Evaluating Interventions to Increase Influenza Vaccination Rates among Pediatric Inpatients

Improving Pneumococcal Vaccination Rates in Immunosuppressed Pediatric Patients with Rheumatic Disease

Background

Patients with rheumatic diseases are at a high risk of invasive pneumococcal disease due to immunosuppression. We conducted a quality improvement project, and the first aim was to increase the percentage of patients with systemic lupus erythematosus and mixed connective tissue disease that is up to date on pneumococcal vaccinations from 9.6% to 80% within one year. Subsequently, the second aim was to increase the percentage of patients on immunosuppression with systemic lupus erythematosus, mixed connective tissue disease, juvenile dermatomyositis and systemic vasculitis that is up to date on pneumococcal vaccinations from 62.6% to 80% within one year.

Methods

Two process measures were up-to-date vaccination status on (1) 13-valent pneumococcal conjugated vaccine (PCV13) and (2) 23-valent pneumococcal polysaccharide vaccine (PPSV23). Our outcome measure was being fully up to date on both pneumococcal vaccinations. Interventions included an immunization algorithm, reporting of eligible patients, education, reminders, and pre-visit planning.

Results

There were shifts in the centerline for all quality measures in both phases of this project. The combined pneumococcal vaccination rate for Phase 1 increased from 9.6% to 91.1%, and this centerline was sustained. Pneumococcal vaccination rates also significantly increased for Phase 2: 68.8% to 93.4% for PCV13, 65.2% to 88.5% for PPSV23, and 62.6% to 86.5% for the combined pneumococcal vaccination rate.

Conclusions

Quality improvement methodology significantly increased and sustained pneumococcal vaccination rates in our high-risk, immunosuppressed patients. We continue to prioritize this important initiative to mitigate the risk of invasive pneumococcal disease.

Toward Multidimensional Message Tailoring to Address COVID-19 and Influenza Vaccine-Hesitancy: A Latent Profile Analysis Approach

Vaccines remain the best strategy as the COVID-19 pandemic enters into later stages and governments begin to shed pandemic-control measures. Vaccine hesitancy continues to be a major obstacle in efforts to end the pandemic. This study reports formative evaluation research that adopted a multidimensional approach using latent profile analysis to audience segmentation and message targeting. Within the framework of the integrated behavioral model, data were collected from a US national survey to explore the dimensions in which vaccine-confident vs. -hesitant individuals differed significantly across the topics of COVID-19 and influenza. Latent profile analyses were performed to identify subgroups and establish measurement invariance between COVID-19 and influenza vaccines. Matching message strategies were proposed for the distinctive characteristics of the subgroups for both topics and to be tested in future research.

Effectiveness of hospital-based strategies for improving childhood immunization coverage: A systematic review

BACKGROUND

Hospital settings represent an opportunity to offer and/or promote childhood vaccination. The purpose of the systematic review was to assess the effectiveness of different hospital-based strategies for improving childhood vaccination coverage.

METHODS

A systematic search of multiple bibliographic databases, thesis databases, and relevant websites was conducted to identify peer-reviewed articles published up to September 20, 2021. Articles were included if they evaluated the impact of a hospital (inpatient or emergency department)-based intervention on childhood vaccination coverage, were published in English or French, and were conducted in high-income countries. High quality studies were included in a narrative synthesis.

RESULTS

We included 25 high quality studies out of 7,845 unique citations. Studies focused on routine, outbreak, and influenza vaccines, and interventions included opportunistic vaccination (i.e. vaccination during hospital visit) (n = 7), patient education (n = 2), community connection (n = 2), patient reminders (n = 2), and opportunistic vaccination combined with patient education and/or reminders (n = 12). Opportunistic vaccination interventions were generally successful at improving vaccine coverage, though results ranged from no impact to vaccinating 71 % of eligible children with routine vaccines and 9-61 % of eligible children with influenza vaccines. Interventions that aimed to increase vaccination after hospital discharge (community connection, patient education, reminders) were less successful.

CONCLUSIONS

Some interventions that provide vaccination to children accessing hospitals improved vaccine coverage; however, the baseline coverage level of the population, as well as implementation strategies used impact success. There is limited evidence that interventions promoting vaccination after hospital discharge are more successful if they are tailored to the individual.

Australian hospital paediatricians and nurses' perspectives and practices for influenza vaccine delivery in children with medical comorbidities

INTRODUCTION

Influenza vaccination of children with medical comorbidities is critical due their increased risks for severe influenza disease. In Australia, hospitals are an avenue for influenza vaccine delivery to children with comorbidities but are not always effectively utilised. Qualitative enquiry sought to ascertainment the barriers and enablers for influenza vaccination recommendation, delivery, and recording of these children at Australian hospitals.

METHODS

Semi-structured interviews and discussion group sessions were conducted with paediatricians and nurses at four tertiary paediatric specialist hospitals and two general community hospitals in three Australian states. Transcripts from interviews and group sessions were inductively analysed for themes. The Capability, Opportunity, Motivation, and Behaviour (COM-B) model was used to explore the elements of each theme and identify potential interventions to increase influenza vaccination recommendation and delivery behaviours by providers.

RESULTS

Fifteen discussion sessions with 28 paediatricians and 26 nurses, and nine in-depth interviews (five paediatricians and four nurses) were conducted. Two central thematic domains were identified: 1. The interaction between hospital staff and parents/patients for influenza vaccine recommendation, and 2. Vaccination delivery and recording in the hospital environment. Six themes across these domains emerged detailing the importance of dedicated immunisation services, hospital leadership, paediatricians' vaccine recommendation role, the impact of comorbidities, vaccination recording, and cocooning vaccinations. Supportive hospital leadership, engaged providers, and dedicated immunisation services were identified as essential for influenza vaccination of children with comorbidities in Australian hospital.

CONCLUSION

Recommendation of influenza vaccination for Australian children with comorbidities is impacted by the beliefs of paediatricians and the perceived impact of influenza disease on children's comorbidities. Dedicated immunisation services and supportive hospital leadership were drivers for influenza vaccine delivery at hospitals. Future interventions targeting hospital-based influenza vaccine delivery for children with comorbidities should take a rounded approach targeting providers' attitudes, the hospital environment and leadership support.

A novel household-based patient outreach pilot program to boost late-season influenza vaccination rates during the COVID-19 pandemic

Background

The objective of this study was to test a novel household‐based approach to improve late‐season influenza vaccine uptake during the 2020–2021 season, using Epic's MyChart patient portal messages and/or interactive voice response telephone calls.

Methods

This study was a non‐blinded, quality improvement program using a block randomized design conducted among patients from Reliant Medical Group clinics residing in a traditional household (≥2 individuals clinically active in the Reliant system living at the same address). Households were randomized 1:1:1 into intervention arms: non‐tailored communication (messaging based on CDC's seasonal influenza vaccination campaign), tailored communication (comprehensive communication including reinforcement of the importance of influenza vaccination for high‐risk individuals), and standard‐of‐care control. Influenza vaccination during the program was captured via medical records, and the odds of vaccination among communication arms versus the control arm were assessed. A survey assessing influenza vaccination drivers was administered using MyChart.

Results

Influenza vaccination increased by 3.3% during the program period, and no significant differences in vaccination were observed in intervention arms relative to the control arm. Study operationalization faced substantial challenges related to the concurrent COVID‐19 pandemic. Compared with vaccinated survey respondents, unvaccinated respondents less frequently reported receiving a recommendation for influenza vaccination from their healthcare provider (15.8% vs. 42.3%, p < 0.001) or awareness that vaccination could protect themselves and higher risk contacts (82.3% vs. 92.6%, p < 0.001).

Conclusions

No significant effects of the interventions were observed. Survey results highlighted the importance of healthcare provider recommendations and the need for increased education around the benefits of vaccination.

An Opportunity in Cancer Prevention: Human Papillomavirus Vaccine Delivery in the Hospital

OBJECTIVE

Pediatric hospitalizations are a missed opportunity for delivery of the human papilloma virus (HPV) vaccination. In this study, the authors' aim was to increase HPV vaccination rates among adolescents cared for by the pediatric hospital medicine (PHM) service at our academic children's hospital.

METHODS

This quality improvement (QI) study included adolescents ≥13 years who were discharged from PHM. Interventions included: modification of discharge order sets to include vaccination status and provider training seminars regarding the delivery of the HPV vaccine. Follow-up materials were distributed to providers by e-mail. The primary outcome measure was adolescent HPV vaccination rates. Secondary outcome measures were adolescent meningococcal vaccination rates and accuracy of immunization status documentation. The balancing measure was length of stay (LOS). Data were collected via chart review. Statistical process control charts were used to analyze for special cause variation.

RESULTS

From May 2019 through February 2020, 440 patients were included in this analysis. Throughout the study, HPV and meningococcal vaccination rates increased from a baseline median of 4.6% to 21.2% and 8.3% to 26.6%, respectively. HPV vaccination was not significantly associated with sex, HPV dose due, or admitting service. Accuracy of immunization status documentation and LOS remained unchanged.

CONCLUSIONS

Using QI methodology we were successful in increasing HPV and meningococcal vaccination rates among hospitalized adolescents. Considering the relationship of these 2 vaccines is a potential topic of future work. Discerning the correct immunization status at time of admission may be a potential opportunity for improvement in future work.

Parental Vaccine Hesitancy and Association With Childhood Diphtheria, Tetanus Toxoid, and Acellular Pertussis; Measles, Mumps, and Rubella; Rotavirus; and Combined 7-Series Vaccination

INTRODUCTION

Parental vaccine hesitancy can be a barrier to routine childhood immunization and contribute to greater risk for vaccine-preventable diseases. This study examines the impact of parental vaccine hesitancy on childhood vaccination rates.

METHODS

This study assessed the association of parental vaccine hesitancy on child vaccination coverage with ≥4 doses of diphtheria, tetanus toxoid, and acellular pertussis vaccine; ≥1 dose of measles, mumps, and rubella vaccine; up-to-date rotavirus vaccine; and combined 7-vaccine series coverage for a sample of children aged 19-35 months using data from the 2018 and 2019 National Immunization Survey-Child (N=7,645). Adjusted differences in multivariable analyses of vaccination coverage were estimated among vaccine hesitant and nonhesitant parents and population attributable risk fraction of hesitancy on undervaccination, defined as not being up to date for each vaccine.

RESULTS

Almost a quarter of parents reported being vaccine hesitant, with the highest proportion of vaccine hesitancy among parents of children who are non-Hispanic Black (37.0%) or Hispanic (30.1%), mothers with a high school education or less (31.9%), and households living below the poverty level (35.6%). Childhood vaccination coverage for all vaccines was lower for children of hesitant than nonhesitant parents, and the population attributable fraction of hesitancy on undervaccination ranged from 15% to 25%, with the highest percentage for ≥1 dose of measles, mumps, and rubella vaccine.

CONCLUSIONS

Parental vaccine hesitancy may contribute up to 25% of undervaccination among children aged 19-35 months. Implementation of strategies to address parental vaccine hesitancy is needed to improve vaccination coverage for children and minimize their risk of vaccine-preventable diseases.

Vaccine Administration in Children's Hospitals

OBJECTIVES

To examine inpatient vaccine delivery across a national sample of children's hospitals.

METHODS

We conducted a retrospective cohort study examining vaccine administration at 49 children's hospitals in the Pediatric Health Information System database. Children <18 years old admitted between July 1, 2017, and June 30, 2019, and age eligible for vaccinations were included. We determined the proportion of hospitalizations with ≥1 dose of any vaccine type administered overall and by hospital, the type of vaccines administered, and the demographic characteristics of children who received vaccines. We calculated adjusted hospital-level rates for each vaccine type by hospital. We used logistic and linear regression models to examine characteristics associated with vaccine administration.

RESULTS

There were 1 185 667 children and 1 536 340 hospitalizations included. The mean age was 5.5 years; 18% were non-Hispanic Black, and 55% had public insurance. There were ≥1 vaccine doses administered in 12.9% (95% confidence interval: 12.8-12.9) of hospitalizations, ranging from 1% to 45% across hospitals. The most common vaccines administered were hepatitis B and influenza. Vaccine doses other than the hepatitis B birth dose and influenza were administered in 1.9% of hospitalizations. Children had higher odds of receiving a vaccine dose other than the hepatitis B birth dose or influenza if they were <2 months old, had public insurance, were non-Hispanic Black race, were medically complex, or had a length of stay ≥3 days.

CONCLUSIONS

In this national study, few hospitalizations involved vaccine administration with substantial variability across US children's hospitals. Efforts to standardize inpatient vaccine administration may represent an opportunity to increase childhood vaccine coverage.

Beyond Influenza Vaccination: Expanding Infrastructure for Hospital-Based Pediatric COVID-19 Vaccine Delivery

Controlling the spread of severe acute respiratory syndrome–coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), will rely on vaccination at increasing rates and in an equitable manner. The main reasons for under-vaccination are varied among different segments of the population and include vaccine hesitancy and lack of access. While vaccine hesitancy is complicated and requires long-term solutions, access can be enhanced through evidence-based delivery strategies that augment conventional approaches. Hospital-based COVID-19 vaccination programs hold particular promise in reaching populations with decreased vaccine access and those at higher risk for adverse outcomes from SARS-CoV-2 infection. Hospitals have the necessary equipment and storage capabilities to maintain cold chain requirements—a common challenge in the primary care setting—and can serve as a central distribution point for delivering vaccines to patients in diverse hospital locations, including inpatient units, emergency departments, urgent care centers, perioperative areas, and subspecialty clinics. They also have the capacity for mass-vaccination programs and other targeted outreach efforts. Hospital-based programs that have been successful in implementing influenza and other routine vaccinations can leverage existing infrastructure, such as electronic health record–related tools. With the possibility of COVID-19 becoming endemic, much like seasonal influenza, these programs will require flexibility as well as planning for long-term sustainability. This commentary highlights existing vaccine delivery to children in hospital-based settings, including key advantages and important challenges, and outlines how these systems could be expanded to include the COVID-19 vaccine delivery.

Identifying Practices to Promote Inpatient Adolescent and Influenza Vaccine Delivery

OBJECTIVES

Many hospitalized children are underimmunized. We assessed the association between hospital immunization practices and tetanus, diphtheria, and acellular pertussis (Tdap), meningococcal, human papillomavirus (HPV), and influenza vaccine delivery.

METHODS

An electronic survey regarding hospital vaccine delivery practices was distributed via the Pediatric Health Information System (PHIS) and Pediatric Research in Inpatient Settings networks to PHIS hospitals. Number of vaccines delivered and total discharges in 2018 were obtained from the PHIS database to determine hospital vaccine delivery rates; patients 11 to 18 years old (adolescent vaccines) and 6 months to 18 years old (influenza vaccine) were included. Vaccine delivery rates were risk adjusted by using generalized linear mixed-effects modeling and compared with survey responses to determine associations between the number or presence of specific practices and vaccine delivery. Adjusted HPV and meningococcal vaccine delivery rates could not be calculated because of low delivery.

RESULTS

Twenty-nine hospitals completed a survey (57%). 152 499 and 423 046 patient encounters were included for the adolescent and influenza vaccines, respectively. Unadjusted inpatient vaccine delivery rates varied. After adjustment, the number of practices was associated only with influenza vaccine delivery (P = .02). Visual prompts (P = .02), nurse or pharmacist ordering (P = .003), and quality improvement projects (P = .048) were associated with increased influenza vaccine delivery; nurse or pharmacist ordering had the greatest impact. No practices were associated with Tdap vaccine delivery.

CONCLUSIONS

The number and presence of specific hospital practices may impact influenza vaccine delivery. Further research is needed to identify strategies to augment inpatient adolescent immunization.

Improving Birth Dose Hepatitis B Vaccination Rates: A Quality Improvement Intervention

BACKGROUND

There are 43 000 new cases of hepatitis B virus infection and 1000 cases of perinatally acquired infection each year in the United States. National recommendations are to administer hepatitis B (HepB) vaccine to all stable newborns >2000 g within 24 hours of birth. Our primary objective was to increase institutional vaccination rates from a baseline of 52% to goal >85% before hospital discharge.

METHODS

In February 2017, we instituted a multidisciplinary quality improvement project aimed at increasing HepB vaccination birth dose rates. Interventions included (1) standardizing the process of offering HepB vaccine via scripting and timing, (2) engaging and educating parents, and (3) educating physicians and nurses regarding the importance of HepB vaccination and strategies to discuss HepB vaccination with vaccine-hesitant parents. The main outcome measure was the percentage of newborns receiving HepB vaccination by discharge. The secondary outcome was the percentage of newborns receiving HepB vaccination by 12 hours of life per New York State Department of Health recommendation. Data were analyzed by using statistical process control P-charts.

RESULTS

A total of 21 108 newborns were included between July 2015 and April 2019. In addition to several upward centerline shifts, implementation of interventions resulted in increased and sustained HepB vaccination rates by hospital discharge from a baseline of 52.4% to 72.5%. Rates by 12 hours of life increased from 21.5% to 42.5%.

CONCLUSIONS

Multidisciplinary collaboration, scripting, and provider and staff education regarding the risks of hepatitis B virus, benefits of HepB vaccine, and strategies to discuss HepB vaccination with parents significantly increased vaccination rates. Further efforts to improve vaccination rates to within 12 hours are preferable.

Influenza-Related Knowledge, Beliefs, and Experiences Among Caregivers of Hospitalized Children

OBJECTIVE

Caregivers frequently decline influenza vaccine for their hospitalized child. In this study, we aimed to examine factors impacting their influenza vaccine decision-making.

METHODS

We conducted a cross-sectional survey study of English- and Spanish-speaking caregivers of children hospitalized at a tertiary care pediatric hospital between November 2017 and April 2018. The survey assessed influenza-related knowledge, beliefs, experiences, and vaccine hesitancy. Multivariable logistic regression examined associations between survey responses and child influenza vaccination status at admission (already vaccinated versus not yet vaccinated this season) and, among caregivers with vaccine-eligible children, influenza vaccine acceptance (versus declination) for their child during hospitalization.

RESULTS

Caregivers (N =522; 88.9% response rate) were mostly non-Hispanic white (66.9%) and English-speaking (97.7%). At admission, 63.2% of children were already vaccinated this season. The caregiver view that influenza vaccination is important for their child's health was the strongest positive predictor of having an already vaccinated child (adjusted odds ratio [aOR]: 3.16; 95% confidence interval [CI]: 2.46-4.05); vaccine hesitancy was the strongest negative predictor (aOR: 0.61; 95% CI: 0.50-0.75). Among caregivers with vaccine-eligible children, 30.3% accepted influenza vaccine for their hospitalized child. Their belief regarding the child health benefits of influenza vaccination was associated with vaccine acceptance during hospitalization (aOR: 6.87; 95% CI: 3.38-13.96). Caregiver vaccine hesitancy and agreement that children with mild illness should delay vaccination negatively impacted vaccine acceptance (aOR: 0.39; 95% CI: 0.25-0.62; aOR: 0.33; 95% CI: 0.20-0.56, respectively).

CONCLUSIONS

We identified key factors impacting influenza vaccine decision-making among caregivers of hospitalized children, a critical step to improving uptake in this population.

Evaluation of a Clinical Decision Support Strategy to Increase Seasonal Influenza Vaccination Among Hospitalized Children Before Inpatient Discharge

IMPORTANCE

Hospitalized children are at increased risk of influenza-related complications, yet influenza vaccine coverage remains low among this group. Evidence-based strategies about vaccination of vulnerable children during all health care visits are especially important during the COVID-19 pandemic.

OBJECTIVE

To design and evaluate a clinical decision support (CDS) strategy to increase the proportion of eligible hospitalized children who receive a seasonal influenza vaccine prior to inpatient discharge.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study was conducted among children eligible for the seasonal influenza vaccine who were hospitalized in a tertiary pediatric health system providing care to more than half a million patients annually in 3 hospitals. The study used a sequential crossover design from control to intervention and compared hospitalizations in the intervention group (2019-2020 season with the use of an intervention order set) with concurrent controls (2019-2020 season without use of an intervention order set) and historical controls (2018-2019 season with use of an order set that underwent intervention during the 2019-2020 season).

INTERVENTIONS

A CDS intervention was developed through a user-centered design process, including (1) placing a default influenza vaccine order into admission order sets for eligible patients, (2) a script to offer the vaccine using a presumptive strategy, and (3) just-in-time education for clinicians addressing vaccine eligibility in the influenza order group with links to further reference material. The intervention was rolled out in a stepwise fashion during the 2019-2020 influenza season.

MAIN OUTCOMES AND MEASURES

Proportion of eligible hospitalizations in which 1 or more influenza vaccines were administered prior to discharge.

RESULTS

Among 17 740 hospitalizations (9295 boys [52%]), the mean (SD) age was 8.0 (6.0) years, and the patients were predominantly Black (n = 8943 [50%]) or White (n = 7559 [43%]) and mostly had public insurance (n = 11 274 [64%]). There were 10 997 hospitalizations eligible for the influenza vaccine in the 2019-2020 season. Of these, 5449 (50%) were in the intervention group, and 5548 (50%) were concurrent controls. There were 6743 eligible hospitalizations in 2018-2019 that served as historical controls. Vaccine administration rates were 31% (n = 1676) in the intervention group, 19% (n = 1051) in concurrent controls, and 14% (n = 912) in historical controls (P < .001). In adjusted analyses, the odds of receiving the influenza vaccine were 3.25 (95% CI, 2.94-3.59) times higher in the intervention group and 1.28 (95% CI, 1.15-1.42) times higher in concurrent controls than in historical controls.

CONCLUSIONS AND RELEVANCE

This quality improvement study suggests that user-centered CDS may be associated with significantly improved influenza vaccination rates among hospitalized children. Stepwise implementation of CDS interventions was a practical method that was used to increase quality improvement rigor through comparison with historical and concurrent controls.

National Inpatient Immunization Patterns: Variation in Practice and Policy Between Vaccine Types

BACKGROUND

Many hospitalized children are underimmunized, yet little is known about current systems supporting inpatient vaccination. We aim to describe national pediatric inpatient immunization practices and determine if variation exists among adolescent, childhood, and influenza vaccines.

METHODS

An electronic survey regarding hospital vaccination practices was sent to physician, nurse, and pharmacy leaders via the Pediatric Research in Inpatient Settings Network in spring 2019. Hospitals reported the presence of various practices to support inpatient vaccination stratified by vaccine type: tetanus, diphtheria, and acellular pertussis, meningococcal, human papillomavirus, childhood series, and influenza. One-way analysis of variance testing compared differences in numbers of practices and χ² tests compared proportions of sites reporting each practice between vaccine types. Qualitative responses were evaluated via content analysis.

RESULTS

Fifty-one of 103 eligible hospitals completed the survey (50%). Standardized policies existed in 92% of hospitals for influenza, 41% for childhood, and 29% for adolescent vaccines. Hospitals identified an average of 5.1 practices to deliver influenza vaccines, compared with 1.5 for childhood; 0.9 for tetanus, diphtheria, and acellular pertussis; 0.7 for meningococcal; and 0.6 for human papillomavirus vaccines (P < .001). Standardized screening tools, visual prompts, standing orders, nurse- or pharmacy-driven screening or ordering, staff education, and quality improvement projects were reported more often for influenza vaccines than other vaccine types (P < .01 for all comparisons). Common barriers to delivery included communication difficulties, lack of systems optimization, and parent and provider discomfort with inpatient immunization.

CONCLUSIONS

Existing hospital infrastructure supports influenza vaccine delivery over other vaccine types, potentially creating missed inpatient vaccination opportunities.

Improving Influenza Vaccination in Children With Comorbidities: A Systematic Review

CONTEXT

Children with medical comorbidities are at greater risk for severe influenza and poorer clinical outcomes. Despite recommendations and funding, influenza vaccine coverage remains inadequate in these children.

OBJECTIVE

We aimed to systematically review literature assessing interventions targeting influenza vaccine coverage in children with comorbidities and assess the impact on influenza vaccine coverage.

DATA SOURCES

PubMed, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, and Web of Science databases were searched.

STUDY SELECTION

Interventions targeting influenza vaccine coverage in children with medical comorbidities.

DATA EXTRACTION

Two reviewers independently screened articles, extracting studies' methods, interventions, settings, populations, and results. Four reviewers independently assessed risk of bias.

RESULTS

From 961 screened articles, 35 met inclusion criteria. Published studies revealed that influenza vaccine coverage was significantly improved through vaccination reminders and education directed at either patients' parents or providers, as well as by vaccination-related clinic process changes. Interventions improved influenza vaccine coverage by an average 60%, but no significant differences between intervention types were detected. Significant bias and study heterogeneity were also identified, limiting confidence in this effect estimate.

LIMITATIONS

A high risk of bias and overall low quality of evidence limited our capacity to assess intervention types and methods.

CONCLUSIONS

Interventions were shown to consistently improve influenza vaccine coverage; however, no significant differences in coverage between different intervention types were observed. Future well-designed studies evaluating the effectiveness of different intervention are required to inform future optimal interventions.

The COVID-19 mRNA Vaccines and the Pandemic: Do They Represent the Beginning of the End or the End of the Beginning?

In December 2020, the US Food and Drug Administration issued emergency use authorizations for two mRNA vaccines against coronavirus disease 2019. These vaccines represent an incredible scientific achievement and a major step in efforts to bring the global pandemic to a close. However, these vaccines create many logistical challenges that limit just how far-reaching their impact can be. This commentary reviews how these vaccines offer immunity, summarizes the Phase III trial results, and offers a discussion of the challenges that remain after these vaccines are introduced for widespread use.

Influenza vaccination: A qualitative study of practice level barriers from medical practitioners caring for children with special risk medical conditions

BACKGROUND

Understanding the influenza vaccination practices of general practitioners (GP) and paediatric hospital specialists caring for children with special risk medical conditions (SRMC) is imperative for designing interventions to improve uptake. This study aimed to identify the vaccination decision making, provider practices and perceived barriers and facilitators to recommending or delivering influenza vaccine for children with SRMCs at the tertiary and primary care levels.

METHODS

Nominated GPs and hospital specialists from a single tertiary hospital were interviewed to explore influenza vaccination practices and challenges for children with confirmed SRMCs. Interviews were digitally recorded, transcribed verbatim and thematic analysis was used to inductively code these data. Resulting themes were mapped across the COM-B ('capability', 'opportunity', 'motivation' and 'behaviour') theoretical framework to understanding barriers and potential interventions.

RESULTS

Twenty-six medical practitioners (21 GPs and 5 hospital specialists) completed semi-structured interviews. Barriers, and facilitators for influenza vaccine recommendation (the intended behaviour) were thematically grouped. Opportunity themes included structural barriers (e.g. limited use of systems and processes to support the identification of children with SRMCs); recommendation as standard practice; vaccination inconvenience; lack of communication and educational resources; social acceptance and normalisation; and media messaging. Capability themes included provider communication with parents; knowledge of influenza vaccine recommendations; and professional boundaries to implement the recommendation. Themes in the Motivation category included provider clinical prioritisation and responsibility towards providing a recommendation.

CONCLUSIONS

The main barriers to influenza recommendation raised by our study participants were structural. These included lack of processes to identify children with SRMCs, limited use of reminder systems and unclear delineation of role responsibility between hospital specialists and GPs. An important driver that emerged was GPs' responsibility for providing a recommendation. To increase influenza vaccine coverage for children with SRMCs, consideration should be given to addressing practice level structural barriers and improving collaboration.

Be inFLUential: Evaluation of a multifaceted intervention to increase influenza vaccination rates among pediatric inpatients

BACKGROUND AND OBJECTIVE

Annual influenza vaccination is recommended for individual ≥6 months of age, yet vaccination rates remain below national targets in the US. Hospitalization provides another medical setting for influenza vaccination, but the effectiveness of inpatient interventions has not been well studied. Our objective was to evaluate the effectiveness of a multifaceted intervention to increase influenza vaccination rates among pediatric inpatients.

METHODS

We conducted a pre-post interventional study on medical inpatient units at Children's Hospital Colorado from September 2016-April 2017 (pre-intervention) and September 2017-April 2018 (intervention). The intervention targeted nurses (web-based education modules, huddles and reminders) and providers (vaccination lists in the electronic health record, reminders, vaccination reports and financial incentives for residents). Outcomes were influenza vaccine ordering rates, and influenza vaccination rates at discharge. We analyzed data using descriptive statistics, bivariate and logistic regression.

RESULTS

Among 4,050 inpatients in 2016-2017 and 4,523 inpatients in 2017 aged ≥ 6 months, vaccination status was documented for 2,902/4,050 (71.7%) and 3,431/4,523 (75.9%) children aged > 6 months of age hospitalized during the study period. The vaccine ordering rate among eligible children was 28.8% in the pre-intervention season versus 50.2% in the intervention season (p < 0.001). The intervention was associated with 1.23 (95% CI 1.11-1.35) times higher odds of appropriate vaccination screening on admission, 2.27 (95% CI 2.01-2.56) times higher odds of a vaccination being ordered, and 1.39 (95% CI 1.27-1.53) times higher odds of a child being vaccinated against influenza at discharge (all p < 0.001). Residents (56%) and medical providers (39%) were more likely to order vaccines compared with nurses (5%), p = 0.014).

CONCLUSION

A multifaceted intervention targeting nurses, residents and providers comprising education, visual reminders, vaccination reports and financial incentives is an effective way of improving influenza vaccine ordering, resulting in higher inpatient influenza vaccination rates.

Pediatric Resident Attitudes Toward Inpatient Immunization of Children and Adolescents: Highlighting Differences in Human Papillomavirus Vaccination

Over a decade after its debut, human papillomavirus (HPV) vaccine coverage remains suboptimal. The inpatient setting presents a largely unexplored opportunity to increase vaccination rates. This study aims to describe pediatric resident attitudes toward inpatient immunization and compare differences by vaccine, in particular HPV. An anonymous survey of beliefs and practices regarding inpatient vaccines was distributed to pediatric resident physicians at a single freestanding urban children’s hospital in September 2017. A total of 58 surveys were collected (64% response rate). We found that pediatric residents were more likely to report that they never or rarely discuss the HPV vaccine during hospitalization compared with the primary childhood series (P = .001), Tdap (P = .02), and the influenza vaccine (P < .001), and rarely offer the HPV vaccine during hospitalization compared with childhood vaccines (P = .003) and influenza (P = .001). This suggests that provider hesitancy still exists for the HPV vaccine, presenting opportunities for further education and inpatient interventions.

Pediatric Inpatient Immunizations: A Literature Review

CONTEXT

Timely vaccine uptake in children remains suboptimal. Eliminating missed opportunities is key to increasing childhood immunization rates, and hospitalization offers another potential setting to vaccinate.

OBJECTIVE

To better understand pediatric inpatient immunization programs, including vaccination rates of inpatients, parental and provider attitudes, barriers to vaccine delivery, and interventions to increase provision of inpatient vaccines.

DATA SOURCES

A search was conducted of PubMed, Embase, and Web of Science to identify articles and conference abstracts related to pediatric inpatient immunization.

STUDY SELECTION

Inclusion criteria were studies published in English between January 1990 and January 2019 in which pediatric vaccination in the hospital setting was discussed. Findings from 30 articles and conference abstracts were summarized and organized by topic area.

DATA EXTRACTION

Abstracts were screened for relevance, articles were read, and themes were identified.

RESULTS

Children who are hospitalized have been shown to have lower immunization rates compared with the general population, with 27% to 84% of pediatric inpatients due or overdue for vaccines nationally when verified with official records. Unfortunately, little is done to catch up these children once they have been identified. Access to accurate vaccine histories remains a major barrier in inpatient immunization programs because providers frequently under document and parents over recall a child's vaccine status. Strategies identified to increase inpatient vaccination included creation of a multidisciplinary immunization team, educational interventions, visual reminders, catch-up vaccine plans, order sets, and nursing-driven screening. When offered inpatient vaccination, a majority of parents accepted immunizations for their children.

CONCLUSIONS

Hospitalization may provide an opportunity to augment vaccine uptake. Further research is needed to develop evidence-based strategies to overcome barriers to inpatient vaccination.