Who knows more about immunization?: Survey of public health nurses and physicians.

OBJECTIVE: To report the findings of a knowledge survey of nurse and physician immunization providers. DESIGN: Cross-sectional postal survey assessing demographic characteristics and vaccine knowledge. SETTING: British Columbia (BC). PARTICIPANTS: Nurse and physician immunization providers in BC. MAIN OUTCOME MEASURES: Knowledge of vaccine-preventable diseases, vaccines in general, and vaccine administration and handling practices. RESULTS: Survey responses were received from 256 nurses and 292 physicians (response rates of 48.6% and 18.3%, respectively). Most nurses (98.4%) reported receiving immunization training outside of the academic setting compared with 55.6% of physicians. Overall, nurse immunizers scored significantly higher than physician immunizers on all 3 domains of immunization knowledge (83.7% vs 72.8%, respectively; P < .001). Physicians scored highest on the vaccine-preventable disease domain and least well on the general vaccine domain. Nurses with more experience as health care providers scored higher. Physicians scored higher if they were female, served patient populations predominantly younger than 5 years, or received immunization training outside of academic settings. CONCLUSION: In BC, nurse immunizers appear to have higher overall immunization knowledge than physicians and are more likely to receive immunization training when in practice. Physician immunizers might benefit most from further training on vaccines and vaccine administration and handling.

Implementation of a new clinical practice guideline regarding pain management during childhood vaccine injections.

OBJECTIVE: To determine the impact of a multifaceted knowledge translation strategy for a new vaccination pain management guideline on public health immunizers' attitudes, beliefs and use of pain-relieving strategies during childhood vaccination. METHOD: Using a randomized controlled pre-post study design, public health nurses (PHNs) at intervention sites received a multifaceted knowledge translation intervention about new pain management guidelines incorporated in the British Columbia Immunization Program Manual, including education, supplies and online support. Attitudes and beliefs of PHNs toward immunization pain and pain management, and use of pain-relieving strategies were compared for the intervention sites between the pre- and postimplementation phases. RESULTS: A total of 516 children were immunized by 31 PHNs pre- and postimplementation in the intervention sites. Postimplementation, satisfaction and confidence with ability to manage pain and willingness to use newly recommended strategies were significantly more positive (P<0.05) in the intervention sites, and overall use of at least one newly recommended strategy increased from 49.8% preintervention to 77.6% postimplementation (P<0.001). CONCLUSION: The knowledge translation intervention improved PHN immunizers' attitudes, beliefs and practices regarding paediatric vaccination pain management. Reducing pain may result in a better immunization experience for children, caregivers and immunizers.

OBJECTIF: Déterminer les conséquences d'une stratégie polyvalente de transfert du savoir contenu dans un nouveau guide de gestion de la douleur causée par la vaccination sur les attitudes et les croyances de vaccinateurs de la santé publique ainsi que sur leur utilisation des stratégies de soulagement de la douleur pendant la vaccination des enfants. MÉTHODOLOGIE: Au moyen d'une méthodologie d'étude avantaprès aléatoire et contrôlée, des infirmières de la santé publique (ISP) ont profité d'une démarche polyvalente de transfert du savoir à leur établissement d'intervention à l'égard de nouvelles directives sur la gestion de la douleur contenues dans le British Columbia Immunization Program Manual, y compris la formation, les fournitures et le soutien virtuel. Les chercheurs ont comparé les attitudes et les croyances des ISP à l'égard de la douleur et de la gestion de la douleur de la vaccination ainsi que les stratégies de soulagement de la douleur qu'elles utilisaient aux établissements d'intervention avant et après la mise en œuvre des directives. RÉSULTATS: Au total, 516 enfants ont été vaccinés par 31 ISP avant et après la mise en œuvre aux établissements d'intervention. Après la mise en œuvre, la satisfaction et la confiance en la capacité de gérer la douleur et la volonté d'utiliser les stratégies nouvellement recommandées étaient significativement plus positives (P<0,05). L'utilisation globale d'au moins une stratégie nouvellement recommandée est passée de 49,8 % avant la démarche à 77,6 % après la mise en œuvre (P<0,001). CONCLUSION: L'intervention de transfert du savoir a amélioré les attitudes, les croyances et les pratiques des ISP vaccinatrices au sujet de la gestion de la douleur des vaccins en pédiatrie. L'atténuation de la douleur peut susciter une meilleure expérience de vaccination pour les enfants, les personnes qui s'occupent d'eux et les vaccinateurs.

Establishing physician advocates for human papillomavirus vaccination in British Columbia.

OBJECTIVE: To survey general practitioners in oncology (GPOs) in British Columbia (BC) to identify opportunities for them to serve as public supporters of human papillomavirus (HPV) vaccination. DESIGN: A mailed or online survey. SETTING: British Columbia. PARTICIPANTS: Forty-two GPOs who worked in the community in BC. MAIN OUTCOME MEASURES: Current practices, knowledge, and resource needs concerning HPV, the vaccine, and the HPV immunization program, and the willingness of respondents to be contacted to participate in stated public HPV vaccine supporter activities. RESULTS: The survey found that 42% of surveyed GPOs were willing to act as public supporters of the HPV vaccine. The survey also identified education needs among GPOs concerning HPV, the vaccine, and the HPV immunization program in BC. CONCLUSION: This study found that GPOs in BC are willing to publicly support the HPV immunization program. This study shows that involving physicians in the promotion of public health programs is a viable option that should be further explored and evaluated.

Method of administration affects adolescent post-immunization survey response rate: phone, paper, internet.

The recent introduction of new vaccines into the school-based immunization program in British Columbia (BC) included monitoring of adverse events following immunization (AEFI) for these new vaccines. This commentary discusses different methods used to collect AEFIs in school immunization campaigns and the effects on response rate. The results of a study using an internet-based tool inspired this paper. The study examined adverse events following human papillomavirus (HPV) vaccine given to grades 6 and 9 students. The low response rate of the internet survey resulted in insufficient findings regarding adverse events. Consequent to the analysis of the study's data, a literature review was conducted to examine survey methodologies used to collect adverse event data following school-based immunization of adolescents. A PubMed search used various combinations of the following terms: vaccine, immunization, immunization programs, reactogenicity, adverse reactions, safety, adolescent, schoolchildren, and survey. Potentially relevant papers were identified based upon the titles and abstracts and subsequently reviewed. Only four studies were deemed appropriate for comparison purposes: all were done in Canada.

A population-based evaluation of a publicly funded, school-based HPV vaccine program in British Columbia, Canada: parental factors associated with HPV vaccine receipt.

BACKGROUND: Information on factors that influence parental decisions for actual human papillomavirus (HPV) vaccine receipt in publicly funded, school-based HPV vaccine programs for girls is limited. We report on the level of uptake of the first dose of the HPV vaccine, and determine parental factors associated with receipt of the HPV vaccine, in a publicly funded school-based HPV vaccine program in British Columbia, Canada. METHODS AND FINDINGS: All parents of girls enrolled in grade 6 during the academic year of September 2008-June 2009 in the province of British Columbia were eligible to participate. Eligible households identified through the provincial public health information system were randomly selected and those who consented completed a validated survey exploring factors associated with HPV vaccine uptake. Bivariate and multivariate analyses were conducted to calculate adjusted odds ratios to identify the factors that were associated with parents' decision to vaccinate their daughter(s) against HPV. 2,025 parents agreed to complete the survey, and 65.1% (95% confidence interval [CI] 63.1-67.1) of parents in the survey reported that their daughters received the first dose of the HPV vaccine. In the same school-based vaccine program, 88.4% (95% CI 87.1-89.7) consented to the hepatitis B vaccine, and 86.5% (95% CI 85.1-87.9) consented to the meningococcal C vaccine. The main reasons for having a daughter receive the HPV vaccine were the effectiveness of the vaccine (47.9%), advice from a physician (8.7%), and concerns about daughter's health (8.4%). The main reasons for not having a daughter receive the HPV vaccine were concerns about HPV vaccine safety (29.2%), preference to wait until the daughter is older (15.6%), and not enough information to make an informed decision (12.6%). In multivariate analysis, overall attitudes to vaccines, the impact of the HPV vaccine on sexual practices, and childhood vaccine history were predictive of parents having a daughter receive the HPV vaccine in a publicly funded school-based HPV vaccine program. By contrast, having a family with two parents, having three or more children, and having more education was associated with a decreased likelihood of having a daughter receive the HPV vaccine. CONCLUSIONS: This study is, to our knowledge, one of the first population-based assessments of factors associated with HPV vaccine uptake in a publicly funded school-based program worldwide. Policy makers need to consider that even with the removal of financial and health care barriers, parents, who are key decision makers in the uptake of this vaccine, are still hesitant to have their daughters receive the HPV vaccine, and strategies to ensure optimal HPV vaccine uptake need to be employed.

Identifying attitudes, beliefs and reported practices of nurses and doctors as immunization providers.

AIM: This paper is a report of a study conducted to examine the attitudes, beliefs, behavioural intentions and self-reported behaviour of nurses and physicians relating to key immunization behaviours and compare the findings for nurses and physicians. BACKGROUND: Immunization is an important and effective public health intervention. Understanding immunization providers' attitudes and beliefs toward immunization has the potential to improve educational efforts and lead to behavioural change. METHOD: A postal survey was conducted with all immunization providers in British Columbia, Canada, in 2005. The survey elicited data on demographics, practice characteristics, attitudes, perceived social norms and perceived behavioural control related to key immunization behaviours. RESULTS: Responses were received from 344 nurses and 349 physicians. The response rate was 67% for nurses and 22% for physicians. More nurses than physicians thought that administering all recommended vaccines at one visit was important (89.2% vs. 63.2%P < 0.001); nurses felt more pressure from parents to administer all recommended vaccines (82.4% vs. 48.7%P < 0.001), and nurses were also more likely to intend to give all recommended vaccines at one visit (98.8% vs. 73.8%P < 0.001). Both nurses and physicians thought that their own receipt of influenza vaccine each year was important (88.9%, 87.1% respectively P = 0.65). CONCLUSION: The foundational work done to develop the survey tool can be used to modify it so that survey findings can be validated according to the Theory of Planned Behaviour. The results could inform the development of behavioural change interventions targeting the identified determinants of immunization provider behaviour.

Cervical cancer prevention by vaccination: nurses' knowledge, attitudes and intentions.

AIM: This paper is a report of a survey: (1) to document nurses' knowledge, attitudes and information needs regarding human papillomavirus prevention and (2) to determine factors associated with their willingness to recommend human papillomavirus vaccines. BACKGROUND: Persistent infection with human papillomavirus has been causally linked to cervical cancer. Two human papillomavirus vaccines have recently been approved for use in more than 65 countries. Nurses' level of support for the prevention of human papillomavirus related diseases by vaccination has not been researched. METHODS: A survey was conducted in 2007. Self-administered questionnaires were mailed to 1799 randomly selected nurses. Descriptive statistics were generated for all variables. Multivariable logistic regression models were estimated to determine variables associated with the willingness to recommend human papillomavirus vaccines. RESULTS: A total of 946 questionnaires were analyzed and showed that: 97% of nurses perceived routinely recommended vaccines as very useful; 93% would support human papillomavirus vaccination if it is publicly funded; 85% would recommend human papillomavirus vaccines to their patients; 33%, 46% and 61% expect the vaccination to permit screening to begin later in life, reduction of the frequency of screening, and reduction of the number of postscreening interventions, respectively. Respondents' knowledge score was 3.8 out of 7. Several modifiable factors, including knowledge, perceived self-efficacy, and societal and colleagues support were associated with willingness to recommend vaccines. CONCLUSION: Most nurses' support human papillomavirus vaccination, but their active involvement should not be taken for granted. Targeted educational efforts are needed to ensure nurses' involvement in the prevention of human papillomavirus-related diseases.

One arm or two? Concurrent administration of meningococcal C conjugate and hepatitis B vaccines in pre-teens.

BACKGROUND: The purpose of this study was to: (a) compare rates of local reactions from meningococcal C conjugate (Neis Vac-C) and hepatitis B vaccines (Recombivax HB), and (b) compare local reactions when both injections were given in one arm versus one in each arm. METHODS: Schools were randomized to have grade six students receive both vaccines in one arm (One Arm Group), or one vaccine in each arm (Two Arm Group; MCC always given in left arm). Structured telephone interviews of parents were conducted, and respondents were asked about local and systemic reactions, interference with school or other activities, need for medical attention, and lost parental work time. FINDINGS: The Two Arm Group reported significantly more local redness >46 mm (6.5% vs. 0.5%, p < 0.001), moderate to severe tenderness (28% vs. 18%, p < 0.05), and drowsiness (14% vs. 7%, p < 0.05). When adjusted for sex, ethnicity, and town of residence, report of any tenderness was associated with town of residence only; moderate or severe tenderness was independently associated with the Two Arm Group (OR 1.4, 95% CI 1.1-1.85). There were no statistically significant differences between groups for interference with school attendance or other activities, need for medical attention, or lost parental work time. Among participants of the Two Arm Group (188 students), there was more redness (6% vs. 2%, p < 0.05) and tenderness (54% vs. 32%, p < 0.001) experienced with Neis Vac-C than with Recombivax HB, respectively. CONCLUSIONS: Injecting two vaccines in one arm did not cause more local reaction than one injection in each arm and remains an option for those who prefer it for logistical reasons, If vaccinating in two arms, Neis Vac-C should preferentially be given in the nondominant arm.

Parental intention to have daughters receive the human papillomavirus vaccine.

BACKGROUND: Concerns have been raised that parents may be reluctant to have their daughters receive the human papillomavirus (HPV) vaccine, because of a belief that doing so might be interpreted as condoning earlier and more frequent sexual activity. We determined intentions regarding vaccination among Canadian parents and factors that predicted parental intention to have their daughters vaccinated against HPV. METHODS: Parents of children 8-18 years of age, recruited from across Canada, were asked to respond to questions in the context of a grade 6, publicly funded, school-based HPV vaccine program. We performed backward logistic regression analysis to identify factors predictive of parents' intention to have their daughters vaccinated against HPV. RESULTS: Of the 1350 respondents with female children, more than 70% (73.8%; 95% confidence interval [CI] 71.5%-76.1%) intended to have their daughters undergo vaccination against HPV. In multivariable modelling, parents who had positive attitudes toward vaccines (odds ratio [OR] 9.9, 95% CI 4.7-21.1), those who were influenced by subjective norms (OR 9.2, 95% CI 6.6-12.9), those who felt that the vaccine had limited influence on sexual behaviour (OR 3.2, 95% CI 2.2-4.6) and those who thought someone they knew was likely to get cervical cancer (OR 1.5, 95% CI 1.1-2.1) were more likely to intend that their daughters receive the HPV vaccine. Parents who were older (v. younger) (OR 0.6, 95% CI 0.4-0.8) and those who resided in British Columbia or Yukon Territory (v. Atlantic Canada) (OR 0.5, 95% CI 0.3-0.9) were less likely to intend that their daughters receive the HPV vaccine. INTERPRETATION: Most of the parents surveyed intended that their daughters would receive vaccination against HPV. Overall attitudes toward vaccines in general and toward the HPV vaccine in particular constituted the most significant predictor of parental intention with regard to vaccination.

University students immunized and not immunized for measles: a comparison of beliefs, attitudes, and perceived barriers and benefits.

OBJECTIVE: To compare students who were immunized or not immunized during the 1997 Simon Fraser University measles outbreak in British Columbia. METHODS: Descriptive comparative study using the Health Belief Model as a theoretical framework. A self-administered questionnaire was mailed to a stratified random sample of 400 immunized and 400 non-immunized SFU students. RESULTS: Perceived susceptibility, severity, barriers, cues to action, threat and student age were significantly related to being immunized. Logistic regression analysis achieved an overall correct prediction rate of 84.7% by including the contribution of the four variables of susceptibility, barriers, cues to action, and health motivation. Content analysis of the non-immunized students' descriptions of what it would have taken for them to be immunized indicated the influence of these four variables. DISCUSSION: The Immunization Health Belief Model Scale is a valuable tool for ascertaining attitudes and beliefs relating to immunization decision-making. Interventions targeted to significant beliefs may increase immunization coverage levels and result in improved disease prevention.

Solicited adverse events after influenza immunization among infants, toddlers, and their household contacts.

OBJECTIVES: We assessed adverse events, including oculorespiratory syndrome, following influenza immunization during the first year of a publicly-funded program for infants, toddlers and their household members in Canada. METHODS: Parents bringing infants and toddlers for influenza immunization to clinics in Quebec or British Columbia consented to structured telephone interview 5 to 10 days later. One adult provided information for all household members. Symptom experience commencing before and after immunization was assessed. Non-immunized persons also served as a comparison group for immunized household members. RESULTS: Sample included 690 immunized infants and toddlers and 1801 household members, 1374 immunized. Only fussiness, fever, decreased appetite, drowsiness, and nasal congestion/coryza were reported for >5% of infants/ toddlers within 72 hours of immunization, but only arm discomfort was reported among >5% of immunized household contacts. In multivariate analysis, muscle ache was the only systemic symptom reported more often by immunized household members compared to non-immunized persons. Oculorespiratory symptoms were infrequent and there was no difference between immunized and non-immunized household members in their report. Less than 1% of adults required time off work because of adverse events following influenza immunization in the household. Less than 2% of subjects experiencing an adverse event following influenza immunization were considered unlikely to be vaccinated again. CONCLUSION: Influenza vaccine is well-tolerated by infants, toddlers and their household members. Post-marketing observational designs are an expedient way to assess adverse events following influenza immunization. These methods should be established and rehearsed annually in preparation for a pandemic.

Adult tetanus, diphtheria and pertussis immunization: knowledge, beliefs, behavior and anticipated uptake.

BACKGROUND: Lifetime protection against pertussis has been adopted as a goal of immunization programs in Canada. To anticipate adult coverage with a combined product containing tetanus (T) and diphtheria (d) toxoids and acellular pertussis (aP) vaccine as a booster dose, we conducted a survey of households in British Columbia, Canada. METHODS: In a random telephone survey involving 800 adults, 25 years of age and older, we assessed current behaviors related to adult Td immunization and beliefs regarding pertussis vaccine under various scenarios relevant to adult decision-making. RESULTS: Forty-five percent of participants reported having received tetanus vaccine within the previous 10 years; this rate was lowest amongst elderly persons 65 years of age or more (28%). On multi-variate analysis, being up-to-date with tetanus immunization was independently associated with belief that an adult should be immunized against tetanus and perception that tetanus is life-threatening and inversely associated with being elderly. At baseline, 59% of respondents indicated willingness to receive pertussis immunization if provided free; this increased to 76% following sequential information about communicability and severity of pertussis illness and safety, efficacy and convenience of vaccine and up to 87% if accompanied by physician or nurse recommendation. Sixty-three percent of adults indicated they would receive the vaccine if required to pay $40.00 (Cdn) for it. CONCLUSIONS: Personal risk perception, public funding and physician recommendation are important to adults when considering tetanus and pertussis immunization. These factors may be relevant as immunization programs are expanded to include more adults generally.

Injection-site reactions to booster doses of acellular pertussis vaccine: rate, severity, and anticipated impact.

BACKGROUND: Acellular pertussis (aP)-containing vaccines cause fewer adverse events than whole-cell versions for primary doses. Booster doses, however, may be followed by extensive injection-site reactions. This study compares the frequency, severity, and impact of local reactions among children receiving 5 consecutive doses of an aP combination vaccine (including inactivated polio virus, conjugated Haemophilus influenzae type b antigen, and diphtheria and tetanus toxoids) to children receiving a mixed series of whole-cell and aP combination vaccines. METHODS: Participants were parents or guardians of children 4 to 6 years old immunized at public health clinics across British Columbia, Canada. This included 398 children receiving the fifth consecutive dose of an aP combination vaccine and 402 receiving the fifth dose in a mixed series consisting of at least 1 prior dose of whole-cell pertussis combination vaccine with the remainder as aP combination vaccine. A cross-sectional telephone survey evaluated the extent of local reactions 48 to 96 hours after immunization by asking participants to compare the size of redness and swelling with familiar household items such as Oreo cookies or coins. Associated discomfort and impact on recreational activities, health care utilization, parental time off work, and attitudes toward immunization were also assessed. RESULTS: Children who received the fifth consecutive dose of an aP combination vaccine more often experienced redness (24%) or swelling (16%) the size of an Oreo cookie or larger (>or=46 mm) than children given a mixed series (10% and 9%, respectively) but less often experienced tenderness or limitation of movement at the injection site. Related health care utilization was low. There was no discernible effect on participation in recreational activities or parental attitudes toward vaccine; 90% would recommend the same vaccine to others with children of the same age. CONCLUSIONS: We conclude that injection-site reactions are more extensive after the fifth consecutive dose of an aP combination vaccine compared with the fifth dose in a mixed series of whole-cell and aP combination vaccines. These reactions are unlikely to affect parental acceptance of immunization recommendations or health care utilization.