Cost effectiveness of school-located influenza vaccination programs for elementary and secondary school children

Quadrivalent Live-Attenuated Influenza Vaccine in Milan preschools: an Italian experience of school-located flu vaccination within the 2022-2023 season

BACKGROUND

In Italy, since the 2020-2021 flu season, the flu vaccine recommendation was extended to all children aged 6 months to 6 years and quadrivalent Live-Attenuated Influenza Vaccine (qLAIV) was introduced. Since school-aged children are important carriers of annual influenza epidemics, a school-based influenza vaccination program may potentially increase vaccine uptake. Recent studies, conducted in the UK and the US, show that school-based vaccination can reach higher percentage of paediatric vaccination coverage compared to children vaccinated in other settings.

METHODS

During 2022-2023 flu season in 9 preschools located in Milan healthcare personnel vaccinated children with qLAIV at the end of a school day. A Google Form questionnaire was administered to preschoolers' parents of all preschools within the Municipality of Milan.

RESULTS

In the preschools engaged in the vaccination program, 233 out of 1939 children were vaccinated (12%). Among these, 61 (26.2%) had never been vaccinated for influenza before. Vaccination coverage was 11.5% for Italian children and 14.3% for children coming from an immigrant background. We collected 3659 questionnaire responses, divided according to study participation status (371 from preschools that participated in the vaccination program and 3288 from other preschools in Milan). 57% of the families who answered to the questionnaire vaccinated their children for flu. qLAIV accounted for 85.6% of vaccinations. We observed a statistically significant difference in the percentage of vaccinated children between those attending a school participating in the project (67.9%) and children attending other schools (56%) (p < 0.001). Vaccination was administered by family pediatricians (48.9%), in vaccination centers (34.8%), in vaccine hubs (11.3%), in schools (2.6%), by private pediatricians (1.6%) and in other settings (0.7%). Focusing on the responses from families whose children attend schools participating in the vaccination program, 21.8% stated that the vaccination was provided in school.

CONCLUSION

According to our experience, in Italy, at the moment, only the cooperation between health providers and alternative settings, including schools, may expand flu vaccination coverage. In particular, schools are to be considered a place to inform and reach out to families, useful to increase vaccination coverage.

Social Processes and COVID-19 Vaccination of Children of Hesitant Mothers

OBJECTIVE

Investigate relationships between pediatric COVID-19 vaccination and social processes of healthcare provider recommendations and school encouragement to provide insights into social processes that may support pediatric COVID-19 vaccination among hesitant mothers.

METHODS

We analyzed survey data from a subsample (n = 509) of vaccine-hesitant mothers to child patients (ages 2 to 17) in regional clinics across Arkansas. Data were collected between September 16th and December 6th, 2022. Full information maximum likelihood multivariable logistic regression was conducted to evaluate associations with pediatric COVID-19 vaccination.

RESULTS

Adjusted odds of pediatric COVID-19 vaccination were more than three times greater when a child's healthcare provider recommended vaccination compared to when they did not (aOR = 3.52; 95% CI[2.06, 6.01]). Adjusted odds of pediatric COVID-19 vaccination were 85% greater when a child's school encouraged parents to vaccinate compared to when the school did not (aOR = 1.85; 95% CI[1.13, 3.03]).

CONCLUSIONS

For pediatric COVID-19 vaccination, having a personal healthcare provider is not significantly different from having no personal healthcare provider if they do not recommend the child be vaccinated.

PRACTICE IMPLICATIONS

Clinical and public health interventions should consider social processes of healthcare provider recommendations and school encouragement.

Identifying implementation strategies to address barriers of implementing a school-located influenza vaccination program in Beijing

BACKGROUND

The school-located influenza vaccinations (SLIV) can increase influenza vaccination and reduce influenza infections among school-aged children. However, the vaccination rate has remained low and varied widely among schools in Beijing, China. This study aimed to ascertain barriers and facilitators of implementing SLIV and to identify implementation strategies for SLIV quality improvement programs in this context.

METHODS

Semi-structured interviews were conducted with diverse stakeholders (i.e., representatives of both the Department of Health and the Department of Education, school physicians, class headteachers, and parents) involved in SLIV implementation. Participants were identified by purposive and snowball sampling. The Consolidated Framework for Implementation Research was adopted to facilitate data collection and analysis. Themes and subthemes regarding barriers and facilitators were generated using deductive and inductive approaches. Based on the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change (CFIR-ERIC) matching tool, practical implementation strategies were proposed to address the identified barriers of SLIV delivery.

RESULTS

Twenty-four participants were interviewed. Facilitators included easy access to SLIV, clear responsibilities and close collaboration among government sectors, top-down authority, integrating SLIV into the routine of schools, and priority given to SLIV. The main barriers were parents' misconception, inefficient coordination for vaccine supply and vaccination dates, the lack of planning, and inadequate access to knowledge and information about the SLIV. CFIR-ERIC Matching tool suggested implementation strategies at the system (i.e., developing an implementation blueprint, and promoting network weaving), school (i.e., training and educating school implementers), and consumer (i.e., engaging students and parents) levels to improve SLIV implementation.

CONCLUSIONS

There were substantial barriers to the delivery of the SLIV program. Theory-driven implementation strategies developed in this pre-implementation study should be considered to address those identified determinants for successful SLIV implementation.

Risk perceptions regarding inclusion of seasonal influenza vaccinations in the school immunization program in Israel: Arab vs. Jewish mothers

Background

The issue of whether to include seasonal influenza vaccinations in school-located vaccination programs (SLIV) has been examined in many countries, mainly in the context of economic effectiveness and morbidity prevention. Yet not enough studies have examined the impact of parental risk perceptions, health literacy and SLIV on parental vaccination uptake.

Objectives

The most recent statistics in Israel point to a higher rate of seasonal influenza vaccination among Arab children (aged 7–9 years) than among Jewish children in the same age group. The present study attempts to explain this high vaccination uptake among mothers from Arab society by comparing their risk perceptions regarding seasonal influenza vaccination and disease to those of Jewish mothers. The study further examines the impact of SLIV on parental risk perceptions and influenza vaccination uptake.

Methods

This cross-sectional study included mothers of children in the second and third grades faced with the decision of whether their children should receive the seasonal influenza vaccination at school. The study population included a stratified sample of Jewish mothers (n = 159) and Arab mothers from all the Arab population sub-groups: Muslim, Christian, Druse and Bedouin (n = 534).

Results

A comparison of the Arab and Jewish populations revealed a significant difference in vaccination rates; 61.7% among Arab mothers compared to 33.5% among Jewish mothers (χ²(1) = 39.15, P<0.0001). Moreover, significant differences emerged between the Arab and Jewish populations in health literacy and ability to seek information regarding the seasonal influenza vaccination (t (691) = -5.81, p < 0.0001). While no differences emerged in mothers’ perceptions regarding influenza as a disease (t (691) = 1.20, p = 0.2318), Arab mothers perceived the vaccination to be safer than Jewish mothers (t (691) = 2.74, p = 0.0063) and saw its inclusion in the school-located vaccination program as providing more legitimacy (Z = -6.6719, P < .0001).

Conclusion

This study showed that the factors influencing vaccination uptake among both the Arab and the Jewish populations include perceived influenza risk, perceived vaccination risk, inclusion in the school-located vaccination program and health literacy. Moreover, influenza vaccination uptake is higher among those who have positive attitudes toward vaccinations, low risk perceptions regarding the vaccine, and low health literacy that impedes their ability to seek information. The research also points to the need for education and tools to boost health literacy among minority groups so that mothers can make independent and informed decisions about whether or not to vaccinate their children.

Factors associated with seasonal influenza and HPV vaccination uptake among different ethnic groups in Arab and Jewish society in Israel

Background

Parents in the Arab population of Israel are known to be “pro-vaccination” and vaccinate their children at higher rates than the Jewish population, specifically against human papilloma virus (HPV) and seasonal influenza.

Objectives

This study seeks to identify and compare variables associated with mothers’ uptake of two vaccinations, influenza and HPV, among different subgroups in Arab and Jewish society in Israel.

Methods

A cross-sectional study of the entire spectrum of the Israeli population was conducted using a stratified sample of Jewish mothers (n = 159) and Arab mothers (n = 534) from different subgroups: Muslim, Christian, Druse and Northern Bedouins. From March 30, 2019 through October 20, 2019, questionnaires were distributed manually to eighth grade pupils (13–14 years old) who had younger siblings in second (7–8 years old) or third (8–9 years old) grades.

Results

Arab mothers exhibited a higher rate of uptake for both vaccinations (p < .0001, HPV – 90%; influenza – 62%) than Jewish mothers (p = 0.0014, HPV – 46%; influenza – 34%). Furthermore, results showed that HPV vaccination uptake is significantly higher than seasonal influenza vaccination uptake in both populations. Examination of the different ethnic subgroups revealed differences in vaccination uptake. For both vaccinations, the Northern Bedouins exhibited the highest uptake rate of all the Arab subgroups (74%), followed by the Druse (74%) and Muslim groups (60%). The Christian Arab group exhibited the lowest uptake rate (46%). Moreover, the uptake rate among secular Jewish mothers was lower than in any of the Arab groups (38%), though higher than among religious/traditional Jewish mothers, who exhibited the lowest uptake rate (26%). A comparison of the variables associated with mothers’ vaccination uptake revealed differences between the ethnic subgroups.

Moreover, the findings of the multiple logistic regression revealed the following to be the most significant factors in Arab mothers’ intake of both vaccinations: school-located vaccination and mothers’ perceived risk and perceived trust in the system and in the family physician. These variables are manifested differently in the different ethnic groups.

Conclusions

This research shows that all Arabs cannot be lumped together as one monolithic group in that they exhibit major differences according to religion, education and access to information. Ranking of variables associated with uptake of the two vaccines can provide decision-makers an empirical basis for tailoring appropriate and specific interventions to each subgroup to achieve the highest vaccine uptake rate possible. Media campaigns targeting the Arab population should be segmented to appeal to the various sub-groups according to their viewpoints, needs and health literacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01523-1.

Costs of Interventions to Increase Vaccination Coverage Among Children in the United States: A Systematic Review

BACKGROUND

The Community Preventive Services Task Force (CPSTF) has recommended several interventions that have been demonstrated to be effective at increasing vaccination coverage.

OBJECTIVE

Conduct a systematic review to examine the costs of interventions designed to increase vaccination coverage among children and adolescents in the United States.

DATA SOURCES

PubMed, EconLit, Embase, and Cochrane.

STUDY ELIGIBILITY, PARTICIPANTS, AND INTERVENTIONS

Peer-reviewed articles from January 1, 2009 to August 31, 2019.

APPRAISAL AND SYNTHESIS METHODS

Studies were identified with systematic searches of the literature, reviewed for inclusion criteria, abstracted for data on intervention, target population, costs, and risk of bias. Cost measures were reported as costs per child in the target population, costs per vaccinated child, incremental costs per vaccinated child, and costs per vaccine dose administered. Results were stratified by intervention type, vaccine, and age group.

RESULTS

Thirty-seven studies were identified for full-text review. Across all interventions and age groups, the cost per child ranged from $0.10 to $537.38, and the incremental cost per vaccinated child ranged from $6.52 to $5,098.57. Provider assessment and feedback interventions had the lowest (median) cost per child ($0.17) and a healthcare system-based combined intervention with multiple components had the lowest (median) incremental cost per vaccinated child ($26.65). A community-based combined intervention with multiple components had the highest median cost per child ($537.38) and the highest median incremental cost per vaccinated child ($5,098.57).

LIMITATIONS

A small number of included intervention types and inconsistent cost definition.

CONCLUSIONS

There is substantial variability in the costs of CPSTF-recommended interventions.

Health Economic Evaluation Alongside Stepped Wedge Trials: A Methodological Systematic Review

BACKGROUND

Recently, there has been an increase in use of the stepped wedge trial (SWT) design in the context of health services research, due to its pragmatic and methodological advantages over the parallel group design.

OBJECTIVE

Our objective was to summarise the statistical methods used when conducting economic evaluations alongside SWTs.

METHODS

A systematic literature search extending to February 2020 was conducted in the PubMed, Scopus, Cochrane and National Health Service Economic Evaluation Database (NHS-EED) databases to find and evaluate studies where there was an intention to conduct an economic evaluation alongside an SWT. Studies were assessed for their eligibility, findings, reporting of statistical methods and quality of reporting.

RESULTS

Of the 586 studies retrieved from the literature search, 69 studies were identified and included in this systematic review. A total of 54 studies were published protocols, with eight economic evaluations and seven studies reporting full trial results. Included studies varied in terms of their reporting of statistical methods, in both detail and methodology. There were 34 studies that did not report any statistical methods for the economic evaluation, and only 16 studies reported appropriate methods, mainly using some form of mixed/multilevel model, and two used seemingly unrelated regression. Twelve studies reported the use of generic bootstrap methods and other modelling techniques, whilst the remaining studies failed to appropriately account for clustering, correlation or adjustment for time.

CONCLUSIONS

The use of appropriate statistical methods that account for time, clustering and correlation between costs and outcomes is an important part of SWT health economics analysis, one that will benefit from an effort to communicate the methods available and their performance.

Attitudes of Dilated Cardiomyopathy Patients and Investigators Toward Genomic Study Enrollment, Consent Process, and Return of Genetic Results

Precision medicine genetics study design requires large, diverse cohorts and thoughtful use of electronic technologies. Involving patients in research design may increase enrollment and engagement, thereby enabling a means to relevant patient outcomes in clinical practice. Few data, however, illustrate attitudes of patients with dilated cardiomyopathy (DCM) and their family members toward genetic study design. This study assessed attitudes of 16 enrolled patients and their family members (P/FM), and 18 investigators or researchers (I/R) of the ongoing DCM Precision Medicine Study during a conjoint patient and investigator meeting using structured, self‐administered surveys examining direct‐to‐participant enrollment and web‐based consent, return of genetic results, and other aspects of genetic study design. Survey respondents were half women and largely identified as white. Web‐based consent was supported by 93% of P/FM and 88% of I/R. Most respondents believed that return of genetic results would motivate study enrollment, but also indicated a desire to opt out. Ideal study design preferences included a 1‐hour visit per year, along with the ability to complete study aspects by telephone or web and possibility of prophylactic medication. This study supports partnership of patients and clinical researchers to inform research priorities and study design to attain the promise of precision medicine for DCM.

Nontraditional Uses of Live Attenuated Influenza Vaccine: School-Located Influenza Vaccination

Immunization against influenza continues to be the best method of preventing influenza infection in children, and additionally, indirectly helping to lower disease in adults, given the role of children as "spreaders" of influenza to the community at large. An increasing evidence base exists for the use of school-located influenza vaccination (SLIV) programs to increase the influenza vaccination rates among children. Live, attenuated influenza vaccine (LAIV) has unique characteristics that make it useful for SLIV programs, including ease of immunization without needles, faster delivery, and in many (but not all) years, good vaccine effectiveness. Reviewed herein are results of selected published trials as well as guidance on planning a successful SLIV program.