1
|
Daley MF, Clarke CL, Glanz JM, Albers AN, Michels SY, Freeman RE, Newcomer SR. National trends in patterns of under-vaccination in early childhood: National Immunization Survey-Child, United States, 2011-2021. Expert Rev Vaccines 2024; 23:740-749. [PMID: 39109453 DOI: 10.1080/14760584.2024.2389922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/24/2024] [Accepted: 08/05/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND The study's objective was to examine national trends in patterns of under-vaccination in the United States. RESEARCH DESIGN AND METHODS The National Immunization Survey-Child (NIS-Child) is an annual cross-sectional survey that collects provider-verified vaccination records from a large national probability sample of children. Records from the 2011-2021 NIS-Child were used to assess receipt of the combined 7-vaccine series by age 24 months. Based on prior work, patterns indicative of hesitancy included zero vaccines, not starting ≥1 series, and consistent vaccine-limiting. Patterns indicative of practical issues included starting all series but missing doses. Up-to-date (UTD) was defined as receiving all doses in the combined 7-vaccine series. RESULTS The study population comprised 127,257 children. Over the observation period, patterns indicative of hesitancy significantly decreased (p-trend < 0.0001), patterns indicative of practical issues significantly decreased (p-trend < 0.0001), and UTD significantly increased (p-trend < 0.0001). In 2021, the weighted percentage in each category was as follows: probable hesitancy 6.3% (95% confidence interval [CI] 5.4%, 7.2%), probable practical issues 26.0% (95% CI 24.4%, 27.6%), and UTD 67.7% (95% CI 66.0%, 69.4%). CONCLUSION Over an 11-year period, vaccination coverage in the United States for the combined 7-vaccine series has improved, with patterns suggestive of practical issues or hesitancy declining.
Collapse
Affiliation(s)
- Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christina L Clarke
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Alexandria N Albers
- Center for Population Health Research, University of Montana, Missoula, MT, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | - Sarah Y Michels
- Center for Population Health Research, University of Montana, Missoula, MT, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| | - Rain E Freeman
- Center for Population Health Research, University of Montana, Missoula, MT, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Sophia R Newcomer
- Center for Population Health Research, University of Montana, Missoula, MT, USA
- School of Public and Community Health Sciences, University of Montana, Missoula, MT, USA
| |
Collapse
|
2
|
Bumatay S, Dickinson C, Larsen R, Stock I, Day MR, Hatch B, Robison S, Darden PM, Sullivan E, Carney PA. A comparison of electronic health records and the Oregon state immunization registry for human papilloma virus vaccine delivery (2005-2022). Vaccine 2023; 41:5758-5762. [PMID: 37573204 DOI: 10.1016/j.vaccine.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/14/2023]
Abstract
INTRODUCTION Immunization Information Systems (IIS) play an important information-sharing role at the point of care, and provide vital vaccination data for research studies and policy-makers. Previous validation studies comparing the accuracy of state registry data to health records have had mixed results. METHODS We conducted a retrospective review of EHR vaccination data for 9-17 year-old patients from 10 Oregon primary care clinics who had at least one ambulatory care visit in the past 3 years from the date of validation data collection. Data on 100 age eligible youth were captured per clinic. We compared HPV and Tdap vaccinations captured in the EHR to the Oregon ALERT IIS. All clinics were located in rural areas with both family medicine (n = 7) and pediatric (n = 3) primary care clinics. RESULTS Overall agreement for HPV vaccination between EHR and ALERT IIS was 89.4 % (k = 0.83; p < 0.05). For Tdap vaccination overall agreement was 80.8 % (k = 0.60; p < 0.05). Pediatric clinics showed a higher overall vaccine agreement for both HPV at 93.3 % (k = 0.89; p < 0.05) and Tdap at 95.3 % (k = 0.90; p < 0.05). Among clinics that used bidirectional data exchange (only family medicine clinics), HPV agreement was higher at 91 % (k = 0.85) versus 88 % (k = 0.81; p < 0.05) and was lower for Tdap 75 % with bidirectional data exchange (k = 0.50) versus 86 % without bidirectional data exchange (k = 0.70; p < 0.05). When the EHR and ALERT IIS disagreed, ALERT ISS usually had additional vaccines. CONCLUSIONS ALERT IIS data provides more accurate data than EHRs can provide when measuring vaccine delivery among adolescents in rural Oregon.
Collapse
Affiliation(s)
- Sarah Bumatay
- Senior Clinical Research Assistant, Oregon Rural Practice-based Research Network, Portland, OR, United States
| | - Caitlin Dickinson
- Senior Research Project Manager, Oregon Rural Practice-based Research Network, Portland, OR, United States
| | - Rex Larsen
- Oregon Immunization Program Surveillance and Quality Manager, Portland, OR, United States
| | - Isabel Stock
- Research Project Coordinator, Oregon Rural Practice-based Research Network, Portland, OR, United States
| | - Michael R Day
- Oregon Immunization Program Immunization ALERT IIS Deputy Director, Portland, OR, United States
| | - Brigit Hatch
- Associate Professor of Family Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Steven Robison
- Oregon Immunization Program Epidemiologist, Portland, OR, United States
| | - Paul M Darden
- Chief of Population Health, Professor of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Eliana Sullivan
- Research Data Analyst, Oregon Rural Practice-based Research Network, Portland, OR, United States
| | - Patricia A Carney
- Professor of Family Medicine, Oregon Health & Science University, Portland, OR, United States.
| |
Collapse
|
3
|
Daley MF, Reifler LM, Shoup JA, Narwaney KJ, Kharbanda EO, Groom HC, Jackson ML, Jacobsen SJ, McLean HQ, Klein NP, Williams JTB, Weintraub ES, McNeil MM, Glanz JM. Temporal Trends in Undervaccination: A Population-Based Cohort Study. Am J Prev Med 2021; 61:64-72. [PMID: 34148627 PMCID: PMC8899861 DOI: 10.1016/j.amepre.2021.01.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/28/2020] [Accepted: 01/20/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Monitoring the trends in undervaccination, including that because of parental vaccine refusal or delay, can inform public health responses directed at improving vaccine confidence and vaccination coverage. METHODS A retrospective cohort study was conducted in the Vaccine Safety Datalink. The cohort included all children born in 2004-2017 with ≥3 well-child visits between ages 2 and 23 months. Using electronic health record-based vaccination data, the average days undervaccinated was calculated for each child. Undervaccination patterns were assessed through age 23 months. Temporal trends were inspected for inflection points and were analyzed using linear regression. Nested within the cohort study, a survey was conducted to compare parent reports of vaccine refusal or delay with observed vaccination patterns. Data were analyzed in 2020. RESULTS The study cohort consisted of 808,170 children. The percentage of children with average days undervaccinated=0 (fully vaccinated, no delays) rose from a nadir of 47.1% for the birth year 2008 to 68.4% for the birth year 2017 (ptrend<0.001). The percentage with no vaccines rose from 0.35% for the birth year 2004 to 1.28% for the birth year 2017 (ptrend<0.001). Consistent vaccine limiting was observed in 2.04% for the birth year 2017. Omission of measles, mumps, and rubella vaccine peaked at 4.76% in the birth year 2007 and declined thereafter (ptrend<0.001). On the parent survey (response rate 60.2%), a high proportion of parents of the most undervaccinated children reported refusing or delaying vaccines. CONCLUSIONS In a 14-year cohort study, vaccination timeliness has improved. However, the small but increasing number of children who received no vaccines by age 23 months warrants additional attention.
Collapse
Affiliation(s)
- 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.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | | | - Holly C Groom
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | | | - Huong Q McLean
- Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Nicola P Klein
- Kaiser Permanente Vaccine Study Center, Oakland, California
| | - Joshua T B Williams
- Department of General Pediatrics, Denver Health and Hospitals, Denver, Colorado
| | - 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, Georgia
| | - 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, Georgia
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado; Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Wagner NM, Dempsey AF, Narwaney KJ, Gleason KS, Kraus CR, Pyrzanowski J, Glanz JM. Addressing logistical barriers to childhood vaccination using an automated reminder system and online resource intervention: A randomized controlled trial. Vaccine 2021; 39:3983-3990. [PMID: 34059372 DOI: 10.1016/j.vaccine.2021.05.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 05/04/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND As the rates of vaccination decline in children with logistical barriers to vaccination, new strategies to increase vaccination are needed. The goal of this study was to develop and evaluate the effectiveness of the Vaccines For Babies (VFB) intervention, an automated reminder system with online resources to address logistical barriers to vaccination in caregivers of children enrolled in an integrated healthcare system. Effectiveness was evaluated in a randomized controlled trial. METHODS Qualitative interviews were conducted with parents of children less than two years old to identify logistical barriers to vaccination that were used to develop the VFB intervention. VFB included automated reminders to schedule the 6- and 12-month vaccine visit linking caregivers to resources to address logistic barriers, sent to the preferred mode of outreach (text, email, and/or phone). Parents of children between 3 and 10 months of age with indicators of logistical barriers to vaccination were randomized to receive VFB or usual well child care (UC). The primary outcome was percentage of days undervaccinated at 2 years of life. A difference in differences analysis was conducted. RESULTS Qualitative interviews with 6 parents of children less than 2 years of age identified transportation, scheduling challenges, and knowledge of vaccine timing as logistical barriers to vaccination. We enrolled 250 participants in the trial, 45% were loss to follow-up. There were no significant differences in vaccination uptake between those enrolled in UC or the VFB intervention (0.51%, p = 0.86). In Medicaid enrolled participants, there was a modest decrease in percentage of days undervaccinated in the VFB intervention compared to UC (6.3%, p = 0.07). CONCLUSION Automated Reminders and with links to heath system resources was not shown to increase infant vaccination uptake demonstrating additional resources are needed to address the needs of caregivers experiencing logistical barriers to vaccination.
Collapse
Affiliation(s)
- Nicole M Wagner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States; Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, United States.
| | - Amanda F Dempsey
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, United States; Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States
| | - Courtney R Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States
| | - Jennifer Pyrzanowski
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, United States
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, United States; Department of Epidemiology, School of Public Health, University of Colorado, Aurora, CO, United States
| |
Collapse
|
6
|
Deerin JF, Clifton R, Elmi A, Lewis PE, Kuo I. Hepatitis B birth dose vaccination patterns in the military health System, 2014-2018. Vaccine 2021; 39:2094-2102. [PMID: 33741189 DOI: 10.1016/j.vaccine.2021.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Since 2005, the universal hepatitis B (HepB) birth dose has been recommended for all medically stable infants weighing ≥2,000 g at birth. The timing of the birth dose provides a critical safeguard and prevents infection among infants born to HBsAg-positive mothers not identified prenatally. We assess infant HepB vaccination in the U.S. Department of Defense's Military Health System (MHS) to identify trends in vaccination coverage and sociodemographic factors associated with non-receipt of the birth dose, receiving the first HepB vaccine >3 days of life, and not receiving any HepB vaccine in the first 18 months of life utilizing parental refusal codes. To our knowledge, this is one of the first studies assessing trends in parental refusal of the HepB birth dose utilizing administrative claims parental refusal codes. METHODS We conducted a retrospective cohort analysis of MHS live births from January 1, 2014 through December 31, 2018 utilizing administrative claims data. Data were included from 44 hospitals in 24 unique states, territories, or countries. We analyzed diagnosis codes for vaccine refusal and vaccination and current procedural terminology (CPT) codes to identify vaccination patterns. Generalized linear mixed effects models with a logit link were used to assess factors associated with vaccination patterns. RESULTS HepB birth dose vaccination coverage increased from 79.6% in 2014 to 88.1% in 2018 (p < .0001). Refusal rates also increased from 3.7% in 2014 to 4.5% in 2018 (p < .0001). The percentage of patients with missing diagnosis codes for vaccine refusal or vaccination decreased from 16.7% in 2014 to 7.4% in 2018. Factors associated with non-receipt of the birth dose included earlier year of birth, white maternal race, higher maternal age, higher birth order, and longer infant length of stay in hospital. CONCLUSION Vaccination coverage for HepB birth dose is high in the MHS and increased over time; concurrently, refusal rates also increased over time. Utilizing administrative claims data has the benefit of differentiating reasons for non-receipt of the birth dose over time.
Collapse
Affiliation(s)
- Jessica Fung Deerin
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology, United States.
| | - Rebecca Clifton
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology, United States
| | - Angelo Elmi
- The George Washington University, Milken Institute School of Public Health, Department of Biostatistics and Bioinformatics, United States
| | - Paul E Lewis
- Defense Health Agency, Armed Forces Health Surveillance Branch, United States
| | - Irene Kuo
- The George Washington University, Milken Institute School of Public Health, Department of Epidemiology, United States
| |
Collapse
|
7
|
Glanz JM, Wagner NM, Narwaney KJ, Pyrzanowski J, Kwan BM, Sevick C, Resnicow K, Dempsey AF. Web-Based Tailored Messaging to Increase Vaccination: A Randomized Clinical Trial. Pediatrics 2020; 146:e20200669. [PMID: 33046584 PMCID: PMC7605085 DOI: 10.1542/peds.2020-0669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To increase vaccine acceptance, we created a Web-based the "Vaccines and Your Baby" intervention (VAYB) that provided new parents with vaccine information messages tailored to vaccine beliefs and values. We evaluated the effectiveness of the VAYB by comparing timely uptake of infant vaccines to an untailored version of the intervention (UT) or usual care intervention (UC) only. METHODS Between April 2016 and June 2019, we conducted a randomized clinical trial. Pregnant women and new parents were randomly assigned to the VAYB, UT, or UC arms. In the VAYB and UT arms, participants were exposed to interventions at 4 time points from pregnancy until their child was 15 months of age. The primary outcome was up-to-date status for recommended vaccines from birth to 200 days of age. A modified intent-to-treat analysis was conducted. Data were analyzed with logistic regression to generate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS We enrolled 824 participants (276 VAYB, 274 UT, 274 UC), 143 (17.4%) of whom were lost to follow-up. The up-to-date rates in the VAYB, UT, and UC arms were 91.44%, 92.86%, and 92.31%, respectively. Infants in the VAYB arm were not more likely to be up to date than infants in the UC arm (OR = 0.89; 95% CI, 0.45-1.76) or in the UT arm (OR = 0.82; 95% CI, 0.42-1.63). The odds of being up to date did not differ between UT and UC arms (OR = 1.08; 95% CI, 0.54-2.18). CONCLUSIONS Delivering Web-based vaccine messages tailored to parents' vaccine attitudes and values did not positively impact the timely uptake of infant vaccines.
Collapse
Affiliation(s)
- Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado;
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
| | - Nicole M Wagner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
- Adult and Child Consortium for Health Outcomes Research and Delivery Science and
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Jennifer Pyrzanowski
- Adult and Child Consortium for Health Outcomes Research and Delivery Science and
| | - Bethany M Kwan
- Adult and Child Consortium for Health Outcomes Research and Delivery Science and
- Departments of Family Medicine and
| | - Carter Sevick
- Adult and Child Consortium for Health Outcomes Research and Delivery Science and
| | - Kenneth Resnicow
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Amanda F Dempsey
- Adult and Child Consortium for Health Outcomes Research and Delivery Science and
- Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| |
Collapse
|
8
|
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.
Collapse
|
9
|
Kiely M, Boulianne N, Talbot D, Ouakki M, Guay M, Landry M, Sauvageau C, De Serres G. Impact of vaccine delays at the 2, 4, 6 and 12 month visits on incomplete vaccination status by 24 months of age in Quebec, Canada. BMC Public Health 2018; 18:1364. [PMID: 30537969 PMCID: PMC6288945 DOI: 10.1186/s12889-018-6235-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 11/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Timeliness in the administration of recommended vaccines is often evaluated using vaccine delays and provides more information regarding the susceptibility of children to vaccine-preventable diseases compared with vaccine coverage at a given age. The importance of on-time administration of vaccines scheduled at the first visit is well documented, but data are scarce about the impact of vaccine delays at other visits on vaccination status by 24 months of age. Using vaccine delays for the first three doses of DTaP-containing vaccines and for the first dose of measles-containing vaccines as markers of timeliness at the 2, 4, 6 and 12 month visits, we estimated the proportion of incomplete vaccination status by 24 months of age attributable to a vaccine delay at each of these visits. METHODS We used the data from six cross-sectional coverage surveys conducted in the Province of Quebec from 2006 to 2016 which included 7183 children randomly selected from the universal health insurance database. A vaccine dose was considered delayed if received 30 days or more after the recommended age. The impact of new vaccine delays at each visit on incomplete vaccination status by 24 months of age was estimated with the attributable risk in the population. RESULTS The proportion of children with vaccine delay was 5.4% at 2 months, 13.3% at 4 months, 23.1% at 6 months and 23.6% at 12 months. Overall, 72.5% of all 2-year-old children with an incomplete status by 24 months were attributable with a vaccine delay, of which 16.1% were attributable with a first vaccine delay at 2 months, 10.6% at 4 months, 14.0% at 6 months and 31.8% at 12 months. CONCLUSIONS While great emphasis has been put on vaccine delays at the first vaccination visit, the prevalence of vaccine delays was greater with later visits and most children with an incomplete vaccination status by 24 months had a vaccine delay occurring during these later visits. Interventions to improve timeliness should address vaccine delays at each visit and not only focus on the first visit.
Collapse
Affiliation(s)
- Marilou Kiely
- Institut national de santé publique du Quebec, 2400 d'Estimauville Avenue, Quebec, G1E 7G9, Canada. .,Department of Social and Preventive Medicine, Laval University, Quebec, Canada.
| | - Nicole Boulianne
- Institut national de santé publique du Quebec, 2400 d'Estimauville Avenue, Quebec, G1E 7G9, Canada
| | - Denis Talbot
- Department of Social and Preventive Medicine, Laval University, Quebec, Canada.,CHU de Québec-Université Laval, Quebec, Canada
| | - Manale Ouakki
- Institut national de santé publique du Quebec, 2400 d'Estimauville Avenue, Quebec, G1E 7G9, Canada
| | - Maryse Guay
- Institut national de santé publique du Quebec, 2400 d'Estimauville Avenue, Quebec, G1E 7G9, Canada.,Department of Community Health Sciences, Sherbrooke University, Quebec, Canada.,Centre intégré de Santé et Services Sociaux de la Montérégie-Centre, Quebec, Canada
| | - Monique Landry
- Ministère de la Santé et des Services Sociaux, Quebec, Canada
| | - Chantal Sauvageau
- Institut national de santé publique du Quebec, 2400 d'Estimauville Avenue, Quebec, G1E 7G9, Canada.,Department of Social and Preventive Medicine, Laval University, Quebec, Canada.,CHU de Québec-Université Laval, Quebec, Canada
| | - Gaston De Serres
- Institut national de santé publique du Quebec, 2400 d'Estimauville Avenue, Quebec, G1E 7G9, Canada.,Department of Social and Preventive Medicine, Laval University, Quebec, Canada.,CHU de Québec-Université Laval, Quebec, Canada
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Rafferty E, Hetherington E, Tough S, Aujla S, McNeil D, Saini V, McDonald S, MacDonald SE. The impact of time since vaccination and study design on validity in parental recall of childhood vaccination status in the All Our Families cohort. Vaccine 2018; 36:2953-2959. [PMID: 29699787 DOI: 10.1016/j.vaccine.2018.04.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 04/13/2018] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Parental reporting of childhood vaccination status is often used for policy and program evaluation and research purposes. Many factors can bias parental reporting of childhood vaccination status, however, to our knowledge, no analysis has assessed whether time since vaccination impacts reporting accuracy. Therefore, using the Calgary electronic vaccine registry (PHANTIM) as the gold standard, we aimed to test the accuracy of parental reporting of childhood vaccination status at three different time-points since vaccination. METHODS The All Our Families (AOF) cohort study asked parents to report their child's 2, 4, 6, 12 and 18 month vaccines (vaccination time-point) on questionnaires given when the child was 1, 2 and 3 years of age (survey time-point). We linked the AOF parental reporting of vaccination status to the PHANTIM registry and calculated the percent agreement and difference in coverage estimates between PHANTIM and AOF at each vaccination and survey time-point combination. Furthermore, we measured the sensitivity and specificity, and negative (NPV) and positive predictive values (PPV) of parental vaccine recall across time. RESULTS AOF parent reports of coverage rates were consistently higher than the PHANTIM estimates. While we saw significant differences in percent agreement for certain vaccination time-points, we saw no consistent directional difference by survey time-point, suggesting that parental accuracy did not change with time. We found a uniformly high sensitivity across all vaccination and survey time-points, and no consistent patterns in the specificity, PPV and NPV results. CONCLUSION Time since vaccination may not be the most important consideration when designing and implementing a vaccination survey. Other factors that may contribute to the bias associated with parental reporting of vaccination status include the complexity of the vaccine schedule, schedule changes over time, and the wording and structure of the questionnaires.
Collapse
Affiliation(s)
- Ellen Rafferty
- University of Alberta, Faculty of Nursing, 5-308 Edmonton Clinic Health Academy, Edmonton, AB T6G 1C9, Canada
| | - Erin Hetherington
- University of Calgary, Cumming School of Medicine, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Suzanne Tough
- University of Calgary, Cumming School of Medicine, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Shyrose Aujla
- University of Calgary, Cumming School of Medicine, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada
| | - Deborah McNeil
- University of Calgary, Cumming School of Medicine, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada; Strategic Clinical Networks, Alberta Health Services, Seventh Street Plaza, 14th Floor, North Tower, 10030 - 107 Street NW, Edmonton, AB T5J 3E4, Canada; University of Calgary, Faculty of Nursing, 2800 University Way N.W., Calgary, AB T2N 1N4, Canada
| | - Vineet Saini
- Population, Public and Indigenous Health, Alberta Health Services, Seventh Street Plaza, 14th Floor, North Tower, 10030 - 107 Street NW, Edmonton, AB T5J 3E4, Canada
| | - Sheila McDonald
- Population, Public and Indigenous Health, Alberta Health Services, Seventh Street Plaza, 14th Floor, North Tower, 10030 - 107 Street NW, Edmonton, AB T5J 3E4, Canada
| | - Shannon E MacDonald
- University of Alberta, Faculty of Nursing, 5-308 Edmonton Clinic Health Academy, Edmonton, AB T6G 1C9, Canada; University of Calgary, Cumming School of Medicine, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada.
| |
Collapse
|
12
|
Glanz JM, Newcomer SR, Daley MF, DeStefano F, Groom HC, Jackson ML, Lewin BJ, McCarthy NL, McClure DL, Narwaney KJ, Nordin JD, Zerbo O. Association Between Estimated Cumulative Vaccine Antigen Exposure Through the First 23 Months of Life and Non-Vaccine-Targeted Infections From 24 Through 47 Months of Age. JAMA 2018; 319:906-913. [PMID: 29509866 PMCID: PMC5885913 DOI: 10.1001/jama.2018.0708] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Some parents are concerned that multiple vaccines in early childhood could weaken their child's immune system. Biological data suggest that increased vaccine antigen exposure could increase the risk for infections not targeted by vaccines. OBJECTIVE To examine estimated cumulative vaccine antigen exposure through the first 23 months of life in children with and without non-vaccine-targeted infections from 24 through 47 months of age. DESIGN, SETTING, AND PARTICIPANTS A nested case-control study was conducted in 6 US health care organizations participating in the Vaccine Safety Datalink. Cases were identified by International Classification of Diseases codes for infectious diseases in the emergency department and inpatient medical settings and then validated by medical record review. Cases of non-vaccine-targeted infection were matched to controls by age, sex, health care organization site, and chronic disease status. Participants were children ages 24 through 47 months, born between January 1, 2003, and September 31, 2013, followed up until December 31, 2015. EXPOSURES Cumulative vaccine antigen exposure, estimated by summing the number of antigens in each vaccine dose received from birth through age 23 months. MAIN OUTCOMES AND MEASURES Non-vaccine-targeted infections, including upper and lower respiratory infections and gastrointestinal infections, from 24 through 47 months of age, and the association between these infections and estimated cumulative vaccine exposure from birth through 23 months. Conditional logistic regression was used to estimate matched odds ratios representing the odds of non-vaccine-targeted infections for every 30-unit increase in estimated cumulative number of antigens received. RESULTS Among the 944 patients (193 cases and 751 controls), the mean (SD) age was 32.5 (6.3) months, 422 (45%) were female, and 61 (7%) had a complex chronic condition. Through the first 23 months, the estimated mean (SD) cumulative vaccine antigen exposure was 240.6 (48.3) for cases and 242.9 (51.1) for controls. The between-group difference for estimated cumulative antigen exposure was -2.3 (95% CI, -10.1 to 5.4; P = .55). Among children with vs without non-vaccine-targeted infections from 24 through 47 months of age, the matched odds ratio for estimated cumulative antigen exposure through age 23 months was not significant (matched odds ratio, 0.94; 95% CI, 0.84 to 1.07). CONCLUSIONS AND RELEVANCE Among children from 24 through 47 months of age with emergency department and inpatient visits for infectious diseases not targeted by vaccines, compared with children without such visits, there was no significant difference in estimated cumulative vaccine antigen exposure through the first 23 months of life.
Collapse
Affiliation(s)
- Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Denver
- Department of Epidemiology, Colorado School of Public Health, Aurora
| | | | - Matthew F Daley
- Institute for Health Research, Kaiser Permanente Colorado, Denver
| | - Frank DeStefano
- Immunization Safety Office (Vaccine Safety Datalink), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Holly C Groom
- Kaiser Permanente Center for Health Research, Northwest Kaiser Permanente, Portland, Oregon
| | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Bruno J Lewin
- Kaiser Permanente Department of Research and Evaluation, Kaiser Permanente of Southern California, Pasadena
| | - Natalie L McCarthy
- Immunization Safety Office (Vaccine Safety Datalink), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David L McClure
- Marshfield Clinic Research Foundation, Marshfield, Wisconsin
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Denver
| | | | - Ousseny Zerbo
- Kaiser Permanente Division of Research, Kaiser Permanente of Northern California, Oakland
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|