Washington State pediatricians' attitudes toward alternative childhood immunization schedules

Considering a COVID-19 vaccine mandate for pediatric kidney transplant candidates

The world continues to face the effects of the SARS-CoV-2 pandemic. COVID-19 vaccines are safe and effective in protecting recipients, decreasing the risk of COVID-19 acquisition, transmission, hospitalization, and death. Transplant recipients may be at greater risk for severe SARS-CoV-2 infection. As a result, transplant programs have begun instituting mandates for COVID-19 vaccine for transplant candidacy. While the question of mandating COVID-19 vaccine for adult transplant candidates has garnered attention in the lay and academic press, these discussions have not explicitly addressed children who may be otherwise eligible for kidney transplants. In this paper we seek to examine the potential ethical justifications of a COVID-19 vaccine mandate for pediatric kidney transplant candidacy through an examination of relevant ethical principles, analogous cases of the use of mandates, differences between adult and pediatric kidney transplant candidates, and the role of gatekeeping in transplant vaccine mandates. At present, it does not appear that pediatric kidney transplant centers are justified to institute a COVID-19 vaccine mandate for candidates. Finally, we will offer suggestions to be considered prior to the implementation of a COVID-19 vaccine mandate.

Hepatitis B birth dose vaccination patterns in the military health System, 2014-2018

BACKGROUND

Since 2005, the universal hepatitis B (HepB) birth dose has been recommended for all medically stable infants weighing ≥2,000 g at birth. The timing of the birth dose provides a critical safeguard and prevents infection among infants born to HBsAg-positive mothers not identified prenatally. We assess infant HepB vaccination in the U.S. Department of Defense's Military Health System (MHS) to identify trends in vaccination coverage and sociodemographic factors associated with non-receipt of the birth dose, receiving the first HepB vaccine >3 days of life, and not receiving any HepB vaccine in the first 18 months of life utilizing parental refusal codes. To our knowledge, this is one of the first studies assessing trends in parental refusal of the HepB birth dose utilizing administrative claims parental refusal codes.

METHODS

We conducted a retrospective cohort analysis of MHS live births from January 1, 2014 through December 31, 2018 utilizing administrative claims data. Data were included from 44 hospitals in 24 unique states, territories, or countries. We analyzed diagnosis codes for vaccine refusal and vaccination and current procedural terminology (CPT) codes to identify vaccination patterns. Generalized linear mixed effects models with a logit link were used to assess factors associated with vaccination patterns.

RESULTS

HepB birth dose vaccination coverage increased from 79.6% in 2014 to 88.1% in 2018 (p < .0001). Refusal rates also increased from 3.7% in 2014 to 4.5% in 2018 (p < .0001). The percentage of patients with missing diagnosis codes for vaccine refusal or vaccination decreased from 16.7% in 2014 to 7.4% in 2018. Factors associated with non-receipt of the birth dose included earlier year of birth, white maternal race, higher maternal age, higher birth order, and longer infant length of stay in hospital.

CONCLUSION

Vaccination coverage for HepB birth dose is high in the MHS and increased over time; concurrently, refusal rates also increased over time. Utilizing administrative claims data has the benefit of differentiating reasons for non-receipt of the birth dose over time.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pediatricians' vaccine attitudes and practices before and after a major measles outbreak

The objective of this study was to describe how a sample of pediatricians were impacted by and responded to the Disneyland measles outbreak in the United States. We conducted three repeated cross-sectional, online surveys in 2014 (before the outbreak), 2015, and 2016 (after the outbreak) among members of three state chapters of the American Academy of Pediatrics. We assessed pediatricians' level of willingness and length of time comfortable delaying the measles-mumps-rubella (MMR) vaccine before and after the outbreak. Frequency of alternative immunization schedule requests and creation of office immunization policies due to the outbreak were measured. The sample included 304 pediatricians in 2014, 270 in 2015, and 221 in 2016. We found no significant changes in willingness or comfort delaying the MMR vaccine before and after the outbreak. In 2015, 38% of pediatricians reported fewer requests for alternative immunization schedules and 20% created stricter office immunization policies. A subsample of pediatricians reported administering the MMR vaccine earlier in the recommended time frame and taking extra precautions in waiting rooms due to the outbreak. Our results suggest that this measles outbreak did not lead to significant changes in attitudes or practices among this sample, but did modestly affect office immunization policies and practices.

Factors Associated With Pediatrician Responses to Alternative Immunization Schedule Requests

We conducted a cross-sectional online survey among 4 chapters of the American Academy of Pediatrics from July through October 2014 to describe characteristics of pediatricians and practices associated with practice-level responses to alternative immunization schedule requests. Among 374 pediatricians, 58% reported frequent alternative immunization schedule requests and 24% reported feeling comfortable using them. Pediatricians who work in practices that accommodate alternative immunization schedule requests have increased odds of having a high frequency of alternative immunization schedule requests, and beliefs that relationships with families would be negatively affected if they refused requests. Practices that discontinue care to families who request alternative immunization schedules have increased odds of being a private group practice and having a formal office vaccine policy. Pediatricians are frequently asked to use alternative immunization schedules and many are not comfortable using them. Practice-level responses to alternative immunization schedules are associated with characteristics of pediatricians and practices.

Missed Opportunities for Hepatitis A Vaccination, National Immunization Survey-Child, 2013

OBJECTIVES

To quantify the number of missed opportunities for vaccination with hepatitis A vaccine in children and assess the association of missed opportunities for hepatitis A vaccination with covariates of interest.

STUDY DESIGN

Weighted data from the 2013 National Immunization Survey of US children aged 19-35 months were used. Analysis was restricted to children with provider-verified vaccination history (n = 13 460). Missed opportunities for vaccination were quantified by determining the number of medical visits a child made when another vaccine was administered during eligibility for hepatitis A vaccine, but hepatitis A vaccine was not administered. Cross-sectional bivariate and multivariate polytomous logistic regression were used to assess the association of missed opportunities for vaccination with child and maternal demographic, socioeconomic, and geographic covariates.

RESULTS

In 2013, 85% of children in our study population had initiated the hepatitis A vaccine series, and 60% received 2 or more doses. Children who received zero doses of hepatitis A vaccine had an average of 1.77 missed opportunities for vaccination compared with 0.43 missed opportunities for vaccination in those receiving 2 doses. Children with 2 or more missed opportunities for vaccination initiated the vaccine series 6 months later than children without missed opportunities. In the fully adjusted multivariate model, children who were younger, had ever received WIC benefits, or lived in a state with childcare entry mandates were at a reduced odds for 2 or more missed opportunities for vaccination; children living in the Northeast census region were at an increased odds.

CONCLUSIONS

Missed opportunities for vaccination likely contribute to the poor coverage for hepatitis A vaccination in children; it is important to understand why children are not receiving the vaccine when eligible.

Countering Vaccine Hesitancy

Immunizations have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about addressing parental concerns about vaccination.

"Everybody just wants to do what's best for their child": Understanding how pro-vaccine parents can support a culture of vaccine hesitancy

BACKGROUND

Although a large majority of parents vaccinate their children, vaccine hesitancy has become more widespread. It is not well understood how this culture of vaccine hesitancy has emerged and how it influences parents' decisions about vaccine schedules.

OBJECTIVE

We sought to examine how attitudes and beliefs of parents who self-report as pro-vaccine are developed and contribute to immunization decisions, including delaying or spacing vaccines.

METHODS

Open-ended, in-depth interviews (N=23) were conducted with upper-middle class parents with young children living in Philadelphia. Interview data were coded and key themes identified related to vaccine decision-making.

RESULTS

Parents who sought out vaccine information were often overwhelmed by the quantity and ambiguity when interpreting that information, and, consequently, had to rely on their own instinct or judgment to make vaccine decisions. In particular, while parents in this sample did not refuse vaccines, and described themselves as pro-vaccine, they did frequently delay or space vaccines. This experience also generated sympathy for and tolerance of vaccine hesitancy in other parents. Parents also perceived minimal severe consequences for deviating from the recommended immunization schedule.

CONCLUSION

These findings suggest that the rise in and persistence of vaccine hesitancy and refusal are, in part, influenced by the conflicts in the information parents gather, making it difficult to interpret. Considerable deviations from the recommended vaccination schedule may manifest even within a pro-vaccine population due to this perceived ambiguity of available information and resulting tolerance for vaccine hesitancy.

Surveys and Response Rates

Surveys continue to be an important research methodology. However, when assessing survey studies, clinicians should review the response rate and consider potential selection bias. Methods of survey administration (electronic, postal, or other means) may differ in cost, missing data, and response rates. In addition, reviewing the questionnaire construction, including the understandability of the questions and response formats, is important in assessing the validity of findings.

Vaccinating my way--use of alternative vaccination schedules in New York State

OBJECTIVE

To identify children vaccinated following an alternative vaccine schedule using immunization information system data and determine the impact of alternative schedule use on vaccine coverage.

STUDY DESIGN

Children born in New York State, outside New York City, between January 1, 2009 and August 14, 2011 were assessed for vaccination patterns consistent with use of an alternative schedule. Children who by 9 months of age had at least 3 vaccination visits recorded in the statewide mandatory immunization information system after 41 days of age were classified as either attempting to conform to the Centers for Disease Control and Prevention published recommended vaccination schedule or an alternative schedule. The number of vaccination visits and up-to-date status at age 9 months were compared between groups.

RESULTS

Of the 222 628 children studied, the proportion of children following an alternative schedule was 25%. These children were significantly less likely to be up-to-date at age 9 months (15%) compared with those conforming to the routine schedule (90%, P < .05). Children following an alternative schedule on average had about 2 extra vaccine visits compared with children following a routine schedule (P < .05).

CONCLUSIONS

Almost 1 in 4 children in this study appear to be intentionally deviating from the routine schedule. Intentional deviation leads to poor vaccination coverage leaving children vulnerable to infection and increasing the potential for vaccine-preventable disease outbreaks.

Epidemiology of vaccine hesitancy in the United States

Vaccines are among the most effective public health interventions against infectious diseases. However, there is evidence in the United States for parents either delaying or refusing recommended childhood vaccination. Exemptions to school immunization laws and use of alternative schedule from those recommended by the Advisory Committee on Immunization Practices and the American Academy of Pediatrics cannot only increase the risk of children contracting vaccine-preventable diseases but also increases the risk of infecting others who are either too young to be vaccinated, cannot be vaccinated for medical reasons or did not develop a sufficient immunological response to the vaccine. Healthcare providers are cited as the most influential source by parents on vaccine decision-making. Vaccine hesitancy needs to be addressed by healthcare providers and the scientific community by listening to the parental concerns and discussing risks associated with either delaying or refusing vaccines.

The architecture of provider-parent vaccine discussions at health supervision visits

OBJECTIVE

To characterize provider-parent vaccine communication and determine the influence of specific provider communication practices on parent resistance to vaccine recommendations.

METHODS

We conducted a cross-sectional observational study in which we videotaped provider-parent vaccine discussions during health supervision visits. Parents of children aged 1 to 19 months old were screened by using the Parent Attitudes about Childhood Vaccines survey. We oversampled vaccine-hesitant parents (VHPs), defined as a score ≥50. We developed a coding scheme of 15 communication practices and applied it to all visits. We used multivariate logistic regression to explore the association between provider communication practices and parent resistance to vaccines, controlling for parental hesitancy status and demographic and visit characteristics.

RESULTS

We analyzed 111 vaccine discussions involving 16 providers from 9 practices; 50% included VHPs. Most providers (74%) initiated vaccine recommendations with presumptive (e.g., "Well, we have to do some shots") rather than participatory (e.g., "What do you want to do about shots?") formats. Among parents who voiced resistance to provider initiation (41%), significantly more were VHPs than non-VHPs. Parents had significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive initiation format (adjusted odds ratio: 17.5; 95% confidence interval: 1.2-253.5). When parents resisted, 50% of providers pursued their original recommendations (e.g., "He really needs these shots"), and 47% of initially resistant parents subsequently accepted recommendations when they did.

CONCLUSIONS

How providers initiate and pursue vaccine recommendations is associated with parental vaccine acceptance.

Parental vaccine concerns, information source, and choice of alternative immunization schedules

Alternative immunization schedules increase the time a child is unvaccinated and require greater resources from providers. Understanding what drives interest in alternative immunization schedules can potentially inform the design of effective, targeted messages that help to reduce time spent counseling and decrease requests for alternative immunization schedules. This study used the Theory of Planned Behavior to explore associations between sources of vaccine information, parental vaccine concerns, peer norms for vaccine behavior and intentions to follow an alternative immunization schedule. We performed logistic regression using medical record data from a private pediatric practice in a large northeastern city. Routine data were recorded in the EMR by the pediatrician during an initial vaccine counseling conversation with the parent(s). Parents who received vaccine information from doctors were less likely to have immunization concerns while parents who got vaccine information from friends and family or from books were more likely to report specific vaccine concerns. Our multivariate analysis shows that number of reported vaccine concerns and concerns about the utility or necessity of vaccines are strongly associated with alternative immunization intentions. We also find a direct relationship between sources of information about vaccines and alternative immunization intentions. Our results suggest that vaccine concerns and non-physician information sources play an important role in alternative immunization intentions while communication from physicians may play an important role in addressing vaccine concerns and promoting adherence to the ACIP immunization schedule.

Timing of measles immunization and effective population vaccine coverage

OBJECTIVE

To describe measles vaccination patterns in a cohort of Swiss children aged up to 3 years insured with a single health insurer.

METHODS

A dynamic cohort study evaluating measles immunizations patterns in children born between 2006 and 2008 was conducted. Time-to-event analysis was used to describe timing of measles immunization. Effective vaccine coverage was calculated by using an area under the curve approach.

RESULTS

In the study cohort, 62.6% of 13-month-old children were up-to-date for the first measles immunization (recommended at 12 months of age). Approximately 59% of 25-month-old children were up-to-date for the second measles immunization (recommended at 15-24 months of age). Most doses were delivered during months in a child's life when well-child visits are recommended (eg, 12 months of age). For second measles vaccine dose, accelerations in vaccine delivery occurred at time points for well-child visits during the months 19 and 25 of age but with lower final uptake than for the first measles vaccine dose. Until their second birthday, children in our cohort spent on average 177 days and 89 days susceptible to measles due to policy recommendations and additional delays, respectively. In a group of children aged 6 months to 2 years reflecting the age distribution in our cohort, effective vaccine coverage was only 48.6%.

CONCLUSIONS

Timing and timeliness of measles immunizations influence effective population vaccine coverage and should be routinely reported in addition to coverage whenever possible. Proposed timing and relation of recommended vaccinations to well-child visits could be relevant aspects in optimizing measles vaccine coverage to reach measles elimination.

Characterizing providers' immunization communication practices during health supervision visits with vaccine-hesitant parents: a pilot study

OBJECTIVE

To determine the feasibility of using direct observation of provider-parent immunization discussions and to characterize provider communication practices with vaccine-hesitant parents.

METHODS

Over a 6 month period in 2010, we videotaped immunization discussions between pediatric providers and vaccine-hesitant parents during health supervision visits involving children 2-15 months old (N=24) in the Seattle area, Washington, USA. Videotapes were analyzed using the qualitative method of conversation analysis.

RESULTS

We approached 96 parents seen by 9 different providers. Of those who were eligible (N=56), we enrolled 43% (N=24). Four videotaped visits were excluded from analysis for failure to obtain parental HIPAA authorization. Of the remaining 20 visits, there were ≥2 visits each that involved children aged 2, 4, 6, 9, 12, and 15 months, and all videotaped visits contained at least a brief immunization discussion. We identified 6 communication practices and several behavior types within each practice relevant to immunization: Practice 1, providers' initiations of the topic of vaccination; Types: participatory or presumptive format; Practice 2, parents' responses to providers' topic initiations; Types: strong or weak acceptance or resistance; Practice 3, providers' follow-ups to parent's responses; Types: no, immediate, or delayed pursuit; Practice 4, parents' vaccine-related questions or statements; Types: fact- or concern-based; Practice 5, providers' explicit solicitations of parent's questions/concerns; Types: designed to discourage or encourage discussion; and Practice 6, parents' responses to providers' solicitations of questions/concerns; Types: no question or fact- or concern-based inquiry.

CONCLUSION

Direct observation of immunization discussions in the primary care pediatric setting is feasible and yields insight into several provider-parent immunization communication practices that are worthy of further study to determine which are effective at improving parental acceptance of immunization.