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Mohy A, Lagoubi Y, Gomez JA, Amadou B, Bouskraoui M. Health economic evaluation of 2-dose and 3-dose rotavirus vaccines in children below 5 years of age in Morocco. Hum Vaccin Immunother 2024; 20:2353480. [PMID: 38757507 PMCID: PMC11110695 DOI: 10.1080/21645515.2024.2353480] [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: 11/27/2023] [Accepted: 05/07/2024] [Indexed: 05/18/2024] Open
Abstract
Following the introduction of rotavirus vaccination into the Moroccan National Immunization Program, the prevalence of the disease has decreased by nearly 50%. However, evidence on the economic value of rotavirus vaccinations in Morocco is limited. This health economic analysis evaluated, from both country payer and societal perspectives, the costs and the cost-effectiveness of three rotavirus vaccines using a static, deterministic, population model in children aged < 5 years in Morocco. Included vaccines were HRV (2-dose schedule), HBRV (3-dose schedule) and BRV-PV 1-dose vial (3-dose schedule). One-way and probabilistic sensitivity analyses were conducted to assess the impact of uncertainty in model inputs. The model predicted that vaccination with HRV was estimated to result in fewer rotavirus gastroenteritis events (-194 homecare events, -57 medical visits, -8 hospitalizations) versus the 3-dose vaccines, translating into 7 discounted quality-adjusted life years gained over the model time horizon. HRV was associated with lower costs versus HBRV from both the country payer (-$1.8 M) and societal (-$4.1 M) perspectives, and versus BRV-PV 1-dose vial from the societal perspective (-$187,000), dominating those options in the cost-effectiveness analysis. However, costs of BRV-PV 1-dose vial were lower than HRV from the payer perspective, resulting in an ICER of approximately $328,376 per QALY, above the assumed cost effectiveness threshold of $3,500. Vaccination with a 2-dose schedule of HRV may be a cost-saving option and could lead to better health outcomes for children in Morocco versus 3-dose schedule rotavirus vaccines.
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Affiliation(s)
- Ahmed Mohy
- Value Evidence & Outcomes Emerging Markets, GSK, Wavre, Belgium
| | | | - Jorge A. Gomez
- Vaccines, Emerging Markets, GSK, Buenos Aires, Argentina
| | - Barry Amadou
- Vaccines Emerging Markets, GSK, Casablanca, Morocco
| | - Mohammed Bouskraoui
- Faculté de Médecine et de Pharmacie, Cadi Ayyad University, Marrakech, Morocco
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Ghaswalla PK, D’Angelo J, Abu-Elyazeed R. Rotavirus vaccination in the US: a systematic review of vaccination coverage and completion. Hum Vaccin Immunother 2021; 17:872-879. [PMID: 32845792 PMCID: PMC7993132 DOI: 10.1080/21645515.2020.1794440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/06/2020] [Indexed: 11/05/2022] Open
Abstract
A systematic literature review of Medline and Embase databases was conducted to describe rotavirus (RV) vaccine coverage for a complete series, timing of receipt of all doses in the series, and predictors of RV vaccination coverage in the US for two licensed RV vaccines (RV1, RV5). Nine publications were included in the review. RV vaccination coverage rates of under 80% suggest RV vaccines are underutilized relative to the Healthy People 2020 target and other childhood vaccines. About 50-90% of children initiating RV vaccination complete the series and coverage for a complete series is lower for black and Hispanic children (vs. whites), uninsured or Medicaid insured (vs. privately insured), and for foreign-born (vs. US-born) children. Series completion is significantly greater in children receiving DTaP, RV1 (vs. RV5), and for those receiving routine care from a pediatrician. There is a need to design and implement better RV immunization strategies for US children.
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Rafferty E, Guo X, McDonald B, Svenson LW, MacDonald SE. Measurement of coverage, compliance and determinants of uptake in a publicly funded rotavirus vaccination programme: a retrospective cohort study. BMJ Open 2019; 9:e031718. [PMID: 31678951 PMCID: PMC6830662 DOI: 10.1136/bmjopen-2019-031718] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/28/2019] [Accepted: 10/03/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES In June 2015, Alberta, Canada instituted a universal publicly funded rotavirus vaccination programme (Rotarix, RV1), with vaccine doses scheduled for 2 and 4 months of age. Vaccination was restricted so that infants were only allowed to receive first dose between 6 and 20 weeks of age, and second dose before eight calendar months of age. We assessed the coverage and schedule non-compliance of rotavirus vaccination for babies born between June 2015 and August 2016, that is, since the inception of the publicly funded rotavirus vaccination programme, and determined factors associated with rotavirus vaccine uptake. DESIGN Retrospective cohort study using linked administrative health data. SETTING Alberta, Canada. PARTICIPANTS Cohort of 66 689 children. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) First and second dose rotavirus vaccination coverage, (2) percent of children non-compliant with recommended vaccine schedule and (3) adjusted ORs for factors associated with vaccination status. RESULTS For the 66 689 children included in the study, coverage levels for one-dose and two-dose rotavirus vaccination were 87% and 83%, respectively. In comparison, two-dose diphtheria-tetanus-pertussis-polio-Haemophilus influenzae type b vaccine coverage was 92%, despite having the same dosing schedule. Schedule non-compliance during the publicly funded programme was very low. We observed socioeconomic disparities in the uptake of the vaccine, with income, location of residence and number of children in the household all contributing to the odds of a child being vaccinated with rotavirus. CONCLUSIONS Compliance to the recommended rotavirus schedule was very high, suggesting that even with the restrictive rotavirus vaccine schedule, the vaccine can be delivered on-time. However, rotavirus vaccine coverage remained lower than DTaP, a similarly scheduled childhood vaccination. We also observed socioeconomic disparities in vaccine uptake. These findings raise concerns about rotavirus protection in the groups at highest risk for gastrointestinal illness, including low-income and rural populations.
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Affiliation(s)
- Ellen Rafferty
- Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Xiaoyan Guo
- Analytics and Performance Reporting Branch, Alberta Ministry of Health, Edmonton, Alberta, Canada
| | - Bruce McDonald
- Analytics and Performance Reporting Branch, Alberta Ministry of Health, Edmonton, Alberta, Canada
| | - Lawrence W Svenson
- Analytics and Performance Reporting Branch, Alberta Ministry of Health, Edmonton, Alberta, Canada
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Shannon Elizabeth MacDonald
- Nursing, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Saokaew S, Prasitsuebsai W, Bibera GL, Kengkla K, Zhang XH, Oh KB, Lee C. Economic Evaluation of Human Rotavirus Vaccine in Thailand. Infect Dis Ther 2019; 8:397-415. [PMID: 31197662 PMCID: PMC6702508 DOI: 10.1007/s40121-019-0246-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Rotavirus gastroenteritis is the leading cause of severe diarrhoea among young children < 5 years old. Previous cost-effectiveness analyses on rotavirus (RV) vaccination in Thailand have generated conflicting results. The aim of this current study is to evaluate the economic impact of introducing RV vaccination in Thailand, using updated Thai epidemiological and cost data. METHODS Both cost-utility analysis (CUA) and budget impact analysis (BIA) of human rotavirus vaccine (HRV) under a universal mass vaccination (UMV) programme were conducted. A published static, deterministic, cross-sectional population model was adapted to assess costs and health outcomes associated with RV vaccination among Thai children < 5 years old during 1 year for CUA and over a 5-year period (2019-2023) for BIA. Data identified through literature review were incorporated into the model after consultation with local experts. Base case CUA was conducted from a societal perspective with quality-adjusted life year (QALY) discounted at 3% annually. Scenario analyses as well as one-way and probabilistic sensitivity analyses were conducted to assess the robustness of the base case CUA results. Costs were updated to 2017. RESULTS At 99% coverage, HRV vaccination would substantially reduce RV-related disease burden. With an incremental cost-effectiveness ratio (ICER) of Thai baht (THB) 49,923/QALY gained, HRV vaccination versus no vaccination was cost-effective when assessed against a local threshold of THB 160,000/QALY gained. Scenario and sensitivity analyses confirmed the cost-effectiveness with all resultant ICERs falling below the willingness-to-pay threshold. HRV use in the UMV programme was estimated to result in a net expenditure of about THB 255-281 million to the Thai government in the 5th year of the programme, depending on vaccine uptake. CONCLUSION HRV vaccination is estimated to be cost-effective in Thailand. The budget impact following inclusion of HRV into the UMV programme is expected to be partially offset by substantial reductions in RV-related disease costs. FUNDING GlaxoSmithKline Biologicals SA GSK STUDY IDENTIFIER: HO-17-18213.
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Affiliation(s)
- Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
- Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Malaysia
| | | | | | - Kirati Kengkla
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
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Layton JB, Butler AM, Brookhart MA, Panozzo CA. Variation in rotavirus vaccination coding in state US Medicaid data. Vaccine 2019; 37:2892-2895. [PMID: 30876721 PMCID: PMC6510625 DOI: 10.1016/j.vaccine.2019.02.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/13/2019] [Accepted: 02/25/2019] [Indexed: 11/26/2022]
Abstract
Differences in state Medicaid policies and practices may result in variation in the recording of individual-level vaccination claims, which may present challenges for vaccination research using state Medicaid data. We describe differences in procedure coding for rotavirus vaccination in four states' Medicaid programs by identifying rotavirus vaccine-specific codes and oral vaccine administration codes. The proportion of vaccinated children with vaccine-specific and oral vaccine administration codes differed substantially across states: two states used vaccine-specific codes almost exclusively (95.9% and 99.0%); one had exclusively oral vaccine administration codes (>99.9%); another had a mixture (32.1% vaccine-specific codes, 40.0% oral vaccine administration codes, and 27.9% both). Depending on the research question, studies using Medicaid data in states without (or with incomplete) vaccine-specific coding may be infeasible. Prior to initiating research, investigators should carefully evaluate state Medicaid policies and patterns of vaccination uptake, as vaccine reimbursement policies and availability of vaccine claims may vary.
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Affiliation(s)
- J Bradley Layton
- RTI Health Solutions, Research Triangle Park, NC, USA; Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Anne M Butler
- Departments of Medicine and Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA.
| | - M Alan Brookhart
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Catherine A Panozzo
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA.
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Aliabadi N, Wikswo ME, Tate JE, Cortese MM, Szilagyi PG, Staat MA, Weinberg GA, Halasa NB, Boom JA, Selvarangan R, Englund JA, Azimi PH, Klein EJ, Moffatt ME, Harrison CJ, Sahni LC, Stewart LS, Bernstein DI, Parashar UD, Payne DC. Factors Associated With Rotavirus Vaccine Coverage. Pediatrics 2019; 143:e20181824. [PMID: 30655333 DOI: 10.1542/peds.2018-1824] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Rotavirus vaccines (RVVs) were included in the US immunization program in 2006 and are coadministered with the diphtheria-tetanus-acellular pertussis (DTaP) vaccine, yet their coverage lags behind DTaP. We assessed timing, initiation, and completion of the RVV series among children enrolled in active gastroenteritis surveillance at 7 US medical institutions during 2014-2016. METHODS We compared coverage and timing of each vaccine series and analyzed characteristics associated with RVV initiation and completion. We report odds ratios (ORs) and 95% confidence intervals (CIs) from multivariable logistic regression models. RESULTS We enrolled 10 603 children. In 2015, ≥1 dose coverage was 91% for RVV and 97% for DTaP. Seven percent of children received their first DTaP vaccine at age ≥15 weeks versus 4% for RVV (P ≤ .001). Recent birth years (2013-2016) were associated with higher odds of RVV initiation (OR = 5.72; 95% CI 4.43-7.39), whereas preterm birth (OR = 0.32; 95% CI 0.24-0.41), older age at DTaP initiation (OR 0.85; 95% CI 0.80-0.91), income between $50 000 and $100 000 (OR = 0.56; 95% CI 0.40-0.78), and higher maternal education (OR = 0.52; 95% CI 0.36-0.74) were associated with lower odds. Once RVV was initiated, recent birth years (2013-2016; OR = 1.57 [95% CI 1.32-1.88]) and higher maternal education (OR = 1.31; 95% CI 1.07-1.60) were associated with higher odds of RVV completion, whereas preterm birth (OR = 0.76; 95% CI 0.62-0.94), African American race (OR = 0.82; 95% CI 0.70-0.97) and public or no insurance (OR = 0.75; 95% CI 0.60-0.93) were associated with lower odds. Regional differences existed. CONCLUSIONS RVV coverage remains lower than that for the DTaP vaccine. Timely DTaP administration may help improve RVV coverage.
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Affiliation(s)
- Negar Aliabadi
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia;
| | - Mary E Wikswo
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jacqueline E Tate
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Margaret M Cortese
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Peter G Szilagyi
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
- University of California, Los Angeles, Los Angeles, California
| | | | - Geoffrey A Weinberg
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | | | - Julie A Boom
- Texas Children's Hospital, Houston, Texas
- Baylor College of Medicine, Houston, Texas
| | | | | | - Parvin H Azimi
- University of California, San Francisco Benioff Children's Hospital Oakland, Oakland, California
| | | | | | | | | | | | | | - Umesh D Parashar
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Daniel C Payne
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Wilson SE, Chung H, Schwartz KL, Guttmann A, Deeks SL, Kwong JC, Crowcroft NS, Wing L, Tu K. Rotavirus vaccine coverage and factors associated with uptake using linked data: Ontario, Canada. PLoS One 2018; 13:e0192809. [PMID: 29444167 PMCID: PMC5812625 DOI: 10.1371/journal.pone.0192809] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 01/30/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In August 2011, Ontario, Canada introduced a rotavirus immunization program using Rotarix™ vaccine. No assessments of rotavirus vaccine coverage have been previously conducted in Ontario. METHODS We assessed vaccine coverage (series initiation and completion) and factors associated with uptake using the Electronic Medical Record Administrative data Linked Database (EMRALD), a collection of family physician electronic medical records (EMR) linked to health administrative data. Series initiation (1 dose) and series completion (2 doses) before and after the program's introduction were calculated. To identify factors associated with series initiation and completion, adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) were calculated using logistic regression. RESULTS A total of 12,525 children were included. Series completion increased each year of the program (73%, 79% and 84%, respectively). Factors associated with series initiation included high continuity of care (aOR = 2.15; 95%CI, 1.61-2.87), maternal influenza vaccination (aOR = 1.55; 95%CI,1.24-1.93), maternal immmigration to Canada in the last five years (aOR = 1.47; 95% CI, 1.05-2.04), and having no siblings (aOR = 1.62; 95%CI,1.30-2.03). Relative to the first program year, infants were more likely to initiate the series in the second year (aOR = 1.71; 95% CI 1.39-2.10) and third year (aOR = 2.02; 95% CI 1.56-2.61) of the program. Infants receiving care from physicians with large practices were less likely to initiate the series (aOR 0.91; 95%CI, 0.88-0.94, per 100 patients rostered) and less likely to complete the series (aOR 0.94; 95%CI, 0.91-0.97, per 100 patients rostered). Additional associations were identified for series completion. CONCLUSIONS Family physician delivery achieved moderately high coverage in the program's first three years. This assessment demonstrates the usefulness of EMR data for evaluating vaccine coverage. Important insights into factors associated with initiation or completion (i.e. high continuity of care, smaller roster sizes, rural practice location) suggest areas for research and potential program supports.
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Affiliation(s)
- Sarah E. Wilson
- Public Health Ontario, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hannah Chung
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Kevin L. Schwartz
- Public Health Ontario, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Shelley L. Deeks
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey C. Kwong
- Public Health Ontario, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Natasha S. Crowcroft
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Laura Wing
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Karen Tu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Parker TC, Mohammed A, Leong T, Mays S, Jain S, Churchill V, Ali F, Immergluck LC. Rotavirus vaccination rate disparities seen among infants with acute gastroenteritis in Georgia. ETHNICITY & HEALTH 2017; 22:585-595. [PMID: 27741577 PMCID: PMC6314174 DOI: 10.1080/13557858.2016.1244744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Rotavirus (RV) is one of the most common diarrheal diseases affecting children less than 5 years of age. RV vaccines have greatly reduced this burden in the United States. The purpose of this study was to determine possible disparities and socio-economic differences in RV vaccination rates. DESIGN Children with acute gastroenteritis were enrolled. Stool was tested for presence of rotavirus using an enzyme immunoassay kit. Vaccination records were abstracted from the state immunization registry and healthcare providers to examine complete and incomplete vaccination status. Cases were identified as children receiving a complete RV dose series and controls were identified as children with incomplete RV doses. A logistic regression model was used to determine disparities seen amongst children with incomplete vaccination status. RESULTS Racial differences between Black and white infants for RV vaccination rates were not significant when controlling for covariates (OR 1.15, 95% CI 0.74-1.78); however ethnicity (p-value .0230), age at onset of illness (p-value .0004), birth year (p-value < .0001), and DTaP vaccination status (p-value < .0001) were all significant in determining vaccination status for children. CONCLUSIONS Racial disparities and socio-economic differences are not determinants in rotavirus vaccination rates; however, age and ethnicity have an effect on RV vaccine status.
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Affiliation(s)
- Trisha C Parker
- a Departments of Pediatrics and Microbiology/Biochemistry/Immunology , Morehouse School of Medicine , Atlanta , GA , USA
- f Postgraduate Medical Institute Clinical Trials Unit , Anglia Ruskin University , Chelmsford , UK
| | - Anaam Mohammed
- b Pediatric Emergency Medicine Associates , Atlanta , GA , USA
| | - Traci Leong
- c Department of Biostatistics and Bioinformatics , Rollins School of Public Health, Emory University , Atlanta , GA , USA
| | - Shelley Mays
- e Children's Healthcare of Atlanta , Atlanta , GA , USA
| | - Shabnam Jain
- d Departments of Pediatrics and Medicine , Emory University , Atlanta , GA , USA
- e Children's Healthcare of Atlanta , Atlanta , GA , USA
| | - Victoria Churchill
- a Departments of Pediatrics and Microbiology/Biochemistry/Immunology , Morehouse School of Medicine , Atlanta , GA , USA
| | - Fatima Ali
- a Departments of Pediatrics and Microbiology/Biochemistry/Immunology , Morehouse School of Medicine , Atlanta , GA , USA
| | - Lilly C Immergluck
- a Departments of Pediatrics and Microbiology/Biochemistry/Immunology , Morehouse School of Medicine , Atlanta , GA , USA
- d Departments of Pediatrics and Medicine , Emory University , Atlanta , GA , USA
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