Do laws bring children in child care centers up to date for immunizations?

Influenza Vaccine Requirements in United States Child Care Centers

BACKGROUND

Influenza vaccine is the most effective means to prevent influenza for the high-risk population of child care attendees. This national survey assessed child care center directors' reports of seasonal influenza vaccine requirements for children and adult caregivers.

METHODS

This was a 2016 telephone-based survey of child care center directors randomly selected from a national database of licensed United States child care centers and queried about influenza vaccine requirements. Conceptually related items were grouped into 4 indexes: general infection control, use of health consultants, quality of child care, and pandemic influenza preparedness. These indexes, along with other center and director characteristics, were used to predict director-reported influenza vaccine requirements.

RESULTS

Of 518 child care center directors, only 24.5% and 13.1% reported an influenza vaccine requirement for children and adult caregivers, respectively. Center and director characteristics and the indexes were not associated with a director-reported influenza vaccine requirement. After adjusting for covariates, only having a state influenza vaccine law for children and an adult influenza vaccine requirement predicted having a child influenza vaccine requirement. Only having a child influenza vaccine requirement predicted having an adult vaccine requirement.

CONCLUSIONS

Director-reported influenza vaccine requirements for children and adult caregivers were influenced primarily by state influenza vaccine laws. Given the high risk of children in child care and low director-reported influenza vaccine requirements, more states should pass laws requiring influenza vaccine for children and adult caregivers at child care programs.

Evidence-based strategies to increase vaccination uptake: a review

PURPOSE OF REVIEW

To summarize evidence-based strategies for improving pediatric immunization rates including physician behaviors, clinic and public health processes, community-based and parent-focused interventions, and legal and policy approaches RECENT FINDINGS: Studies continue to show the effectiveness of audit and feedback, provider reminders, standing orders, and reminder/recall to increase immunization rates. Provider communication strategies may improve immunization rates including use of a presumptive approach and motivational interviewing. Centralized reminder/recall (using a state Immunization Information System) is more effective and cost-effective compared to a practice-based approach. Recent work shows the success of text messages for reminder/recall for vaccination. Web-based interventions, including informational vaccine websites with interactive social media components, have shown effectiveness at increasing uptake of pediatric and maternal immunizations. Vaccination requirements for school attendance continue to be effective policy interventions for increasing pediatric and adolescent vaccination rates. Allowance for and ease of obtaining exemptions to vaccine requirements are associated with increased exemption rates.

SUMMARY

Strategies to increase vaccination rates include interventions that directly impact physician behavior, clinic and public health processes, patient behaviors, and policy. Combining multiple strategies to work across different settings and addressing different barriers may offer the best approach to optimize immunization coverage.

Pertussis Vaccination Among Childcare Center Staff, Administrators, and Parents: Uptake, Policies, and Beliefs

Introduction Little is known about childcare staff's and parents' uptake of and attitudes towards pertussis vaccine. Methods Questionnaires were distributed to St. Louis parents and childcare staff in fall, 2014. Parents versus staff and vaccinated versus unvaccinated individuals' beliefs regarding pertussis vaccine were compared using chi square tests. Multivariate logistic regressions were run to develop predictive models for staff's and parents' vaccine uptake. Results Overall, 351 parents and staff from 23 agencies participated (response rate = 32%). Parents were more likely than staff to have received pertussis vaccine (66.5 vs. 45.8%, X ² = 12.5, p < .001). Predictors for staff vaccination included willingness to get vaccinated even if there was a cost (OR 6.6; CI 1.8-24.6; p < .01), awareness of vaccination recommendations (OR 5.2; CI 1.2-22.8; p < .05), and healthcare provider recommendation (OR 4.2; CI 1.2-15.1; p < .05). Parents' predictors of vaccination included perceived importance of vaccination (OR 9.9; CI 4.1-23.8; p < .001), healthcare provider recommendation (OR 4.6; CI 1.7-12.6; p < .01), believing vaccination is effective (OR 4.4; CI 1.1-18.0; p < .05), and knowing where to get vaccine (OR 3.5; CI 1.5-8.1; p < .01). Among unvaccinated staff (n = 52), 74.5% (n = 38) and 70.0% (n = 35) would receive pertussis vaccine if it were offered free of charge and onsite, respectively. Conclusions for Practice Childcare staff's and parents' pertussis vaccine uptake was higher than overall U.S. rates, though significantly lower than the Global Pertussis Initiative target. Implementing an education campaign and providing free vaccine on-site are likely to result in increased vaccine uptake.

Density of day cares in relation to reported pertussis incidence in Philadelphia

OBJECTIVES

Reported pertussis incidence has increased markedly in recent years. In addition to the documented increase in under-immunization and waning immunity, the increase may be related to the more frequent use of child care services by parents over the last few decades. Additionally, clustering of outbreaks may be related to neighborhood characteristics not previously identified.

STUDY DESIGN

We conducted a citywide case-control study of children in Philadelphia aged birth through six years, between 2001 and 2013. Cases were reported as probable pertussis diagnoses to the Health Department. Controls were sampled from the city's immunization information system and matched to the cases by date of birth.

METHODS

Multilevel logistic regression was used to isolate the independent contributions of individual and neighborhood risk factors and the corresponding relative odds of pertussis. The density of day cares in each neighborhood served as the main exposure and reported incident cases of confirmed and probable pertussis was the main outcome.

RESULTS

Between 2001 and 2013, 410 cases of confirmed and probable pertussis were included with four controls matched per case yielding a final sample of 2050 children from 45 Philadelphia neighborhoods. There was a 30% increase in the risk of pertussis based solely on the neighborhood where the children resided (median odds ratio 1.3, 95% credible interval 1.1, 1.6). The density of day cares in each neighborhood was unrelated to the distribution of pertussis cases.

CONCLUSIONS

Pertussis clustering was observed at the neighborhood level in Philadelphia, but was unrelated to the neighborhood's day care density. From a Health Department perspective, the highest risk neighborhoods should be targeted for vaccine campaigns and further research to identify the etiologic risk factors.

Vaccination for child clients and employees in St Louis childcare agencies: Vaccine uptake and policies versus parents' perceptions

BACKGROUND

Little is known about childcare agency staff vaccination requirements, parents' perceptions of these requirements, or vaccine uptake in these populations.

METHODS

A questionnaire was administered to St Louis parents and childcare agency staff in fall of 2014. The χ(2) tests compared staff's versus parents' uptake of hepatitis A, pertussis, and seasonal influenza vaccines. Multivariate logistic regression was used to examine individuals being fully immunized (ie, having received influenza, hepatitis A, and pertussis vaccines).

RESULTS

Overall, 351 parents and staff from 23 agencies participated (response rate, 32%). One-third of staff (34.4%, n = 33) and parents (37.6%, n = 96) were fully immunized. Parents and staff were equally likely to have received the influenza vaccine (48.8% and 47.3%, respectively), but more staff received the hepatitis A vaccine (85.3% vs 67.5%, χ(2)=11.0, P < .001), and more parents received the pertussis vaccine (66.5% vs 45.8%, χ(2)=12.5, P < .001). Determinants of being fully immunized included having previously received the influenza vaccine, being offered the vaccines, belief that vaccination is important, having immunization recommendation awareness, and not having vaccine misperceptions.

CONCLUSIONS

Childcare agency staff vaccination can protect employees and children from disease, but their uptake of vaccines needs improvement. Future interventions should be aimed at increasing uptake to lower disease transmission in childcare settings.

Parents' and staff's support for a childcare agency employee mandatory vaccination policy or agency certification program

BACKGROUND

Vaccine-preventable diseases pose a significant risk to children in childcare. However, few regulations exist regarding childcare staff vaccination. This study aimed to assess support for a childcare agency staff mandatory vaccination policy.

METHODS

Surveys were distributed to staff and parents at 23 St Louis, Mo, childcare agencies during fall 2014. Staff and parents' support for a mandatory vaccination and/or agency certification program were compared using χ(2) tests. Multivariate logistic regression was conducted using a 2-level nested design and controlling for gender, race, age, and income to determine predictive models for support for a mandatory staff vaccination policy and/or agency certification program.

RESULTS

Overall, 354 parents and staff participated (response rate, 32%). Most supported a mandatory staff vaccination policy (80.0%; n = 280) or agency certification program (81.2%; n = 285), and there were no differences between parents versus staff. Determinants of support for a mandatory policy included willingness to receive influenza vaccine annually, belief that vaccines are safe and effective, and support for the policy only if there were no costs.

CONCLUSIONS

There is strong support for some type of childcare agency staff vaccination policy. Implementing such a policy/program should be a collaborative endeavor that addresses vaccine cost and access.

Effects of automated immunization registry reporting via an electronic health record deployed in community practice settings

BACKGROUND

Among the expected benefits of electronic health records (EHRs) is increased reporting of public health information, such as immunization status. State and local immunization registries aid control of vaccine-preventable diseases and help offset fragmentation in healthcare, but reporting is often slow and incomplete. The Primary Care Information Project (PCIP), an initiative of the NYC Department of Health and Mental Hygiene, has implemented EHRs with immunization reporting capability in community settings.

OBJECTIVE AND METHODS

To evaluate the effect of automated reporting via an EHR on use and efficiency of reporting to the NY Citywide Immunization Registry, we conducted a secondary analysis of 1.7 million de-identified records submitted between January 2007 and June 2011 by 217 primary care practices enrolled in PCIP, pre and post launch of automated reporting via an EHR. We examined differences in records submitted per day, lag time, and documentation of eligibility for subsidized vaccines.

RESULTS

Mean submissions per day did not change. Automated submissions of new and historical records increased by 18% and 98% respectively. Submissions within 14 days increased from 84% to 87%, and within 2 days increased from 60% to 77%. Median lag time decreased from 13 to 10 days. Documentation of eligibility decreased. Results are significant at p<0.001.

CONCLUSIONS

Significant improvements in registry use and efficiency of reporting were found after launch of automated reporting via an EHR. A decrease in eligibility documentation was attributed to EHR workflow. The limitations to comprehensive evaluation found in these data, which were extracted from a registry initiated prior to widespread EHR implementation suggests that reliable evaluation of immunization reporting via the EHR may require modifications to legacy registry databases.

Evaluation of the frequency of immunization information system use for public health research

Immunization information systems (IIS) have been useful for consolidating immunization data and increasing coverage, and have the potential to be a valuable resource for immunization research, but the extent which IIS data are used for research purposes has not been evaluated. We reviewed studies conducted using data from federally supported state and city immunization program IIS, and categorized research type based on study objectives to evaluate patterns in the types of research conducted. Research papers using IIS data published between 1999 and July 3, 2012 were identified by searching the CDC IIS publication database and PubMed. These searches produced 304 and 884 papers, respectively, 44 of which were eligible to be included in this evaluation. The most common research category was evaluation of factors associated with vaccine coverage and vaccine coverage estimates (n = 20). This study shows that IIS may not be used to their full potential with regards to research. Further research is needed to determine barriers to using IIS data for research purposes.

Desigualdades sociais e cobertura vacinal na cidade de Salvador, Bahia

Objetivo: Estimar as coberturas vacinais alcançadas em crianças nascidas na cidade de Salvador, analisando essas coberturas por condições socioeconômicas. Método: Foi realizado um inquérito domiciliar sobre cobertura vacinal, na cidade de Salvador, capital do Estado da Bahia, Nordeste do Brasil, sendo incluídas crianças nascidas em 2005, que no momento do estudo apresentavam 18 a 36 meses de idade. Foi realizada amostragem por conglomerados em múltiplas etapas. Os setores censitários foram estratificados utilizando-se dados do censo demográfico realizado em 2000. Foram coletados dados socioeconômicos dos domicílios. O tamanho da amostra foi definido a partir de metodologia específica para inquéritos de cobertura vacinal. O questionário foi aplicado tomando por base as informações constantes na caderneta de vacinação. Foi estimada a cobertura vacinal nos diversos estratos considerando o plano complexo de amostragem, ponderando as observações segundo a fração amostral, as perdas e o efeito do desenho. Resultados: Observou-se desigualdade socioeconômica nos diversos estratos, com um gradiente diretamente proporcional entre cobertura vacinal e nível socioeconômico. As diferenças mostram-se estatisticamente significantes entre os estratos D e E comparado ao estrato A. Em relação ao esquema completo, as crianças residentes nos estratos D e E apresentam cobertura significantemente menor que aquelas residentes no estrato B. Para vacinas não incluídas no esquema básico, as diferenças são muito acentuadas, sendo inferior a 3% nos estratos D e E. Conclusões: A cobertura vacinal pelo esquema completo ao final dos 18 meses de idade, com doses válidas, foi insatisfatória e foram observadas heterogeneidades entre os estratos socioeconômicos com pior cobertura nos grupos mais pobres.

The effect of policy changes on hepatitis A vaccine uptake in Arizona children, 1995-2008

OBJECTIVE

In 1995, the first hepatitis A vaccines became available for use. At that time, Arizona had the highest hepatitis A incidence of all 50 states. During that same time period, the Arizona State Immunization Information System (ASIIS) was created to collect information on all immunizations given in the state. Four state-level hepatitis A vaccination policies were enacted according to Centers for Disease Control and Prevention recommendations and local initiatives from 1996 to 2005. Our primary objective was to assess the impact of these policies on vaccine uptake in children.

METHODS

Immunization records from ASIIS were used to calculate yearly coverage of children with at least one reported hepatitis A vaccination between 1995 and 2008. Proportions vaccinated were calculated by age group (12-23 months, 24-59 months, 5-9 years, 10-14 years, and 15-19 years) for three regions: Maricopa County; Apache and Navajo counties; and the remaining 12 Arizona counties, which were grouped as one to reflect different target groups for the four policies examined. We calculated percent changes from before and after each policy implementation.

RESULTS

Significantly different percent changes were detected among the three regions that related to the four policies implemented. Percent change in uptake was consistently higher in the regions that were targeted for that specific policy.

CONCLUSIONS

Analysis of ASIIS data revealed a major effect of hepatitis A policy recommendations on vaccine uptake in Arizona. Targeting high-risk populations through vaccine recommendations and child care entry requirements was highly successful in achieving higher vaccination coverage.

Maternal health literacy and late initiation of immunizations among an inner-city birth cohort

To determine if maternal health literacy influences early infant immunization status. Longitudinal prospective cohort study of 506 Medicaid-eligible mother-infant dyads. Immunization status at age 3 and 7 months was assessed in relation to maternal health literacy measured at birth using the Test of Functional Health Literacy in Adults (short version). Multivariable logistic regression quantified the effect of maternal health literacy on immunization status adjusting for the relevant covariates. The cohort consists of primarily African-American (87%), single (87%) mothers (mean age 23.4 years). Health literacy was inadequate or marginal among 24% of mothers. Immunizations were up-to-date among 73% of infants at age 3 months and 43% at 7 months. Maternal health literacy was not significantly associated with immunization status at either 3 or 7 months. In multivariable analysis, compared to infants who had delayed immunizations at 3 months, infants with up-to-date immunizations at 3 months were 11.3 times (95%CI 6.0-21.3) more likely to be up-to-date at 7 months. The only strong predictors of up-to-date immunization status at 3 months were maternal education (high school graduate or beyond) and attending a hospital-affiliated clinic. Though maternal health literacy is not associated with immunization status in this cohort, later immunization status is most strongly predicted by immunization status at 3 months. These results further support the importance of intervening from an early age to ensure that infants are fully protected against vaccine preventable diseases.

Status of school entry requirements for varicella vaccination and vaccination coverage 11 years after implementation of the varicella vaccination program

We reviewed progress toward adoption of day care and school entry requirements in each state and the District of Columbia (DC) and compared varicella vaccination coverage by state to year of implementation of day care entry requirements. By the start of the 2006-2007 school year, 46 states (92%) and DC had implemented entry requirements for varicella vaccination. Between 1997 and 2005, national varicella vaccination coverage among children 19-35 months of age increased from 25.8% to 87.9%. Implementation of day care entry requirements in 2000 or earlier was associated with higher vaccination coverage (> or =90%; P=.002). Implementation of day care and school entry requirements for varicella vaccination is an important strategy for achieving and maintaining high vaccination coverage among preschool- and school-aged children in the United States. The newly adopted vaccine policy recommendation of 2 doses of varicella vaccine for all school-aged children should be incorporated into the states' school entry requirements.

[Immunization control and student registration at the city of São Paulo's Municipal Schools of Infantile Education]

The presentation of the vaccination passbook is mandatory for student registration at the city of São Paulo's Municipal Schools of Infantile Education, as a form of stimulating parents to keep their children's immunizations calendar updated. However, attendants do not verify periodically if the vaccinations are correct. In order to overcome this problem, a project with the aim of facilitating the immunization control through a software that controls immunizations was tested at a Municipal School of Infantile Education. Of the 286 pupils registered in the system, 236 (82.5%) were notified that their vaccines were incomplete. Of these, 21.2% updated their vaccinations, 2.5% returned their passbooks unchanged, and the remainders were still in the process of updating. The program identified the imperfections and encouraged immunization, thus helping to prevent the propagation of transmissible diseases in the school environment.

Associations of daycare and school entry vaccination requirements with varicella immunization rates

School and daycare entry requirements have been credited with increasing immunization rates among school-age children, but no prior study has assessed the nationwide effects of entry requirements while controlling for individual, family, and household characteristics. The 2002 National Immunization Survey (NIS) is a nationally representative annual survey that includes provider record-verified immunization dates for 20,546 children aged 19-35 months without prior history of varicella. In weighted bivariate and multivariate logistic regression models, we examined the association of state entry mandate implementation with children's up-to-date (UTD) status for varicella vaccine, adjusted for sociodemographic characteristics of children, mothers, and household income and for children's UTD status for other recommended vaccines. In this national sample representative of 5.6 million children, 83.2% (95% CI: 82.3%-84.1%) were UTD for varicella vaccine. Between 1997 and 2002 inclusive, 33 states and the District of Columbia had implemented school and/or daycare entry immunization mandates for varicella. In bivariate analyses, 84.9% (83.9%-85.9%) of children in states with varicella entry mandates were UTD, compared to 76.8% (75.3%-78.4%) of children in states without such mandates. In multivariate analyses controlling for child and family characteristics, children living in states with varicella entry mandates remained significantly more likely to be UTD for varicella than children in states without mandates. These findings indicate that immunization entry requirements are associated with higher immunization rates among preschool-age children, and suggest that the effects of entry requirements are independent of other individual and household factors associated with childhood immunization.