Predictors of influenza virus vaccination status in hospitalized children

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.

A hidden vulnerable population: Young children up-to-date on vaccine series recommendations except influenza vaccines

Very young children (under 2 years old) have high risk for influenza-related complications. Children 6 months or older in the US are recommended to receive influenza vaccination annually, yet uptake is substantially lower than other routinely-recommended vaccines. Existing nationally-representative studies on very young child influenza vaccine uptake has several limitations: few examine provider-verified influenza vaccination (relying on parental report), few contain parental vaccine attitudes variables (known to be crucial to vaccine uptake), and none to our knowledge consider intersectionality of social disadvantage nor how influenza vaccine determinants differ from those of other recommended vaccines. This nationally-representative study examines provider-verified data on 7,246 children aged 6–23 months from the most recent (2011) National Immunization Survey to include the restricted Parental Concerns module, focusing on children up-to-date on a series of vaccines (the 4:3:1:3:3:1:4 series) but not influenza vaccines (“hidden vulnerability to influenza”). About 71% of children were up-to-date on the series yet only 33% on influenza vaccine recommendations by their second birthday; 44% had hidden vulnerability to influenza. Independent of parental history of vaccine refusal and a myriad of health services use factors, no parental history of delaying vaccination was associated with 7.5% (2.6–12.5) higher probability of hidden vulnerability to influenza despite being associated with 15.5% (10.8–20.2) lower probability of being up-to-date on neither the series nor influenza vaccines. Thus, parental compliance with broad child vaccine recommendations and lack of vaccine hesitancy may not indicate choice to vaccinate children against influenza. Examination of intersectionality suggests that maternal college education may not confer improved vaccination among non-Hispanic Black and Hispanic children despite that it does for non-Hispanic White children. Policymakers and researchers from public health, sociology, and other sectors need to collaborate to further examine how vaccine hesitancy and intersectional social disadvantage interact to affect influenza vaccine uptake in young US children.

Disparities in parental awareness of children's seasonal influenza vaccination recommendations and influencers of vaccination

Objective

To determine parental awareness of influenza vaccination recommendations for children and explore associations with awareness.

Design

Cross-sectional survey.

Setting/participants

South Australian parents with a telephone listing in the Electronic White Pages were randomly selected.

Methods

Participants were interviewed using Computer Assisted Telephone Interviewing (CATI) during May–July 2016. Univariable and multivariable analyses explored characteristics associated with awareness; with the survey data weighted to reflect the population of SA and the probability of selection within a household.

Results

Of 539 parents, 33% were aware of the recommendation that all children (<5 years) should receive the influenza vaccine annually with 51.9% aware that children with special risk medical conditions (SRMC) should also receive the vaccine annually. Characteristics strongly associated with parental awareness of the recommendation for children aged < 5 years were knowledge of recommendation for children with a SRMC (adjusted Odds Ratio [aOR] 10.46, CI 4.44–24.63) or living in a metropolitan area (aOR 2.91, CI 1.19–7.09). There was lack of awareness in those not working (aOR 0.13, CI 0.04–0.47), with trade level education (compared with high school) (aOR 0.25 CI, 0.09–0.71) and in those born in the UK or Ireland (aOR 0.19, CI 0.04–0.85). Awareness of the recommendation for children with SRMC to receive the vaccine was strongly associated with knowledge of the influenza recommendation for children <5 years (aOR 10.22, CI 4.39–23.77) or not being born in Australia [UK/ Ireland (aOR 7.63, CI 1.86–31.31); other (aOR 3.93, CI 0.94–16.42)]. The most influential cues to future receipt were a general practitioner (GP) recommendation (63.8%) and providing influenza vaccine free for all children (37.6%). More parents who delayed or excluded vaccines believed that their children’s vaccinations (in general) were unnecessary, as other children were vaccinated (42.8%) compared to those with no or minor concerns (11.1%) (p<0.0001).

Conclusions

Parental awareness of children’s influenza vaccine recommendations is low. Targeted communication strategies and resources are required to establish broader community awareness of recommendations. Healthcare provider endorsement of the vaccine remains key and health care professionals, particularly GPs and paediatric specialists should be encouraged to discuss influenza vaccine with parents at every opportunity. Many parents have vaccine concerns and addressing concerns across the spectrum of hesitancy is crucial.

Exploring strategies to promote influenza vaccination of children with medical comorbidities: the perceptions and practices of hospital healthcare workers

BACKGROUND

To explore how the influenza vaccine is promoted and delivered to children with medical comorbidities in the hospital setting, as well as the facilitators of and barriers to vaccination from the healthcare worker perspective.

METHODS

Semi-structured interviews were conducted with staff members (n = 17) at a paediatric hospital in Sydney, Australia between April and July 2018. This included nurses, clinical nurse consultants, pediatricians and department heads. The interviews were transcribed and analysed iteratively to generate the major themes.

RESULTS

Approaches used to promote and/or deliver the influenza vaccine varied among the participants. Some described the vaccine as an ingrained component of their clinical consultation. Others acknowledged that there was missed opportunities to discuss or provide the vaccine, citing competing priorities as well as a lack of awareness, time and resources. Participants perceived that some parents had concerns about safety and appropriateness of the vaccine for their child. While there was some support for sending reminders and/or educating patients through the hospital, there were differing perspectives on whether tertiary centres should be delivering the vaccine.

CONCLUSION

Hospital-based interventions to increase vaccine uptake must consider the needs of staff. Easily accessible information and increased awareness of the recommendations among staff may lead to improved uptake in this hospital. Additional resources would be required to increase on-site delivery of the vaccine.

Influenza in Children With Special Risk Medical Conditions: A Systematic Review and Meta-analysis

BACKGROUND

Children with special risk medical conditions (SRMC) are over-represented in influenza hospitalizations. A systematic review was undertaken to determine whether children with SRMCs experience greater complications or severity following influenza infection.

METHODS

Bibliographies of pertinent articles were searched in MEDLINE and EMBASE (1990 to March 2018) and contact made with the investigators of unpublished studies containing relevant data. Studies of children (aged ≤18 years) with a SRMC hospitalized with influenza were included. Outcomes were pneumonia, intensive care unit (ICU) admission, mechanical ventilation, neurologic outcomes (seizures, encephalopathy), death and length of stay in hospital or ICU.

RESULTS

Twenty-two studies met inclusion criteria. Compared with healthy peers, children with SRMC had higher odds of ICU admission [pooled odds ratio (OR) 1.66 (95% confidence interval (CI): 1.25-2.21)], for mechanical ventilation [pooled OR 1.53 (95% CI: 0.93-2.52)] and death [pooled OR 1.34 (95% CI: 0.74-2.41)]. Additionally, children with SRMC were more likely to develop bacterial pneumonia (crude OR 1.7; 95% CI: 1.1-2.6) or experience prolonged hospital length of stay [adjusted rate ratio 1.75 (95% CI: 1.44-2.11)]. The level of GRADE evidence was low for all outcomes considered in this review.

CONCLUSIONS

While there was evidence that ICU management and bacterial pneumonia increases in children with SRMC, evidence showing an increase in the probability of death or need for mechanical ventilation was inconsistent. Further research using large datasets should evaluate the impact of complications and associated morbidity from influenza in SRMC children.

Influenza vaccine coverage and predictive factors associated with influenza vaccine uptake among pediatric patients

BACKGROUND

Despite recommendations from health care authorities, reports of severe influenza occur yearly among unvaccinated infants and children.

OBJECTIVES

This study investigated influenza vaccine coverage and predictive factors for vaccination status among pediatric patients during the 2016-2017 winter influenza season.

METHODS

A cross-sectional survey was conducted among parents of our study population identified through a major pediatric outpatient clinic in Hong Kong. Parents with a child aged 6 months to 17 years were invited to complete a questionnaire that assessed the current influenza vaccine status of the child and the parents' understanding and beliefs regarding influenza and its vaccine. A backward logistic regression was conducted to determine predictive factors and adjusted odds ratios associated with influenza vaccine uptake.

RESULTS

Our study included 348 parents and 405 pediatric patients. Of these, 142 pediatric patients (35.1%) received full vaccination. Predictive factors associated with the child's positive influenza vaccine status include a "very good" parental understanding of influenza and its vaccine (adjusted odds ratio, 6.7; 95% confidence interval,  2.1-21.5), a child with chronic medical condition and a "high" cue to action (adjusted odds ratio, 5.7; 95% confidence interval, 2.8-11.6), and a "high" perceived susceptibility toward influenza (adjusted odds ratio, 4.8; 95% confidence interval, 2.1-10.8).

CONCLUSIONS

This study reflects the low influenza vaccine coverage among pediatric patients. Interventions focusing on parental knowledge and understanding of influenza and its vaccine may improve future vaccine uptake among the pediatric population.

Association between provider recommendation and influenza vaccination status among children

BACKGROUND

Provider recommendation is associated with influenza vaccination receipt. The objectives of this study were to estimate the percentage of children 6 months-17 years for whom a provider recommendation for influenza vaccination was received, identify factors associated with receipt of provider recommendation, and evaluate the association between provider recommendation and influenza vaccination status among children.

METHODS

National Immunization Survey-Flu (NIS-Flu) parentally reported data for the 2013-14, 2014-15, and 2015-16 seasons were analyzed. Tests of association between provider recommendation and demographic characteristics were conducted using Wald chi-square tests and pairwise comparison t-tests. Multivariable logistic regression was used to determine variables independently associated with receiving provider recommendation and the association between provider recommendation and influenza vaccination status.

RESULTS

Approximately 70% of children had a parent report receiving a provider recommendation for influenza vaccination for their child. The strongest association between receipt of provider recommendation and demographic characteristics was with child's age, with younger children (6-23 months, 2-4 years, and 5-12 years) being more likely to have a provider recommendation than older children (13-17 years). In addition, children living in a household above poverty with household income >$75,000 were more likely to have a parent report receipt of a provider recommendation than children living below poverty. Children with a provider recommendation were twice as likely to be vaccinated than those without.

CONCLUSIONS

This study affirms the importance of provider recommendation for influenza vaccination among children. Ensuring that parents of all children receive a provider recommendation may improve vaccination coverage.

Factors Determining the Uptake of Influenza Vaccination Among Children With Chronic Conditions

BACKGROUND

Studies report that the influenza vaccination uptake rate among children with chronic conditions is alarmingly low. In Hong Kong, there has been no study examining parental decision making about influenza vaccination for children with chronic conditions, thereby limiting the knowledge base to inform the development of specific strategies to improve influenza vaccination rates. The aim of this study was to identify factors determining the uptake of influenza vaccination among children with chronic conditions.

METHODS

We conducted a cross-sectional survey of 623 parents with children having a chronic condition recruited from pediatric wards and specialty outpatient departments of 2 acute hospitals. A questionnaire developed by Daley et al based on the Health Belief Model was used to examine parents' beliefs and attitudes toward influenza and vaccination.

RESULTS

The parents' and their children's mean age were 40.1 ± 8.1 and 8.0 ± 4.5 years, respectively. Among the children, the most prevalent chronic conditions were asthma, chronic respiratory disease and cardiomyopathy. One-third (33%) of the children had influenza vaccination in the past 12 months. More than one-third (39%) of parents intended to vaccinate their children against influenza in the coming influenza season. A multivariable logistic regression analysis revealed that all subscale scores except perceived severity and knowledge about influenza were independently significantly associated with uptake.

CONCLUSIONS

The findings indicate that parents of children with chronic conditions lack awareness of the risks of influenza and have insufficient understanding about the benefits of vaccination. These findings could inform the development of interventions to promote vaccination uptake among children with chronic conditions.

Paediatrician beliefs and practices around influenza vaccination

AIM

The uptake of influenza vaccination in children with high-risk medical conditions continues to be low in Australia and internationally. We aimed to determine Australian paediatricians' beliefs and practices around the influenza vaccination of children.

METHODS

This was conducted as a cross sectional survey of paediatricians from two tertiary paediatric hospitals in Sydney.

RESULTS

There were 101 participants. Influenza vaccination was not prioritised compared with other vaccines and clinical issues, with fewer than half of respondents strongly agreeing that influenza vaccination was useful. Paediatricians' knowledge of guidelines and recommendations in this area was suboptimal. Interventions thought most likely to improve vaccine coverage included better education of doctors, greater vaccine availability in outpatient clinics and automated reminder systems.

CONCLUSION

The inclusion of influenza vaccine on the standard Australian immunisation schedule may be required to improve vaccine coverage in high-risk children.

A Survey of Parental Perception and Pattern of Action in Response to Influenza-like Illness in Their Children: Including Healthcare Use and Vaccination in Korea

Seasonal influenza is a significant cause of morbidity and mortality of children in Korea. However, few data are available on parental perception and action toward childhood influenza. This study aimed to characterize parental perception and patterns of action in response to influenza and influenza-like illnesses (ILIs), including vaccination and healthcare use. This prospective study involved a random survey of parents whose children were aged 6-59 months. The survey was conducted in October 2014. The study included 638 parents of 824 children younger than 6 years. Most parental information of influenza came from mass media (28.2%) and social media (15.5%). The factor that most often motivated parents to vaccinate their children against influenza was promotion of the government or mass media (36.6%). Negative predictors of immunization included safety concerns about influenza vaccination (28.1%) and mistrust in the vaccine's effectiveness (23.3%). Therefore, correct information about influenza and vaccination from mass media will be one of the cornerstones for implementing a successful childhood immunization program and reducing morbidity and mortality in Korea. Furthermore, to enroll younger children in vaccination programs, and to minimize coverage gaps, public concerns about vaccine safety should be resolved. The demographic data in the present study will be used to provide a deeper insight into a parental perception and will help health care providers increase influenza immunization rate.

Complementary and Alternative Medicine and Influenza Vaccine Uptake in US Children

BACKGROUND

Complementary and alternative medicine (CAM) is increasingly used in the United States. Although CAM is mostly used in conjunction with conventional medicine, some CAM practitioners recommend against vaccination, and children who saw naturopathic physicians or chiropractors were less likely to receive vaccines and more likely to get vaccine-preventable diseases. Nothing is known about how child CAM usage affects influenza vaccination.

METHODS

This nationally representative study analyzed ∼9000 children from the Child Complementary and Alternative Medicine File of the 2012 National Health Interview Survey. Adjusting for health services use factors, it examined influenza vaccination odds by ever using major CAM domains: (1) alternative medical systems (AMS; eg, acupuncture); (2) biologically-based therapies, excluding multivitamins/multiminerals (eg, herbal supplements); (3) multivitamins/multiminerals; (4) manipulative and body-based therapies (MBBT; eg, chiropractic manipulation); and (5) mind-body therapies (eg, yoga).

RESULTS

Influenza vaccination uptake was lower among children ever (versus never) using AMS (33% vs 43%; P = .008) or MBBT (35% vs 43%; P = .002) but higher by using multivitamins/multiminerals (45% vs 39%; P < .001). In multivariate analyses, multivitamin/multimineral use lost significance, but children ever (versus never) using any AMS or MBBT had lower uptake (respective odds ratios: 0.61 [95% confidence interval: 0.44-0.85]; and 0.74 [0.58-0.94]).

CONCLUSIONS

Children who have ever used certain CAM domains that may require contact with vaccine-hesitant CAM practitioners are vulnerable to lower annual uptake of influenza vaccination. Opportunity exists for US public health, policy, and medical professionals to improve child health by better engaging parents of children using particular domains of CAM and CAM practitioners advising them.

Determinants of healthcare provider recommendations for influenza vaccinations

OBJECTIVE

Investigate determinants of receiving healthcare provider (HCP) recommendations for seasonal and H1N1 influenza vaccinations.

METHODS

Using a United States national sample of adults 18 + from the National 2009 H1N1 Flu Survey, multivariate regression models estimated the likelihood of receiving a HCP recommendation. Covariates included demographics, socioeconomic status, and Advisory Committee on Immunization Practices (ACIP) priority groups.

RESULTS

Adults age 55-64 and 65 + were more likely to report a HCP recommendation when compared to adults age 18-34 (OR: 1.483, 95%CI: 1.237-1.778 and OR: 1.738, 95%CI: 1.427-2.116, respectively). Chronically ill adults had 58.0% (95%CI: 1.414-1.765) higher odds of receiving a HCP recommendation than non-chronically ill adults. Patients visiting a doctor once and twice had 28.7% (95%CI: 0.618-0.821) and 17.1% (95%CI: 0.721-0.952) lower odds of receiving a HCP recommendation when compared to adults visiting their doctor at least four times. And, compared to Non-Hispanic Whites, Non-Hispanic Blacks had 28.4% (95%CI: 1.064-1.549) higher odds of receiving a recommendation.

CONCLUSIONS

ACIP priority groups experienced higher rates of recommendations compared to non-ACIP groups. Racial differences in HCP recommendations cannot explain racial disparities in flu vaccination rates.

Prevalence and determinants of influenza vaccine coverage at tertiary pediatric hospitals

Despite long-standing recommendations, the uptake of influenza vaccination in children with high risk medical conditions is low. This study aimed to examine the uptake of influenza vaccination amongst a cohort of Australian children and factors associated with vaccine acceptance. Three hundred and sixteen parents of children attending outpatient clinics at the two pediatric hospitals in Sydney were recruited. The reported vaccination coverage rate was 41% among children with high risk conditions and 14% among standard risk children. There was a median of three clinic visits per high risk child at which an opportunity to vaccinate was apparently missed. Healthcare worker recommendation, having a high risk condition and parental beliefs about influenza and influenza vaccination were the most important determinants of vaccine uptake. Further studies on the beliefs and practices of doctors in this area will help guide interventions to improve vaccination rates in high risk children.

Factors associated with receipt of 2009 pandemic influenza A (H1N1) monovalent and seasonal influenza vaccination among school-aged children: Maricopa County, Arizona, 2009-2010 influenza season

CONTEXT

To target school-aged children (SAC), who were identified as a priority for pandemic 2009 Influenza A (pH1N1) vaccination, Maricopa County (MC) initiated school-based influenza vaccination in 69% of its 706 schools during the 2009-2010 influenza season.

OBJECTIVE

To determine factors associated with receipt of pH1N1 monovalent and 2009-2010 seasonal influenza vaccination among SAC and evaluate the association of school-based vaccination with vaccination status of SAC.

DESIGN

Random-digit dialing was used to survey 600 MC households with willing adult participants and children grades K-12. Logistic regression was used to identify factors associated with pH1N1 and seasonal vaccine receipt.

SETTING

Arizona.

PARTICIPANTS

Household adults with children grades K-12.

MAIN OUTCOME MEASURE

Characteristics of children, parents, and households were obtained.

RESULTS

Among 909 SAC, 402 (44%) received pH1N1 and 436 (48%) received seasonal vaccination. Factors associated with pH1N1 vaccination included vaccine availability at school (adjusted odds ratio [AOR]: 1.6; 95% confidence interval [CI]: 1.0-2.7), high-risk medical condition in child (AOR: 2.4; 95% CI: 1.4-4.0), elementary versus high school attendance (AOR: 1.6; 95% CI: 1.0-2.7), and seasonal influenza vaccination (AOR: 10.0; 95% CI: 6.4-15.6). Factors associated with seasonal vaccination included Hispanic ethnicity (AOR: 2.2; 95% CI: 1.1-4.2), health insurance coverage (AOR: 4.8; 95% CI: 1.7-13.7), elementary versus high school attendance (AOR: 1.5; 95% CI: 1.0-2.5), and pH1N1 vaccination (AOR: 10.5; 95% CI: 6.7-16.6).

CONCLUSIONS

Availability of pH1N1 vaccine at school was independently associated with pH1N1 vaccination of MC school-aged children. School-based influenza vaccination campaigns should be considered to increase vaccination among this population.

[Influenza vaccination coverage in children with risk conditions in Catalonia]

INTRODUCTION

Influenza vaccination is recommended in Catalonia in children older than 6 months with risk conditions for developing flu-related complications. The aim of this study is to determine influenza vaccine coverage in children with risk conditions and their association with socio-demographic factors and medical variables.

MATERIAL AND METHOD

Descriptive cross-sectional study of children with risk conditions for developing influenza complications (aged between 6months and 15years old) assigned to Primary Health Care centers in Catalonia at the beginning of the 2011-2012 influenza vaccination campaign. The information on vaccination status and study variables were obtained from data registered on electronic health records by primary care teams. The relationship between influenza vaccination and demographic and medical variables was analyzed using bivariate analysis and a multiple logistic regression model.

RESULTS

Influenza vaccination coverage was 23.9%. Variables associated with influenza vaccination were: age 2years or older (aOR: 1.6 [1.4-1.7] in children 3-5years old; 1.8 [1.7-2.0] in those 6-10 years, and 2.2 [2.0 -2.4] in children ≥11years]); male sex (aOR: 1.1 [1.0-1.1]); foreign nationality (aOR: 1.2 [1.2-1.3]); age-appropriate immunization according to the systematic immunization schedule (aOR: 3.3 [2.8-3.8]); more than one visit to the primary care physician (5 or more visits) (aOR: 4.1 [3.8-4.4]), and more than one risk condition (3 or more conditions) (aOR: 2.5 [1.6-3.9]).

DISCUSSION

Compared to other countries, influenza vaccination coverage among children with risk conditions is low in our study. Strategies to improve coverage should be implemented.

Coverage and parental perceptions of influenza vaccination among parents of children aged 6 to 23 months in Hong Kong

BACKGROUND

The impact of influenza on young children can be severe and even fatal. Influenza vaccination (IV) has been shown to be effective in reducing complications of influenza among children. This study investigated the prevalence and factors of IV among children aged 6-23 months in Hong Kong.

METHODS

A sample of 401 Chinese parents of children aged 6-23 months were interviewed at local Maternal and Child Health Centers. Socio-demographic information, variables related to Health Belief Model, including perceptions about the child's chance of contracting influenza, perceived harm of influenza on children, perceived benefits and side-effects of IV, having received recommendations from health professionals to uptake IV, and IV behaviors of the children were measured. Multivariate analysis was used to examine factors associated with IV behaviors of children.

RESULTS

Only 9% of the children had ever been vaccinated. Among those parents who had heard of IV (92.0%), substantial proportions perceived that IV could reduce the risk of influenza-induced complications (70.5%), hospitalization (70.5%) and death (65.9%). Relatively few of the participants believed that IV had no side effects (17.1%) and even less had been recommended by health care professionals to uptake IV (10.6%). Results from multivariate analysis showed that physician recommendations were associated with a higher likelihood for IV among younger children, whilst parental perceptions of the side effects of IV was associated with a lower likelihood for IV.

CONCLUSION

The prevalence of IV among children aged 6-23 months in Hong Kong was very low. Promotion of IV with the component of physician recommendations and parents' knowledge about IV safety for this group is warranted.

Parental risk perception and influenza vaccination of children in daycare centres

Little information is available about perceptions of influenza vaccination of parents with healthy children in daycare. Therefore, we systematically explored the relationship between parental risk perception and influenza vaccination in children attending daycare. We distributed a self-administered paper survey to parents of children aged 6-59 months attending licensed daycare centres in Tarrant County, Texas. We used conditional logistic regression with penalized conditional likelihood to estimate odds ratios (ORs) and 95% profile likelihood confidence limits (PL) for parental risk-perception factors and influenza vaccination. A high level of parental prevention behaviours (OR 9.1, 95% PL 3.2, 31) and physician recommendation (OR 8.2, 95% PL 2.7, 30) had the highest magnitudes of association with influenza vaccination of healthy children in daycare. Our results provide evidence about critical determinants of influenza vaccination of healthy children in daycare, which could help inform public health interventions aimed at increasing influenza vaccination coverage in this population.

Feasibility of delivering influenza vaccine to household contacts of pediatric patients in a residents' continuity clinic

BACKGROUND

Since 2004, influenza vaccine has been recommended for household contacts (HCs) of healthy infants and young children, who are at high risk for complications from influenza disease. We examined the feasibility of providing influenza vaccine to HCs of pediatric patients during the children's outpatient clinic visits.

METHODS

During influenza season 2006-07, influenza vaccine was offered at no cost to HCs of all patients aged <60 months who received primary care at a pediatric residents' continuity clinic at Children's Medical Center Dallas. The percentage of individuals receiving their first dose of influenza vaccine was calculated for all vaccinated adult HCs and also for a subset of vaccinated adult HCs for whom vaccine was recommended in a previous year, based on the pediatric patient's age.

RESULTS

Influenza vaccine was administered to 1,042 HCs of 611 pediatric patients. Fifty percent of all vaccinated adult HCs had no previous history of influenza vaccination. Eighty-five of the 218 (39%) vaccinated adult HCs for whom influenza vaccine was also recommended in a previous year received their first dose through our program.

CONCLUSIONS

Delivery of influenza vaccine to HCs of pediatric patients can be integrated into the children's clinic visits and may increase vaccine uptake.

Correlates of 2009 H1N1 influenza vaccination among day care-aged children, Miami-Dade County

BACKGROUND

The aim of this study was to assess factors influencing 2009 H1N1 influenza vaccination among a demographically diverse group of day care-aged children. Day care children were chosen because they were an initial target group for vaccination and are at higher risk of influenza infection than children cared for at home.

METHODS

A cross-sectional study was conducted from March to May 2010 among parents of day care aged children in 13 day care facilities in Miami-Dade County. Data was collected by an anonymous self-administered two-page 20 question survey which consisted of demographic variables and information regarding 2009 H1N1 influenza vaccine knowledge, attitude and acceptance. Data was analyzed using SAS to conduct both bivariate and multivariate analyses.

RESULTS

There were 773 participants in the study. The response rate ranged from 42% to 72.2% among day care centers. A total of 172 parents (22.3%) and 225 (29.1%) children had received the 2009 H1N1 influenza vaccine. Non-Hispanic White and Black parents were more likely to vaccinate their children than Hispanic and Haitian parents. Primary reasons for non-vaccination included vaccine safety (36.7%) and side effects (27.1%). Among parents who spoke with a health care professional, 274 (61.4%) stated the health care professional recommended the vaccine.

CONCLUSION

Misperceptions about influenza vaccination among parents created a barrier to 2009 H1N1 influenza vaccination. Parents who got the vaccine, who believed the vaccine was safe and whose children had a chronic condition were more likely to immunize their children. Clear, reliable and consistent vaccine information to the public and health care providers and initiatives targeting minority groups may increase vaccination coverage among this population.

Toward interactive, Internet-based decision aid for vaccination decisions: better information alone is not enough

Vaccination decisions, as in choosing whether or not to immunize one's small child against specific diseases, are both psychologically and computationally complex. The psychological complexities have been extensively studied, often in the context of shaping convincing or persuasive messages that will encourage parents to vaccinate their children. The computational complexity of the decision has been less noted. However, even if the parent has access to neutral, accurate, credible information on vaccination risks and benefits, he or she can easily be overwhelmed by the task of combining this information into a well-reasoned decision. We argue here that the Internet, in addition to its potential as an information source, could provide useful assistance to parents in integrating factual information with their own values and preferences - that is, in providing real decision aid as well as information aid. We sketch one approach for accomplishing this by means of a hierarchy of interactive decision aids ranging from simple advice to full-scale decision analysis.

Correlates of 2009 H1N1 influenza vaccine acceptability among parents and their adolescent children

School-aged children were a priority group for receipt of the pandemic (2009) H1N1 influenza vaccine. Both parental and adolescent attitudes likely influence vaccination behaviors. Data were collected from surveys distributed to middle- and high-school students and their parents in two counties in rural Georgia. Multivariable logistic regression analyses were conducted to assess correlates of parental acceptance of H1N1 influenza vaccination for their children and adolescents' acceptance of vaccination for themselves. Concordance analyses were conducted to assess agreement between parent-adolescent dyads regarding H1N1 influenza vaccine acceptance. Parental acceptance of H1N1 influenza vaccination for their children was associated with acceptance of the vaccine for themselves and feeling motivated by the H1N1 influenza pandemic to get a seasonal influenza vaccine for their child. Adolescents' acceptance was associated with receipt of a seasonal influenza vaccine in the past year, fear of getting H1N1 influenza, feeling comfortable getting the vaccine and parental acceptance of H1N1 influenza vaccine. Half (50%) of parent-adolescent pairs included both a parent and child who expressed H1N1 influenza vaccine acceptance, and 19% of pairs would not accept the vaccine. This research highlights the need for interventions that target factors associated with H1N1 influenza vaccine acceptance among both parents and adolescents.

Correlates of 2009 pandemic H1N1 influenza vaccine acceptance among middle and high school teachers in rural Georgia

BACKGROUND

Teachers play an essential role in the school community, and H1N1 vaccination of teachers is critical to protect not only themselves but also adolescents they come in contact within the classroom through herd immunity. School-aged children have a greater risk of developing H1N1 disease than seasonal influenza. The goal of this study was to assess the relationship between attitudes toward H1N1 vaccination and vaccine acceptance among middle and high school teachers in rural Georgia.

METHODS

Participants were recruited from 2 counties participating in a school-based influenza vaccination intervention in rural Georgia. Data were collected from surveys distributed to middle and high school teachers in participating counties in September 2009 prior to implementing the interventions to increase vaccination against seasonal influenza. Multivariate logistic regression was used to assess the association between teachers' attitudes toward H1N1 vaccination and H1N1 vaccine acceptance, controlling for demographic variables.

RESULTS

Among participants, 52.9% indicated that they would get the H1N1 vaccine. In multivariate analyses, H1N1 vaccine acceptance was associated with male gender (odds ratio[OR] = 3.67, p = .016), fear of contracting H1N1 (OR = 3.18, p = .025), and receipt of a seasonal influenza vaccine in the past year (OR = 3.07, p = .031). H1N1 vaccine acceptance was not significantly associated with age, race, perceived severity of H1N1, belief that the H1N1 vaccine would cause illness, or talking about H1N1 with friends.

CONCLUSIONS

Teachers may play a pivotal role in school-based H1N1 vaccinations. Understanding and addressing teachers' attitudes toward H1N1 vaccination may assist in future immunization efforts.

Adolescent attitudes toward influenza vaccination and vaccine uptake in a school-based influenza vaccination intervention: a mediation analysis

BACKGROUND

School-based vaccination programs may provide an effective strategy to immunize adolescents against influenza. This study examined whether adolescent attitudes toward influenza vaccination mediated the relationship between receipt of a school-based influenza vaccination intervention and vaccine uptake.

METHODS

Participants were recruited from 2 counties participating in a school-based influenza vaccination intervention trial in rural Georgia (N = 337). Data were collected from surveys distributed to adolescents at pre- and post-intervention time points and from documents indicating vaccine uptake. Guided by the Health Belief Model and the Integrated Behavioral Model, surveys assessed demographic, behavioral, and psychosocial variables. A mediation analysis was used to test whether changes in psychosocial variables from baseline to follow-up mediated the relationship between study condition and influenza vaccine uptake.

RESULTS

Controlling for background variables, step 1 of the mediation analysis revealed a significant relationship between study condition and vaccine uptake (odds ratio = 1.77, p = .038). Step 2 of the mediation analysis revealed a significant relationship between study condition and changes in psychosocial variables from baseline to follow-up. Steps 3 and 4 of the mediation analysis revealed that there was full mediation of the relationship between study condition and receipt of an influenza vaccination by intention to receive an influenza vaccination.

CONCLUSION

Findings suggest that the success of our school-based influenza vaccination intervention in increasing vaccine uptake was mediated by adolescents' intention to receive an influenza vaccination. Future influenza vaccination efforts geared toward rural adolescents may benefit from addressing adolescent attitudes toward influenza vaccination, particularly increasing intention to receive a vaccine.

Seasonal and 2009 H1N1 influenza vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination among secondary school teachers and staff

OBJECTIVE

Teachers, like healthcare workers, may be a strategic target for influenza immunization programs. Influenza vaccination is critical to protect both teachers and the students they come into contact with. This study assessed factors associated with seasonal and H1N1 influenza vaccine uptake among middle- and high-school teachers.

METHODS

Participants were recruited from two counties in rural Georgia. Data were collected from surveys in September 2009 and May 2010. Multivariate logistic regression was used to assess the association between teachers' attitudes toward seasonal and H1N1 influenza vaccination and vaccine uptake.

RESULTS

Seventy-eight percent of teachers who planned to receive seasonal influenza vaccine and 36% of those who planned to receive H1N1 influenza vaccine at baseline reported that they did so. Seasonal vaccine uptake was significantly associated with perceived severity (odds ratio [OR] 1.57, P = 0.05) and self-efficacy (OR 4.46, P = 0.006). H1N1 vaccine uptake was associated with perceived barriers (OR 0.7, P = 0.014) and social norms (OR 1.39, P = 0.05). The number one reason for both seasonal and H1N1 influenza vaccine uptake was to avoid getting seasonal/H1N1 influenza disease. The number one reason for seasonal influenza vaccine refusal was a concern it would make them sick and for H1N1 influenza vaccine refusal was concern about vaccine side effects.

CONCLUSIONS

There is a strong association between the intention to be vaccinated against influenza (seasonal or 2009 H1N1) and actual vaccination uptake. Understanding and addressing factors associated with teachers' influenza vaccine uptake may enhance future influenza immunization efforts.

Maternal knowledge and attitudes toward influenza vaccination: a focus group study in metropolitan Atlanta

OBJECTIVE

To explore the knowledge and attitudes of mothers of school-aged children toward influenza vaccination and assess what methods of communication about vaccination and its delivery work best among this audience.

METHODS

The authors conducted focus groups with mothers of school-aged children. Prior to the focus groups, investigators agreed on key themes and discussion points. They independently reviewed transcripts using systematic content analysis and came to an agreement on outcome themes.

RESULTS

Many study participants had misunderstandings about influenza vaccines and the definition of influenza. A common perception was that flu is a catch-all term for a variety of undefined illnesses, ranging from a severe cold to stomach upset. Few participants saw a societal benefit in vaccinating children to protect other populations (eg, the elderly).

CONCLUSIONS

This study represents a first step in understanding how mothers perceive influenza vaccination and for crafting effective communication to increase vaccination among school-aged children.

Psychosocial correlates of intention to receive an influenza vaccination among rural adolescents

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recently expanded annual influenza vaccination recommendations to include all children 6 months through 18 years of age. Adolescent attitudes toward influenza vaccination may play a key role in reaching this newly added age group. This study examined the association between attitudes toward influenza vaccination and intention to be vaccinated among rural adolescents. Data were collected from baseline surveys distributed to adolescents in September/October 2008, prior to the H1N1 influenza pandemic, in two counties participating in a school-based influenza vaccination intervention trial in rural Georgia (N = 337). Survey items were based on constructs from the Health Belief Model and the Integrated Behavioral Model. Approximately one-third of participants (33.8%) intended to receive an influenza vaccination, 33.5% did not intend to be vaccinated and 28.8% were unsure. Controlling for background factors, intention to receive an influenza vaccination was associated with low perceived barriers [odds ratio (OR) = 0.77, P < 0.001], injunctive norms (OR = 1.23, P = 0.002) and receipt of influenza vaccination in the past year (OR =6.21, P < 0.001). Findings suggest that perceived barriers and injunctive social norms may influence vaccination acceptance among rural adolescents. Future influenza vaccination efforts geared toward rural middle and high school students may benefit from addressing adolescent attitudes toward influenza vaccination.

Parental attitudes about influenza immunization and school-based immunization for school-aged children

OBJECTIVES

Identify parental beliefs and barriers related to influenza immunization of school-aged children and acceptance of school-based influenza immunization.

METHODS

We conducted a cross-sectional survey of parents of elementary school-aged children in November 2008. Outcomes were receipt of influenza vaccine, acceptance of school-based immunization, and barriers to immunization.

RESULTS

Response rate was 65% (259/397). Parents reported that 26% of children had received the vaccine and 24% intended receipt. A total of 50% did not plan to immunize. Factors associated with receipt were belief that immunization is a social norm (adjusted odds ratios [AOR], 10.8; 95% CI, 2.8-41.8), belief in benefit (AOR, 7.8; CI, 1.8-33.8), discussion with a doctor (AOR, 7.0; CI, 2.9-16.8), and belief that vaccine is safe (AOR, 4.0; CI, 1.0-15.8). A total of 75% of parents would immunize their children at school if the vaccine were free, including 59% (76/129) who did not plan to immunize. Factors associated with acceptance of school-based immunization were belief in benefit (AOR, 6.1; 95% CI, 2.7-14.0), endorsement of medical setting barriers (AOR, 3.7; 95% CI, 1.3-10.3), and beliefs that immunization is a social norm (AOR, 3.3; 95% CI, 1.4-7.6) and that the child is susceptible to influenza (AOR, 2.6; 95% CI, 1.2-5.7). Medical setting barriers were competing time demands, inconvenience, and cost; school barriers were parents' desire to be with children and competence of person delivering the vaccine.

CONCLUSIONS

School-based immunization programs can increase immunization coverage by targeting parents for whom time demands and inconvenience are barriers, demonstrating that immunization is a social norm, and addressing concerns about influenza vaccine benefit and safety.

Support for universal childhood vaccination against influenza among private pediatric clinics and public health departments in Georgia

Recently, it has been recommended that all persons 6 months to 18 years be vaccinated annually against influenza. To assess support for this universal recommendation leading up to its implementation, a cross-sectional survey of healthcare workers at private pediatric clinics (N = 44) and public health departments (N = 75) was conducted. The survey, conducted in the state of Georgia during 2005-2006, asked about (a) support for universal childhood vaccination against influenza, (b) general and influenza-specific immunization practices in 2004-2005, and (c) types of assistance needed to implement a universal childhood recommendation. Our response rate was 70 percent for private clinics and 71 percent for public health departments. The majority of providers supported universal childhood vaccination against influenza; agreement was especially pronounced at public health departments. Public health departments employed more nurses and were more likely to have a policy of vaccinating parents along with their children; private clinics were more likely to use patient reminders or add extra hours during the influenza vaccination season. Respondents from both types of clinics indicated they would need multiple forms of assistance to implement a universal recommendation for childhood vaccination against influenza. Given the strong support for universal vaccination among healthcare workers at public health departments, these facilities may be instrumental for reaching the large number of children recently added to the recommendations. However, these facilities will need multiple forms of assistance.

Impact of electronic health record-based alerts on influenza vaccination for children with asthma

OBJECTIVE

The goal was to assess the impact of influenza vaccine clinical alerts on missed opportunities for vaccination and on overall influenza immunization rates for children and adolescents with asthma.

METHODS

A prospective, cluster-randomized trial of 20 primary care sites was conducted between October 1, 2006, and March 31, 2007. At intervention sites, electronic health record-based clinical alerts for influenza vaccine appeared at all office visits for children between 5 and 19 years of age with asthma who were due for vaccine. The proportion of captured immunization opportunities at visits and overall rates of complete vaccination for patients at intervention and control sites were compared with those for the previous year, after standardization for relevant covariates. The study had >80% power to detect an 8% difference in the change in rates between the study and baseline years at intervention versus control practices.

RESULTS

A total of 23 418 visits and 11 919 children were included in the study year and 21 422 visits and 10 667 children in the previous year. The majority of children were male, 5 to 9 years of age, and privately insured. With standardization for selected covariates, captured vaccination opportunities increased from 14.4% to 18.6% at intervention sites and from 12.7% to 16.3% at control sites, a 0.3% greater improvement. Standardized influenza vaccination rates improved 3.4% more at intervention sites than at control sites. The 4 practices with the greatest increases in rates (>or=11%) were all in the intervention group. Vaccine receipt was more common among children who had been vaccinated previously, with increasing numbers of visits, with care early in the season, and at preventive versus acute care visits.

CONCLUSIONS

Clinical alerts were associated with only modest improvements in influenza vaccination rates.

A systematic review of decision support needs of parents making child health decisions

OBJECTIVE

To identify the decision support needs of parents attempting to make an informed health decision on behalf of a child.

CONTEXT

The first step towards implementing patient decision support is to assess patients' information and decision-making needs.

SEARCH STRATEGY

A systematic search of key bibliographic databases for decision support studies was performed in 2005. Reference lists of relevant review articles and key authors were searched. Three relevant journals were hand searched.

INCLUSION CRITERIA

Non-intervention studies containing data on decision support needs of parents making child health decisions.

DATA EXTRACTION AND SYNTHESIS

Data were extracted on study characteristics, decision focus and decision support needs. Studies were quality assessed using a pre-defined set of criteria. Data synthesis used the UK Evidence for Policy and Practice Information and Co-ordinating Centre approach.

MAIN RESULTS

One-hundred and forty nine studies were included across various child health decisions, settings and study designs. Thematic analysis of decision support needs indicated three key issues: (i) information (including suggestions about the content, delivery, source, timing); (ii) talking to others (including concerns about pressure from others); and (iii) feeling a sense of control over the process that could be influenced by emotionally charged decisions, the consultation process, and structural or service barriers. These were consistent across decision type, study design and whether or not the study focused on informed decision making.

Influenza vaccination in adolescents with high-risk conditions

OBJECTIVES

We assessed influenza vaccination rates from 1992 to 2002, individual continuity of vaccination, and missed opportunities for vaccination in adolescents with high-risk conditions.

METHODS

We performed a retrospective observational study of 18 703 adolescents with high-risk conditions who were enrolled in a large health maintenance organization and received care at a multisite practice for >or=1 influenza season and the preceding year, between 1992 and 2002, was performed. Subjects were identified as having a high-risk condition if they had >or=1 visit with an associated International Classification of Diseases, Ninth Revision, Clinical Modification code during the season or previous year. Influenza vaccination rates were compared by season in logistic regression analyses, using generalized estimating equations for repeated measurements of subjects enrolled for multiple seasons. Vaccination continuity was measured for adolescents who were enrolled for 4 consecutive seasons (1999-2002) as the number of seasons during which vaccine was received. Missed opportunities were defined as visits during the first 4 months of influenza season at which an unvaccinated adolescent did not receive vaccine.

RESULTS

For adolescents with high-risk conditions, influenza vaccination rates varied from 8.3% to 15.4%. Rates improved significantly from 1992 to 1993, from 8.3% to 12.8%, and again in 2001, reaching 15.4%. Only 11.1% of those enrolled continuously from 1999 to 2002 received vaccine during all 4 seasons. According to season from 1992 to 2002, 45.7% to 53.6% of unvaccinated subjects had >or=1 missed opportunity.

CONCLUSIONS

Influenza vaccination rates in adolescents with high-risk conditions improved from 1992 to 2002 but were still low in recent years. Individual vaccination continuity was poor. Numerous opportunities already exist for improving coverage.

Private Pediatric Clinic Characteristics Associated with Influenza Immunization Efforts in the State of Georgia: A Pilot Evaluation

The Advisory Committee on Immunization Practices (ACIP) recently recommended that all children 6 months to 18 years be vaccinated annually against influenza. Because pediatricians will be critical for implementing this recommendation, we assessed the characteristics of immunization providers associated with the greatest efforts to vaccinate children against influenza. Using a cross-sectional survey of 35 private pediatric clinics in Georgia, we found that adding extra hours for immunization during the influenza vaccination season and having a policy of allowing six or more vaccines to be delivered at one appointment were characteristics associated with a greater intent to vaccinate children in the 2004-2005 influenza vaccination season. Most respondents indicated that for their clinic to implement a universal childhood vaccination policy it would be important to have a formal recommendation from the ACIP and American Academy of Pediatrics, and to be assured that they could receive credits or refunds for unused vaccine.

Influenza burden for children with asthma

OBJECTIVE

The goal was to estimate the influenza disease burden among children with asthma and among healthy children by using active, laboratory-confirmed, population-based surveillance.

METHODS

Children 6 to 59 months of age residing in 3 US counties who were hospitalized with acute respiratory illnesses or fever were enrolled prospectively from 2000 through 2004. Similar children who presented to clinics and emergency departments during 2 of the influenza seasons (2002-2004) were enrolled. Rates of influenza-attributable outpatient visits and hospitalizations for children with asthma and for healthy children were estimated. History of asthma and receipt of influenza vaccine for the study children were determined through parental report. The prevalence of asthma in the surveillance population was assumed to be 6.2% for children 6 to 23 months of age and 12.3% for children 24 to 59 months of age.

RESULTS

Of 81 children 6 to 59 months of age with influenza-confirmed hospitalizations in 2000 to 2004, 19 (23%) had asthma. Average annual influenza-attributable hospitalization rates were significantly higher among children with asthma than among healthy children 6 to 23 months of age (2.8 vs 0.6 cases per 1000 children) but not children 24 to 59 months of age (0.6 vs 0.2 case per 1000 children). Of 249 children 6 to 59 months of age with influenza-confirmed outpatient visits in 2002 to 2004, 38 (15%) had asthma. Estimated outpatient influenza-attributable visit rates were higher among children with asthma than among healthy children 6 to 23 months of age (316 vs 152 cases per 1000 children) and 24 to 59 months of age (188 vs 102 cases per 1000 children) in 2003 to 2004. Few parents reported that their children had been vaccinated, including <30% of children with asthma.

CONCLUSION

Influenza-attributable health care utilization is high among children with asthma and is generally higher than among healthy children.

Trivalent inactivated influenza vaccine compliance rate in neonatal intensive care unit parents

The American Academy of Pediatrics (AAP) recommends injected, inactivated influenza vaccine for all close contacts of high-risk infants. This population includes parents of infants younger than 59 months of age, with an emphasis on children 0-6 months who are not direct candidates for immunization. This 0-6 month age group is a major component of the neonatal intensive care unit (NICU) population. No data exist on the compliance rate with influenza vaccine in this specific parent population. The purpose of this study was to assess the compliance rate among this parent population and compare it with vaccine use in the general adult population at the time, which has traditionally ranged from 25% to 32%. The study also sought reasons for poor compliance with flu vaccine. Answering this question is important in determining whether programs directly aimed at NICU parents are required to achieve compliance or if simply informing parents of the need to be immunized results in sufficient vaccination rates. For 14 weeks during the 2004-2005 influenza season, 92 randomly selected parents (from 56 inborn infants) underwent an informational program regarding influenza vaccine and the risks and benefits of vaccination. Parents were surveyed in the spring to assess if they obtained the injection the previous winter. Subjects were parents of NICU patients admitted to the New York University NICU during the 14-week study period. The main outcome measure was the influenza vaccination rate of the parental cohort that underwent the informational program. For those who intended to receive influenza vaccination but did not, reasons for noncompliance were assessed via standardized telephone interview. After the information session, 85 parents (92%) indicated they intended to obtain the vaccine; however 30 parents (32.6%) actually received it by the following spring. The most commonly cited reason for failing to obtain influenza vaccine was convenience. No correlation between parents who obtained the vaccine and infant birth weight, gestational age, or length of stay was observed. Compliance with national recommendations to obtain trivalent inactivated influenza vaccine in this highly specified parent population is roughly equivalent to the national average of all adults in the general population. Caregivers of high-risk neonates must encourage/offer immunization to this targeted population.

Misperceptions about influenza vaccination among parents of healthy young children

A survey was administered to 828 parents from metropolitan Denver, Colorado, and 57% responded. Of the respondents, 47% thought their child was unlikely to contract influenza, 70% thought influenza vaccine could cause influenza, and 21% considered influenza vaccination unsafe for a 1-year-old child. The influenza immunization rate in children of surveyed parents was 71%. In multivariate analyses, the perception that influenza vaccination was the social norm was positively associated with immunization (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.03-1.69), and anticipating immunization barriers was negatively associated with immunization (OR, 0.68; 95% CI, 0.49-0.95). Parents of young children hold a number of misperceptions about influenza disease and vaccination. Despite this, high immunization rates are achievable in this population.

Influenza vaccination coverage and related factors among Spanish children

OBJECTIVES

To ascertain anti-influenza vaccination coverage and factors associated with anti-influenza vaccination among Spanish children.

METHODS

We analyzed 6464 children (age under 16 years) included in the Spanish National Health Survey (ENS) for 2003. As a dependent variable, we used the reply ("yes" or "no") to the question: Was your child vaccinated against influenza during the last campaign? We calculated anti-influenza vaccine coverage for the whole population and depending on whether or not the vaccine is recommended due to the fact that the children present an associated chronic condition. We analyzed the influence of sociodemographic variables on vaccination.

RESULTS

Vaccination coverage in the Spanish infant population was 5.1%, in children with associated conditions it was 17.5%, and 4.4% in healthy children. The only factor significantly associated with anti-influenza vaccination in children with associated conditions was household income: those from homes with a higher level of income were more likely to be vaccinated (OR=4.26). In children for whom vaccination is not recommended, the probability of being vaccinated against influenza is greater in those whose parents had a lower educational level (OR=2.22).

CONCLUSIONS

Anti-influenza vaccination coverage in the Spanish infant population is very low. There seem to be socio-economic inequalities for receiving this vaccine in Spanish children.

Influenza vaccine coverage and missed opportunities among inner-city children aged 6 to 23 months: 2000-2005

OBJECTIVE

In 2002, the Advisory Committee on Immunization Practices recommended universal influenza vaccination of 6- to 23-month-olds. Little is known about coverage and missed opportunities for influenza vaccination at inner-city practices. The objective of this study was to assess the 2000-2001 to 2004-2005 coverage and the prevalence of missed opportunities for influenza vaccination among inner-city children.

METHODS

We conducted a retrospective review for the 2000-2001 to 2004-2005 influenza seasons at a practice network in New York City. The study population included 5 annual cohorts of 6- to 29-month olds as of March 31 of each year with > or = 1 visit to the network in the previous 12 months (n = 7063). Immunization data were obtained from the network registry and the New York Citywide Immunization Registry. Coverage levels were estimated for 1 dose (partial) and 2 doses (full). Missed opportunities were assessed for visits within each influenza season.

RESULTS

Coverage rose steadily throughout the 5 years (full: 1.6% to 23.7%; partial: 1.5% to 18.1%). The relationship between year and coverage was linear. Missed opportunities occurred in 82% of visits and were more common for first (89%) than for repeat doses (38%). Missed opportunities per child per season decreased from 2.9 to 2.0 during the study period.

CONCLUSIONS

Influenza vaccine coverage among 6- to 23-month-olds at inner-city practices increased steadily from 2000-2001 through 2004-2005, and the prevalence of missed opportunities per child decreased. However, coverage remained suboptimal, with most of children not vaccinated or undervaccinated. Missed opportunities were major contributors to low coverage.

[Influenza vaccination in patients admitted to a tertiary hospital. Factors associated with coverage]

INTRODUCTION

Children aged less than 2 years old and those with chronic diseases have a high risk of complications and hospitalization due to influenza. Despite the broad consensus in the literature on the indication for annual immunization of these patients, less than 30 % of the children with high-risk underlying conditions are immunized each year. The aim of this study is to determine the influenza vaccine coverage in children with high-risk underlying conditions admitted to a university hospital.

PATIENTS AND METHODS

We performed a cross-sectional study of patients aged from 6 months to 18 years old with high-risk medical conditions and who had been hospitalized between January and May, 2005 in the Vall d'Hebron University Hospital (Barcelona). Influenza vaccine coverage, factors associated with immunization, and the reasons for nonvaccination were analyzed.

RESULTS

Overall vaccine coverage was 23.5 %. The highest vaccination coverage was found in patients with congenital heart disease, chronic respiratory disease, and asthma (43.2 %, 42.9 % and 28.6 %, respectively). The factors most frequently associated with influenza vaccination were the type of underlying disease, having been immunized against influenza in the previous season, having received the pneumococcal vaccine, and age younger than 5 years. The main reason for nonvaccination was the lack of influenza vaccine recommendation by health professionals (95.3 %).

CONCLUSIONS

Influenza vaccine coverage in children with high-risk conditions is low. Strategies to increase awareness among health professionals on the importance of recommending influenza immunization are required.

Surveillance for influenza admissions among children hospitalized in Canadian immunization monitoring program active centers, 2003-2004

OBJECTIVES

Influenza is a common childhood infection that may result in hospitalization. Our objectives were to (1) determine characteristics of children hospitalized for influenza and disease manifestations and (2) obtain baseline data before implementation of new recommendations for routine immunization of young children and their caretakers against influenza.

METHODS

All of the children hospitalized with laboratory-confirmed influenza at 9 Canadian tertiary care hospitals during the 2003-2004 influenza season were identified from virology laboratory reports, and their charts were reviewed.

RESULTS

There were 505 children admitted because of influenza. Fifty-seven percent were < 2 years old. Previously healthy children accounted for 58% of all of the cases. Pulmonary and neurologic disorders were the most common underlying chronic conditions. Fever and cough were the most frequent manifestations. Seizures occurred in 9% of cases. Serious complications included myocarditis (2), encephalopathy (6), and meningitis (1). There were 3 influenza-related deaths. Mean duration of hospitalization was 5.3 days. Twelve percent of children required ICU admission, and 6% required mechanical ventilation. Antibiotic therapy was administered in 77% of cases, and 7% received anti-influenza drugs. Information on influenza vaccination was available for 84 of 154 children identified as vaccine candidates. Twenty two had received vaccine, but only 7 children had been fully immunized > 14 days before the onset of illness.

CONCLUSIONS

Healthy young children and children with chronic conditions are at risk for serious illness with influenza. Ongoing surveillance is needed to evaluate the impact of changing immunization recommendations on the burden of influenza illness in children.

Influenza vaccination among children with asthma in medicaid managed care

OBJECTIVE

To describe influenza vaccination rates and identify risk factors for missing vaccination among children with asthma in managed Medicaid.

METHODS

As part of a longitudinal study of asthma care quality, parents of children aged 2-16 years with asthma enrolled in Medicaid managed care organizations in Massachusetts, Washington, and California were surveyed by telephone at baseline and 1 year. We evaluated influenza vaccination rates during the follow-up year.

RESULTS

The study population included 1058 children with asthma. The influenza vaccination rate was 16% among all children with asthma and 21% among those with persistent asthma. Children with persistent asthma (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.36-0.79) and those who had been hospitalized during the follow-up year (OR 0.29, 95% CI 0.11-0.76) were less likely to miss vaccination. Children older than 9 years (OR 1.66, 95% CI 1.13-2.46) and children of parents with less than a high school education (OR 2.29, 95% CI 1.05-5.03), compared with a college degree, were at risk for missing vaccination. Among children with persistent asthma, older children (OR 1.65, 95% CI 1.01-2.69) and children of parents with less than a high school education (OR 4.13, 95% CI 1.43-11.90) were more likely to miss influenza vaccination.

CONCLUSIONS

Our findings suggest that interventions directed toward older children and families with lower educational levels may help improve influenza vaccination rates among this high-risk group. The low overall vaccination rate highlights the need for improvement in this important component of asthma care quality for all children with asthma.

Parental perspectives on influenza vaccination among children with asthma

OBJECTIVES

The objectives of this study were to: (1) identify modifiable factors influencing receipt of influenza vaccination among children with asthma, and (2) to evaluate the effect of heightened media attention on vaccination rates.

METHODS

During November and December 2003, we interviewed parents of children with asthma about their experiences with and beliefs about influenza vaccination. We randomly selected 500 children from a study population of 2,140 children identified with asthma in a managed care organization in Massachusetts. We obtained data on influenza vaccination status from computerized medical records and determined significant factors influencing receipt of influenza vaccination.

RESULTS

Children were more likely to be vaccinated if their parent recalled a physician recommendation (odds ratio [OR] 2.6; 95% confidence interval [CI] 1.5, 4.5), believed the vaccine worked well (OR 2.0; 95% CI 1.4, 2.8), or expressed little worry about vaccine adverse effects (OR 1.3; 95% CI 1.0, 1.6), or if the child was younger (OR 1.1 per year of age; 95% CI 1.0, 1.2). During the study period, there was heightened media attention about influenza illness and the vaccine. The influenza vaccination rate for children with asthma was 43% in 2003-04 compared with 27% in 2002-03. Comparison of weekly influenza vaccination rates in 2003-04 and 2002-03 suggested that the media attention was associated with the increase in vaccination rates.

CONCLUSIONS

Physician recommendations and parental education about influenza vaccine availability, effectiveness, and adverse effects are potentially important influences on influenza vaccination. Our findings suggest that media coverage of the risks of influenza was associated with a significant increase in vaccination rates.

Should healthy children be vaccinated against influenza? A consensus report of the Summits of Independent European Vaccination Experts

Influenza is often regarded as an illness of the elderly portion of the population because most of the excess mortality associated with influenza epidemics occurs in that age group. However, evidence derived from a large number of clinical studies carried out in different countries and various settings has clearly demonstrated that the burden of influenza is also substantial in children. The attack rates of influenza during annual epidemics are consistently highest in children, and young children are hospitalized for influenza-related illnesses at rates comparable to those for adults with high-risk conditions. Especially among children younger than 3 years of age, influenza frequently predisposes the patient to bacterial complications such as acute otitis media. Children also serve as the main transmitters of influenza in the community. A safe and effective vaccine against influenza has been available for decades, but the vaccine is rarely used even for children with high-risk conditions. Despite several existing problems related to influenza vaccination of children, the current evidence indicates that the advantages of vaccinating young children would clearly outweigh the disadvantages. Considering the total burden of influenza in children, children younger than 3 years of age should be regarded as a high-risk group for influenza, analogously with the age-based definition of high risk among persons 65 years of age or older. Annual influenza vaccination should be recommended to all children from 6 months to 3 years of age.

Influenza vaccination coverage among children with high-risk medical conditions

We evaluated influenza vaccination coverage in children with chronic disease at high risk of influenza complications, and the need for methods to increase parents' and pediatricians' knowledge of influenza and its prevention. The 5286 children aged less than 14 years attending our Emergency Department on Wednesdays and Sundays between 1 January and 30 April 2003 included 274 (5.2%) high-risk patients. The use of influenza vaccine during the previous three seasons had been very low, but significantly increased in the last season (2000-2001, 5.1%; 2001-2002, 12.9%; 2002-2003, 26.3%; p<0.001). The children with asthma or cardiac disease showed the lowest vaccination rates; their parents and primary care pediatricians had only a marginal knowledge of influenza and the benefits of its prevention. In conclusion, the delivery of influenza vaccine to children with chronic disease at high risk of influenza complications is completely inadequate, and major efforts are urgently needed to increase parents' and pediatricians' knowledge of its importance.

Influenza vaccinations of young children increased with media coverage in 2003

OBJECTIVE

We sought to evaluate the impact of intense influenza media coverage during the 2003-2004 influenza season on the influenza vaccination status of children 6 to 59 months of age.

METHODS

Children 6 to 59 months of age who presented to a large, academic pediatric continuity clinic or affiliated acute care clinic in the summer of 2004 were enrolled. A parental survey ascertained the influenza vaccination status of the child and family members during the 2003-2004 influenza season and factors that influenced their vaccination status. For children vaccinated in the clinic or health department, influenza vaccination dates were confirmed in a computerized medical chart or state immunization registry.

RESULTS

Of 256 enrolled children, 98 (38%) parents reported that their child had received the 2003-2004 influenza vaccine, and 64 (65%) had confirmed influenza vaccination dates. Unlike the previous influenza season in which confirmed influenza vaccination dates from a similar study population were distributed more evenly from October through December, most children (75%) with confirmed vaccination dates received the vaccine after the media coverage in mid-November. Influenza vaccinations per week increased dramatically after the media coverage began (2.4 vs 8.6 per week; t test: P < .001). In late November and December 2003, the influenza-related media coverage, which focused primarily on an early, severe influenza season, increased dramatically and explained 85% of the variation in influenza vaccinations. Multivariate analysis showed that recalling a physician recommendation (odds ratio [OR]: 6.8; 95% confidence interval [CI]: 2.3-19.7), having a family member who had received the influenza vaccine (OR: 9.5; 95% CI: 4.3-21.3), having a continuity clinic visit between October and January (OR: 4.5; 95% CI: 2.0-10.1), and having a high-risk medical condition (OR: 2.9; 95% CI: 1.1-7.8) strongly predicted the influenza vaccination status in the children.

CONCLUSION

Media coverage in conjunction with explicit physician recommendation for children and their contacts are key factors that are associated with influenza vaccination rates in children.

Influenza among healthy young children: changes in parental attitudes and predictors of immunization during the 2003 to 2004 influenza season

BACKGROUND

In Colorado, the 2003 to 2004 influenza season was unusually early and severe and received substantial media attention.

OBJECTIVES

Among parents of healthy young children, to determine how parental knowledge and attitudes regarding influenza infection and immunization changed during the 2003 to 2004 influenza season and to identify factors predictive of influenza immunization.

METHODS

The study was conducted in 5 metropolitan Denver pediatric practices. A total of 839 healthy children age 6 to 21 months and their parents were randomly selected for participation. Parents were surveyed by telephone before (August 18 to October 7, 2003) and after (March 31 to June 10, 2004) the influenza season.

RESULTS

Among 828 eligible parents, 472 (57%) completed the preseason survey; 316 (67%) of these parents subsequently completed the postseason survey. All analyses were performed for the 316 subjects who completed both preseason and postseason surveys. Compared with their attitudes before the influenza season, 48% of parents interviewed after the season viewed their child as more susceptible to influenza, 58% viewed influenza infections as more severe, and 66% perceived fewer risks associated with influenza vaccine. Ninety-five percent of parents reported hearing in the media about Colorado's influenza outbreak, and having heard about the outbreak in the media was associated with viewing influenza infections as more severe. A total of 258 parents (82%) immunized their child against influenza. In multivariate analyses, positive predictors of immunization included a physician recommendation for immunization and a preseason to postseason increase in the perception that immunization was the social norm. Negative predictors of immunization included high perceived barriers to immunization, less parental education, and preseason intention not to immunize.

CONCLUSIONS

Parent attitudes about influenza infection and immunization changed substantially during the 2003 to 2004 influenza season, with changes favoring increased parental acceptance of influenza vaccination for young children. During an intensively publicized influenza outbreak, a physician recommendation of vaccination was an important predictor of influenza immunization.

Influenza vaccination of high-risk children: what the providers say

BACKGROUND

Despite a longstanding national recommendation to administer influenza vaccine to children at high risk for disease complications, physicians' adherence remains low. This study evaluated physicians' perspectives on previously documented and persistent under-utilization of influenza vaccine for high-risk children.

METHODS

A cross-sectional survey mailed in 2001-2002 to a nationally representative sample of 1460 U.S. physicians in four key medical specialties. The primary outcome was whether the physician provided annual influenza vaccine to children with asthma or other cardiopulmonary diseases. The hypothesis was that factors predicting reported use would fall into four categories: (1) physician knowledge, (2) physician endorsement of recommendation, (3) perceived barriers, and (4) practice patterns.

RESULTS

The overall response rate was 55% (n=600), but differed by specialty. Most physicians were knowledgeable about the recommendation, but collectively tended to overestimate their own achievements in immunizing high-risk children. Adherence varied by physician specialty, endorsement of recommendation, perceived barriers (including difficulty identifying subpopulations of high-risk children and confusion about who should vaccinate those receiving care from multiple providers), and under-utilization of strategies known to improve vaccination rates.

CONCLUSIONS

Better communication strategies are needed to resolve confusion about providing influenza vaccine to high-risk children in subspecialty settings. Because of the difficulties in selectively identifying high-risk patient subgroups, research is needed to assist in putting support strategies into practice. Findings from research in promising areas of practice-based quality improvement may be particularly applicable.

Influenza immunisation in children with solid tumours

We assessed response to immunisation with trivalent split virus influenza vaccine in children with non-leukaemic malignant disease. Children with solid tumours and lymphoma received one or two doses of influenza vaccine, according to current UK guidelines, in autumn 2001 and/or 2002. Children were currently receiving chemotherapy or were within 6 months of completing chemotherapy. Pre and post vaccination sera were assessed for antibodies to the prevalent influenza strains by haemagglutination inhibition (HI). Sixty six children were assessed prior to 69 episodes of vaccination. In 30% episodes, children were susceptible to all three circulating influenza viruses (65% to H1N1, 42% to H3N2 and 90% to B) and only one patient showed protective titres (HI32) against all three strains. Seroresponse rates (4-fold rise in HI) for H1N1, H3N2 and B were 52%, 33% and 51% in 65 episodes. Following immunisation protective titres to all three viruses were seen in 25 episodes (38%) and protective responses to one or two viruses were seen in a further 12 (19%) episodes. There was no significant difference in response rates among children on treatment and off treatment and by intensity of chemotherapy. Children with solid tumours and lymphoma are highly susceptible to influenza infection. Influenza vaccine was well tolerated in this patient group and children showed a significant response to immunisation. These findings support the recommendation for annual influenza vaccination in these children.

HIV vaccine acceptability among women at risk: perceived barriers and facilitators to future HIV vaccine uptake

The purpose of this study is to explore perceived barriers and facilitators to the uptake of future U.S. Food and Drug Administration-approved HIV vaccines among women at elevated risk for HIV. We conducted four client focus groups (N = 41) and one focus group of women's health care professionals (N =9). Participants were recruited from diverse community agencies and health care clinics in Los Angeles using purposive, venue-based sampling. Data were analyzed using narrative thematic analysis and Ethnograph qualitative software. Barriers to HIV vaccine uptake included fear of vaccine-induced HIV infection, reproductive side effects, injection concerns, gendered roles and power dynamics, HIV stigma, discrimination, affordability, and mistrust. The provision of affordable and accessible HIV vaccines, ideally through routine care, along with culturally tailored, gender-specific HIV vaccine intervention and policy, can ensure the full potential of HIV vaccines to empower women to protect themselves against HIV infection.