyed to assess whether EHR data accurately reflected their child's vaccination status. Phases 1 and 2 were conducted at 6 VSD sites, phase 3 at 1 site. RESULTS The study cohort included 361,901 children born 2004 through 2012. By 24months of age, 198,249 (54.8%) were fully vaccinated with no delays, 84,698 (23.4%) experienced delays but were fully vaccinated by 24months of age, 4865 (1.3%) received no vaccines, 3789 (1.0%) delayed starting vaccination until ≥4months of age, 4781 (1.3%) had consistent vaccine-limiting (≤2 vaccines per visit), and the remaining 65,519 (18.1%) were missing vaccine series or doses. When a diagnosis code for vaccine refusal was present in EHR data, encounter notes confirmed vaccine refusal as the reason for under-vaccination for nearly 100% of sampled records. Parent surveys confirmed these findings. Parents of under-vaccinated children were more likely to report visiting an alternative medical provider than parents of fully vaccinated children. CONCLUSIONS Specific groups of children, under-vaccinated due to parental choice, can be identified with relatively low likelihood of misclassification of vaccination status using EHR-based vaccine data and diagnosis codes.
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Affiliation(s)
- Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States.
| | - Sophia R Newcomer
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States.
| | | | - Holly C Groom
- Kaiser Permanente Northwest, Portland, OR, United States.
| | - Marlene M Lugg
- Kaiser Permanente Southern California, Pasadena, CA, United States.
| | - Huong Q McLean
- Marshfield Clinic Research Foundation, Marshfield, WI, United States.
| | - Nicola P Klein
- Kaiser Permanente Northern California, Oakland, CA, United States.
| | - Eric S Weintraub
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.
| | - Michael M McNeil
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States.
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Huang WT, Lin HC, Yang CH. Undervaccination with diphtheria, tetanus, and pertussis vaccine: National trends and association with pertussis risk in young children. Hum Vaccin Immunother 2016; 13:757-761. [PMID: 27858500 DOI: 10.1080/21645515.2016.1249552] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND The high coverage for ≥3 pertussis vaccine doses among Taiwanese children might not imply timely vaccination. Recently, resurgence of pertussis and challenges with availability of DTaP-IPV-Hib prompted this study. METHODS In the 1996-2012 national birth cohort, we calculated the prevalence and days of undervaccination against pertussis by age 36 months. We also compared the odds of undervaccination in each laboratory-confirmed pertussis patient at ages 3-35 months with sex-, residence-, and age-matched controls from the general population, using conditional logistic regression. RESULTS The prevalence of undervaccination was 60.6% (median 16 days) and decreasing (p < 0.0001). Among 145 cases and 2,900 controls, 58 (40.0%) and 721 (24.9%) were undervaccinated (OR 2.28, 95% CI 1.57-3.31). The attributable risk percent was 22.5% (95% CI 14.5-27.9). CONCLUSIONS Undervaccination was decreasing. Approximately up to one-fifth pertussis cases in children aged 3-35 months could have been prevented with on-time vaccination.
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Affiliation(s)
| | - Hui-Chen Lin
- a Taiwan Centers for Disease Control , Taipei , Taiwan
| | - Chin-Hui Yang
- a Taiwan Centers for Disease Control , Taipei , Taiwan
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[Vaccination counselling: The meeting point is possible]. An Pediatr (Barc) 2016; 86:314-320. [PMID: 27436570 DOI: 10.1016/j.anpedi.2016.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 06/05/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION There are recommendations for decision-making as regards parents who do not vaccinate their children, but there are few publications analysing this problem. In November 2014, a pioneer medical clinic opened in Spain, for counselling on immunisation practices. The aim of this study is to determine the success of the recommendations of the American and Spanish Paediatrics Associations according to the number of parents who finally accept vaccination. PATIENTS AND METHODS A descriptive, cross-sectional, prospective and single-centre study was conducted from November 2014 to March 2016. Children under the age of 16 not properly vaccinated, according to the immunisation schedule of the region where the study was conducted, were included after signing informed consent. RESULTS A total of 20 families were counselled. The median age of the children was 2 years, and 80% of them received no vaccine. Absolute non-acceptance of vaccination was practiced by 45% of parents. The main reasons for not vaccinating were: 100% thimerosal-containing, 90% risk of autism, 85% aluminium-containing, 70% presence of other stabilisers and preservatives, and 65% risk of anaphylaxis. The immunisation advice was said to be helpful by 90% of parents. Vaccination was accepted by 90% of parents (45% completely). CONCLUSIONS Anti-vaccination ideologies are strong and hard to change. Paediatricians not denying medical care to parents who endanger the lives of their own children are also hard to find. The meeting point is possible, and society needs it. Active listening, empathy, and good quality information were the keys to our results.
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