Improving childhood vaccination coverage rates: the case of fourth dose of DTaP.

Based on the most recently available national data, vaccination coverage for the combined seven-vaccine series recommended by age 24 months remains substantially below the Healthy People 2020 target of 80%. One focus for improvement is the lack of timely administration of the fourth dose of DTaP vaccine. Based on the perspective of state and local immunization program managers, key strategies include tracking immunization patterns through immunization information systems and other data sources, working with health-care providers to address challenges to timely vaccination, and developing partnerships with daycares, payers, and health systems.

Public Health Opportunities to Improve Late-Adolescent Immunization.

Seven state/local immunization program managers were convened to discuss how public health immunization programs could enhance their efforts to promote adolescent vaccination, with an emphasis on late adolescence (ages 16-18 years). The Centers for Disease Control and Prevention's revised childhood immunization schedule for 2017 and a recently proposed preventive care platform at 16 years of age provide a unique opportunity to focus on increasing adolescent immunization rates in this population. Public health officials discussed challenges to immunizing this population and suggested key strategies for supporting late-adolescent immunization, including partnerships between public health and immunization providers; nationally supported public information campaigns; and using immunization data specific to this population to track progress.

The impacts of email reminder/recall on adolescent influenza vaccination.

BACKGROUND: We sought to: (1) explore the feasibility of using email for seasonal influenza vaccination reminders to parents of adolescents and (2) assess influenza vaccination rates among adolescents whose parents were randomized to either receive or not receive email reminders. METHODS: Email addresses were obtained for parents of patients 10-18years from 4 practices in Michigan. Addresses were randomized to either receive email reminders, or not. Reminder messages were sent during October 2012-March 2013 (Season 1) and October 2013-March 2014 (Season 2). Vaccination status was determined 60days following the last email reminder for each season using the statewide Michigan Care Improvement Registry (MCIR); per protocol bivariate and multivariate logistic regression analyses were conducted to evaluate reminder notification. RESULTS: After email cleaning, testing, and matching with MCIR, approximately half of email addresses (2348 of 5312 in Season 1; 3457 of 6549 in Season 2) were randomized. Bivariate analyses found that influenza vaccination within 60days after notification date was similar among those notified (34%) versus not notified (29%) in both Season 1 (p=0.06) and Season 2 (39% vs. 37%, p=0.20). However, multivariate models adjusted for season, site, and receipt of notification in two seasons found a higher likelihood of influenza vaccination among children that received notification (aOR=1.28, 95% CI=1.09, 1.51); in addition, differences in influenza vaccination were also observed between practice sites (range: p=0.15 to p<0.001). CONCLUSIONS: We found that practice-based email influenza vaccine reminders to parents of adolescents are feasible, but not without complications. Our study demonstrates that email reminders from practices can yield increases in influenza vaccination rates among adolescents. Practices should consider email as an option for influenza reminders and establish business practices for collecting and maintaining patient email addresses. This study is registered at www.ClinicalTrials.gov id #NCT01732315.

Vaccine purchasing groups in the United States: An overview of their policies and practices.

BACKGROUND: Vaccine purchasing groups (VPGs) may help reduce the upfront cost of vaccines. The objective of this study was to describe key business practices of VPGs in the United States. METHODS: Semi-structured, qualitative telephone interviews were conducted with representatives from 11 VPGs, based on a sampling frame of 53 VPGs. Interviews were transcribed and summarized by topic. RESULTS: Characteristics of the 11 VPGs interviewed reflect the broader VPG population: 64% national vs 36% regional; 8% charge a membership fee; membership ranging from 40 to over 300,000 sites. VPGs establish agreements with vaccine manufacturers, typically with either GlaxoSmithKline or Merck and Sanofi Pasteur; 1 VPG reported a single-product (Trumenba) agreement with Pfizer. VPG agreements specify "product loyalty" benchmarks (proportion of that manufacturer's product line) that the VPG and its members must meet to receive discounted vaccine pricing. The amount of discount is considered proprietary. Practices may actively participate with only one VPG; the member discount is automatically applied by the manufacturer at the time of ordering. Vaccine manufacturers monitor sales data to ensure compliance with product loyalty terms; practices that do not meet benchmarks may be removed from the VPG. VPGs are paid administration fees by the manufacturers. VPGs use these fees to cover their operating expenses and often rebate a portion of these fees back to their members. All 11 VPGs offer additional services to members, ranging from immunization-focused education and technical assistance to discounts on a broad range of medical and business supplies. CONCLUSIONS: VPGs can facilitate access to reduced purchase prices for most vaccines routinely recommended in the United States. Data on the magnitude of the price reductions were not publicly available. VPG members must balance loyalty-based price reductions against considerations of having a wider choice of vaccine products.

Change in settings for early-season influenza vaccination among US adults, 2012 to 2013.

Vaccination in non-medical settings is recommended as a strategy to increase access to seasonal influenza vaccine. To evaluate change in early-season influenza vaccination setting, we analyzed data from the National Internet Flu Survey. Bivariate comparison of respondent characteristics by location of vaccination was assessed using chi-square tests. Multinomial logistic regression was performed to compare the predicted probability of being vaccinated in medical, retail, and mobile settings in 2012 vs 2013. In both 2012 and 2013, vaccination in medical settings was more likely among elderly adults, those with chronic conditions, and adults with a high school education or less. Adults 18-64 without a chronic condition had a lower probability of vaccination in the medical setting, and higher probability of vaccination in a retail or mobile setting, in 2013 compared to 2012. Adults 18-64 with a chronic condition had no change in their location of flu vaccination. Elderly adults had a lower probability of vaccination in the medical setting, and higher probability of vaccination in a retail setting, in 2013 compared to 2012. Non-medical settings continue to play an increasing role in influenza vaccination of adults, particularly for adults without a chronic condition and elderly adults. Retail and mobile settings should continue to be viewed as important mechanisms to ensure broad access to influenza vaccination.

Understanding Non-Completion of the Human Papillomavirus Vaccine Series: Parent-Reported Reasons for Why Adolescents Might Not Receive Additional Doses, United States, 2012.

Completion rates of the human papillomavirus (HPV) vaccine series among U.S. adolescents are below public health targets. We explored parent-reported reasons for their children's non-completion of the HPV vaccine series using a nationally representative online survey of parents of children aged 9-17 years, fielded in October 2012. Among the 1,653 parents who responded, the proportion reporting that their child would definitely continue with the HPV vaccine series among those who had started the series ranged from 28% to 54%. The most common reason cited by parents for non-completion of the series was their child's fear of needles, followed by lack of awareness about additional doses and safety concerns. These findings demonstrate the need to encourage adoption of strategies addressing needle fears, utilize reminders for parents about subsequent doses, and emphasize recent HPV vaccine safety data in discussions with parents.

Parent Perception of Provider Interactions Influences HPV Vaccination Status of Adolescent Females.

Human papillomavirus (HPV) vaccination coverage among adolescent females is well below national public health goals. Many known barriers to HPV vaccine receipt can be addressed in parent-physician conversations. This study sought to explore parent experiences and attitudes related to HPV vaccination of adolescent girls, focused on interactions with providers. We conducted a cross-sectional survey of parents using a nationally representative online panel. Among parents with ≥1 daughter aged 11 to 17 years, provider recommendations for HPV vaccine and specified age to begin the HPV vaccine series were associated with HPV vaccine status. Parents who reported their daughters were unlikely to complete the HPV series were more likely to have had no discussion of HPV vaccine with the provider. Efforts to increase HPV vaccination rates among adolescent females should continue to focus on improving provider discussion of HPV vaccine.

Parent HPV vaccine perspectives and the likelihood of HPV vaccination of adolescent males.

In 2013, approximately one-third of US adolescent males age 13-17 y had received ≥1 doses of HPV vaccines and only 14% had received ≥3 doses. This study used a nationally representative, online survey to explore experiences and attitudes related to HPV vaccination among parents with adolescent sons. Analyses compared the perspective of parents who do not intend to initiate HPV vaccine for ≥1 adolescent son to that of parents who are likely to initiate or continue HPV vaccination. Of 809 parents of sons age 11-17 years, half were classified as Unlikely to Initiate HPV vaccination and 39% as Likely to Vaccinate. A higher proportion of the Likely to Vaccinate group felt their son's doctor was knowledgeable about HPV vaccine, did a good job explaining its purpose, and spent more time discussing HPV vaccine; in contrast, over half of the Unlikely to Initiate group had never discussed HPV vaccine with their child's doctor. The majority of parents in both groups showed favorable attitudes to adolescent vaccination in general, with lower levels of support for HPV vaccine-specific statements. Physician-parent communication around HPV vaccine for adolescent males should build on positive attitude toward vaccines in general, while addressing parents' HPV vaccine-specific concerns.

Association of Older Sister's HPV Vaccination Status on HPV Vaccine Receipt by Adolescents.

OBJECTIVE: Efforts to increase human papillomavirus (HPV) vaccine coverage rates in adolescents include finding ways to improve discussions between clinicians and parents. One potentially important piece of information for these discussions is the HPV vaccination status of older siblings. METHODS: A nationally representative online panel was used to conduct a cross-sectional survey of parents of children aged 9 to 17 years in October 2012. RESULTS: Overall, 768 adolescents (35%) had ≥1 older sister aged 10 to 26 years. Male and female adolescents with an older sister who had received no HPV vaccine doses demonstrated higher rates of having no doses themselves, compared with those who had no older sister or those who had an older sister who had received ≥1 HPV vaccine dose. CONCLUSIONS: Discussing the HPV vaccination status of older sisters may be a useful strategy for providers to differentiate HPV vaccine messages to parents of unvaccinated younger siblings.

Ability to deliver services in Spanish: a survey of Michigan home health agencies, 2012.

The capacity of home health agencies to serve children from families with low English proficiency is not well understood. We conducted an exploratory survey of home health agencies in Michigan in 2012 to document whether they can provide services in Spanish, serve children, and accept Medicaid.

Screening practices for identifying type 2 diabetes in adolescents.

OBJECTIVE: To characterize pediatrician and family physician (FP) screening practices for type 2 diabetes among adolescents and to examine the impact of the 2010 American Diabetes Association (ADA) guidelines, recommending use of Hemoglobin A1c (HbA1c). METHODS: We conducted a cross-sectional mail survey of a random sample of 1,400 U.S. pediatricians and FPs and we received 604 eligible responses. Our main outcome measure was the types of tests ordered by physicians, particularly HbA1c, when presented with a hypothetical scenario. RESULTS: The overall response rate was 52% (57% for pediatricians and 48% for FPs). Fasting glucose and HbA1c were the most commonly ordered tests. Overall, at least 58% of physicians ordered HbA1c; 35% ordered HbA1c in conjunction with fasting tests; and 22% ordered HbA1c alone or with nonfasting tests. Only 38% of providers were aware of the new ADA recommended HbA1c screening guidelines. However, a majority (67%) said they would change their screening practices. In the context of the guidelines, 84% of physicians would now order HbA1c. Furthermore, there was a large increase in the proportion of physicians who would shift to using HbA1c only or with other nonfasting tests. CONCLUSIONS: When screening adolescents for type 2 diabetes, providers are more likely to order HbA1c and order fewer fasting tests in response to the new ADA guidelines. HbA1c has lower sensitivity and higher costs than other testing modalities in children, therefore increasing uptake of this test (HbA1c) in children may have implications for both detection rates and healthcare costs.

Statewide pandemic influenza vaccination reminders for children with chronic conditions.

OBJECTIVES: We evaluated the use of a statewide immunization information system (IIS) to target influenza vaccine reminders to high-risk children during a pandemic. METHODS: We used Michigan's IIS to identify high-risk children (i.e., those with ≥ 1 chronic condition) aged 6 months to 18 years with no record of pH1N1 vaccination among children currently or previously enrolled in Medicaid (n = 202,133). Reminders were mailed on December 7, 2009. We retrospectively assessed children's eligibility for evaluation and compared influenza vaccination rates across 3 groups on the basis of their high-risk and reminder status. RESULTS: Of the children sent reminders, 53,516 were ineligible. Of the remaining 148,617 children, vaccination rates were higher among the 142,383 high-risk children receiving reminders than among the 6234 high-risk children with undeliverable reminders and the 142,383 control group children without chronic conditions who were not sent reminders. CONCLUSIONS: Midseason reminders to parents of unvaccinated high-risk children with current or past Medicaid enrollment were associated with increased pH1N1 and seasonal influenza vaccination rates. Future initiatives should consider strategies to expand targeting of high-risk groups and improve IIS reporting during pandemic events.

Obstetricians and the 2009-2010 H1N1 vaccination effort: implications for future pandemics.

Our objective was to describe the experiences of obstetricians during the 2009-2010 H1N1 vaccination campaign in order to identify possible improvements for future pandemic situations. We conducted a cross-sectional mail survey of a national random sample of 4,000 obstetricians, fielded in Summer 2010. Survey items included availability, recommendation, and patient acceptance of H1N1 vaccine; prioritization of H1N1 vaccine when supply was limited; problems with H1N1 vaccination; and likelihood of providing vaccine during a future influenza pandemic. Response rate was 66 %. Obstetricians strongly recommended H1N1 vaccine during the second (85 %) and third (86 %) trimesters, and less often during the first trimester (71 %) or the immediate postpartum period (76 %); patient preferences followed a similar pattern. H1N1 vaccine was typically available in outpatient obstetrics clinics (80 %). Overall vaccine supply was a major problem for 30 % of obstetricians, but few rated lack of thimerosal-free vaccine as a major problem (12 %). Over half of obstetricians had no major problems with the H1N1 vaccine campaign. Based on this experience, 74 % would be "very likely" and 12 % "likely" to provide vaccine in the event of a future influenza pandemic. Most obstetricians strongly recommended H1N1 vaccine, had few logistical problems beyond limited vaccine supply, and are willing to vaccinate in a future pandemic. Addressing concerns about first-trimester vaccination, developing guidance for prioritization of vaccine in the event of severe supply constraints, and continued facilitation of the logistical aspects of vaccination should be emphasized in future influenza pandemics.

Involvement of endocrinologists in the 2009 to 2010 H1N1 vaccination effort.

OBJECTIVE: To assess the level of participation of endocrinologists in the United States in the 2009 to 2010 H1N1 vaccination campaign and explore their perspectives on H1N1 vaccination. METHODS: We conducted a cross-sectional, mailed survey of a national sample of 1,991 endocrinologists in June through September 2010. The extent of the response and the survey responses are reported and analyzed. RESULTS: The overall response rate was 59%. The majority of endocrinologists strongly recommended H1N1 vaccine for children, whereas about a third did so for both nonelderly adults and seniors. Just over half (52%) of the responding endocrinologists had agreed to participate in the 2009 to 2010 H1N1 vaccine campaign and received vaccine, in comparison with 73% who offered seasonal influenza vaccine. The supply of H1N1 vaccine was a significant challenge, but otherwise endocrinologists reported few major problems with administration of H1N1 vaccine. Overall, less than half of the respondents thought that they would be "very likely" to provide vaccine in the event of a future influenza pandemic, with a much higher proportion among those endocrinologists who offered seasonal influenza vaccine and H1N1 vaccine. CONCLUSION: Although the experiences of endocrinologists who provided H1N1 vaccine were generally positive, many did not offer the vaccine and indicated that they are hesitant about providing vaccine during a future influenza pandemic. Approaches to increase their participation in future pandemics in an effort to reach persons at high risk for influenza and its complications, such as those with diabetes, should be further explored.

Perspectives of allergists/immunologists on the 2009-2010 H1N1 vaccination effort.

BACKGROUND: Persons with high-risk conditions such as asthma were a target group for national H1N1 vaccine recommendations. Allergists/immunologists (allergists) are a provider group that could vaccinate persons with asthma and other high-risk conditions. Their level of participation in and experiences with the 2009-2010 H1N1 vaccination campaign are unknown. OBJECTIVE: To describe the experiences of allergists related to the 2009-2010 H1N1 vaccination campaign. METHODS: A cross-sectional, mailed survey of a national sample of 1955 allergists providing outpatient care was conducted in June-September 2010. RESULTS: The overall response rate was 72%. Most allergists "strongly recommended" H1N1 vaccine for children, and most "recommended" or "strongly recommended" vaccine for adults. The majority (71%) agreed to participate in the H1N1 vaccine campaign and received vaccine. Vaccine supply was a significant challenge, but otherwise few major problems were experienced with administering H1N1 vaccine. The majority of respondents, particularly among those who participated in the 2009-2010 H1N1 vaccination campaign, felt they would be very likely to vaccinate in the event of future influenza pandemic. CONCLUSIONS: The experiences of allergists in the H1N1 vaccine campaign were generally positive. Most allergists are willing to serve as vaccinators in future influenza pandemics, which will help facilitate broad access to vaccine for patients with asthma and other high-risk conditions.

Feasibility of initiating and sustaining registry-based immunization recall in private practices.

OBJECTIVE: To assess the feasibility of initiating and sustaining immunization recall by private practices, including the barriers and costs, using a statewide immunization information system (IIS). METHODS: Private practices in southeast Michigan were recruited in 2007 to perform IIS-based immunization recalls. Enrolled practices were provided with training and asked to conduct 4 recalls during the course of 12 months of children 19 to 35 months of age. Each practice recorded the time they spent performing recall-related activities; labor costs were estimated. Formative and summative evaluations with semistructured interviews were conducted to identify barriers. RESULTS: Of 97 eligible pediatric and family medicine practices, 44 declined to participate, 32 did not respond to repeated contacts, and 20 agreed to enroll in the study (21%). A total of 56 recalls were conducted during the study period, with 9 practices completing at least 4 recalls and 7 practices completing 1 to 3 recalls; 4 practices conducted no recalls. Common barriers reported included time constraints and executing all steps of the recalls. Practice costs per patient recalled ranged from $0.05 to more than $6 and were primarily driven by the type of personnel who performed recalls. The costs of creating a roster of current patients comprised nearly one-half of total labor costs. CONCLUSIONS: Few private provider practices that we contacted were willing to participate in this study of IIS-based recall, and less than one-half of enrolled practices completed the desired 4 recall cycles in 12 months. Time constraints and other real-world problems should not be underestimated in determining the feasibility of practice-based immunization recall. Efforts to increase the use of a statewide IIS for recall in private practice settings should emphasize ongoing training and technical support to practice staff. Improved interoperability with electronic health record systems may foster practice-based recall by reducing the labor intensity of roster building and other recall activities.

Perspectives of Pulmonologists on the 2009-2010 H1N1 Vaccination Effort.

Persons with high-risk conditions such as asthma were a target group for H1N1 vaccine recommendations. We conducted a mailed survey of a national sample of pulmonologists to understand their participation in the 2009-2010 H1N1 vaccine campaign. The response rate was 59%. The majority of pulmonologists strongly recommended H1N1 vaccine for children (73%) and adults aged 25-64 years (51%). Only 60% of respondents administered H1N1 vaccine in their practice compared to 87% who offered seasonal influenza vaccine. Other than vaccine supply, respondents who provided H1N1 vaccine reported few logistical problems. Two-thirds of respondents would be very likely to vaccinate during a future influenza pandemic; this rate was higher among those who provided H1N1 vaccine and/or seasonal flu vaccine. In total, the H1N1 vaccine-related experiences of pulmonologists seemed to be positive. However, additional efforts are needed to increase participation in future pandemic vaccination campaigns.

Influenza vaccine-related information needs of US primary care physicians.

OBJECTIVE: To explore influenza-related information needs of primary care providers, given expanded influenza vaccine recommendations and new influenza vaccine products. METHODS: A cross-sectional, mailed survey of a national sample of primary care physicians (family physicians, general internists, pediatricians), conducted in July-October 2010. The overall response rate was 70%. RESULTS: Among respondents who offer immunizations, almost all expected to provide injectable influenza vaccine for the 2010-11 influenza season, while only pediatricians planned wide use of intranasal vaccine. The information needs most frequently rated as high priority were subpopulations to prioritize if vaccine supply is limited and use of a higher dose formulation for the elderly. Most physicians who do not currently use intranasal vaccine rated that topic as a low priority. CONCLUSION: Primary care providers have a number of high-priority information needs related to influenza vaccination. However, the limited interest of family physicians and internists in receiving more information about intranasal vaccine may impede efforts to expand its use among healthy adults.

Private-sector vaccine purchase costs and insurer payments: a disincentive for using combination vaccines?

Combination vaccines have been endorsed as a means to decrease the number of injections needed to complete the childhood immunization schedule, yet anecdotal reports suggest that private providers lose money on combination vaccines. The objective of this study was to determine whether practices purchasing combination vaccines had significantly different vaccine costs and reimbursement compared to practices that were not purchasing combination vaccines. Using cross-sectional purchase and insurer payment data collected from a targeted sample of private practices in five US states, we calculated the average total vaccine cost and reimbursement across the childhood immunization schedule. The average vaccine purchase cost across the childhood schedule was significantly higher for practices using a combined vaccine with diphtheria, tetanus, acellular pertussis vaccine, inactivated polio vaccine, and Hepatitis B vaccine (DTaP-IPV-HepB) than for practices using either separate vaccine products or a combined vaccine with Haemophilus influenzae, type b vaccine and Hepatitis B vaccine (Hib-HepB). The average insurer payment for vaccine administration across the childhood schedule was significantly lower for practices using DTaP-IPV-HepB combination vaccine than for practices using separate vaccine products. This study appears to validate anecdotal reports that vaccine purchase costs and insurer payment for combination vaccines can have a negative financial impact for practices that purchase childhood vaccines.