1
|
Correira JW, Pettigrew SM, Kamstra R, Megyeri PR, Silverstein GJ, Kambrich S, Ma J, Doll MK. Exploring the impact of the New York State repeal of nonmedical vaccination exemptions on student enrollment, absenteeism, and school workload: Perspectives from a survey of school administrators. Hum Vaccin Immunother 2023; 19:2261176. [PMID: 37750393 PMCID: PMC10524776 DOI: 10.1080/21645515.2023.2261176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/17/2023] [Indexed: 09/27/2023] Open
Abstract
In June 2019, New York State (NYS) adopted Senate Bill 2994A eliminating nonmedical vaccine exemptions from school entry laws. Since student noncompliance with the law required school exclusion, we sought to evaluate the law's effects on student enrollment and absenteeism, and school workloads related to its implementation. In November 2019, we sent an electronic survey to NYS (excluding New York City) schools. Due to the COVID-19 pandemic, outreach was curtailed in March 2020 with 525 (14%) of 3,759 eligible schools responding. To account for non-response, results were analyzed using inverse probability weighting. After weighting, 39% (95% CI: 34%, 44%) of schools reported enrollment changes and 31% (95% CI: 26%, 36%) of schools reported absenteeism related to the law. In addition, 95% (95% CI: 93%, 98%) of schools reported holding meetings and/or preparing correspondence about the law, spending a mean of 14 (95% CI: 11, 18) hours on these communication efforts. Schools in the highest pre-mandate nonmedical exemption tertile (vs. lowest) were more likely to report enrollment and absenteeism changes, and higher workloads. While our results should be interpreted with caution, changes in student enrollment, absenteeism, and school workloads may represent important considerations for policymakers planning similar legislation.
Collapse
Affiliation(s)
- John W. Correira
- Department of Allied Health Sciences, Albany College of Pharmacy & Health Sciences, Albany, NY, USA
| | - Stacy M. Pettigrew
- Department of Allied Health Sciences, Albany College of Pharmacy & Health Sciences, Albany, NY, USA
| | | | - Perrie Rose Megyeri
- Department of Allied Health Sciences, Albany College of Pharmacy & Health Sciences, Albany, NY, USA
| | - Gabriel J. Silverstein
- Department of Allied Health Sciences, Albany College of Pharmacy & Health Sciences, Albany, NY, USA
| | | | - Julia Ma
- Precision Analytics, Montreal, Quebec, Canada
| | - Margaret K. Doll
- Department of Allied Health Sciences, Albany College of Pharmacy & Health Sciences, Albany, NY, USA
| |
Collapse
|
2
|
Novilla MLB, Goates MC, Redelfs AH, Quenzer M, Novilla LKB, Leffler T, Holt CA, Doria RB, Dang MT, Hewitt M, Lind E, Prickett E, Aldridge K. Why Parents Say No to Having Their Children Vaccinated against Measles: A Systematic Review of the Social Determinants of Parental Perceptions on MMR Vaccine Hesitancy. Vaccines (Basel) 2023; 11:vaccines11050926. [PMID: 37243030 DOI: 10.3390/vaccines11050926] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023] Open
Abstract
Ongoing outbreaks of measles threaten its elimination status in the United States. Its resurgence points to lower parental vaccine confidence and local pockets of unvaccinated and undervaccinated individuals. The geographic clustering of hesitancy to MMR indicates the presence of social drivers that shape parental perceptions and decisions on immunization. Through a qualitative systematic review of published literature (n = 115 articles; 7 databases), we determined major themes regarding parental reasons for MMR vaccine hesitancy, social context of MMR vaccine hesitancy, and trustworthy vaccine information sources. Fear of autism was the most cited reason for MMR hesitancy. The social drivers of vaccine hesitancy included primary care/healthcare, education, economy, and government/policy factors. Social factors, such as income and education, exerted a bidirectional influence, which facilitated or hindered vaccine compliance depending on how the social determinant was experienced. Fear of autism was the most cited reason for MMR hesitancy. Vaccine hesitancy to MMR and other childhood vaccines clustered in middle- to high-income areas among mothers with a college-level education or higher who preferred internet/social media narratives over physician-based vaccine information. They had low parental trust, low perceived disease susceptibility, and were skeptical of vaccine safety and benefits. Combating MMR vaccine misinformation and hesitancy requires intersectoral and multifaceted approaches at various socioecological levels to address the social drivers of vaccine behavior.
Collapse
Affiliation(s)
| | - Michael C Goates
- Harold B. Lee Library, Brigham Young University, Provo, UT 84602, USA
| | - Alisha H Redelfs
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Mallory Quenzer
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | | | - Tyler Leffler
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Christian A Holt
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Russell B Doria
- School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, USA
| | - Michael T Dang
- School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, USA
| | - Melissa Hewitt
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Emma Lind
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Elizabeth Prickett
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| | - Katelyn Aldridge
- Department of Public Health, Brigham Young University, Provo, UT 84602, USA
| |
Collapse
|
3
|
Hsu C, Evers S, Ibrahim A, Patricia M, Throne P, Melton M, Marcuse EK, Ali A, Dunn J, Hofstetter AM. Sometimes Your Heart Says 'I Don't Know': Insights From Parents of Undervaccinated Children. Acad Pediatr 2023; 23:57-67. [PMID: 36228981 DOI: 10.1016/j.acap.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE To explore drivers of suboptimal vaccination rates by understanding why parents without strong antivaccine beliefs do not fully vaccinate their children. METHODS Four focus groups were conducted in Washington state with 41 parents of children aged 24 to 48 months who delayed, declined, or missed some but not all vaccines. During the focus groups, parents were asked about reasons their child was undervaccinated, information that might address their concerns, and additional support they needed. Transcripts were analyzed using template analysis with deductive and inductive codes. RESULTS Focus groups identified multiple reasons for parents deciding to delay or decline vaccines for their children, including issues of individualism and control. The groups emphasized the impact of personal circumstances, such as changes in insurance, on whether children were vaccinated. Our data also shed light on the reasons that parents do vaccinate their children, including school vaccination requirements, negative experiences with vaccine-preventable diseases, and a family tradition of vaccinating. Focus group participants offered suggestions for improving vaccine communication with parents such as having more parent/patient-friendly vaccine information, providing forums to discuss their concerns, and offering vaccination information in advance of well-child appointments. CONCLUSIONS To achieve the full benefit of vaccines on individual and community health, we need better ways to address vaccine hesitancy and decrease barriers. We suggest that many hesitant parents would benefit from more dialog with health care providers about vaccines, more approachable educational materials, and enforcement of existing policies requiring vaccines in schools and childcare facilities.
Collapse
Affiliation(s)
- Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute (C Hsu, S Evers, and J Dunn), Seattle, Wash.
| | - Sarah Evers
- Kaiser Permanente Washington Health Research Institute (C Hsu, S Evers, and J Dunn), Seattle, Wash
| | - Anisa Ibrahim
- Department of Pediatrics, University of Washington School of Medicine (A Ibrahim, EK Marcuse, and AM Hofstetter), Seattle, Wash; Somali Health Board (A Ibrahim and A Ali), Tukwila, Wash
| | - M Patricia
- Washington State Department of Health (M Patricia deHart, P Throne, and AM Hofstetter), Tumwater, Wash
| | - Paul Throne
- Washington State Department of Health (M Patricia deHart, P Throne, and AM Hofstetter), Tumwater, Wash
| | | | - Edgar K Marcuse
- Department of Pediatrics, University of Washington School of Medicine (A Ibrahim, EK Marcuse, and AM Hofstetter), Seattle, Wash; Seattle Children's Research Institute (EK Marcuse), Seattle, Wash
| | - Ahmed Ali
- Somali Health Board (A Ibrahim and A Ali), Tukwila, Wash
| | - John Dunn
- Kaiser Permanente Washington Health Research Institute (C Hsu, S Evers, and J Dunn), Seattle, Wash
| | - Annika M Hofstetter
- Department of Pediatrics, University of Washington School of Medicine (A Ibrahim, EK Marcuse, and AM Hofstetter), Seattle, Wash; Washington State Department of Health (M Patricia deHart, P Throne, and AM Hofstetter), Tumwater, Wash
| |
Collapse
|
4
|
Childers-Strawbridge S, Eiden AL, Nyaku MK, Bhatti AA. Attitudes and Beliefs around the Value of Vaccination in the United States. Vaccines (Basel) 2022; 10:vaccines10091470. [PMID: 36146548 PMCID: PMC9501875 DOI: 10.3390/vaccines10091470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 11/16/2022] Open
Abstract
Despite the benefits of immunization, differences in attitudes persist toward vaccines. We captured individuals’ perceptions of vaccines and vaccination across the United States (US) to inform vaccine-related policy development. A survey was completed by 5000 respondents from 10 states. Respondents were screened for inclusion, which included individuals ≥ 18 years of age that had received a vaccine or were unvaccinated but indicated a favorable or neutral attitude towards vaccinations. Participants were excluded if they indicated they did not support the idea of vaccinations. Questions explored perceptions of vaccines for all age groups. Among unvaccinated individuals, the most common concerns were about safety (38%). Most respondents (95%) highlighted the importance of state immunization programs for disease prevention. Access to health and immunization records and immunization information systems were important to 96% and 88% of respondents, respectively, for future health planning. Doctors and healthcare professionals (HCPs) were considered trusted sources for vaccine information (95%). Overall, respondents recognized the importance of vaccination, but documented concerns among the unvaccinated indicated a need for greater promotion regarding vaccine safety. Doctors and HCPs, as trusted information sources, should continue to and increasingly advocate for the importance of immunization to increase vaccine uptake.
Collapse
|
5
|
Vasudevan L, Bruening R, Hung A, Woolson S, Brown A, Hastings SN, Linton T, Embree G, Hostler CJ, Mahanna E, Okeke NL, Bosworth H, Sperber NR. COVID-19 vaccination intention and activation among health care system employees: A mixed methods study. Vaccine 2022; 40:5141-5152. [PMID: 35902277 PMCID: PMC9276645 DOI: 10.1016/j.vaccine.2022.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Achieving high COVID-19 vaccination rates among employees is necessary to prevent outbreaks in health care settings. The goal of the study was to produce actionable and timely evidence about factors underlying the intention and decisions to obtain the COVID-19 vaccine by employees. METHODS The study was conducted from December 2020 - May 2021 with employees from a VA health care system in Southeastern US. The study used a convergent mixed methods design comprising two main activities: a cross-sectional survey conducted prior to COVID-19 vaccine distribution, and semi-structured interviews conducted 4-6 months after vaccine distribution. Data were collected about participant characteristics, vaccination intention prior to distribution, vaccination decision post-distribution, determinants of vaccination intention and decision, activating factors, sources of information and intervention needs. Data from the survey and interviews were analyzed separately and integrated narratively in the discussion. RESULTS Prior to vaccine distribution, 77% of employees wanted to be vaccinated. Post vaccine distribution, we identified 5 distinct decision-making groups: 1) vaccine believers who actively sought vaccination and included those sometimes described as "immunization advocates", 2) go along to get along (GATGA) individuals who got vaccinated but did not actively seek it, 3) cautious acceptors who got the COVID-19 vaccine after some delay, 4) fence sitters who remained uncertain about getting vaccinated, and 5) vaccine refusers who actively rejected the COVID-19 vaccine. Participants identifying with Black or multiple races were more likely to express hesitancy in their vaccination intention. CONCLUSION The findings of our study highlight distinct decision-making profiles associated with COVID-19 vaccination among employees of a VA health care system, and provide tailored recommendations to reduce vaccine hesitancy in this population.
Collapse
Affiliation(s)
- Lavanya Vasudevan
- Department of Family Medicine and Community Health, Duke University, Durham, NC, USA; Duke Global Health Institute, Durham, NC, USA; Duke Human Vaccine Institute, Durham, NC, USA.
| | - Rebecca Bruening
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
| | - Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Sandra Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
| | - Adrian Brown
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA; Geriatrics Research, Education and Clinical Center, Durham VA Health Care System, Durham, NC, USA
| | - Tammy Linton
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA; Office of Public Health and Epidemiology, Durham VA Health Care System, Durham, NC, USA
| | - Genevieve Embree
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Office of Public Health and Epidemiology, Durham VA Health Care System, Durham, NC, USA
| | - Christopher J Hostler
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Office of Public Health and Epidemiology, Durham VA Health Care System, Durham, NC, USA
| | - Elizabeth Mahanna
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA
| | - Nwora Lance Okeke
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Hayden Bosworth
- Department of Family Medicine and Community Health, Duke University, Durham, NC, USA; Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
| | - Nina R Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Duke-Margolis Center for Health Policy, Durham, NC, USA
| |
Collapse
|
6
|
Hong K, Hill HA, Tsai Y, Lindley MC, Zhou F. Vaccination Coverage of Privately Insured Children: Comparing U.S. Survey and Administrative Data. Am J Prev Med 2022; 63:107-110. [PMID: 35317958 PMCID: PMC9996641 DOI: 10.1016/j.amepre.2022.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION National Immunization Survey-Child data are used widely to assess childhood vaccination coverage in the U.S. This study compares National Immunization Survey-Child coverage estimates with estimates using other supplementary data sources. METHODS Retrospective analyses in 2021 assessed vaccination coverage of privately insured children for vaccines recommended by the Advisory Committee on Immunization Practices by age 2 years, using the 2015-2018 MarketScan Commercial Claims and Encounters databases and the 2018-2019 Healthcare Effectiveness Data and Information Set. The coverage estimates were compared statistically with those using the 2016-2018 National Immunization Survey-Child. RESULTS Estimated coverage ranged from 69.9% (≥2 doses of influenza vaccine) to 95.0% (≥3 doses of diphtheria, tetanus toxoids, and acellular pertussis vaccine) using the MarketScan Commercial Claims and Encounters data and from 68.0% (≥2 doses of influenza vaccine) to 92.2% (≥1 dose of measles, mumps, and rubella vaccine) using the Healthcare Effectiveness Data and Information Set. The difference between the MarketScan Commercial Claims and Encounters and National Immunization Survey-Child estimates ranged from 0.1 to 4.3 percentage points and was statistically significant for 6 of the 13 assessed vaccines/doses and percentage of children receiving no vaccinations. The difference between the Healthcare Effectiveness Data and Information Set and National Immunization Survey-Child estimates ranged from 0.4 to 7.2 percentage points and was statistically significant for 6 of the 10 assessed vaccines/doses. CONCLUSIONS For certain vaccines and populations of interest, the National Immunization Survey-Child, MarketScan Commercial Claims and Encounters, and Healthcare Effectiveness Data and Information Set data might give comparable coverage of privately insured children.
Collapse
Affiliation(s)
- Kai Hong
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Holly A Hill
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yuping Tsai
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Megan C Lindley
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Fangjun Zhou
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
7
|
Bangs AC, Gastañaduy P, Neilan AM, Fiebelkorn AP, Walker AT, Rao SR, Ryan ET, LaRocque RC, Walensky RP, Hyle EP. The Clinical and Economic Impact of Measles-Mumps-Rubella Vaccinations to Prevent Measles Importations From US Pediatric Travelers Returning From Abroad. J Pediatric Infect Dis Soc 2022; 11:257-266. [PMID: 35333347 PMCID: PMC9214784 DOI: 10.1093/jpids/piac011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/01/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pediatric international travelers account for nearly half of measles importations in the United States. Over one third of pediatric international travelers depart the United States without the recommended measles-mumps-rubella (MMR) vaccinations: 2 doses for travelers ≥12 months and 1 dose for travelers 6 to <12 months. METHODS We developed a model to compare 2 strategies among a simulated cohort of international travelers (6 months to <6 years): (1) No pretravel health encounter (PHE): travelers depart with baseline MMR vaccination status; (2) PHE: MMR-eligible travelers are offered vaccination. All pediatric travelers experience a destination-specific risk of measles exposure (mean, 30 exposures/million travelers). If exposed to measles, travelers' age and MMR vaccination status determine the risk of infection (range, 3%-90%). We included costs of medical care, contact tracing, and lost wages from the societal perspective. We varied inputs in sensitivity analyses. Model outcomes included projected measles cases, costs, and incremental cost-effectiveness ratios ($/quality-adjusted life year [QALY], cost-effectiveness threshold ≤$100 000/QALY). RESULTS Compared with no PHE, PHE would avert 57 measles cases at $9.2 million/QALY among infant travelers and 7 measles cases at $15.0 million/QALY among preschool-aged travelers. Clinical benefits of PHE would be greatest for infants but cost-effective only for travelers to destinations with higher risk for measles exposure (ie, ≥160 exposures/million travelers) or if more US-acquired cases resulted from an infected traveler, such as in communities with limited MMR coverage. CONCLUSIONS Pretravel MMR vaccination provides the greatest clinical benefit for infant travelers and can be cost-effective before travel to destinations with high risk for measles exposure or from communities with low MMR vaccination coverage.
Collapse
Affiliation(s)
- Audrey C Bangs
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul Gastañaduy
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anne M Neilan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA,Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Parker Fiebelkorn
- Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Allison Taylor Walker
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sowmya R Rao
- MGH Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Edward T Ryan
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA,Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA,Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Regina C LaRocque
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA,Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Emily P Hyle
- Corresponding Author: Emily P. Hyle, MD, MSc, Division of Infectious Diseases, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA 02114, USA. E-mail:
| |
Collapse
|
8
|
Dong E, Boom JA, McGuire AL. Should Pediatricians Dismiss Families Who Refuse a COVID-19 Vaccine? Clin Pediatr (Phila) 2022; 61:99-103. [PMID: 34875894 DOI: 10.1177/00099228211065258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Elizabeth Dong
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Julie A Boom
- Department of Pediatrics, Baylor College of Medicine, Houstan, TX, USA
- Immunization Project, Texas Children's Hospital, Houston, TX, USA
| | - Amy L McGuire
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
9
|
Recio-Román A, Recio-Menéndez M, Román-González MV. Vaccine Hesitancy and Political Populism. An Invariant Cross-European Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182412953. [PMID: 34948573 PMCID: PMC8701982 DOI: 10.3390/ijerph182412953] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 11/25/2022]
Abstract
Vaccine-hesitancy and political populism are positively associated across Europe: those countries in which their citizens present higher populist attitudes are those that also have higher vaccine-hesitancy rates. The same key driver fuels them: distrust in institutions, elites, and experts. The reluctance of citizens to be vaccinated fits perfectly in populist political agendas because is a source of instability that has a distinctive characteristic known as the “small pockets” issue. It means that the level at which immunization coverage needs to be maintained to be effective is so high that a small number of vaccine-hesitants have enormous adverse effects on herd immunity and epidemic spread. In pandemic and post-pandemic scenarios, vaccine-hesitancy could be used by populists as one of the most effective tools for generating distrust. This research presents an invariant measurement model applied to 27 EU + UK countries (27,524 participants) that segments the different behaviours found, and gives social-marketing recommendations for coping with the vaccine-hesitancy problem when used for generating distrust.
Collapse
|
10
|
Chamberlain LJ, Bruce J, De La Cruz M, Huffman L, Steinberg JR, Bruguera R, Peterson JW, Gardner RM, He Z, Ordaz Y, Connelly E, Loeb S. A Text-Based Intervention to Promote Literacy: An RCT. Pediatrics 2021; 148:peds.2020-049648. [PMID: 34544847 DOI: 10.1542/peds.2020-049648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Children entering kindergarten ready to learn are more likely to thrive. Inequitable access to high-quality, early educational settings creates early educational disparities. TipsByText, a text-message-based program for caregivers of young children, improves literacy of children in preschool, but efficacy for families without access to early childhood education was unknown. METHODS We conducted a randomized controlled trial with caregivers of 3- and 4-year-olds in 2 public pediatric clinics. Intervention caregivers received TipsByText 3 times a week for 7 months. At pre- and postintervention, we measured child literacy using the Phonological Awareness Literacy Screening Tool (PALS-PreK) and caregiver involvement using the Parent Child Interactivity Scale (PCI). We estimated effects on PALS-PreK and PCI using multivariable linear regression. RESULTS We enrolled 644 families, excluding 263 because of preschool participation. Compared with excluded children, those included in the study had parents with lower income and educational attainment and who were more likely to be Spanish speaking. Three-quarters of enrollees completed pre- and postintervention assessments. Postintervention PALS-PreK scores revealed an unadjusted treatment effect of 0.260 (P = .040); adjusting for preintervention score, child age, and caregiver language, treatment effect was 0.209 (P = .016), equating to ∼3 months of literacy gains. Effects were greater for firstborn children (0.282 vs 0.178), children in 2-parent families (0.262 vs 0.063), and 4-year-olds (0.436 vs 0.107). The overall effect on PCI was not significant (1.221, P = .124). CONCLUSIONS The health sector has unique access to difficult-to-reach young children. With this clinic-based texting intervention, we reached underresourced families and increased child literacy levels.
Collapse
Affiliation(s)
- Lisa J Chamberlain
- Division of General Pediatrics .,Center for Policy, Outcomes, and Prevention
| | | | | | | | | | | | | | | | | | | | | | - Susanna Loeb
- Education, Stanford University, Stanford, California
| |
Collapse
|
11
|
Antivirals targeting paramyxovirus membrane fusion. Curr Opin Virol 2021; 51:34-47. [PMID: 34592709 DOI: 10.1016/j.coviro.2021.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 01/29/2023]
Abstract
The Paramyxoviridae family includes enveloped single-stranded negative-sense RNA viruses such as measles, mumps, human parainfluenza, canine distemper, Hendra, and Nipah viruses, which cause a tremendous global health burden. The ability of paramyxoviral glycoproteins to merge viral and host membranes allows entry of the viral genome into host cells, as well as cell-cell fusion, an important contributor to disease progression. Recent molecular and structural advances in our understanding of the paramyxovirus membrane fusion machinery gave rise to various therapeutic approaches aiming at inhibiting viral infection, spread, and cytopathic effects. These therapeutic approaches include peptide mimics, antibodies, and small molecule inhibitors with various levels of success at inhibiting viral entry, increasing the potential of effective antiviral therapeutic development.
Collapse
|
12
|
Clayton K, Finley C, Flynn DJ, Graves M, Nyhan B. Evaluating the effects of vaccine messaging on immunization intentions and behavior: Evidence from two randomized controlled trials in Vermont. Vaccine 2021; 39:5909-5917. [PMID: 34481697 DOI: 10.1016/j.vaccine.2021.08.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 03/17/2021] [Accepted: 08/09/2021] [Indexed: 11/18/2022]
Abstract
The effectiveness of vaccines in reducing child morbidity and mortality worldwide relies on public acceptance. However, relatively little is known about the effects of vaccine communication on vaccine attitudes and immunization behavior. Previous research suggests that common communication approaches may be ineffective or even counterproductive, especially among vaccine-hesitant parents. However, these studies typically rely on observational data or self-reported measures of vaccination intention. Using novel research designs, we tested the attitudinal and behavioral effects of messages encouraging vaccination in both a survey experiment conducted among a large sample of parents in Vermont who expressed hesitancy about childhood immunizations and a field experiment among parents whose children were overdue for vaccines. We find that neither a message promoting immunization as a social norm nor a message correcting common misperceptions about vaccines was measurably more effective than a standard public health message at improving parents' attitudes toward vaccines, intention to vaccinate their children, or compliance with the recommended vaccine schedule. Our results highlight the need for more research on approaches to successfully reducing vaccine hesitancy among parents.
Collapse
Affiliation(s)
- Katherine Clayton
- Department of Political Science, Stanford University, United States.
| | - Christine Finley
- Immunization Program, Vermont Department of Health, United States
| | - D J Flynn
- School of Global and Public Affairs, IE University, Spain
| | - Meredith Graves
- Immunization Program, Vermont Department of Health, United States
| | - Brendan Nyhan
- Department of Government, Dartmouth College, United States
| |
Collapse
|
13
|
Hofstetter AM, Opel DJ, Stockwell MS, Hsu C, Zhou C, Mangione-Smith RM, Englund JA. Associations Between Health Care Professional Communication Practices and Influenza Vaccination of Hospitalized Children. Acad Pediatr 2021; 21:1142-1150. [PMID: 34217901 DOI: 10.1016/j.acap.2021.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 06/15/2021] [Accepted: 06/27/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Health care professionals (HCPs) (eg, nurses, doctors) play a key role in vaccine uptake. Few studies describe HCP influenza vaccine communication with parents of hospitalized children. METHODS This study included English- and Spanish-speaking parents of influenza vaccine-eligible children hospitalized at a tertiary care pediatric hospital between October 2018 and May 2019. A survey was completed online or via telephone 2 to 15 weeks (median 4 weeks) after discharge. It examined parental intent to vaccinate their child during hospitalization and parent-reported inpatient HCP communication practices (eg, vaccine recommendation strength, format for initiating the recommendation). Multivariable logistic regression examined the associations between HCP communication practices and influenza vaccination during hospitalization, adjusting for demographic, clinical, and visit characteristics. RESULTS Parents (n = 194; 63.0% response rate) were mostly white (66.8%) and English-speaking (97.4%). Their children were primarily 5 through 17 years (67.0%) with chronic disease (68.6%); 24.7% were vaccinated before discharge. Most parents initially had no plan (55.6%) or planned to decline (31.1%) influenza vaccine for their child during hospitalization. Of these parents, 22.2% decided to accept the vaccine, 66.7% citing a HCP conversation as the main reason for changing their mind. Overall, 75.3% recalled a HCP conversation about influenza vaccination. Of these parents, 61.0% reported a HCP recommendation (53.8% described it as "very strong"; 11.1% noted a presumptive initiation format). A parent-reported HCP conversation (adjusted odds ratio [AOR] 5.23, 95% confidence interval [CI] 1.64-16.68) and recommendation (AOR 5.59, 95% CI 2.01-15.51) were associated with influenza vaccination during hospitalization. CONCLUSION This study highlights the importance of discussing and recommending influenza vaccination with parents of hospitalized children.
Collapse
Affiliation(s)
- Annika M Hofstetter
- Department of Pediatrics, University of Washington School of Medicine (AM Hofstetter, DJ Opel, C Zhou, and JA Englund), Seattle, Wash; Seattle Children's Research Institute (AM Hofstetter, DJ Opel, C Zhou, and JA Englund), Seattle, Wash.
| | - Douglas J Opel
- Department of Pediatrics, University of Washington School of Medicine (AM Hofstetter, DJ Opel, C Zhou, and JA Englund), Seattle, Wash; Seattle Children's Research Institute (AM Hofstetter, DJ Opel, C Zhou, and JA Englund), Seattle, Wash
| | - Melissa S Stockwell
- Department of Pediatrics, Columbia University (MS Stockwell), New York, NY; Department of Population and Family Health, Mailman School of Public Health, Columbia University (MS Stockwell), New York, NY
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute (C Hsu and RM Mangione-Smith), Seattle, Wash
| | - Chuan Zhou
- Department of Pediatrics, University of Washington School of Medicine (AM Hofstetter, DJ Opel, C Zhou, and JA Englund), Seattle, Wash; Seattle Children's Research Institute (AM Hofstetter, DJ Opel, C Zhou, and JA Englund), Seattle, Wash
| | - Rita M Mangione-Smith
- Kaiser Permanente Washington Health Research Institute (C Hsu and RM Mangione-Smith), Seattle, Wash
| | - Janet A Englund
- Department of Pediatrics, University of Washington School of Medicine (AM Hofstetter, DJ Opel, C Zhou, and JA Englund), Seattle, Wash; Seattle Children's Research Institute (AM Hofstetter, DJ Opel, C Zhou, and JA Englund), Seattle, Wash
| |
Collapse
|
14
|
Kates OS, Stohs EJ, Pergam SA, Rakita RM, Michaels MG, Wolfe CR, Danziger-Isakov L, Ison MG, Blumberg EA, Razonable RR, Gordon EJ, Diekema DS. The limits of refusal: An ethical review of solid organ transplantation and vaccine hesitancy. Am J Transplant 2021; 21:2637-2645. [PMID: 33370501 PMCID: PMC8298607 DOI: 10.1111/ajt.16472] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/30/2020] [Accepted: 12/21/2020] [Indexed: 01/25/2023]
Abstract
Patients pursuing solid organ transplantation are encouraged to receive many vaccines on an accelerated timeline. Vaccination prior to transplantation offers the best chance of developing immunity and may expand the pool of donor organs that candidates can accept without needing posttransplant therapy. Furthermore, transplant recipients are at greater risk for acquiring vaccine-preventable illnesses or succumbing to severe sequelae of such illnesses. However, a rising rate of vaccine refusal has challenged transplant centers to address the phenomenon of vaccine hesitancy. Transplant centers may need to consider adopting a policy of denial of solid organ transplantation on the basis of vaccine refusal for non-medical reasons (i.e., philosophical or religious objections or personal beliefs that vaccines are unnecessary or unsafe). Arguments supporting such a policy are motivated by utility, stewardship, and beneficence. Arguments opposing such a policy emphasize justice and respect for persons, and seek to avoid worsening inequities or medical coercion. This paper examines these arguments and situates them within the special cases of pediatric transplantation, emergent transplantation, and living donation. Ultimately, a uniform national policy addressing vaccine refusal among transplant candidates is needed to resolve this ethical dilemma and establish a consistent, fair, and standard approach to vaccine refusal in transplantation.
Collapse
Affiliation(s)
- Olivia S. Kates
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Erica J. Stohs
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Steven A. Pergam
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Robert M. Rakita
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Marian G. Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Pittsburgh, School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Cameron R. Wolfe
- Division of Infectious Diseases, Duke University Medical School, Durham, NC, USA
| | - Lara Danziger-Isakov
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Michael G. Ison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emily A. Blumberg
- Department of Medicine, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA, USA
| | - Raymund R. Razonable
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Elisa J. Gordon
- Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Douglas S. Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| |
Collapse
|
15
|
CDC Recommends Concurrent Immunizations: Does the COVID-19 Vaccination Campaign Offer Opportunities for Improving Vaccination Rates Across the Lifespan? INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021; 29:e259. [PMID: 34276176 PMCID: PMC8270226 DOI: 10.1097/ipc.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
Hofstetter AM, Opel DJ, Stockwell MS, Hsu C, deHart MP, Zhou C, Mangione-Smith RM, Englund JA. Influenza-Related Knowledge, Beliefs, and Experiences Among Caregivers of Hospitalized Children. Hosp Pediatr 2021; 11:815-832. [PMID: 34272235 DOI: 10.1542/hpeds.2020-003459] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Caregivers frequently decline influenza vaccine for their hospitalized child. In this study, we aimed to examine factors impacting their influenza vaccine decision-making. METHODS We conducted a cross-sectional survey study of English- and Spanish-speaking caregivers of children hospitalized at a tertiary care pediatric hospital between November 2017 and April 2018. The survey assessed influenza-related knowledge, beliefs, experiences, and vaccine hesitancy. Multivariable logistic regression examined associations between survey responses and child influenza vaccination status at admission (already vaccinated versus not yet vaccinated this season) and, among caregivers with vaccine-eligible children, influenza vaccine acceptance (versus declination) for their child during hospitalization. RESULTS Caregivers (N =522; 88.9% response rate) were mostly non-Hispanic white (66.9%) and English-speaking (97.7%). At admission, 63.2% of children were already vaccinated this season. The caregiver view that influenza vaccination is important for their child's health was the strongest positive predictor of having an already vaccinated child (adjusted odds ratio [aOR]: 3.16; 95% confidence interval [CI]: 2.46-4.05); vaccine hesitancy was the strongest negative predictor (aOR: 0.61; 95% CI: 0.50-0.75). Among caregivers with vaccine-eligible children, 30.3% accepted influenza vaccine for their hospitalized child. Their belief regarding the child health benefits of influenza vaccination was associated with vaccine acceptance during hospitalization (aOR: 6.87; 95% CI: 3.38-13.96). Caregiver vaccine hesitancy and agreement that children with mild illness should delay vaccination negatively impacted vaccine acceptance (aOR: 0.39; 95% CI: 0.25-0.62; aOR: 0.33; 95% CI: 0.20-0.56, respectively). CONCLUSIONS We identified key factors impacting influenza vaccine decision-making among caregivers of hospitalized children, a critical step to improving uptake in this population.
Collapse
Affiliation(s)
- Annika M Hofstetter
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington .,Seattle Children's Research Institute, Seattle, Washington
| | - Douglas J Opel
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| | - Melissa S Stockwell
- Department of Pediatrics, Vagelos College of Physicians and Surgeons.,Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, New York
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - M Patricia deHart
- Office of Immunization and Child Profile, Washington State Department of Health, Olympia, Washington
| | - Chuan Zhou
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| | | | - Janet A Englund
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| |
Collapse
|
17
|
Cunningham RM, Guffey D, Minard CG, Opel DJ, Boom JA. The effect of screening for vaccine hesitancy on the subsequent development of hesitancy: a randomized controlled trial, Houston, TX. Hum Vaccin Immunother 2021; 17:1994-2000. [PMID: 33499719 DOI: 10.1080/21645515.2020.1859320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Vaccine hesitancy remains a global health threat. Addressing parental vaccine hesitancy is essential to maintaining high vaccine coverage levels and preventing disease outbreaks; however, it is unknown if administering a vaccine hesitancy screening tool negatively impacts parental vaccine beliefs. We conducted a stratified randomized controlled trial in pediatric primary care practices. English-speaking parents ≥18 years of age seeking routine care for infants <3 months of age were eligible. Participants were randomized to receive 1 of 2 surveys - the Parent Attitudes about Childhood Vaccines (PACV) survey or a placebo survey. Six months after initial enrollment, all participants were asked to complete the PACV, regardless of initial randomization group. Our primary outcome was the proportion of hesitant to non-hesitant parents at 6-months between randomization groups. We examined associations between vaccine hesitancy and participant characteristics. We also evaluated the change in the proportion of vaccine-hesitant parents in the PACV group between baseline and 6-month follow up. We enrolled 1705 parents at baseline. At 6-month follow up, 819 parents completed the PACV (50.2% from PACV group vs. 54.1% from placebo group). The proportion of hesitant parents at 6 months did not differ between PACV and placebo groups (6.6% vs. 6.1%; p = .78) and the odds of hesitancy among PACV group participants was not higher than those in the placebo group (OR = 1.10; 95% CI: 0.63-1.93; p = .743). Race was the only characteristic significantly associated with vaccine hesitancy at 6-month follow up (p = .003). Overall, administration of the PACV did not trigger vaccine hesitancy in this study population.
Collapse
Affiliation(s)
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Charles G Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Douglas J Opel
- Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Julie A Boom
- Immunization Project, Texas Children's Hospital, Houston, TX, USA.,Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
18
|
Dutta T, Agley J, Meyerson BE, Barnes PA, Sherwood-Laughlin C, Nicholson-Crotty J. Perceived enablers and barriers of community engagement for vaccination in India: Using socioecological analysis. PLoS One 2021; 16:e0253318. [PMID: 34170920 PMCID: PMC8232440 DOI: 10.1371/journal.pone.0253318] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 06/02/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is high level policy consensus in India that community engagement (CE) improves vaccination uptake and reduces burden of vaccine preventable diseases. However, to date, vaccination studies in the country have not explicitly focused on CE as an outcome in and of itself. Therefore, this study sought to examine the barriers and enablers of community engagement for vaccination in India. METHODS Employing qualitative methods, twenty-five semi-structured elite interviews among vaccine decisionmakers' were triangulated with twenty-four national-level vaccine policy documents and researcher field notes (December 2017 to February 2018). Data collected for this study included perceptions and examples of enablers of and barriers to CE for vaccination uptake. Concepts, such as the absence of formal procedures or data collection approaches related to CE, were confirmed during document review, and a final convening to review study results was conducted with study respondents in December 2018 and January 2019 to affirm the general set of findings from this study. The Social Ecological Model (SEM) was used to organize and interpret the study findings. RESULTS Although decisionmakers and policy documents generally supported CE, there were more CE barriers than facilitators in the context of vaccination, which were identified at all social-ecological levels. Interviews with vaccine decisionmakers in India revealed complex systemic and structural factors which affect CE for vaccination and are present across each of the SEM levels, from individual to policy. Policy-level enablers included decisionmakers' political will for CE and policy documents and interviews highlighted social mobilization, whereas barriers were lack of a CE strategy document and a broad understanding of CE by decisionmakers. At the community level, dissemination of Social-behavioral Change Communication (SBCC) materials from the national-level to the states was considered a CE facilitator, while class, and caste-based power relations in the community, lack of family-centric CE strategies, and paternalistic attitude of decisionmakers toward communities (the latter reported by some NGO heads) were considered CE barriers. At the organizational level, partnerships with local organizations were considered CE enablers, while lack of institutionalized support to formalize and incentivize these partnerships highlighted by several decisionmakers, were barriers. At the interpersonal level, SBCC training for healthcare workers, sensitive messaging to communities with low vaccine confidence, and social media messaging were considered CE facilitators. The lack of strategies to manage vaccine related rumors or replicate successful CE interventions during the during the introduction and rollout of new vaccines were perceived as CE barriers by several decisionmakers. CONCLUSION Data obtained for this study highlighted national-level perceptions of the complexities and challenges of CE across the entire SEM, from individual to systemic levels. Future studies should attempt to associate these enablers and barriers with actual CE outcomes, such as participation or community support in vaccine policy-making, CE implementation for specific vaccines and situations (such as disease outbreaks), or frequency of sub-population-based incidents of community resistance and community facilitation to vaccination uptake. There would likely be value in developing a population-based operational definition of CE, with a step-by-step manual on 'how to do CE.' The data from this study also indicate the importance of including CE indicators in national datasets and developing a compendium documenting CE best-practices. Doing so would allow more rigorous analysis of the evidence-base for CE for vaccination in India and other countries with similar immunization programs.
Collapse
Affiliation(s)
- Tapati Dutta
- Public Health Department, Fort Lewis College, Durango, CO, United States of America
| | - Jon Agley
- Department of Applied Health Science, Deputy Director of Research, Prevention Insights, Indiana University School of Public Health-Bloomington, Bloomington, Indiana, United States of America
| | - Beth E. Meyerson
- Research Professor at University of Arizona, Southwest Institute for Research on Women (SIROW), Tucson, AZ, United States of America
| | - Priscilla A. Barnes
- Department of Applied Health Science, Indiana University School of Public Health-Bloomington, Bloomington, IN, United States of America
| | - Catherine Sherwood-Laughlin
- Department of Applied Health Science, Indiana University School of Public Health-Bloomington, Bloomington, IN, United States of America
| | - Jill Nicholson-Crotty
- School of Public and Environmental Affairs, Indiana University, Bloomington, IN, United States of America
| |
Collapse
|
19
|
Masters NB, Delamater PL, Boulton ML, Zelner J. Measuring Multiple Dimensions and Indices of Nonvaccination Clustering in Michigan, 2008-2018. Am J Epidemiol 2021; 190:1113-1121. [PMID: 33305789 DOI: 10.1093/aje/kwaa264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/23/2020] [Accepted: 12/07/2020] [Indexed: 11/15/2022] Open
Abstract
Michigan experienced a significant measles outbreak in 2019 amidst rising rates of nonmedical vaccine exemptions (NMEs) and low vaccination coverage compared with the rest of the United States. There is a critical need to better understand the landscape of nonvaccination in Michigan to assess the risk of vaccine-preventable disease outbreaks in the state, yet there is no agreed-upon best practice for characterizing spatial clustering of nonvaccination, and numerous clustering metrics are available in the statistical, geographical, and epidemiologic literature. We used school-level data to characterize the spatiotemporal landscape of vaccine exemptions in Michigan for the period 2008-2018 using Moran's I, the isolation index, the modified aggregation index, and the Theil index at 4 spatial scales. We also used nonvaccination thresholds of 5%, 10%, and 20% to assess the bias incurred when aggregating vaccination data. We found that aggregating school-level data to levels commonly used for public reporting can lead to large biases in identifying the number and location of at-risk students and that different clustering metrics yielded variable interpretations of the nonvaccination landscape in Michigan. This study shows the importance of choosing clustering metrics with their mechanistic interpretations in mind, be it large- or fine-scale heterogeneity or between- and within-group contributions to spatial variation.
Collapse
|
20
|
Kraus N, Condon SB. Measles (Rubeola): A Case Of Vaccine Hesitancy And Pregnancy. J Midwifery Womens Health 2021; 66:391-396. [PMID: 34022106 DOI: 10.1111/jmwh.13223] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/14/2021] [Accepted: 01/23/2021] [Indexed: 12/13/2022]
Abstract
Measles (rubeola) is a highly contagious virus. Vaccination has nearly eradicated measles in the United States, yet sporadic outbreaks persist. Although the live-attenuated measles, mumps, rubella vaccine has not been found to cause fetal harm, pregnancy is considered a contraindication for the vaccine and contracting measles during pregnancy can have serious sequelae. Furthermore, lifelong immunity conferred by childhood vaccination is questionable as the vaccine's protection may wane during the childbearing years. Reluctance to vaccinate, or vaccine hesitancy, may leave a proportion of people of childbearing age unprotected. It is unlikely that many clinicians providing preconception, primary, and perinatal care have had occasion to diagnose measles. Susceptibility to infection combined with clinician inexperience may contribute to missed opportunities to halt the spread of this highly contagious, preventable illness. A case of parents' religion-based vaccine hesitancy complicating the pregnancy of their adult daughter is presented. Guidelines for screening for immunity, identifying measles in the clinical setting, and protocols for mitigating spread are reviewed.
Collapse
Affiliation(s)
- Nancy Kraus
- Independent researcher, New Rochelle, New York
| | | |
Collapse
|
21
|
Cataldi JR. The Many Costs of Measles Outbreaks and Undervaccination: Why We Need to Invest in Public Health. Pediatrics 2021; 147:peds.2020-035303. [PMID: 33712548 DOI: 10.1542/peds.2020-035303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jessica R Cataldi
- Section of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
| |
Collapse
|
22
|
Feldman AG, O'Leary ST, Isakov LD. The Risk of Resurgence in Vaccine Preventable Infections Due to COVID-Related Gaps in Immunization. Clin Infect Dis 2021; 73:1920-1923. [PMID: 33580243 PMCID: PMC7929016 DOI: 10.1093/cid/ciab127] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Indexed: 11/14/2022] Open
Abstract
Nationally, immunization delivery has decreased significantly during COVID-19. Internationally, over 60 national vaccine programs have been disrupted or suspended. As a result of these immunization declines, the global community is at risk for a resurgence in vaccine preventable infections including measles, pertussis and polio; all highly contagious diseases that result in significant morbidity and mortality in children. Measles outbreaks have already occurred in many countries who suspended their vaccination programs. Outbreaks in the United States are likely to occur when social distancing stops and children return to school. Health care providers have acted quickly to institute multiple risk mitigation strategies to restore vaccine administration. However, childhood immunization rates remain below pre-COVID levels. Partnerships between healthcare providers, community leaders and local, state, regional and national public health departments are needed to reassure families that vaccine delivery during COVID is safe and to identify and catch-up those children who are under-immunized.
Collapse
Affiliation(s)
- Amy G Feldman
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Anschutz Medical Campus & Children's Hospital Colorado, Aurora, CO, USA
| | - Sean T O'Leary
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Anschutz Medical Campus & Children's Hospital Colorado, Aurora, CO, USA.,Section of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Lara Danziger Isakov
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
23
|
Jones B. Eating meat and not vaccinating: In defense of the analogy. BIOETHICS 2021; 35:135-142. [PMID: 33222212 PMCID: PMC7753820 DOI: 10.1111/bioe.12834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/21/2020] [Accepted: 10/25/2020] [Indexed: 06/11/2023]
Abstract
The devastating impact of the COVID-19 (coronavirus disease 2019) pandemic is prompting renewed scrutiny of practices that heighten the risk of infectious disease. One such practice is refusing available vaccines known to be effective at preventing dangerous communicable diseases. For reasons of preventing individual harm, avoiding complicity in collective harm, and fairness, there is a growing consensus among ethicists that individuals have a duty to get vaccinated. I argue that these same grounds establish an analogous duty to avoid buying and eating most meat sold today, based solely on a concern for human welfare. Meat consumption is a leading driver of infectious disease. Wildlife sales at wet markets, bushmeat hunting, and concentrated animal feeding operations (CAFOs) are all exceptionally risky activities that facilitate disease spread and impose immense harms on human populations. If there is a moral duty to vaccinate, we also should recognize a moral duty to avoid most meat. The paper concludes by considering the implications of this duty for policy.
Collapse
Affiliation(s)
- Ben Jones
- Rock Ethics InstituteThe Pennsylvania State UniversityUniversity ParkPennsylvania
| |
Collapse
|
24
|
Seither R, McGill MT, Kriss JL, Mellerson JL, Loretan C, Driver K, Knighton CL, Black CL. Vaccination Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten - United States, 2019-20 School Year. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2021; 70:75-82. [PMID: 33476312 PMCID: PMC7821768 DOI: 10.15585/mmwr.mm7003a2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
State and local school vaccination requirements serve to protect students against vaccine-preventable diseases (1). This report summarizes data collected by state and local immunization programs* on vaccination coverage among children in kindergarten (kindergartners) in 48 states, exemptions for kindergartners in 49 states, and provisional enrollment and grace period status for kindergartners in 28 states for the 2019-20 school year, which was more than halfway completed when most schools moved to virtual learning in the spring because of the coronavirus 2019 (COVID-19) pandemic. Nationally, vaccination coverage† was 94.9% for the state-required number of doses of diphtheria and tetanus toxoids, and acellular pertussis vaccine (DTaP); 95.2% for 2 doses of measles, mumps, and rubella vaccine (MMR); and 94.8% for the state-required number of varicella vaccine doses. Although 2.5% of kindergartners had an exemption from at least one vaccine,§ another 2.3% were not up to date for MMR and did not have a vaccine exemption. Schools and immunization programs can work together to ensure that undervaccinated students are caught up on vaccinations in preparation for returning to in-person learning. This follow-up is especially important in the current school year, in which undervaccination is likely higher because of disruptions in vaccination during the ongoing COVID-19 pandemic (2-4).
Collapse
|
25
|
Abstract
Although vaccine acceptance and uptake are overall high among children in the United States, vaccine delays or refusals are a growing concern. Vaccine hesitancy is a challenge for the pediatric provider, given the diverse factors associated with hesitancy and the limited evidence on effective strategies for addressing vaccine hesitancy in the provider office. In this article, we review available evidence and approaches for vaccine communication, including the importance of using a whole-team approach, building trust, starting the conversation early, using a presumptive approach for vaccine recommendations, motivational interviewing with parents who have concerns for vaccines, and additional techniques for responding to parent questions. We also review organizational strategies to help create a culture of immunization in the practice, including evidence-based approaches for increasing vaccine uptake and efficiency. Although these communication approaches and organizational strategies are intended to reassure parents who are vaccine hesitant that all routine, universally recommended vaccines are safe and effective, they likely will take on increased significance as the development, implementation, and evaluation of coronavirus disease 2019 vaccines continue to unfold. [Pediatr Ann. 2020;49(12):e523-e531.].
Collapse
|
26
|
McLean T, Norbury L, Conduit R, Shepherd N, Coloe P, Sasse A, Smooker P. Inactivated tetanus as an immunological smokescreen: A major step towards harnessing tetanus-based therapeutics. Mol Immunol 2020; 127:164-174. [PMID: 33002728 DOI: 10.1016/j.molimm.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/01/2020] [Accepted: 09/08/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Tetanus neurotoxin has many potential therapeutic applications, due to its ability to increase localised muscle tone when injected directly into a muscle. It is a closely related molecule to botulinum neurotoxin (most commonly known as Botox), which has been widely used to release muscle tension for therapeutic and cosmetic applications. However, tetanus toxin has been relegated to the "maybe pile" for protein therapeutics - as most of the population is vaccinated, leading to highly effective antibody-mediated protection against the toxin. The potential for tetanus-based therapeutics remains substantial if the problem of pre-existing immunity can be resolved. EXPERIMENTAL APPROACH A well-established murine model of localised muscular contraction was utilised. We administered functional tetanus toxin combined with an immunogenic, but functionally inactive, decoy molecule. KEY RESULTS Incorporation of the decoy molecule greatly reduces the dose of active toxin required to induce a localised increase in muscle tone in mice vaccinated with the human toxoid vaccine. CONCLUSION AND IMPLICATIONS Our results clearly demonstrate that the barriers to developing a tetanus toxin therapeutic are not insurmountable and the technology presented here is the first major step towards realising the therapeutic potential of this powerful neurotoxin. Opening the therapeutic potential of tetanus toxin will have huge implications for the wide range of diseases caused by low-tone muscle.
Collapse
Affiliation(s)
- Thomas McLean
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia.
| | - Luke Norbury
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia.
| | - Russell Conduit
- School of Health and Biomedical Sciences, College of Science, Engineering and Health, RMIT University, Bundoora, VIC 3083, Australia.
| | - Natalie Shepherd
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia
| | - Peter Coloe
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia.
| | - Anthony Sasse
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia; Latrobe Regional Hospital, Gippsland, Australia.
| | - Peter Smooker
- Bioscience and Food Technology, School of Science, Plenty Road, Building 223 Bundoora West campus, RMIT University, Bundoora, VIC 3083, Australia.
| |
Collapse
|
27
|
Zuo S, Zhang D, Mu Q, Dai L, Du W, Xu F, Feng J, Heffelfinger JD. Increasing vaccination coverage: The school entry vaccination record check program in Guizhou Province China, 2003–2018. Vaccine 2020; 38:7379-7383. [DOI: 10.1016/j.vaccine.2020.08.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 08/04/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
|
28
|
Williams JTB, O'Leary ST, Nussbaum AM. Caring for the Vaccine-Hesitant Family: Evidence-Based Alternatives to Dismissal. J Pediatr 2020; 224:137-140. [PMID: 32446723 PMCID: PMC7242184 DOI: 10.1016/j.jpeds.2020.05.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/07/2020] [Accepted: 05/14/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Joshua T B Williams
- Department of Pediatrics, Denver Health Medical Center, Denver, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Sean T O'Leary
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO; Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Aurora, CO
| | - Abraham M Nussbaum
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO; Department of Behavioral Health, Denver Health Medical Center, Denver, CO
| |
Collapse
|
29
|
Jacobson RM. Routine Childhood Vaccines Given From 1 through 18 Years of Age. Mayo Clin Proc 2020; 95:1780-1795. [PMID: 32753151 DOI: 10.1016/j.mayocp.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/20/2020] [Accepted: 06/02/2020] [Indexed: 11/21/2022]
Abstract
In addition to the vaccines due in the first year of life, the US Advisory Committee on Immunization Practices recommends that children continue to receive vaccines regularly against a variety of infectious diseases. Starting at 12 to 15 months of life, these include the two-dose measles-mumps-rubella vaccine series and the two-dose varicella vaccine series. Also in the second year of life, infants should begin the two-dose hepatitis A vaccine series and complete the Haemophilus influenzae type B vaccine series as well as the pneumococcal conjugate vaccine series. Before 19 months of life, infants should receive the third dose of the poliovirus vaccine and the fourth dose of diphtheria-tetanus-acellular pertussis (DTaP) vaccine. The final doses of poliovirus and tetanus-diphtheria-acellular pertussis vaccines are both due at 4 to 6 years of life. Before each influenza season, every child should receive the influenza vaccine. Those less than 9 years of age who previously received less than two doses need two doses a month apart. At 11 to 12 years of life, all should get two doses of the human papillomavirus vaccine, the adolescent/adult version of the tetanus-diphtheria-acellular pertussis vaccine, and begin a two-dose series of meningococcal ACWY vaccine. Each of these vaccines is due when the vaccine works to protect against both an immediate risk as well as to provide long-term protection. Each vaccine-preventable disease varies in terms of the nature of exposure, the form of the morbidity, the risk of mortality, and potential to prevent or ameliorate its harm.
Collapse
Affiliation(s)
- Robert M Jacobson
- Department of Pediatric and Adolescent Medicine, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
| |
Collapse
|
30
|
Persistence of US measles risk due to vaccine hesitancy and outbreaks abroad. THE LANCET. INFECTIOUS DISEASES 2020; 20:1114-1115. [PMID: 32738934 PMCID: PMC7392555 DOI: 10.1016/s1473-3099(20)30522-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 06/08/2020] [Indexed: 11/20/2022]
|
31
|
A qualitative study examining pediatric clinicians' perceptions of delayed vaccine schedules. Vaccine 2020; 38:4740-4746. [PMID: 32418792 DOI: 10.1016/j.vaccine.2020.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 04/24/2020] [Accepted: 05/06/2020] [Indexed: 11/21/2022]
Abstract
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.
Collapse
|
32
|
Park KK. The role of the dermatologist in the return of measles. Int J Womens Dermatol 2020; 6:97-98. [PMID: 32258340 PMCID: PMC7105647 DOI: 10.1016/j.ijwd.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 11/30/2022] Open
|
33
|
Pan RJ. The modern plague of antivaccine extremists. Ann Allergy Asthma Immunol 2020; 125:6-7. [PMID: 32007566 DOI: 10.1016/j.anai.2020.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 10/25/2022]
|