Regional differences in pediatric pneumococcal vaccine schedules for Indigenous children in Canada: an environmental scan.

BACKGROUND: Streptococcus pneumoniae bacteria causes substantial morbidity and mortality worldwide, especially in children under 5 years of age. Prevention of these outcomes by pneumococcal conjugate vaccines (PCV) is an important public health initiative, supported by publicly funded vaccination programs in Canada. While the National Advisory Committee on Immunization (NACI) provides national recommendations for vaccination schedules, decisions on vaccination program delivery are made regionally, creating potential for variability across the country. In addition, defining the groups that are most at risk has become a complex endeavor for provinces and territories in Canada, specifically considering Indigenous children. METHODS: In this environmental scan, we reviewed policy documents, provincial/territorial and international PCV schedules, and scientific literature, and consulted with vaccination program stakeholders and experts from across the country, in order to understand the evolution of PCV vaccination guidelines and policies in Canada and identify whether and how the needs of Indigenous children are addressed. RESULTS: As of March 2023, most regions do not specify particular vaccination requirements for Indigenous children; however, three provinces identify Indigenous children as "high risk" and use varying language to recommend a four dose, rather than the routine three dose, schedule. Our results also draw attention to evidence gaps supporting a differing practice for Indigenous populations. CONCLUSIONS: Future PCV program innovation requires inclusive and clear policies as well as definitive evidence-based policies and practices in order to improve equitable population health.

Development and evaluation of virtual simulation games to increase the confidence and self-efficacy of healthcare learners in vaccine communication, advocacy, and promotion.

BACKGROUND: Although healthcare providers (HCPs) are the most trusted source of vaccine information, there is a paucity of easily accessible, multidisciplinary educational tools on vaccine communication for them. Virtual simulation games (VSGs) are innovative yet accessible and effective tools in healthcare education. The objectives of our study were to develop VSGs to increase HCP confidence and self-efficacy in vaccine communication, advocacy, and promotion, and evaluate the VSGs' effectiveness using a pre-post self-assessment pilot study. METHODS: A multidisciplinary team of experts in medicine, nursing, pharmacy, and simulation development created three VSGs for HCP learners focused on addressing conversations with vaccine hesitant individuals. We evaluated the VSGs with 24 nursing students, 30 pharmacy students, and 18 medical residents who completed surveys and 6-point Likert scale pre-post self-assessments to measure changes in their confidence and self-efficacy. RESULTS: There were no significant differences in baseline confidence and self-efficacy across the three HCP disciplines, despite varied levels of education. Post-VSG confidence and self-efficacy (median: 5) were significantly higher than pre-VSG (median: 4-5) for all three HCP disciplines (P ≤ 0.0005), highlighting the effectiveness of the VSGs. Medical residents reported significantly lower post-VSG confidence and self-efficacy than nursing and pharmacy learners despite completing the most significant amount of education. CONCLUSIONS: Following the completion of the VSGs, learners in medicine, nursing, and pharmacy showed significant improvement in their self-assessed confidence and self-efficacy in holding vaccine conversations. The VSGs as an educational tool, in combination with existing clinical immunization training, can be used to increase HCP confidence and engagement in vaccine discussions with patients, which may ultimately lead to increased vaccine confidence among patients.

Characterizing the Pain Experience of Children With Acute Gastroenteritis Based on Identified Pathogens.

OBJECTIVES: Pain is common with acute gastroenteritis (AGE) yet little is known about the severity associated with specific enteropathogens. We sought to explore the correlation of pain severity with specific enteropathogens in children with AGE. METHODS: Participants were prospectively recruited by the Alberta Provincial Pediatric EnTeric Infection TEam at 2 pediatric emergency departments (EDs) (December 2014-August 2018). Pain was measured (by child and/or caregiver) using the 11-point Verbal Numerical Rating Scale. RESULTS: We recruited 2686 participants; 46.8% (n = 1256) females, with median age 20.1 months (interquartile range 10.3, 45.3). The mean highest pain scores were 5.5 [standard deviation (SD) 3.0] and 4.2 (SD 2.9) in the 24 hours preceding the ED visit, and in the ED, respectively. Prior to ED visit, the mean highest pain scores with bacterial detection were 6.6 (SD 2.5), compared to 5.5 (SD 2.9) for single virus and 5.5 (SD 3.1) for negative stool tests. In the ED, the mean highest pain scores with bacterial detection were 5.5 (SD 2.7), compared to 4.1 (SD 2.9) for single virus and 4.2 (SD 3.0) for negative stool tests. Using multivariable modeling, factors associated with greater pain severity prior to ED visit included older age, fever, illness duration, number of diarrheal or vomiting episodes in the preceding 24 hours, and respiratory symptoms, but not enteropathogen type. CONCLUSION: Children with AGE experience significant pain, particularly when the episode is associated with the presence of a bacterial enteric pathogen. However, older age and fever appear to influence children's pain experiences more than etiologic pathogens.

Parents' perceptions on COVID-19 vaccination as the new routine for their children ≤ 11 years old.

Canadian children 5-11 years old became eligible for COVID-19 vaccination on November 19, 2021, with eligibility for younger children expected later. We aimed to descriptively assess parents' COVID-19 vaccine intentions and acceptability of future doses, including co-administration and annual vaccination for their children. We conducted a cross-sectional Canadian online survey of parents from October 14-November 12, 2021, just prior to authorization of the pediatric formulation of the BNT162b2 COVID-19 vaccine for children aged 5-11 years. We assessed parents' intention to vaccinate their children aged 5-11 years, 2-4 years, and 6-23 months; reasons for their intention; and preferences for delivery and access to vaccines. Of 1129 parents, 56% intended to vaccinate their child aged 5-11 years against COVID-19; intentions were lower for children aged 6-23 months (41.9%) and 2-4 years (45.4%). Most parents who intended to vaccinate supported co-administration with routine (61.1%) or influenza (55.4%) vaccines, administration at school (63.6%), receipt of booster doses of COVID-19 vaccine (57.8%), and annual vaccination (56.4%) for their child. Despite parents' high COVID-19 vaccination uptake for themselves (88.8%), intentions for children aged 5-11 years was low. Currently, 56.9% of Canadian children aged 5-11 years have received one dose of a COVID-19 vaccine, and only 37.1% are fully vaccinated. Given that intentions for children <5 years was lower than those 5-11 years, we can also expect low uptake in this group. Parents' preferences regarding delivery and access to COVID-19 vaccination should be considered by public health officials when planning vaccination strategies for children.

Transition to endemic: acceptance of additional COVID-19 vaccine doses among Canadian adults in a national cross-sectional survey.

BACKGROUND: Additional doses of COVID-19 vaccine have been proposed as solutions to waning immunity and decreased effectiveness of primary doses against infection with new SARS-CoV-2 variants. However, the effectiveness of additional vaccine doses relies on widespread population acceptance. We aimed to assess the acceptance of additional COVID-19 vaccine doses (third and annual doses) among Canadian adults and determine associated factors. METHODS: We conducted a national, cross-sectional online survey among Canadian adults from October 14 to November 12, 2021. Weighted multinomial logistic regression analyses were used to identify sociodemographic and health-related factors associated with third and annual dose acceptance and indecision, compared to refusal. We also assessed influences on vaccine decision-making, and preferences for future vaccine delivery. RESULTS: Of 6010 respondents, 70% reported they would accept a third dose, while 15.2% were undecided. For annual doses, 64% reported acceptance, while 17.5% were undecided. Factors associated with third dose acceptance and indecision were similar to those associated with annual dose acceptance and indecision. Previous COVID-19 vaccine receipt, no history of COVID-19 disease, intention to receive an influenza vaccine, and increasing age were strongly associated with both acceptance and indecision. Chronic illness was associated with higher odds of acceptance, while self-reported disability was associated with higher odds of being undecided. Higher education attainment and higher income were associated with higher odds of accepting additional doses. Minority first language was associated with being undecided about additional doses, while visible minority identity was associated with being undecided about a third dose and refusing an annual dose. All respondents reported government recommendations were an important influence on their decision-making and identified pharmacy-based delivery and drop-in appointments as desirable. Co-administration of COVID-19 and influenza vaccines was viewed positively by 75.5% of the dose 3 acceptance group, 12.3% of the undecided group, and 8.4% of the refusal group. CONCLUSIONS: To increase acceptance, targeted interventions among visible minority and minority language populations, and those with a disability, are required. Offering vaccination at pharmacies and through drop-in appointments are important to facilitate uptake, while offering COVID-19/influenza vaccine co-administration may have little benefit among those undecided about additional doses.

Measuring inequalities in COVID-19 vaccination uptake and intent: results from the Canadian Community Health Survey 2021.

BACKGROUND: By July 2021, Canada had received enough COVID-19 vaccines to fully vaccinate every eligible Canadian. However, despite the availability of vaccines, some eligible individuals remain unvaccinated. Differences in vaccination uptake can be driven by health inequalities which have been exacerbated and amplified by the pandemic. This study aims to assess inequalities in COVID-19 vaccination uptake and intent in adults 18 years or older across Canada by identifying sociodemographic factors associated with non-vaccination and low vaccination intent using data drawn from the June to August 2021 Canadian Community Health Survey (CCHS). METHODS: The CCHS is an annual cross-sectional and nationally representative survey conducted by Statistics Canada, which collects health-related information. Since September 2020, questions about the COVID-19 pandemic are asked. Adjusted logistic regression models were fitted to examine associations between vaccination uptake or intent and sociodemographic and health related variables. Region, age, gender, level of education, Indigenous status, visible minority status, perceived health status, and having a regular healthcare provider were considered as predictors, among other factors. RESULTS: The analysis included 9,509 respondents. The proportion of unvaccinated was 11%. Non-vaccination was associated with less than university education (aOR up to 3.5, 95% CI 2.1-6.1), living with children under 12 years old (aOR 1.6, 95% CI 1.1-2.4), not having a regular healthcare provider (aOR 1.6, 95% CI 1.1-2.2), and poor self-perceived health (aOR 1.8, 95% CI 1.3-2.4). Only 5% of the population had low intention to get vaccinated. Being unlikely to get vaccinated was associated with the Prairies region (aOR 2.2, 95% CI 1.2-4.1), younger age groups (aOR up to 4.0, 95% CI 1.3-12.3), less than university education (aOR up to 3.8, 95% CI 1.9-7.6), not being part of a visible minority group (aOR 3.0, 95% CI 1.4-6.4), living with children under 12 years old (aOR 1.8, 95% CI 1.1-2.9), unattached individuals (aOR 2.6, 95% CI 1.1-6.1), and poor self-perceived health (aOR 2.0, 95% CI 1.3-2.9). CONCLUSIONS: Disparities were observed in vaccination uptake and intent among various sociodemographic groups. Awareness of inequalities in COVID-19 vaccination uptake and intent is needed to determine the vaccination barriers to address in vaccination promotion strategies.

Sociodemographic Disparities in COVID-19 Vaccine Uptake and Vaccination Intent in Canada.

Introduction: This study's objective was to examine sociodemographic disparities in COVID-19 vaccine uptake and vaccination intent in the Canadian provinces by identifying factors associated with vaccine uptake in seniors prioritized for vaccination at the time of the survey and vaccination intent in all adults. Data and methods: A cross-sectional survey of Canadian adults was conducted in all provinces from mid-April to mid-May 2021. In addition to sociodemographic characteristics, respondents (n=10,678) provided information on their COVID-19 vaccination status or their intent to get vaccinated. Logistic regression models were fitted using sociodemographic factors as explanatory variables and vaccination status (unvaccinated vs at least one dose) or vaccination intent (unlikely versus likely or already vaccinated) as outcomes. To account for vaccine prioritization groups, multiple regression models were adjusted for province of residence, age, Indigenous identity and health care worker status. Results: Seniors with a lower household income (less than $60,000) and those living in smaller communities (fewer than 100,000 inhabitants) had higher odds of being unvaccinated. Among Canadian adults, the odds of being unlikely to get vaccinated were higher for males (adjusted odds ratio [AOR] 1.3), individuals younger than 60 (AOR between 3.3 and 5.1), non-health care workers (AOR 3.3), those with less than a high school education (AOR 3.4) or a household income of less than $30,000 (AOR 2.7) and individuals who do not identify as South Asian, Chinese, Black, Filipino, Arab, Latin American, Southeast Asian, West Asian, Korean or Japanese (AOR 1.7). Interpretation: COVID-19 vaccine uptake (80%) and vaccination intent (95%) were high among Canadians; however, relative disparities were observed among specific groups. Continued efforts targeted toward these groups are essential in reducing potential inequity in access or service provision.

Association of COVID-19 Vaccination in Pregnancy With Adverse Peripartum Outcomes.

Importance: There is limited comparative epidemiological evidence on outcomes associated with COVID-19 vaccination during pregnancy; monitoring pregnancy outcomes in large populations is required. Objective: To evaluate peripartum outcomes following COVID-19 vaccination during pregnancy. Design, Setting, and Participants: Population-based retrospective cohort study in Ontario, Canada, using a birth registry linked with the provincial COVID-19 immunization database. All births between December 14, 2020, and September 30, 2021, were included. Exposures: COVID-19 vaccination during pregnancy, COVID-19 vaccination after pregnancy, and no vaccination. Main Outcomes and Measures: Postpartum hemorrhage, chorioamnionitis, cesarean delivery (overall and emergency cesarean delivery), admission to neonatal intensive care unit (NICU), and low newborn 5-minute Apgar score (<7). Linear and robust Poisson regression was used to generate adjusted risk differences (aRDs) and risk ratios (aRRs), respectively, comparing cumulative incidence of outcomes in those who received COVID-19 vaccination during pregnancy with those vaccinated after pregnancy and those with no record of COVID-19 vaccination at any point. Inverse probability of treatment weights were used to adjust for confounding. Results: Among 97 590 individuals (mean [SD] age, 31.9 [4.9] years), 22 660 (23%) received at least 1 dose of COVID-19 vaccine during pregnancy (63.6% received dose 1 in the third trimester; 99.8% received an mRNA vaccine). Comparing those vaccinated during vs after pregnancy (n = 44 815), there were no significantly increased risks of postpartum hemorrhage (incidence: 3.0% vs 3.0%; aRD, -0.28 per 100 individuals [95% CI, -0.59 to 0.03]; aRR, 0.91 [95% CI, 0.82-1.02]), chorioamnionitis (0.5% vs 0.5%; aRD, -0.04 per 100 individuals [95% CI, -0.17 to 0.09]; aRR, 0.92 [95% CI, 0.70-1.21]), cesarean delivery (30.8% vs 32.2%; aRD, -2.73 per 100 individuals [95% CI, -3.59 to -1.88]; aRR, 0.92 [95% CI, 0.89-0.95]), NICU admission (11.0% vs 13.3%; aRD, -1.89 per 100 newborns [95% CI, -2.49 to -1.30]; aRR, 0.85 [95% CI, 0.80-0.90]), or low Apgar score (1.8% vs 2.0%; aRD, -0.31 per 100 newborns [95% CI, -0.56 to -0.06]; aRR, 0.84 [95% CI, 0.73-0.97]). Findings were qualitatively similar when compared with individuals who did not receive COVID-19 vaccination at any point (n = 30 115). Conclusions and Relevance: In this population-based cohort study in Ontario, Canada, COVID-19 vaccination during pregnancy, compared with vaccination after pregnancy and with no vaccination, was not significantly associated with increased risk of adverse peripartum outcomes. Study interpretation should consider that the vaccinations received during pregnancy were primarily mRNA vaccines administered in the second and third trimester.

Attribution of Pediatric Acute Gastroenteritis Episodes and Emergency Department Visits to Norovirus Genogroups I and II.

BACKGROUND: Norovirus is a leading cause of acute gastroenteritis. With vaccines in development, population-based estimates of norovirus burden are needed to identify target populations, quantify potential benefits, and understand disease dynamics. METHODS: We estimated the attributable fraction (AF) for norovirus infections in children, defined as the proportion of children testing positive for norovirus whose gastroenteritis was attributable to norovirus. We calculated the standardized incidence and emergency department (ED) visit rates attributable to norovirus using provincial gastroenteritis visit administrative data. RESULTS: From 3731 gastroenteritis case patients and 2135 controls we determined that the AFs were 67.0% (95% confidence interval [CI], 31.5%-100%) and 91.6% (88.8%-94.4%) for norovirus genogroups I (GI) and II (GII), respectively. Norovirus GII AF varied by season but not age. We attributed 116 episodes (95% CI, 103-129) and 59 (51-67) ED visits per 10 000 child-years to norovirus GII across all ages, accounting for 20% and 18% of all medically attended gastroenteritis episodes and ED visits, respectively. CONCLUSIONS: In children, a large proportion of norovirus GII detections reflect causation, demonstrating significant potential for norovirus GII vaccines. Seasonal variation in the norovirus GII AF may have implications for understanding the role asymptomatic carriage plays in disease dynamics.

Characterizing Pain in Children with Acute Gastroenteritis Who Present for Emergency Care.

OBJECTIVE: To characterize the pain experienced by children with acute gastroenteritis (AGE) in the 24 hours before emergency department (ED) presentation. Secondary objectives included characterizing ED pain, discharge recommendations, overall analgesic use, and factors that influenced analgesic use and pain severity. STUDY DESIGN: A prospective cohort was recruited from 2 pediatric EDs (December 2014 to September 2017). Eligibility criteria included <18 years of age, AGE (≥3 episodes of diarrhea or vomiting in the previous 24 hours), and symptom duration <7 days at presentation. RESULTS: We recruited 2136 patients, median age 20.8 months (IQR 10.4, 47.4) and 45.8% (979/2136) female. In the 24 hours before enrollment, most caregivers reported moderate (28.6% [610/2136, 95% CI 26.7-30.5]) or severe (46.2% [986/2136, CI 44.0-48.3]) pain for their child. In the ED, they reported moderate (31.1% [664/2136, 95% CI 29.1-33.1]) or severe ([26.7% [571/2136, 95% CI 24.9-28.7]) pain; analgesia was provided to 21.2% (452/2131). The most common analgesics used in the ED were acetaminophen and ibuprofen. At discharge, these were also most commonly recommended. Factors associated with greater analgesia use in the ED were high pain scores during the index visit, having a primary care physician, earlier presentation to emergency care, fewer diarrheal episodes, presence of fever, and hospitalization at index visit. CONCLUSIONS: Most caregivers of children presenting to the ED with AGE reported moderate or severe pain, both before and during their visit. Future research should focus on the development of effective, safe, and timely pain management plans.