Hepatitis B Vaccination of Low Birth Weight Infants in Washington State.

OBJECTIVE: The U.S. Advisory Committee on Immunization Practices (ACIP) recommends that infants born weighing less than 2,000 g receive the hepatitis B (HepB) vaccine at hospital discharge or 30 days of age. This study aimed to assess timely HepB vaccination among low birth weight infants. We hypothesized that many of these vulnerable infants would fail to receive their HepB birth dose on time. STUDY DESIGN: This retrospective cohort study included Washington State infants born weighing less than 2,000 g at an academic medical center between 2008 and 2013. Data were abstracted from electronic health records and linked to vaccine data from the Washington State Immunization Information System. Multivariable logistic regression was used to examine the associations between sociodemographic, clinical, and visit characteristics and HepB vaccination by birth hospitalization discharge or 30 days of age. RESULTS: Among 976 study infants, 58.4% received their HepB vaccine by birth hospitalization discharge or 30 days of age. Infants had higher odds of timely HepB vaccination if they were Hispanic (adjusted odds ratio [AOR] = 1.80, 95% confidence interval [CI]: 1.10-2.95) or non-Hispanic black (AOR = 2.28, 95% CI: 1.36-3.80) versus non-Hispanic white or if they were hospitalized 14 days or longer versus less than 14 days (AOR = 2.43, 95% CI: 1.66-3.54). Infants had lower odds of timely HepB vaccination if they were born before 34 weeks versus on or after 34 weeks of gestational age (AOR = 0.41, 95% CI: 0.27-0.63) or if they had an estimated household income less than $50,845 versus 50,845 or greater (AOR = 0.64, 95% CI: 0.48-0.86). CONCLUSION: Many infants born weighing less than 2,000 g did not receive their first HepB birth dose according to ACIP recommendations. Strategies are needed to improve timely HepB vaccination in this high-risk population. KEY POINTS: · Low birth weight infants are at increased risk for vaccine preventable diseases.. · Many of these vulnerable infants failed to receive their first hepatitis B vaccine on time.. · This study identified key factors associated with timely hepatitis B vaccination..

Geospatial Variation in Rotavirus Vaccination in Infants, United States, 2010-2017.

We evaluated rotavirus vaccination rates in the United States by using records from a nationwide health database. From data on 519,697 infants, we found 68.6% received the entire rotavirus vaccine series. We noted pockets of undervaccination in many states, particularly in the Northeast and in some western states.

Prostaglandin E2 Mediates Cardiorespiratory Disturbances during Infection in Neonates.

OBJECTIVE: To determine whether infection, with associated eicosanoid release, is a main cause of respiratory disruption in neonates, by measuring levels of prostaglandin E2 (PGE2) and its metabolite (PGEM) in cerebrospinal fluid (CSF). STUDY DESIGN: Of 59 eligible infants, 25 preterm infants (mean gestational age, 28 ± 0.5 weeks) and 22 full-term infants (mean gestational age, 40 ± 0.5 weeks) from a level 3 neonatal intensive care unit and the general maternity neonatal ward were enrolled prospectively. Infants with a condition that can cause secondary apnea were excluded. Cardiorespiratory disturbances, such as apnea, bradycardia, and desaturation (ABD) events, were quantified. All infants were subjected to standard laboratory analysis of blood and CSF concentrations of biomarkers, including PGE2 and PGEM, within 24 hours of lumbar puncture, which were correlated with ABD events and culture-verified infections. RESULTS: PGEM levels were highest in infants with culture-verified sepsis and meningitis (P < .01). In infants without culture-verified bacterial infections, PGEM levels were higher in preterm infants compared with term infants (P < .05). The numbers of desaturation events and apnea events in neonates were positively associated with PGE2 levels in CSF (P < .05). CONCLUSION: PGE2 and PGEM are rapidly elevated in CSF during an infectious event and may explain cardiorespiratory disturbances, which are the major presenting symptoms of neonatal infections. PGE2 and PGEM are released during bacterial infections and could serve as biomarkers for sepsis and autonomic dysfunction in neonates.

Factors impacting influenza vaccination of urban low-income Latino children under nine years requiring two doses in the 2010-2011 season.

The Advisory Committee on Immunization Practices (ACIP) recommends that certain children under 9 years of age receive two influenza vaccine doses in a season for optimal protection. Recent data indicate that many of these children fail to receive one or both of these needed doses. Contributing factors to under-vaccination of this population remain unclear. Caregivers of children aged 6 months-8 years requiring two influenza vaccine doses in the 2010-2011 season were identified from households enrolled in four urban Head Start programs. Recruitment and survey administration were conducted between March and June 2011. The impact of caregiver, provider, and practice-based factors on influenza vaccine receipt was assessed using bivariate and multivariable logistic regression analyses. Caregivers (n = 128) were predominantly mothers, Latina, Spanish-speaking, and non-U.S. born. Few children received one (31 %) or both (7 %) influenza vaccine doses. Caregivers who discussed influenza vaccination with providers were more likely to know their child needed two doses (55 vs. 35 %, p < 0.05) and have a fully vaccinated child (11 vs. 0 %, p < 0.05). Among caregivers whose child received the first dose, those who reported being told when to return for the second dose were also more likely to have a fully vaccinated child (35 vs. 0 %, p = 0.05). Belief in influenza vaccine effectiveness was positively associated with vaccination (p < 0.001), while safety concerns were negatively associated (p < 0.05). This study highlights the importance of provider-family communication about the two-dose regimen as well as influenza vaccine effectiveness and safety.

Current thinking on genital herpes.

PURPOSE OF REVIEW: Genital herpes has a high global prevalence and burden of disease. This manuscript highlights recent advances in our understanding of genital herpes simplex virus (HSV) infections. RECENT FINDINGS: Studies demonstrate a changing epidemiological landscape with an increasing proportion of genital herpes cases associated with HSV type 1. There is also growing evidence that the majority of infected individuals exhibit frequent, brief shedding episodes that are most often asymptomatic, which likely contribute to high HSV transmission rates. Given this finding as well as readily available serological assays, some have proposed that routine HSV screening be performed; however, this remains controversial and is not currently recommended. Host immune responses, particularly local CD4 and CD8 T cell activity, are crucial for HSV control and clearance following initial infection, during latency and after reactivation. Prior HSV immunity may also afford partial protection against HSV reinfection and disease. Although HSV vaccine trials have been disappointing to date and existing antiviral medications are limited, novel prophylactic and therapeutic modalities are currently in development. SUMMARY: Although much remains unknown about genital herpes, improved knowledge of HSV epidemiology, pathogenesis and host immunity may help guide new strategies for disease prevention and control.

Cervical cytology screening among low-income, minority adolescents in New York City following the 2009 ACOG guidelines.

OBJECTIVES: In December 2009, the American College of Obstetricians and Gynecologists recommended that cervical cancer screening begin at age 21 for young women. In this study, we examine receipt of first lifetime Papanicolaou (Pap) test and predictors of over-screening among adolescents within a large urban ambulatory care network. METHODS: We compared the proportion of first lifetime Pap test of adolescents aged 13-20years between June 2007 - November 2009 (n=7700) and December 2009-June 2012 (n=9637) using electronic health records. We employed multivariable regression models to identify demographic and health care factors associated with receiving a first lifetime Pap test at age <21years in the post-guideline period (over-screening). RESULTS: The proportion of Pap tests declined from 19.3% to 4.2% (p<0.001) between the two periods. Multivariable logistic regression results showed receiving care from gynecologic/obstetric/family planning clinics compared to pediatric clinics, having more clinic encounters, and older age were associated with over-screening in the post-guideline period. CONCLUSIONS: We found that guideline adherence differed by clinic type, insurance status, and health care encounters. In the quickly evolving field of cervical cancer control, it is important to monitor practice trends as they relate to shifts in population-based guidelines, especially in high-risk populations.

Vaccine Confidence as Critical to Pandemic Preparedness and Response.

Vaccine confidence is a belief that vaccines work, are safe, and are part of a trustworthy medical system. The COVID-19 pandemic exposed the fragility of the public's confidence in vaccines and the vaccine enterprise, limiting the public health impact of vaccination. In this review, we examine the critical nature of vaccine confidence to pandemic preparedness and response.

Timeliness of pediatric influenza vaccination compared with seasonal influenza activity in an urban community, 2004-2008.

OBJECTIVES: We assessed pediatric influenza vaccination in relation to community influenza activity. METHODS: We examined seasonal influenza vaccination in 34,012 children aged 6 months through 18 years from 5 academically affiliated clinics in northern Manhattan, New York (an urban low-income community) during the 2004-2008 seasons using hospital and city immunization registries. We calculated the cumulative number of administered influenza vaccine doses and proportion of children with any (≥ 1 dose) or full (1-2 doses per age recommendations) vaccination at the onset and peak of community polymerase chain reaction-confirmed influenza activity according to state surveillance reports and by March 31 each season. RESULTS: Influenza vaccine administration began before October 1, peaked before influenza activity onset, and declined gradually over each season. Coverage at influenza activity onset, peak, and by March 31 increased over the 5 seasons. However, most children lacked full vaccination at these time points, particularly adolescents, minorities, and those requiring 2 doses. CONCLUSIONS: Despite early initiation of influenza vaccination, few children were fully vaccinated when influenza began circulating. Interventions should address factors negatively affecting timely influenza vaccination, especially in high-risk populations.

Influenza vaccination coverage and timeliness among children requiring two doses, 2004-2009.

OBJECTIVE: To assess influenza vaccination coverage and timeliness among children requiring two doses in a season. METHODS: This study examined seasonal influenza vaccination of 17,800 children from five academically-affiliated clinics in New York City using hospital and city immunization registries. Eligible children were 6 months-8 years and needed two influenza vaccine doses in a given season between 2004-05 and 2009-10. Any (≥ 1 dose) and full (2 doses) vaccination coverage by December 15 and March 31 as well as interval between doses were calculated. Vaccination trends over time, determinants, and missed opportunities were assessed. RESULTS: Children were primarily Latino and publicly insured. Full coverage by March 31 increased between the 2004-05 and 2009-10 seasons (9% vs. 29%, p<0.001). Few children received both doses by December 15 (2-13%). The interval between doses was almost twice as long as recommended and increased over time (2004-05: 52 days; 2009-10: 64 days; p<0.001). Older age and Latino ethnicity were negative predictors of full vaccination by March 31. Missed opportunities for the second dose were common. CONCLUSION: Despite improvements, low-income, minority children requiring two influenza vaccine doses remain at risk of incomplete and delayed vaccination. Barriers to and strategies for timely full vaccination should be explored.

Parental and provider preferences and concerns regarding text message reminder/recall for early childhood vaccinations.

OBJECTIVE: To assess parental, provider, and medical staff opinions about text message reminder/recall for early childhood vaccination. METHODS: A cross-sectional survey was conducted between January and March 2011 among 200 parents of 6-59 month-old children, 26 providers, and 20 medical staff at four academically-affiliated pediatric practices in New York City with text messaging experience. Survey questions addressed interest in, preferences for, and concerns/barriers related to vaccine-related text message reminder/recall. RESULTS: Parents were primarily Latino, Spanish-speaking, and had a high school education or less. Most parents owned a text message-enabled cell phone (89%) and used text messaging services (97%). While 84% had never received health-related text messages, 88% were comfortable receiving them. Nearly all parents reported interest in receiving reminder/recall text messages, many endorsing them over phone calls and/or letters. Preferences included personalization, interactivity, and multiple messages. While 25% of parents had no concerns, 38% were concerned about incorrect numbers; only 6% worried about cost. Providers and staff were also supportive of vaccine-related text messages. Their biggest concerns were correct cell phone numbers, appointment availability, and increased call volume. CONCLUSION: Text message reminder/recall for early childhood vaccination was widely supported. Important barriers were identified that should be addressed to maximize their effectiveness.

Influenza Vaccine Hesitancy: Scope, Influencing Factors, and Strategic Interventions.

Influenza vaccination rates in children are suboptimal. One underlying reason is influenza vaccine hesitancy. Tools such as the Parent Attitudes about Childhood Vaccines survey and the Vaccine Hesitancy Scale can be used to measure influenza vaccine hesitancy. The adapted Increasing Vaccination Model from Brewer and colleagues can help identify factors that influence influenza vaccine hesitancy, motivation, and uptake. Several strategies can be used to address influenza vaccine hesitancy, which we discuss further in this review.

Sometimes Your Heart Says 'I Don't Know': Insights From Parents of Undervaccinated Children.

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.

Beyond Influenza Vaccination: Expanding Infrastructure for Hospital-based Pediatric COVID-19 Vaccine Delivery.

Controlling the spread of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), will rely on vaccination at increasing rates and in an equitable manner. The main reasons for under-vaccination are varied among different segments of the population and include vaccine hesitancy and lack of access. While vaccine hesitancy is complicated and requires long-term solutions, access can be enhanced through evidence-based delivery strategies that augment conventional approaches. Hospital-based COVID-19 vaccination programs hold particular promise in reaching populations with decreased vaccine access and those at higher risk for adverse outcomes from SARS-CoV-2 infection. Hospitals have the necessary equipment and storage capabilities to maintain cold chain requirements-a common challenge in the primary care setting-and can serve as a central distribution point for delivering vaccines to patients in diverse hospital locations, including inpatient units, emergency departments, urgent care centers, perioperative areas, and subspecialty clinics. They also have the capacity for mass-vaccination programs and other targeted outreach efforts. Hospital-based programs that have been successful in implementing influenza and other routine vaccinations can leverage existing infrastructure, such as electronic health record-related tools. With the possibility of COVID-19 becoming endemic, much like seasonal influenza, these programs will require flexibility as well as planning for long-term sustainability. This commentary highlights existing vaccine delivery to children in hospital-based settings, including key advantages and important challenges, and outlines how these systems could be expanded to include the COVID-19 vaccine delivery.

Vaccine Administration in Children's Hospitals.

OBJECTIVES: To examine inpatient vaccine delivery across a national sample of children's hospitals. METHODS: We conducted a retrospective cohort study examining vaccine administration at 49 children's hospitals in the Pediatric Health Information System database. Children <18 years old admitted between July 1, 2017, and June 30, 2019, and age eligible for vaccinations were included. We determined the proportion of hospitalizations with ≥1 dose of any vaccine type administered overall and by hospital, the type of vaccines administered, and the demographic characteristics of children who received vaccines. We calculated adjusted hospital-level rates for each vaccine type by hospital. We used logistic and linear regression models to examine characteristics associated with vaccine administration. RESULTS: There were 1 185 667 children and 1 536 340 hospitalizations included. The mean age was 5.5 years; 18% were non-Hispanic Black, and 55% had public insurance. There were ≥1 vaccine doses administered in 12.9% (95% confidence interval: 12.8-12.9) of hospitalizations, ranging from 1% to 45% across hospitals. The most common vaccines administered were hepatitis B and influenza. Vaccine doses other than the hepatitis B birth dose and influenza were administered in 1.9% of hospitalizations. Children had higher odds of receiving a vaccine dose other than the hepatitis B birth dose or influenza if they were <2 months old, had public insurance, were non-Hispanic Black race, were medically complex, or had a length of stay ≥3 days. CONCLUSIONS: In this national study, few hospitalizations involved vaccine administration with substantial variability across US children's hospitals. Efforts to standardize inpatient vaccine administration may represent an opportunity to increase childhood vaccine coverage.

Childhood and Adolescent Vaccination in Alternative Settings.

Although pediatric and adolescent vaccination rates are generally high in the United States, delayed and under-vaccination exist within certain patient populations and communities, leaving them vulnerable to vaccine-preventable diseases. One strategy for addressing this major public health concern is to offer vaccinations in nonprimary care settings such as schools, emergency rooms, hospitals, and pharmacies. This article reviews the unique advantages, challenges, and experiences regarding vaccine delivery in each alternative setting. It describes the key components that each must possess as well as other important factors to consider when assessing the ability of each to deliver vaccines to the children and adolescents they serve. It also highlights the need for sufficient funding and reimbursement for vaccine-related costs in these settings, the importance of orienting staff, providers, and practices to offering preventive care services through education and evidenced-based approaches, and the necessity of effective, efficient coordination of vaccination efforts across sites. By expanding the scope of non-primary care settings to include vaccine delivery and striving to capture all vaccination opportunities in these locations, the proportion of children and adolescents receiving on-time doses will undoubtedly increase. It is important to emphasize that these settings should not replace the medical home as the primary location for vaccination, but rather serve as a critical safety net for high-risk individuals and communities and in situations where access to traditional locations may be limited such as during the COVID-19 pandemic.

Facilitators and Barriers to Providing Vaccinations During Hospital Visits.

BACKGROUND: Many children are undervaccinated at the time of hospital admission. Our objective was to explore the facilitators and barriers to vaccinating during hospitalization. METHODS: We conducted qualitative interviews of parents, primary care pediatricians, emergency department (ED) physicians, and pediatric hospitalists. Parents of undervaccinated hospitalized children who were admitted through the ED were invited to participate. We used purposive sampling to identify physician participants. Semistructured interviews querying participants' perspectives on hospital-based vaccination were audiorecorded and transcribed. Parent demographics and physician practice characteristics were collected. Transcripts were analyzed for facilitators and barriers to vaccinating during acute hospital visits by using inductive content analysis. A conceptual framework was developed on the basis of the social ecological model. RESULTS: Twenty-one parent interviews and 10 physician interviews were conducted. Of parent participants, 86% were female; 76% were white. Physician participants included 3 primary care pediatricians, 3 ED physicians, and 4 hospitalists. Facilitators and barriers fell under 4 major themes: (1) systems-level factors, (2) physician-level factors, (3) parent-provider interactional factors, and (4) parent- and child-level factors. Parent participants reported a willingness to receive vaccines during hospitalizations, which aligned with physician participants' experiences. Another key facilitator identified by parent and physician participants was the availability of shared immunization data. Identified by parent and physician participants included the availability of shared immunization data. Barriers included being unaware that the child was vaccine-eligible, parental beliefs against vaccination, and ED and inpatient physicians' perceived lack of skills to effectively communicate with vaccine-hesitant parents. CONCLUSIONS: Parents and physicians identified several key facilitators and barriers to vaccinating during hospitalization. Efforts to provide inpatient vaccines need to address existing barriers.

A Risk Prediction Model to Identify Newborns at Risk for Missing Early Childhood Vaccinations.

BACKGROUND: Approximately 30% of US children aged 24 months have not received all recommended vaccines. This study aimed to develop a prediction model to identify newborns at high risk for missing early childhood vaccines. METHODS: A retrospective cohort included 9080 infants born weighing ≥2000 g at an academic medical center between 2008 and 2013. Electronic medical record data were linked to vaccine data from the Washington State Immunization Information System. Risk models were constructed using derivation and validation samples. K-fold cross-validation identified risk factors for model inclusion based on alpha = 0.01. For each patient in the derivation set, the total number of weighted adverse risk factors was calculated and used to establish groups at low, medium, or high risk for undervaccination. Logistic regression evaluated the likelihood of not completing the 7-vaccine series by age 19 months. The final model was tested using the validation sample. RESULTS: Overall, 53.6% failed to complete the 7-vaccine series by 19 months. Six risk factors were identified: race/ethnicity, maternal language, insurance status, birth hospitalization length of stay, medical service, and hepatitis B vaccine receipt. Likelihood of non-completion was greater in the high (77.1%; adjusted odds ratio [AOR] 5.6; 99% confidence interval [CI]: 4.2, 7.4) and medium (52.7%; AOR 1.9; 99% CI: 1.6, 2.2) vs low (38.7%) risk groups in the derivation sample. Similar results were observed in the validation sample. CONCLUSIONS: Our prediction model using information readily available in birth hospitalization records consistently identified newborns at high risk for undervaccination. Early identification of high-risk families could be useful for initiating timely, tailored vaccine interventions.

Associations Between Health Care Professional Communication Practices and Influenza Vaccination of Hospitalized Children.

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.

Influenza-Related Knowledge, Beliefs, and Experiences Among Caregivers of Hospitalized Children.

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.

Effect of Electronic Health Record Reminders for Routine Immunizations and Immunizations Needed for Chronic Medical Conditions.

BACKGROUND: Immunization reminders in electronic health records (EHR) provide clinical decision support (CDS) that can reduce missed immunization opportunities. Little is known about using CDS rules from a regional immunization information system (IIS) to power local EHR immunization reminders. OBJECTIVE: This study aimed to assess the impact of EHR reminders using regional IIS CDS-provided rules on receipt of immunizations in a low-income, urban population for both routine immunizations and those recommended for patients with chronic medical conditions (CMCs). METHODS: We built an EHR-based immunization reminder using the open-source resource used by the New York City IIS in which we overlaid logic regarding immunizations needed for CMCs. Using a randomized cluster-cross-over pragmatic clinical trial in four academic-affiliated clinics, we compared captured immunization opportunities during patient visits when the reminder was "on" versus "off" for the primary immunization series, school-age boosters, and adolescents. We also assessed coverage of CMC-specific immunizations. Up-to-date immunization was measured by end of quarter. Rates were compared using chi square tests. RESULTS: Overall, 15,343 unique patients were seen for 26,647 visits. The alert significantly impacted captured opportunities to complete the primary series in both well-child and acute care visits (57.6% on vs. 54.3% off, p = 0.001, and 15.3% on vs. 10.1% off, p = 0.02, respectively), among most age groups, and several immunization types. Captured opportunities for CMC-specific immunizations remained low regardless of alert status. The alert did not have an effect on up-to-date immunization overall (89.1 vs. 88.3%). CONCLUSION: CDS in this population improved captured immunization opportunities. Baseline high rates may have blunted an up-to-date population effect. Converting Centers for Disease Control and Prevention (CDC) rules to generate sufficiently sensitive and specific alerts for CMC-specific immunizations proved challenging, and the alert did not have an impact on CMC-specific immunizations, potentially highlighting need for more work in this area.