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.

Text4Health: impact of text message reminder-recalls for pediatric and adolescent immunizations.

OBJECTIVES: We conducted 2 studies to determine the impact of text message immunization reminder-recalls in an urban, low-income population. METHODS: In 1 study, text message immunization reminders were sent to a random sample of parents (n = 195) whose children aged 11 to 18 years needed either or both meningococcal (MCV4) and tetanus-diphtheria-acellular pertussis (Tdap) immunizations. We compared receipt of MCV4 or Tdap at 4, 12, and 24 weeks with age- and gender-matched controls. In the other study, we compared attendance at a postshortage Haemophilus influenzae B (Hib) immunization recall session between parents who received text message and paper-mailed reminders (n = 87) and those who only received paper-mailed reminders (n = 87). RESULTS: Significantly more adolescents with intervention parents received either or both MCV4 and Tdap at weeks 4 (15.4% vs 4.2%; P < .001), 12 (26.7% vs 13.9%; P < .005), and 24 (36.4% vs 18.1%; P < .001). Significantly more parents who received both Hib reminders attended a recall session compared with parents who only received a mailed reminder (21.8% vs 9.2%; P < .05). After controlling for age, gender, race/ethnicity, insurance status, and language, text messaging was still significantly associated with both studies' outcomes. CONCLUSIONS: Text messaging for reminder-recalls improved immunization coverage in a low-income, urban population.

Effect of a text messaging intervention on influenza vaccination in an urban, low-income pediatric and adolescent population: a randomized controlled trial.

CONTEXT: Influenza infection results in substantial costs, morbidity, and mortality. Vaccination against influenza is particularly important in children and adolescents who are a significant source of transmission to other high-risk populations, yet pediatric and adolescent vaccine coverage remains low. Traditional vaccine reminders have had a limited effect on low-income populations; however, text messaging is a novel, scalable approach to promote influenza vaccination. OBJECTIVE: To evaluate targeted text message reminders for low-income, urban parents to promote receipt of influenza vaccination among children and adolescents. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial of 9213 children and adolescents aged 6 months to 18 years receiving care at 4 community-based clinics in the United States during the 2010-2011 influenza season. Of the 9213 children and adolescents, 7574 had not received influenza vaccine prior to the intervention start date and were included in the primary analysis. INTERVENTION: Parents of children assigned to the intervention received up to 5 weekly immunization registry-linked text messages providing educational information and instructions regarding Saturday clinics. Both the intervention and usual care groups received the usual care, an automated telephone reminder, and access to informational flyers posted at the study sites. MAIN OUTCOME MEASURES: Receipt of an influenza vaccine dose recorded in the immunization registry via an electronic health record by March 31, 2011. Receipt was secondarily assessed at an earlier fall review date prior to typical widespread influenza activity. RESULTS: Study children and adolescents were primarily minority, 88% were publicly insured, and 58% were from Spanish-speaking families. As of March 31, 2011, a higher proportion of children and adolescents in the intervention group (43.6%; n = 1653) compared with the usual care group (39.9%; n = 1509) had received influenza vaccine (difference, 3.7% [95% CI, 1.5%-5.9%]; relative rate ratio [RRR], 1.09 [95% CI, 1.04-1.15]; P = .001). At the fall review date, 27.1% (n = 1026) of the intervention group compared with 22.8% (n = 864) of the usual care group had received influenza vaccine (difference, 4.3% [95% CI, 2.3%-6.3%]; RRR, 1.19 [95% CI, 1.10-1.28]; P < .001). CONCLUSIONS: Among children and adolescents in a low-income, urban population, a text messaging intervention compared with usual care was associated with an increased rate of influenza vaccination. However, the overall influenza vaccination rate remained low. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01146912.

How parents' negative experiences at immunization visits affect child immunization status in a community in New York City.

OBJECTIVE: Little is known about how families' experiences with immunization visits within the medical home may affect children's immunization status. We assessed the association between families' negative immunization experiences within the medical home and underimmunization. METHODS: We surveyed parents (n = 392) of children aged 2-36 months about immunization experiences at community health centers, hospital-based clinics, private practices, and community-based organizations in New York City. We used Chi-square tests and odds ratios (ORs) to assess the relationship between medical home elements and parental immunization experience ratings. We used multivariable analysis to determine the association between negative experiences during immunization visits and underimmunization, controlling for insurance, maternal education, and receipt of benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children. RESULTS: The majority of children were of Latino race/ethnicity and had Medicaid and a medical home. One-sixth (16.9%) of families reported a previous negative immunization experience, primarily related to the child's reaction, waiting time, and attitudes of medical and office staff. Parents' negative immunization experiences were associated with the absence of four components of the medical home: continuity of care, family-centered care, compassionate care, and comprehensive care. In addition, children in families who reported a negative experience were more likely to have been underimmunized (adjusted OR = 2.00; 95% confidence interval 1.12, 3.58). CONCLUSIONS: In a community in New York City, underimmunization of young children was associated with negative immunization experiences. Strategies to improve family experiences with immunization visits within the medical home (particularly around support for the family), medical and ancillary staff attitudes, and reduced waiting time may lead to improved immunization delivery.

Change in parental reasons for use of an urban pediatric emergency department in the past decade.

OBJECTIVE: To assess changes over the past decade in parental reasons associated with nonurgent visits to pediatric emergency departments (PEDs) during regular primary care office hours. METHODS: Secondary analysis of cross-sectional surveys of families of children younger than 3 years visiting a PED in a low-socioeconomic area in New York City conducted in 1997 and 2006. We performed multivariable analyses to assess differences in parental reported reasons for PED use over the period, controlling for sociodemographic factors. RESULTS: Most children (95.6%) had a usual source of care across both periods. Compared with those seen in 1997, children seen in 2006 were far less likely to be brought to the PED during regular primary care office hours for parental perceived urgency (adjusted odds ratio [AOR], 0.076; 95% confidence interval [CI], 0.024-0.24; P < 0.001). At the same time, these children were more likely to be brought to the PED for limited access to their usual source of care (AOR, 3.35; 95% CI, 1.24-9.02; P < 0.05) and greater trust in the medical expertise of the PED (AOR, 5.95 95% CI, 1.20-29.45; P < 0.05). CONCLUSIONS: Over the last decade, despite the presence of a usual source of care, a greater number of parents report visiting this urban PED during regular office hours for reasons unrelated to parental perceived urgency. Limited access to care and greater trust in the medical expertise available in PEDs have played important roles. Approaches to decreasing nonurgent visits must take into account all of these factors.

Timeliness of 2009 H1N1 vaccine coverage in a low-income pediatric and adolescent population.

Despite being at highest risk for 2009 H1N1 virus morbidity and mortality, many children were not immunized with the vaccine. Identification of factors that put certain children at higher risk for under-immunization could reveal populations who may need to be specifically targeted for vaccination interventions in future pandemics. Little is known about the prevalence of, or factors associated with, 2009 H1N1 vaccine coverage in low-income, urban pediatric populations. This study evaluated 2009 H1N1 vaccination coverage in 19,643 children aged 6months to 18years receiving care at one of five community clinics associated with an academic medical center in a low-income community. Any (≥1 dose) and full coverage (1 dose for children ≥10years old, 2 doses for those <10years) was determined as of December 1, 2009 and the end of vaccination period (June 30, 2010). Multivariable analyses were used to assess the impact of race/ethnicity, age, insurance, gender, and language on vaccine coverage and timeliness. By December 1, only 16.6% of children had received one dose, and 5.3% had full coverage. By the end of the vaccination period, 36.2% had received at least one H1N1 dose and 23.6% had full coverage. On multivariable analysis, older age, minority race/ethnicity, and private insurance were negatively associated with vaccination by December 1 and end of vaccination period, even after accounting for attendance at a clinic visit. In future pandemics, when timely receipt of a new vaccine in large populations may be imperative, general vaccination programs as well as special targeted education and vaccine reminders for these at risk groups may be warranted.

Harnessing technology for adolescent health promotion.

Sexually active adolescents are at risk for unintended pregnancy. Teen pregnancies can be prevented by consistent use of birth control, such as oral contraceptives. However, many teens forget their daily doses and eventually stop using oral contraceptives altogether. Teen pregnancies are more likely to be medically complicated and can adversely impact the teen, her child, and their community. Cell-phone use is becoming widespread, and teen cell-phone users frequently use text messaging. We describe a study in which we use cell-phone text-messaging technology in a novel way: we provide daily oral contraceptive dosing reminders and educational messages and evaluate oral contraceptive continuation at 6 months. We will use the information we obtain to develop specific, practice-based interventions to improve reproductive health programs and policies.