The number of injected same-day preschool vaccines relates to preadolescent needle fear and HPV uptake

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

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

Acceptance of HPV vaccination in boys among mothers from selected churches in Accra, Ghana

BACKGROUND

Almost all cases of cervical and anal cancer have been linked to the human papillomavirus (HPV). However, in addition to women who develop HPV-related cervical cancer, both men and women can also develop cancers of the anus, oral cavity, and oropharynx that are attributed to HPV. However, literature on HPV vaccination among boys globally, in Africa, and most especially in Ghana is scarce. Thus, the main objective of this study was to explore the acceptance of HPV vaccination in boys among mothers from selected churches in Accra, Ghana.

METHODS

In this study, a qualitative exploratory design was utilized to enlist 30 mothers who have male children aged between 9 and 12 years from the Greater Accra Region of Ghana. The recruitment of participants was carried out using a purposive sampling technique, and they were subsequently interviewed in-depth in a face-to-face setting, with the entire conversation being recorded for reference. After transcription, the recorded data were analyzed through content analysis.

FINDINGS

Upon analyzing the data, two (2) primary themes and 11 sub-themes emerged. The research showed that although the majority of the mothers were unaware of HPV in boys, they perceived it as a positive initiative and expressed a willingness to allow their sons to receive the vaccine. However, some participants mentioned certain factors that they believed could hinder the acceptance of HPV vaccination in boys among mothers. These included concerns about injection-related pain, high cost, and fears that the vaccine could make men immoral or infertile.

CONCLUSION

The study revealed poor awareness of HPV vaccination in boys among mothers, and hence, suggested the need to increase the awareness on HPV vaccination in boys among mothers as well as the public to increase its acceptance.

Factors Associated With Low Procedural Pain Scores Among 1- to 5-Year-Old Patients Undergoing Facial Laceration Repair

OBJECTIVES

Our objectives were to quantify pain experienced by young children undergoing facial laceration repair and identify factors associated with low procedural pain scores.

METHODS

We conducted a prospective cohort study of children's distress among a convenience sample of children aged 1 to 5 years undergoing facial or scalp laceration repair in 2 pediatric emergency departments. We reviewed video recordings and documented pain scores at 15-second intervals using the Face, Leg, Activity, Cry, Consolability-Revised (FLACC-r) scale. We dichotomized FLACC-r into low/high scores (≤3 and >3) to evaluate practice variables.

RESULTS

We included 11,474 FLACC-r observations from 258 procedures in the analysis. Two-thirds of 3- to 5-year-olds completed their laceration repair without the use of restraint, sedation, or anxiolytics. Mean distress scores were low (≤2.5 out of 10) across all procedure phases for 2- to 5-year-old patients. One-year-old patients experienced significantly more distress than their older counterparts (mean ≤4.2 out of 10). Odds of having low FLACC scores (≤3) were greater for patients with an expert clinician (adjusted odds ratio [aOR]: 1.72; 95% confidence interval [CI], 1.05-2.84). Wound infiltration (aOR, 0.35; 95% CI, 0.13-0.93), patient observation of a needle (aOR, 0.21; 95% CI, 0.14-0.33), and restraint (aOR, 0.04; 95% CI, 0.02-0.06) were negatively associated with low FLACC score.

CONCLUSION

The majority of 3- to 5-year-old patients were able to undergo facial laceration repair without restraint, sedation, or anxiolytics and with low mean distress scores. Our findings suggest that children's risk of experiencing moderate and severe distress during facial and scalp laceration repair may be reduced by prioritizing wound closure by expert-level clinicians, ensuring effective lidocaine-epinephrine-tetracaine application, avoiding restraint, and concealing needles from patient view.

Timing of Monovalent Vaccine Administration in Infants Receiving DTaP-based Combination Vaccines in the United States

BACKGROUND

The recommended US infant immunization schedule includes doses of diphtheria, tetanus, acellular pertussis (DTaP), inactivated poliovirus (IPV), Haemophilus influenzae type b (Hib) and hepatitis B virus (HepB) during the first 6 months of life. Little information is available about the timing of associated, complementary monovalent vaccine administration in infants receiving DTaP-based pentavalent combination vaccines.

METHODS

This was a retrospective cohort study of infants born between July 1, 2010, and June 30, 2018, in the US MarketScan commercial claims and encounters database. Descriptive statistics were used to assess vaccine administration patterns. Multivariate logistic regression was performed to explore factors associated with coadministration of DTaP-IPV/Hib and HepB.

RESULTS

Among infants who received DTaP-HepB-IPV (n = 129,885), 93.7% had claims for at least 2 Hib doses; most (91.5%-98.3%) of these doses were administered on the same day as DTaP-HepB-IPV doses. Among infants who received DTaP-IPV/Hib (n=214,172), 95.3% had claims for ≥2 doses of HepB. Although coverage was high, 59.2% received the second HepB dose on the same day as the first DTaP-IPV/Hib dose, and 44.6% received the third dose of HepB on the same day as the third DTaP-IPV/Hib dose. Differences in coadministration of the second and third HepB doses with DTaP-IPV/Hib were associated with the region of residence, provider type, health plan type and coadministration of pneumococcal conjugate vaccine and rotavirus vaccine.

CONCLUSIONS

Almost all infants received the appropriate, complementary monovalent vaccine series. However, this study found variability in the timing of HepB doses in relation to DTaP-IPV/Hib doses with many infants not completing the HepB series until 9 months of age.

Needle Fear among Children during Mass Measles Rubella (MR) Injectable Vaccination Campaign in North India: an Observational Study

The cross-sectional observational study evaluated the prevalence and predictors of needle-fear among school-going children during mass Measles-Rubella (MR) immunization campaign (year 2017) in the north Indian city of Chandigarh. Fear of needle was assessed using a single-item self-report global question, anxiety was assessed using the Likert scale (score 1-5) and the standardized "Children Faces Scale" where facial responses were graded from 0 to 4. Out of a total sample of 2568 school children, 1225 (47.7%) reported needle fear (95% CI: 45.8%-49.6%) on a global single item assessment. On an anxiety related Likert scale, 52.3% did not respond (mainly younger children) and among those who responded, 42.6% (523/1226) showed significant anxiety (score of ≥3 on Likert scale of 1 to 5). Finally, 17.4% children (95% CI: 15.9%-18.9%) (n = 446/2568) scored 2 or above (indicating significant needle fear) on the 'Children Faces Scale' during the actual vaccination procedure. The needle fear were significantly increased among girl students as compared to boys (adjusted OR 2.58; 95% CI: 2.05-3.24, p < 0.001) as well as children accompanied by their parents (adjusted OR 2.05; 95% CI:1.57-2.69, p < 0.001). On the other hand, needle fear was significantly lowered in children studying in private schools as compared to public school children (adjusted OR 0.45; 95% CI: 0.28-0.74, p = 0.002). The needle fear, which was an overriding concern in the minds of girls, children accompanied by their parents, and public-school students, must be proactively addressed for successful mass vaccination campaigns. These findings assume further importance with recent international roll out of COVID 19 vaccine.

Boosting of SARS-CoV-2 immunity in nonhuman primates using an oral rhabdoviral vaccine

An orally active vaccine capable of boosting SARS-CoV-2 immune responses in previously infected or vaccinated individuals would help efforts to achieve and sustain herd immunity. Unlike mRNA-loaded lipid nanoparticles and recombinant replication-defective adenoviruses, replicating vesicular stomatitis viruses with SARS-CoV-2 spike glycoproteins (VSV-SARS2) were poorly immunogenic after intramuscular administration in clinical trials. Here, by G protein trans-complementation, we generated VSV-SARS2(+G) virions with expanded target cell tropism. Compared to parental VSV-SARS2, G-supplemented viruses were orally active in virus-naive and vaccine-primed cynomolgus macaques, powerfully boosting SARS-CoV-2 neutralizing antibody titers. Clinical testing of this oral VSV-SARS2(+G) vaccine is planned.

Effect of a School-Based Educational Intervention About the Human Papillomavirus Vaccine on Psychosocial Outcomes Among Adolescents: Analysis of Secondary Outcomes of a Cluster Randomized Trial

IMPORTANCE

Delivery of vaccination to adolescents via a school-based program provides an opportunity to promote their involvement in health decision-making, service provision, and self-efficacy (belief in one's ability to perform a certain behavior).

OBJECTIVE

To examine the effect of a human papillomavirus (HPV) vaccination education and logistical intervention on adolescent psychosocial outcomes.

DESIGN, SETTING, AND PARTICIPANTS

In this cluster randomized trial and process and qualitative evaluation, adolescents aged 12 to 13 years (first year of high school) were recruited at high schools in Western Australia (WA) and South Australia (SA) in 2013 and 2014. Statistical analysis was performed from January 2016 to December 2020.

INTERVENTIONS

The complex intervention consisted of an adolescent intervention to promote knowledge and psychosocial outcomes, shared decisional support tool, and logistical strategies.

MAIN OUTCOMES AND MEASURES

Prespecified secondary outcomes were assessed. The HPV Adolescent Vaccination Intervention Questionnaire (HAVIQ) was used to measure changes in adolescent knowledge (6-item subscale), fear and anxiety (6-item subscale), self-efficacy (5-item subscale), and decision-making (8-item subscale). The hypothesis was that the intervention would improve adolescent involvement in vaccine decision-making (measured before dose 1 only), improve vaccine-related self-efficacy, and reduce vaccine-related fear and anxiety (measured before doses 1, 2, and 3). Mean (SD) scores for each subscale were compared between intervention and control students. In the process evaluation, focus groups were conducted. Analyses of the HAVIQ data were conducted from 2016 to 2020. Qualitative analyses of the focus groups were undertaken from 2017 to 2020.

RESULTS

The trial included 40 schools (21 intervention and 19 control) across sectors with 6967 adolescents (mean [SD] age, 13.70 [0.45] years). There were 3805 students (1689 girls and 2116 boys) in the intervention group and 3162 students (1471 girls and 1691 boys) in the control group. The overall response rate for the HAVIQ was 55%. In WA, where parental consent was required, the response rate was 35% (1676 of 4751 students); in SA, where parental consent was not required, it was 97% (2166 of 2216 students). The mean (SD) score for decision-making in the intervention group before dose 1 was 3.50 (0.42) of 5 points and 3.40 (0.40) in the control group, a small but significant difference of 0.11 point (95% CI, 0.06 to 0.16 point; P < .001). There was a small difference in favor of the intervention group in reduced vaccination-related anxiety (pre-dose 1 difference, -0.11 point [95% CI, -0.19 to -0.02 point]; pre-dose 2 difference, -0.18 point [95% CI, -0.26 to -0.10 point]; pre-dose 3 difference, -0.18 [95% CI, -0.24 to -0.11]) and increased vaccination self-efficacy (pre-dose 1 difference, 4.0 points; [95% CI, 1.0 to 7.0 points]; pre-dose 2 difference, 4.0 points [95% CI, 2.0 to 6.0 points]; pre-dose 3 difference, 3.0 points [95% CI, 1.0 to 5.0 points]). Focus group data from 111 adolescents in 6 intervention and 5 control schools revealed more confidence and less anxiety with each vaccine dose.

CONCLUSIONS AND RELEVANCE

In this cluster randomized trial, there was a small difference in adolescent decisional involvement and vaccine-related confidence and reduced vaccination-related fear and anxiety that was maintained throughout the vaccine course in the intervention vs control groups. Guidelines for vaccination at school should incorporate advice regarding how this outcome can be achieved.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN12614000404628.

Exploring and Monitoring the Reasons for Hesitation with COVID-19 Vaccine Based on Social-Platform Text and Classification Algorithms

(1) Background: The COVID-19 pandemic is globally rampant, and it is the common goal of all countries to eliminate hesitation in taking the COVID-19 vaccine and achieve herd immunity as soon as possible. However, people are generally more hesitant about the COVID-19 vaccine than about other conventional vaccines, and exploring the specific reasons for hesitation with the COVID-19 vaccine is crucial. (2) Methods: this paper selected text data from a social platform to conduct qualitative analysis of the text to structure COVID-19 vaccine hesitancy reasons, and then conducted semiautomatic quantitative content analysis of the text through a supervised machine-learning method to classify them. (3) Results: on the basis of a large number of studies and news reports on vaccine hesitancy, we structured 12 types of the COVID-19 vaccine hesitancy reasons. Then, in the experiment, we conducted comparative analysis of three classifiers: support vector machine (SVM), logistic regression (LR), and naive Bayes classifier (NBC). Results show that the SVM classification model with TF-IDF and SMOTE had the best performance. (4) Conclusions: our study structured 12 types of COVID-19 vaccine hesitancy reasons through qualitative analysis, filling in the gaps of previous studies. At the same time, this work provides public health institutions with a monitoring tool to support efforts to mitigate and eliminate COVID-19 vaccine hesitancy.

A Pilot Study to Understand the Adolescent Pain Experience During Contraceptive Implant Insertion

PURPOSE

In adolescents, concrete thinking may present as avoidance of an immediate, painful or uncomfortable experience despite long-term benefits, which may affect contraceptive choice. In this pilot study, we sought to better understand the pain that adolescents and young adults experience during contraceptive implant insertion.

MATERIALS AND METHODS

In this cohort study, we surveyed 30 adolescents and young adults at their implant insertion visit about pre-procedure anxiety and pain experienced during lidocaine injection and Nexplanon™ placement.

RESULTS

The average pre-procedure anxiety (Visual Analog Scale-Anxiety) score was 40 ± 29 mm. The average pain reported during lidocaine injection was 19 ± 21 mm and 6 ± 11 mm for implant insertion. Pre-procedure anxiety was not associated with pain during lidocaine injection (P = .61) or implant placement (P = .85).

CONCLUSION

Pain scores were low with both lidocaine injection and implant placement. Pre-procedure anxiety did not predict pain during lidocaine or implant placement. Patients considering an implant should be reassured by these data.

Multi-Electrode Array of Sensory Neurons as an In Vitro Platform to Identify the Nociceptive Response to Pharmaceutical Buffer Systems of Injectable Biologics

PURPOSE

Pharmaceutical buffer systems, especially for injectable biologics such as monoclonal antibodies, are an important component of successful FDA-approved medications. Clinical studies indicate that buffer components may be contributing factors for increased injection site pain.

METHODS

To determine the potential nociceptive effects of clinically relevant buffer systems, we developed an in vitro multi-electrode array (MEA) based recording system of rodent dorsal root ganglia (DRG) sensory neuron cell culture. This system monitors sensory neuron activity/firing as a surrogate of nociception when challenged with buffer components used in formulating monoclonal antibodies and other injectable biologics.

RESULTS

We show that citrate salt and citrate mannitol buffer systems cause an increase in mean firing rate, burst frequency, and burst duration in DRG sensory neurons, unlike histidine or saline buffer systems at the same pH value. Lowering the concentration of citrate leads to a lower firing intensity of DRG sensory neurons.

CONCLUSION

Increased activity/firing of DRG sensory neurons has been suggested as a key feature underlying nociception. Our results support the utility of an in vitro MEA assay with cultured DRG sensory neurons to probe the nociceptive potential of clinically relevant buffer components used in injectable biologics.

What Is the State-of-the-Art in Clinical Trials on Vaccine Hesitancy 2015-2020?

BACKGROUND

Vaccine hesitancy is related to a delay in acceptance or refusal of vaccination.

AIM

to perform a systematic review of clinical trials on vaccine hesitancy (2015-2020).

METHODS

a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria (PRISMA). Five databases were screened-PubMed, Cochrane Library, DOAJ, SciELO and b-on-which comprise multiple resources.

KEYWORDS

"Vaccine hesitancy" and ("randomized controlled trial" or "clinical trial").

INCLUSION CRITERIA

trials about "vaccine hesitancy" enrolling patients and/or health professionals (2015-2020).

EXCLUSION CRITERIA

studies about other topics, repeated and qualitative studies, reviews and papers written in languages other than English, Portuguese, French or Spanish.

RESULTS

a total of 35 trials out of 90 were selected (19 PubMed, 14 Cochrane Library, 0 DOAJ, 0 SciELO and 2 b-on). Selected trials were classified into five topics: children/pediatric (n = 5); online or electronic information (n = 5); vaccination against a specific disease (n = 15) (e.g., influenza or COVID-2019); miscellaneous (n = 4); and educational strategies (n = 6).

CONCLUSION

the provision of online or electronic information (e.g., through virtual reality, social websites of experts, or apps), communication-based interventions and training of health professionals, residents or subjects seemed to improve vaccine hesitancy.

Multi-domain narrative review of vaccine hesitancy in childhood

Vaccine hesitancy, where individuals delay or refuse some or all vaccines, is a perennial problem. It undermines the success of the immunisation programmes and places the society, especially vulnerable populations such as children, at risk of contracting infectious diseases. The phenomenon has been extensively analysed based on four aspects - confidence, complacency, convenience and costs. We suggest the alternative use of a multi-dimensional framework adapted from the "Generalist Wheel of Knowledge, Understanding and Inquiry" that was developed by Prof Larry Green and Kurt Stange, to assess the multiple facilitators and barriers towards vaccine hesitancy in childhood vaccination. The framework identifies domains in the healthcare system namely the child and parent/family, the clinician, the healthcare system and policy, and the infectious disease and corresponding vaccine that influence vaccine hesitancy. This narrative review includes literature beyond those covered by the World health Organisation Global Vaccine Action Plan (WHO GVAP). It identifies emotional distress, past negative experience and misconceptions that contribute to vaccine hesitancy in children and family, while attitude and motivation underpin vaccine hesitancy in clinicians. The healthcare system contributes to vaccine hesitancy when enforcements, diligent monitoring and transparency are absent or lacking. Inefficient dissemination of information about the disease and its associated vaccine as well as inadequate surveillance of misinformation add to vaccine hesitancy. The inter-domain factors highlight the roles of relationship between the clinician, child and parent, information mastery of the clinician, prioritisation of resources and equity in combating vaccine hesitancy. Using this framework, we present evidence-based strategies which have been effective in mitigating vaccine hesitancy for each domain and their corresponding inter-domains. By providing new perspectives of a complex problem and its potential solutions, this narrative review aims to complement and support the WHO GVAP by developing a coordinated multi-domain strategy to mitigate vaccine hesitancy in childhood.

Subcutaneous Delivery of High-Dose/Volume Biologics: Current Status and Prospect for Future Advancements

Subcutaneous (SC) delivery of biologics has traditionally been limited to fluid volumes of 1-2 mL, with recent increases to volumes of about 3 mL. This injection volume limitation poses challenges for high-dose biologics, as these formulations may also require increased solution concentration in many cases, resulting in high viscosities which can affect the stability, manufacturability, and delivery/administration of therapeutic drugs. Currently, there are technologies that can help to overcome these challenges and facilitate the delivery of larger amounts of drug through the SC route. This can be achieved either by enabling biologic molecules to be formulated or delivered as high-concentration injectables (>100 mg/mL for antibodies) or through facilitating the delivery of larger volumes of fluid (>3 mL). The SC Drug Delivery and Development Consortium, which was established in 2018, aims to identify and address critical gaps and issues in the SC delivery of high-dose/volume products to help expand this delivery landscape. Identified as a high priority out of the Consortium's eight problem statements, it highlights the need to shift perceptions of the capabilities of technologies that enable the SC delivery of large-volume (>3 mL) and/or high-dose biologics. The Consortium emphasizes a patient-focused approach towards the adoption of SC delivery of large-volume/high-concentration dosing products to facilitate the continued expansion of the capabilities of novel SC technologies. To raise awareness of the critical issues and gaps in high-dose/volume SC drug development, this review article provides a generalized overview of currently available and emerging technologies and devices that could facilitate SC delivery of high-dose/volume drug formulations. In addition, it discusses the challenges, gaps, and future outlook in high-dose/volume SC delivery as well as potential solutions to exploit the full value of the SC route of administration.

Strategies to improve human papillomavirus vaccination rates among adolescents in family practice settings in the United States: A systematic review

AIMS AND OBJECTIVES

To explore the interventions aimed at increasing human papillomavirus (HPV) vaccination rates among adolescents in family practice settings.

BACKGROUND

HPV is the most common sexually transmitted disease in the United States, and the cause of thousands of anogenital and oropharyngeal cancers annually. Although HPV infection can be prevented with recommended vaccination during adolescence, national HPV vaccine rates remain low.

DESIGN

Systematic review.

METHODS

Four databases (MEDLINE, CINAHL, EMBASE and the Cochrane Library) were searched. The search was guided by PRISMA and by the question, 'What are targeted interventions that improve HPV vaccination rates among adolescents in family practice settings?' Articles were reviewed for study characteristics and appraised for quality using the revised Cochrane risk of bias tools.

RESULTS

Eleven studies met inclusion and exclusion criteria. Individual study size samples ranged from 749-147,294, with a combined total from all included studies of 276,205; the largest sample reviewed to date from family practice settings. Interventions used to increase HPV vaccination rates included reminder systems; provider and staff education; sensory incentives such as hitting a gong or petting a puppy; and iPad tailored messaging programmes. Studies that employed interventions pre-, during and postvisit were most effective in increasing HPV vaccination rates.

CONCLUSIONS

This review provides the largest data supporting multimodal strategies to increase HPV vaccination rates among adolescent populations. It provides strong evidence to suggest that vaccination rates can be improved using measures at varying times of the patient visit.

RELEVANCE TO CLINICAL PRACTICE

Adolescents seek health care in various settings. Many studies have examined interventions to increase HPV vaccination in paediatric settings, but few have examined interventions in family practice settings. This review suggests that family practices should implement multimodal measures before, during and after visits to increase HPV vaccination among adolescent patients.

Effects of psychological intervention and relevant influence factors on pregnant women undergoing interventional prenatal diagnosis

BACKGROUND

This study aims to explore the effects of psychological intervention on eliminating anxiety and fear in pregnant women caused by interventional prenatal diagnosis, and the success rate of surgery.

METHODS

A total of 100 pregnant women who scheduled for interventional prenatal diagnosis were included in this study, and were randomly divided into two groups: control group and intervention group. Women in the control group were given routine nursing care, and women in the intervention group were given psychological intervention in different stages of the operation. Psychological status were assessed by the symptom checklist-90 (SCL-90), self-rating anxiety scale (SAS), self-rating depression scale (SDS), and visual analogue scale (VAS). Furthermore, the success rate of surgery and the incidence of postoperative complications were tracked.

RESULTS

Compared with the control group, the SCL-90 test scores of pregnant women in the intervention group were significantly lower in the following five factors: somatization, interpersonal sensitivity, depression, anxiety, and fear (p < 0.05). Furthermore, postoperative SAS, SDS, and VAS scores in the intervention group were significantly lower than in the control group; and the differences were statistically significant (p < 0.01).

CONCLUSION

Before pregnant women undergo interventional prenatal diagnosis, nurses should understand their psychological status and give psychological guidance in time, calm their anxiety, tension and fear, and help them build confidence to weather the pregnancy stages before and after the operation. This would improve the success rate of puncture and reduce the incidence of complications.

Understanding the basis of transcutaneous vaccine delivery

Under many circumstances, prophylactic immunizations are considered as the only possible strategy to control infectious diseases. Considerable efforts are typically invested in immunogen selection but, erroneously, the route of administration is not usually a major concern despite the fact that it can strongly influence efficacy. The skin is now considered a key component of the lymphatic system with tremendous potential as a target for vaccination. The purpose of this review is to present the immunological basis of the skin-associated lymphoid tissue, so as to provide understanding of the skin vaccination strategies. Several strategies are currently being developed for the transcutaneous delivery of antigens. The classical, mechanical or chemical disruptions versus the newest approaches based on microneedles for antigen delivery through the skin are discussed herein.

Acute Pediatric Pain Management in the Primary Care Office

Pain is a chief complaint in children seeking medical care, yet it may also be experienced in evaluation and treatment during office visits. Inadequate relief of children's procedural pain and distress not only affects the experience of the children and their parents, but also adversely affects procedural outcomes. Despite increasing awareness and research, management of procedural pain and anxiety in children is often inadequate. In addition, parent and patient satisfaction is often tied to pain management. Development of a pain management plan must be systematic, individualized, and multimodal. We present a review of nonpharmacologic modalities, topical and oral analgesic agents, and intranasal adjuncts for use in routine outpatient practice. [Pediatr Ann. 2018;47(3):e124-e129.].