Parents' Perspectives on How to Improve the Childhood Vaccination Process

Common issues and improvement solution of vaccine hesitancy in children with underlying neurological conditions: Experience from one National Children's Medical Center in China

BACKGROUND

Parents and healthcare providers usually defer or avoid immunization for children with neurological conditions. This study was conducted to investigate the common issues of immunization among these special children and the impact of specialists' recommendation on improving immunization practice.

METHOD

We included 2,221 children with underlying neurological conditions seeking vaccination consultation at the first Immunization Advisory Clinic in China during 2017-2019. The primary neurological conditions and immunization status were analyzed. All parents were informed to self-report the adverse events following catch-up immunization. For specially concerned children with hereditary disorders, immune-related encephalopathy and epilepsy, we conducted the active follow-up to monitor the compliance with recommendation and the adverse events.

RESULT

All counselling children were assessed as not having any contraindication of immunization. A total of 2,019 (90.9%) children with underlying neurological conditions had delayed immunization and 99 (4.5%) had non-immunization. The coverage rate of age-appropriate vaccines was 56.1%. The most concerned vaccines were diphtheria, tetanus and acellular pertussis combined vaccine, diphtheria and tetanus combined vaccine, meningococcal polysaccharide vaccine and Japanese encephalitis vaccine. Resuming immunization was recommended for the 2,048 (92.2%) children. Most of counselling children complied with the specialists' recommendation. Neither progress nor flaring of the neurological medical conditions was reported from parents.

CONCLUSION

Vaccine hesitancy was a common issue for Chinese children with all kinds of neurological conditions. Specialized consultation on immunization is helpful to build vaccine confidence for the special children. Immunization for children with underlying neurological conditions is generally safe.

Is the pre-natal period a missed opportunity for communicating with parents about immunizations? Evidence from a longitudinal qualitative study in Victoria, British Columbia

Background

Growing evidence shows that many parents begin the decision-making process about infant vaccination during pregnancy and these decisions – once established – may be resistant to change. Despite this, many interventions targeting vaccination are focused on communicating with parents after their baby is born. This suggests that the prenatal period may constitute a missed opportunity for communicating with expectant parents about infant vaccination.

Methods

Using a longitudinal qualitative design, we conducted two interviews (prepartum and postpartum) with women (n = 19) to explore the optimal timing of vaccination information. The data were analyzed thematically, and examined across all sets of pre- and post-partum interviews as well as within each individual participant to draw out salient themes.

Results

Most participants formed their intentions to vaccinate before the baby was born and indicated that they would welcome information about vaccination from their maternity care providers. However, few individuals recalled their maternity care providers initiating vaccination-related conversations with them.

Conclusion

The prenatal period is an important time to begin conversations with expectant parents about vaccinating their infants, particularly if these conversations are initiated by trusted maternity care providers. More information is needed on how maternity care providers can be better supported to have these conversations with their patients.

Temporal Trends in Undervaccination: A Population-Based Cohort Study

INTRODUCTION

Monitoring the trends in undervaccination, including that because of parental vaccine refusal or delay, can inform public health responses directed at improving vaccine confidence and vaccination coverage.

METHODS

A retrospective cohort study was conducted in the Vaccine Safety Datalink. The cohort included all children born in 2004-2017 with ≥3 well-child visits between ages 2 and 23 months. Using electronic health record-based vaccination data, the average days undervaccinated was calculated for each child. Undervaccination patterns were assessed through age 23 months. Temporal trends were inspected for inflection points and were analyzed using linear regression. Nested within the cohort study, a survey was conducted to compare parent reports of vaccine refusal or delay with observed vaccination patterns. Data were analyzed in 2020.

RESULTS

The study cohort consisted of 808,170 children. The percentage of children with average days undervaccinated=0 (fully vaccinated, no delays) rose from a nadir of 47.1% for the birth year 2008 to 68.4% for the birth year 2017 (p_trend<0.001). The percentage with no vaccines rose from 0.35% for the birth year 2004 to 1.28% for the birth year 2017 (p_trend<0.001). Consistent vaccine limiting was observed in 2.04% for the birth year 2017. Omission of measles, mumps, and rubella vaccine peaked at 4.76% in the birth year 2007 and declined thereafter (p_trend<0.001). On the parent survey (response rate 60.2%), a high proportion of parents of the most undervaccinated children reported refusing or delaying vaccines.

CONCLUSIONS

In a 14-year cohort study, vaccination timeliness has improved. However, the small but increasing number of children who received no vaccines by age 23 months warrants additional attention.

Vaccine Hesitancy, Acceptance, and Anti-Vaccination: Trends and Future Prospects for Public Health

An often-stated public health comment is that "vaccination is a victim of its own success." While the scientific and medical consensus on the benefits of vaccination is clear and unambiguous, an increasing number of people are perceiving vaccines as unsafe and unnecessary. The World Health Organization identified "the reluctance or refusal to vaccinate despite availability of vaccines" as one of the 10 threats to global health in 2019. The negative influence of anti-vaccination movements is often named as a cause of increasing vaccine resistance in the public. In this review, we give an overview of the current literature on the topic, beginning by agreeing on terminology and concepts before looking at potential causes, consequences, and impacts of resistance to vaccination.

Infant vaccination education preferences among low-income pregnant women

Childhood vaccination is an important public health intervention, yet many children remain under-vaccinated. The objective of this study was to examine infant vaccination education preferences in a population of low-income pregnant women by ethnicity, nativity, and language. Pregnant women 14–44 y old (n = 335) attending a participating low-income reproductive health clinic in southeast Texas from May 26-July 21, 2017, and who completed a paper survey offered in English and Spanish were included. Participants were asked to complete questions about their demographic characteristics and preferences about infant vaccination education. To examine differences in vaccine education preferences by participant demographic characteristics, chi-squared tests, or Fisher’s exact tests and one-way analysis of variance (ANOVA) were conducted using Stata SE Version 15.1 with α = 0.05. Nearly half (47.5%) of participants considered pregnancy the best time to get information about infant vaccination and were most likely (40.6%) to indicate the nurse who gives vaccines during pregnancy as the health-care worker with whom they would like to discuss infant vaccination. There were no demographic differences in preferred timing of vaccine education delivery or provider who delivers vaccine education. Prenatal, nurse-delivered vaccine educational programs would be well accepted in this low-income population.

Web-Based Tailored Messaging to Increase Vaccination: A Randomized Clinical Trial

BACKGROUND

To increase vaccine acceptance, we created a Web-based the "Vaccines and Your Baby" intervention (VAYB) that provided new parents with vaccine information messages tailored to vaccine beliefs and values. We evaluated the effectiveness of the VAYB by comparing timely uptake of infant vaccines to an untailored version of the intervention (UT) or usual care intervention (UC) only.

METHODS

Between April 2016 and June 2019, we conducted a randomized clinical trial. Pregnant women and new parents were randomly assigned to the VAYB, UT, or UC arms. In the VAYB and UT arms, participants were exposed to interventions at 4 time points from pregnancy until their child was 15 months of age. The primary outcome was up-to-date status for recommended vaccines from birth to 200 days of age. A modified intent-to-treat analysis was conducted. Data were analyzed with logistic regression to generate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

We enrolled 824 participants (276 VAYB, 274 UT, 274 UC), 143 (17.4%) of whom were lost to follow-up. The up-to-date rates in the VAYB, UT, and UC arms were 91.44%, 92.86%, and 92.31%, respectively. Infants in the VAYB arm were not more likely to be up to date than infants in the UC arm (OR = 0.89; 95% CI, 0.45-1.76) or in the UT arm (OR = 0.82; 95% CI, 0.42-1.63). The odds of being up to date did not differ between UT and UC arms (OR = 1.08; 95% CI, 0.54-2.18).

CONCLUSIONS

Delivering Web-based vaccine messages tailored to parents' vaccine attitudes and values did not positively impact the timely uptake of infant vaccines.

A Review of Recommendations for Routine Immunization Services During COVID-19 Pandemic That are Relevant for Nursing Personnel Involved in the Implementation of Immunoprophylaxis

Immunization programmes are of key importance for maintaining good health and protecting life. Disruption to routine immunization may increase the incidence of diseases that can be prevented by vaccinations. The aim of this review is to present the current recommendations on immunization services during the COVID-19 pandemic that are relevant for the nursing practice. It contains an overview of recommended guidelines published in March and April 2020, and of scientific publications on immunizations for children and adults, taking into account recommendations related to the new epidemiological risk caused by SARS-CoV-2 infections. The ongoing global pandemic of COVID-19 calls for changes in the organization of health care and puts an additional burden on all resources forming the healthcare system. The COVID-19 pandemic poses a particular challenge to public health, as active immunoprophylaxis should make it possible to control other infectious diseases. Protection against the spread of SARS-CoV-2 may hamper routine immunization services, which must be administered with particular regard to epidemiological safety. Nurses have always had an important role to play in the implementation and promotion of vaccinations and in emphasizing their importance for public health. Therefore, it is crucial that they have up-to-date information on vaccinological interventions that reduce the risk of transmission of SARS-CoV-2 infections.

A qualitative study examining pediatric clinicians' perceptions of delayed vaccine schedules

OBJECTIVE

To explore pediatric clinicians' attitudes, beliefs, and perceived social norms about the impact of delayed vaccine schedules on the clinical management of their patients.

METHODS

We conducted 30 semi-structured qualitative interviews with academic (Infectious Diseases, Emergency Medicine) and community pediatric clinicians (General Pediatrics) to explore clinicians' perspectives on how delayed schedules influence their clinical management of patients. The interview guide was based on the Theory of Planned Behavior. We analyzed interview transcripts using both an inductive and deductive thematic approach.

RESULTS

The pediatric clinicians in our study overwhelmingly supported the recommended schedule, sought guidance on approaches to navigating conversations with vaccine hesitant families, and desired more evidence to effectively promote on-time vaccination. Clinicians described how delayed schedules have consequences for sick children (e.g., increased antibiotics, laboratory tests, emergency department visits) and healthy children (e.g., increased vaccine visits, out-of-pocket costs, fears among children receiving frequent shots). Clinicians stated that delayed schedules also negatively impact pediatric practices (e.g., increased time counseling patients, staff burden, clogged clinic space, unpredictable vaccine utilization, costs).

CONCLUSIONS

Pediatric clinicians perceive that delayed vaccine schedules negatively affect patients, pediatric practices, the healthcare system, and society. Future research should quantify the consequences of delayed schedules and identify strategies that promote vaccine adherence. Results from future studies can better support clinician-parent conversations about vaccine hesitancy, guide decision-makers about practice-level approaches to vaccine schedules, and advise payors and policymakers regarding vaccine-related policies.

Distinguishing Subgroups in Opposition to Infant Immunization: Results From the Listening to Mothers III Survey

Objective

To investigate factors associated with parental intention of refusing or altering their child's vaccination schedule.

Methods

Data were from the 2011-2012 Listening to Mothers III survey (N = 1,053). Weighted bivariate and multivariate analyses examined factors related to refusing or altering vaccination.

Results

3.2% of mothers planned to refuse vaccination and 12.3% preferred to alter the recommended schedule. Preference to refuse was associated with maternal age <25 years (AOR 4.33; 95% CI: 1.18, 15.9), prior refusal of maternity care (AOR 6.04; 95% CI: 1.88, 19.4), and living outside of the Northeast. Schedule modification was only associated with prior refusal of care.

Conclusions

Mothers preferring not to immunize their children and those wishing to alter the vaccination schedule represent two distinct groups.

Assessing Potential Confounding and Misclassification Bias When Studying the Safety of the Childhood Immunization Schedule

OBJECTIVES

Some parents are concerned the childhood immunization schedule could increase risk for allergic disorders, including asthma. To inform future safety studies of this speculated association, a parent survey was conducted to examine the risk of misclassification of vaccination status in electronic health record data, and to assess the potential for confounding if asthma risk factors varied by vaccination status.

METHODS

A survey was conducted among parents of children 19 to 35 months old at 6 medical organizations within the Vaccine Safety Datalink. Parents of children in 4 vaccination groups were surveyed: 1) no vaccines by 12 months of age and a diagnosis of parental vaccine refusal; 2) consistent vaccine limiting (≤2 vaccines per visit); 3) not consistently vaccine limiting but otherwise undervaccinated with a vaccine refusal diagnosis; and 4) fully vaccinated with no delays and no vaccine refusal. Parents were surveyed about their child's vaccination status and whether asthma risk factors existed.

RESULTS

Among a survey sample of 2043 parents, 1209 responded (59.2%). For receiving no vaccines, the observed agreement between parent report and electronic health record data was 94.0% (κ = 0.79); for receiving all vaccines with no delays, the observed agreement was 87.3% (κ = 0.73). Although most asthma risk factors (allergic rhinitis, eczema, food allergies, family asthma history) reported by parents did not differ significantly between children in the vaccination groups studied, several factors (aeroallergen sensitivity, breastfeeding) differed significantly between groups.

CONCLUSIONS

Measurement and control of disease risk factors should be carefully considered in observational studies of the safety of the immunization schedule.

Web-based Social Media Intervention to Increase Vaccine Acceptance: A Randomized Controlled Trial

BACKGROUND

Interventions to address vaccine hesitancy and increase vaccine acceptance are needed. This study sought to determine if a Web-based, social media intervention increases early childhood immunization.

METHODS

A 3-arm, randomized controlled trial was conducted in Colorado from September 2013 to July 2016. Participants were pregnant women, randomly assigned (3:2:1) to a Web site with vaccine information and interactive social media components (VSM), a Web site with vaccine information (VI), or usual care (UC). Vaccination was assessed in infants of participants from birth to age 200 days. The primary outcome was days undervaccinated, measured as a continuous and dichotomous variable.

RESULTS

Infants of 888 participants were managed for 200 days. By using a nonparametric rank-based analysis, mean ranks for days undervaccinated were significantly lower in the VSM arm versus UC (P = .02) but not statistically different between the VI and UC (P = .08) or between VSM and VI arms (P = .63). The proportions of infants up-to-date at age 200 days were 92.5, 91.3, and 86.6 in the VSM, VI, and UC arms, respectively. Infants in the VSM arm were more likely to be up-to-date than infants in the UC arm (odds ratio [OR] = 1.92; 95% confidence interval [CI], 1.07-3.47). Up-to-date status was not statistically different between VI and UC arms (OR = 1.62; 95% CI, 0.87-3.00) or between the VSM and VI arms (OR = 1.19, 95% CI, 0.70-2.03).

CONCLUSIONS

Providing Web-based vaccine information with social media applications during pregnancy can positively influence parental vaccine behaviors.

Assessing misclassification of vaccination status: Implications for studies of the safety of the childhood immunization schedule

BACKGROUND

To address public concern about the safety of the childhood immunization schedule, the Institute of Medicine recommended observational studies comparing adverse health outcomes of fully vaccinated children to children under-vaccinated due to parental choice. Misclassification of vaccination status could bias such studies.

OBJECTIVE

To assess risk of misclassification of vaccination status within the Vaccine Safety Datalink (VSD).

DESIGN/METHODS

A retrospective cohort study was conducted in three phases. In phase 1, electronic health record (EHR) data were used to identify patterns of under-vaccination during the first 24months of life potentially due to parental choice. In phase 2, a random sample of records of under-vaccinated children was manually reviewed. In phase 3, a separate sample of parents were surveyed to assess whether EHR data accurately reflected their child's vaccination status. Phases 1 and 2 were conducted at 6 VSD sites, phase 3 at 1 site.

RESULTS

The study cohort included 361,901 children born 2004 through 2012. By 24months of age, 198,249 (54.8%) were fully vaccinated with no delays, 84,698 (23.4%) experienced delays but were fully vaccinated by 24months of age, 4865 (1.3%) received no vaccines, 3789 (1.0%) delayed starting vaccination until ≥4months of age, 4781 (1.3%) had consistent vaccine-limiting (≤2 vaccines per visit), and the remaining 65,519 (18.1%) were missing vaccine series or doses. When a diagnosis code for vaccine refusal was present in EHR data, encounter notes confirmed vaccine refusal as the reason for under-vaccination for nearly 100% of sampled records. Parent surveys confirmed these findings. Parents of under-vaccinated children were more likely to report visiting an alternative medical provider than parents of fully vaccinated children.

CONCLUSIONS

Specific groups of children, under-vaccinated due to parental choice, can be identified with relatively low likelihood of misclassification of vaccination status using EHR-based vaccine data and diagnosis codes.

Parental weighting of seizure risks vs. fever risks in vaccination tradeoff decisions

As part of a survey of about vaccination beliefs, a nationally representative sample of parents of young children answered a series of tradeoff questions that asked them to choose between two vaccination approaches that differed in terms of risks of vaccine complications, number of injections, and/or vaccine effectiveness. Most parents were willing to have their children endure more injections, and many were willing to forgo disease protection, in order to reduce the rare chance of febrile seizures. Yet, most parents were unwilling to trade disease protection to reduce the risk of fever alone, even though this is correlated with the risk of febrile seizures. Vaccine risk communications need to address the heightened emotional weight that parents give to febrile seizure risk, even when the rarity of such events is explicit.

Parents' confidence in recommended childhood vaccinations: Extending the assessment, expanding the context

There has been significant and growing interest in vaccine hesitancy and confidence in the United States as well as across the globe. While studies have used confidence measures, few studies have provided in-depth assessments and no studies have assessed parents' confidence in vaccines in relationship to other frequently recommended health-related products for young children. This study used a nationally representative sample of 1000 US parents to identify confidence levels for recommended vaccinations, antibiotics, over-the-counter (OTC) medicines, and vitamins for children. The analyses examined associations between confidence ratings, vaccination behaviors and intentions, and trust in healthcare provider, along with associations between confidence ratings and use of the other health-related products. Parents' confidence in vaccines was relatively high and high relative to antibiotics, OTC medicines and vitamins. For all 4 health-related products examined, past product experience and knowledge of bad or adverse outcomes negatively impacted parents' confidence levels. Confidence levels were associated with both trust in advice from their child's healthcare provider and acceptance of healthcare provider recommendations. Parents in some groups, such as those with lower income and education levels, were more likely to have less confidence not just in vaccines, but also in antibiotics and OTC medicines for children. Overall, the findings extend understanding of vaccine confidence, including by placing it into a broader context.