The Texas Children's Hospital immunization forecaster: conceptualization to implementation.

OBJECTIVES: Immunization forecasting systems evaluate patient vaccination histories and recommend the dates and vaccines that should be administered. We described the conceptualization, development, implementation, and distribution of a novel immunization forecaster, the Texas Children's Hospital (TCH) Forecaster. METHODS: In 2007, TCH convened an internal expert team that included a pediatrician, immunization nurse, software engineer, and immunization subject matter experts to develop the TCH Forecaster. Our team developed the design of the model, wrote the software, populated the Excel tables, integrated the software, and tested the Forecaster. We created a table of rules that contained each vaccine's recommendations, minimum ages and intervals, and contraindications, which served as the basis for the TCH Forecaster. RESULTS: We created 15 vaccine tables that incorporated 79 unique dose states and 84 vaccine types to operationalize the entire United States recommended immunization schedule. The TCH Forecaster was implemented throughout the TCH system, the Indian Health Service, and the Virginia Department of Health. The TCH Forecast Tester is currently being used nationally. CONCLUSIONS: Immunization forecasting systems might positively affect adherence to vaccine recommendations. Efforts to support health care provider utilization of immunization forecasting systems and to evaluate their impact on patient care are needed.

COVID-19 Vaccine Hesitancy in Caregivers of Hospitalized Children From 2020 Through 2023.

OBJECTIVES: Data on US caregiver perceptions on coronavirus disease 2019 (COVID-19) and COVID-19 vaccination are limited. We identified trends in and associations with COVID-19 vaccine hesitancy in caregivers of hospitalized children. METHODS: Cross-sectional surveys on pediatric COVID-19 disease and vaccine attitudes, behaviors, and beliefs were administered across study years (December 8, 2020-April 5, 2021, November 30, 2021-March 15, 2022, and October 26, 2022-March 15, 2023). English and Spanish-speaking caregivers of hospitalized children ages 6 months to 11 years were included. General vaccine hesitancy was assessed using the Parent Attitudes about Childhood Vaccines survey. RESULTS: Of 1268 caregivers from diverse backgrounds, one-third vaccinated or intended to vaccinate their child. Half endorsed fear of their child receiving the COVID-19 vaccine and were concerned the vaccine was new. Over time, more believed "the COVID-19 vaccine does not work" and fewer agreed "children who are otherwise healthy can die from COVID-19." Study season (2022-2023), older child age, higher income, child receipt of influenza vaccine, caregiver receipt of COVID-19 vaccine, and not being worried about vaccine novelty were positively associated with child vaccination. Intent to vaccinate was negatively associated with study season (2022-2023), Parent Attitudes about Childhood Vaccines score ≥50, lack of child influenza and caregiver COVID-19 vaccination, lack of fear of their child "getting COVID-19" and being "worried that the COVID-19 vaccine is new." The majority who intended to vaccinate were willing to immunize before discharge. CONCLUSIONS: Vaccine novelty and perceived lack of need were associated with refusal. Caregiver COVID-19 and child influenza vaccine acceptance were positively associated with COVID-19 vaccine acceptance. The inpatient setting offers the opportunity to improve vaccine uptake.

Telling stories of vaccine-preventable diseases: why it works.

In this paper, we explore the benefits of storytelling in health communication and, in particular, immunization education. During the mid-20th century polio epidemic, both personal stories and scientific information abounded in the media. However, as rates of vaccine-preventable diseases declined, narratives about the dangers of such diseases faded as did the public fear of them. Meanwhile, anti-vaccine advocates flooded the media and Internet with stories of injured children and tied those injuries, such as autism, to vaccines. Medical experts often counter anti-vaccine concerns with scientific information which can fail to persuade parents. Furthermore, evidence suggests that many people misunderstand quantitative information resulting in a misinterpretation of risk. Compared to scientific information, stories relate life lessons and values. They are effective because they are memorable and relatable. Evidence also suggests that storytelling can effectively improve health knowledge and behaviors. Inspired by In Harm's Way--True Stories of Uninsured Texas Children by the Children's Defense Fund and Faces of Influenza by the American Lung Association, we published Vaccine-Preventable Disease: The Forgotten Story, a collection of photographs and personal stories of families affected by vaccine-preventable diseases. We have found that the stories included in our booklet capture all the benefits of storytelling. Given the many benefits of storytelling, providers should strive to include stories along with medical facts in their daily practice.

The effect of screening for vaccine hesitancy on the subsequent development of hesitancy: a randomized controlled trial, Houston, TX.

Vaccine hesitancy remains a global health threat. Addressing parental vaccine hesitancy is essential to maintaining high vaccine coverage levels and preventing disease outbreaks; however, it is unknown if administering a vaccine hesitancy screening tool negatively impacts parental vaccine beliefs. We conducted a stratified randomized controlled trial in pediatric primary care practices. English-speaking parents ≥18 years of age seeking routine care for infants <3 months of age were eligible. Participants were randomized to receive 1 of 2 surveys - the Parent Attitudes about Childhood Vaccines (PACV) survey or a placebo survey. Six months after initial enrollment, all participants were asked to complete the PACV, regardless of initial randomization group. Our primary outcome was the proportion of hesitant to non-hesitant parents at 6-months between randomization groups. We examined associations between vaccine hesitancy and participant characteristics. We also evaluated the change in the proportion of vaccine-hesitant parents in the PACV group between baseline and 6-month follow up. We enrolled 1705 parents at baseline. At 6-month follow up, 819 parents completed the PACV (50.2% from PACV group vs. 54.1% from placebo group). The proportion of hesitant parents at 6 months did not differ between PACV and placebo groups (6.6% vs. 6.1%; p = .78) and the odds of hesitancy among PACV group participants was not higher than those in the placebo group (OR = 1.10; 95% CI: 0.63-1.93; p = .743). Race was the only characteristic significantly associated with vaccine hesitancy at 6-month follow up (p = .003). Overall, administration of the PACV did not trigger vaccine hesitancy in this study population.

Understanding Vaccine Hesitancy Among Parents of Children With Autism Spectrum Disorder and Parents of Children With Non-Autism Developmental Delays.

Parents of children with autism spectrum disorder (ASD) may be at greater risk for developing antivaccine beliefs that lead to vaccine delays and/or refusals for their children. We investigated current parental vaccine hesitancy, parents' beliefs about causes of children's developmental delays, and children's vaccination histories among parents of children with ASD or non-ASD developmental delays. Data were analyzed from 89/511 parents (17.4%) who completed the Parent Attitudes About Childhood Vaccines questionnaire and the Revised Illness Perception Questionnaire; 46.1% had childhood vaccination records available. Overall, 21/89 (23.6%, 95% confidence interval [CI]: 15.0-34.0) of parents were vaccine hesitant (ASD n = 19/21 [90.5%], non-ASD n = 2/21 [9.5%]). Parents of children with ASD were significantly more likely to agree with "toxins in vaccines" as a cause of their child's developmental delays (28.4% vs 5.0%, P = .034). The odds of being vaccine hesitant were 11.9 times (95% CI 2.9-48.0) greater among parents who agreed versus disagreed that toxins in vaccines caused their children's developmental delays. Rates of prior vaccine receipt did not differ between hesitant and nonhesitant groups.

Use of Deep Learning to Analyze Social Media Discussions About the Human Papillomavirus Vaccine.

Importance: Human papillomavirus (HPV) vaccine hesitancy or refusal is common among parents of adolescents. An understanding of public perceptions from the perspective of behavior change theories can facilitate effective and targeted vaccine promotion strategies. Objective: To develop and validate deep learning models for understanding public perceptions of HPV vaccines from the perspective of behavior change theories using data from social media. Design, Setting, and Participants: This retrospective cohort study, conducted from April to August 2019, included longitudinal and geographic analyses of public perceptions regarding HPV vaccines, using sampled HPV vaccine-related Twitter discussions collected from January 2014 to October 2018. Main Outcomes and Measures: The prevalence of social media discussions related to the construct of health belief model (HBM) and theory of planned behavior (TPB), categorized by deep learning algorithms. Locally estimated scatterplot smoothing (LOESS) revealed trends of constructs. Social media users' US state-level home location information was extracted from their profiles, and geographic analyses were performed to identify the clustering of public perceptions of the HPV vaccine. Results: A total of 1 431 463 English-language posts from 486 116 unique usernames were collected. Deep learning algorithms achieved F-1 scores ranging from 0.6805 (95% CI, 0.6516-0.7094) to 0.9421 (95% CI, 0.9380-0.9462) in mapping discussions to the constructs of behavior change theories. LOESS revealed trends in constructs; for example, prevalence of perceived barriers, a construct of HBM, deceased from its apex in July 2015 (56.2%) to its lowest prevalence in October 2018 (28.4%; difference, 27.8%; P < .001); Positive attitudes toward the HPV vaccine, a construct of TPB, increased from early 2017 (30.7%) to 41.9% at the end of the study (difference, 11.2%; P < .001), while negative attitudes decreased from 42.3% to 31.3% (difference, 11.0%; P < .001) during the same period. Interstate variations in public perceptions of the HPV vaccine were also identified; for example, the states of Ohio and Maine showed a relatively high prevalence of perceived barriers (11 531 of 17 106 [67.4%] and 1157 of 1684 [68.7%]) and negative attitudes (9655 of 17 197 [56.1%] and 1080 of 1793 [60.2%]). Conclusions and Relevance: This cohort study provided a good understanding of public perceptions on social media and evolving trends in terms of multiple dimensions. The interstate variations of public perceptions could be associated with the rise of local antivaccine sentiment. The methods described in this study represent an early contribution to using existing empirically and theoretically based frameworks that describe human decision-making in conjunction with more intelligent deep learning algorithms. Furthermore, these data demonstrate the ability to collect large-scale HPV vaccine perception and intention data that can inform public health communication and education programs designed to improve immunization rates at the community, state, or even national level.

Beliefs about causes of autism and vaccine hesitancy among parents of children with autism spectrum disorder.

Vaccine hesitancy may be more common among parents of children with autism spectrum disorder (ASD). We examined factors associated with ASD-specific vaccine hesitancy among caregivers of children with ASD who participated in the SPARK study (Simons Foundation Powering Autism Research for Knowledge). 225 participants completed an online survey containing the Parent Attitudes About Childhood Vaccines (PACV) questionnaire (measure of vaccine hesitancy) and the Illness Perception Questionnaire revised for parents of children with ASD (IPQ-R-ASD; measure of parents' views about ASD). 65 participants (28.8%) were vaccine hesitant (PACV score ≥ 50); children of vaccine-hesitant parents (VHPs) were less likely to be first born (n = 27, 41.5%), had greater ASD-symptom severity (mean Social Communication Questionnaire score = 23.9, SD = 6.9), and were more likely to have experienced developmental regression (n = 27, 50.9%) or plateau (n = 37, 69.8%). Compared to non-hesitant parents, VHPs significantly more often endorsed accident/injury, deterioration of the child's immune system, diet, environmental pollution, general stress, parents' negative views, parents' behaviors/decisions, parents' emotional state, and vaccines as causes for ASD. VHPs also had higher scores on the Personal Control, Treatment Control, Illness Coherence, and Emotional Representations subscales of the IPQ-R than did non-hesitant parents. In the final model, ASD-related vaccine hesitancy was significantly associated with higher scores on the Emotional Representations subscale (OR = 1.13, p = 0.10), agreement with deterioration of the child's immunity as a cause of ASD (OR = 12.47, p < 0.001), the child not having achieved fluent speech (OR = 2.67, p = 0.17), and the child experiencing a developmental plateau (OR = 3.89, p = 0.002). Findings suggest that a combination of child functioning and developmental history, as well as parents' negative views about and their sense of control over ASD, influence vaccine hesitancy among parents of children with ASD.

Vaccine Hesitancy and Illness Perceptions: Comparing Parents of Children with Autism Spectrum Disorder to other Parent Groups.

Fears persist despite compelling evidence refuting associations between vaccines and autism spectrum disorder (ASD). We compared vaccine hesitancy (VH) and beliefs about illness causes among parents of children in four groups: ASD, non-ASD developmental disorders, rheumatologic conditions, and the general pediatric population. VH was 19.9% overall; parents of children with ASD reported highest VH rates (29.5%) and more frequently attributed ASD to toxins in vaccines (28.9% vs. 15.7%, p=0.004). The odds of VH were increased among parents who attributed their child's condition to diet or eating habits (aOR 4.2; 95% CI: 1.6, 11.2) and toxins found in vaccines (aOR 20, 95% CI: 7.1, 55.9). Parents who attributed the condition to chance or bad luck were less likely to be vaccine hesitant (aOR 0.1; 95% CI: 0.03, 0.5).

Longitudinal Evaluation of Clinical Decision Support to Improve Influenza Vaccine Uptake in an Integrated Pediatric Health Care Delivery System, Houston, Texas.

OBJECTIVE: Our study retrospectively evaluated the implementation of an influenza vaccine best practice alert (BPA) in an electronic medical record within an integrated pediatric health care delivery system. METHODS: An influenza BPA was implemented throughout a large pediatric health care delivery system in Houston, TX, to improve vaccine uptake. Outcomes were measured retrospectively over 3 years of BPA implementation and compared with a control year prior to BPA implementation. Primary outcomes were influenza vaccine uptake, distribution of influenza vaccines ordered by week, proportion of BPA displays ignored, and missed vaccination opportunities. RESULTS: Influenza vaccine uptake declined from the pre-BPA year (47.2%; 95% confidence interval [CI]: 47.0, 47.4) to the last study year (45.1%; 95% CI: 44.9, 45.2). BPA displays were increasingly ignored by clinical staff throughout the study years from 59.6% in 2014-2015 to 72.5% in 2016-2017. For providers, BPA displays were ignored less frequently each year from 53.4% in 2014-2015 to 51.4% in 2017-2017. Within the primary care outpatient group, the proportion of missed vaccination opportunities in sick visits decreased from 86.8% during the pre-BPA year to 81.0, 79.8, and 82.7% during the subsequent study years 2014-2015, 2015-2016, and 2016-2017, respectively. CONCLUSION: Implementation of a widespread influenza BPA in an integrated pediatric health care delivery system did not produce meaningful increases in influenza vaccine uptake. Differences between clinical staff and providers on BPA use warrant further investigation.

Leveraging deep learning to understand health beliefs about the Human Papillomavirus Vaccine from social media.

Our aim was to characterize health beliefs about the human papillomavirus (HPV) vaccine in a large set of Twitter posts (tweets). We collected a Twitter data set related to the HPV vaccine from 1 January 2014, to 31 December 2017. We proposed a deep-learning-based framework to mine health beliefs on the HPV vaccine from Twitter. Deep learning achieved high performance in terms of sensitivity, specificity, and accuracy. A retrospective analysis of health beliefs found that HPV vaccine beliefs may be evolving on Twitter.

Development of a Spanish version of the parent attitudes about childhood vaccines survey.

The Parent Attitudes about Childhood Vaccines (PACV) survey is a validated instrument for identifying vaccine-hesitant parents; however, a Spanish version is not available. Utilizing the WHO framework for translating survey instruments, we used an iterative process for developing the Spanish PACV that included forward translation, expert panel review, back translation and pre-testing that utilized cognitive interviewing. We made revisions to the Spanish PACV at each step, focusing on addressing inclusivity, readability, clarity and conceptual equivalence. The expert panel was comprised of 6 Spanish-speaking medical and research professionals who worked alongside 3 study team members. Pre-testing was conducted using convenience sampling of Spanish-speaking parents (N = 35) who had a child receiving care at the residents' continuity clinic at Texas Children's Hospital. Most pre-testing participants were married (80.6%), mothers (97.1%), ≥30 years of age (88.2%) and had a high school education or less (70.6%). While the majority of participants stated the survey was easy to complete, the translation of 5 PACV items was further revised to improve interpretability. We conclude that the final Spanish PACV is conceptually equivalent and culturally appropriate for most Hispanic populations.

Prevalence of Vaccine Hesitancy Among Expectant Mothers in Houston, Texas.

OBJECTIVE: Nonmedical exemptions continue to rise because of increasing proportions of vaccine-hesitant parents. The proportion of expectant parents who are vaccine-hesitant is currently unknown. We assessed the prevalence of vaccine hesitancy among expectant parents receiving care at an obstetrics clinic in Houston, Texas. METHODS: We conducted a cross-sectional survey of expectant parents between 12 and 31 weeks gestation who received care at Texas Children's Pavilion for Women between July 2014 and September 2015. Using convenience sampling, participants completed a questionnaire that included questions on demographic items, self-assessed pregnancy risk, receipt of annual influenza vaccine, and the 15-item Parents Attitudes About Childhood Vaccines survey, a validated tool to identify vaccine-hesitant parents. We used multivariable logistic regression to determine the association of demographic characteristics, pregnancy risk, and influenza vaccine receipt with vaccine hesitancy after controlling for variables significant in univariable analyses. RESULTS: Six hundred ten expectant mothers and 38 expectant fathers completed the Parents Attitudes About Childhood Vaccines survey. Overall, 50 of 610 expectant mothers (8.2%; 95% confidence interval [CI], 6.1%-10.7%) were vaccine-hesitant. Expectant mothers were primarily non-Hispanic white, 30 years old or older, and married. The odds of being vaccine-hesitant were 2.2 times greater (95% CI, 1.2-4.1) among expectant mothers with a college level of education or less compared with those with more than a 4-year degree. The odds of being vaccine-hesitant were 7.4 times greater (95% CI, 3.9-14.0) among expectant mothers who do not receive an annual influenza vaccine compared with those who do. CONCLUSIONS: Our findings suggest the need to identify and address vaccine hesitancy among expectant parents before birth.

Parental report of vaccine receipt in children with autism spectrum disorder: Do rates differ by pattern of ASD onset?

A contentious theory espoused by some parents is that regressive-onset of autism spectrum disorder (ASD) is triggered by vaccines. If this were true, then vaccine receipt should be higher in children with regressive-onset ASD compared with other patterns of onset. Parental report of rate of receipt for six vaccines (DPT/DTaP, HepB, Hib, polio, MMR, varicella) was examined in children with ASD (N=2755) who were categorized by pattern of ASD onset (early onset, plateau, delay-plus-regression, regression). All pairwise comparisons were significantly equivalent within a 10% margin for all vaccines except varicella, for which the delay-plus-regression group had lower rates of receipt (81%) than the early-onset (87%) and regression (87%) groups. Findings do not support a connection between regressive-onset ASD and vaccines in this cohort.