Approximate maximum likelihood estimation in cure models using aggregated data, with application to HPV vaccine completion.

Research into vaccine hesitancy is a critical component of the public health enterprise, as rates of communicable diseases preventable by routine childhood immunization have been increasing in recent years. It is therefore important to estimate proportions of "never-vaccinators" in various subgroups of the population in order to successfully target interventions to improve childhood vaccination rates. However, due to privacy issues, it may be difficult to obtain individual patient data (IPD) needed to perform the appropriate time-to-event analyses: state-level immunization information services may only be willing to share aggregated data with researchers. We propose statistical methodology for the analysis of aggregated survival data that can accommodate a cured fraction based on a polynomial approximation of the mixture cure model log-likelihood function relying only on summary statistics. We study the performance of the method through simulation studies and apply it to a real-world data set from a study examining reminder/recall approaches to improve human papillomavirus (HPV) vaccination uptake. The proposed methods may be generalized for use when there is interest in fitting complex likelihood-based models but IPD is unavailable due to data privacy or other concerns.

Pediatric Sepsis in General Emergency Departments: Association Between Pediatric Sepsis Case Volume, Care Quality, and Outcome.

STUDY OBJECTIVE: To assess whether a general emergency department's (ED) annual pediatric sepsis volume increases the odds of delivering care concordant with Surviving Sepsis pediatric guidelines. METHODS: A retrospective cohort study of children <18 years with sepsis presenting to 29 general EDs. Emergency department and hospital data were abstracted from the medical records of 2 large health care systems, including all hospitals to which children were transferred. Guideline-concordant care was defined as intravenous antibiotics within 3 hours, intravenous fluid bolus within 3 hours, and lactate measured. The association between annual ED pediatric sepsis encounters and the probability of receiving guideline-concordant care was assessed. RESULTS: We included 1,527 ED encounters between January 1, 2015, and September 30, 2021. Three hundred and one (19%) occurred in 25 EDs with <10 pediatric sepsis encounters annually, 466 (31%) in 3 EDs with 11 to 100 pediatric sepsis encounters annually, and 760 (50%) in an ED with more than 100 pediatric sepsis encounters annually. Care was concordant in 627 (41.1%) encounters. In multivariable analysis, annual pediatric sepsis volume was minimally associated with the probability of guideline-concordant care (odds ratio 1.002 [95% confidence interval 1.001 to 1.00]). Care concordance increased from 23.1% in 2015 to 52.8% in 2021. CONCLUSION: Guideline-concordant sepsis care was delivered in 41% of pediatric sepsis cases in general EDs, and annual ED pediatric sepsis encounters had minimal association with the odds of concordant care. Care concordance improved over time. This study suggests that factors other than pediatric sepsis volume are important in driving care quality and identifying drivers of improvement is important for children first treated in general EDs.

Survey of Physician Practices, Attitudes, and Knowledge Regarding Recombinant Zoster Vaccine.

BACKGROUND: Herpes zoster vaccination rates remain low despite longstanding national recommendations to vaccinate immunocompetent adults aged ≥ 50 years. The Advisory Committee on Immunization Practice (ACIP) updated its recommendations for recombinant zoster vaccine (RZV) in October 2021 to include immunocompromised adults aged ≥19 years. OBJECTIVE: To assess practices, attitudes, and knowledge about RZV, barriers to recommending RZV, and likelihood of recommending RZV to patients with various immunocompromising conditions. DESIGN: Mail and internet-based survey conducted from May through July 2020. PARTICIPANTS: General internists and family physicians throughout the USA. MAIN MEASURES: Survey responses. KEY RESULTS: The response rate was 66% (632/955). Many physicians were already recommending RZV to immunocompromised populations, including adults ≥50 years with HIV (67% of respondents) and on recombinant human immune modulator therapy (56%). Forty-seven percent of respondents both stocked/administered RZV and referred patients elsewhere, frequently a pharmacy, for vaccination; 42% did not stock RZV and only referred patients. The majority agreed pharmacies do not inform them when RZV has been given (64%). Physicians were generally knowledgeable about RZV; however, 25% incorrectly thought experiencing side effects from the first dose of RZV that interfere with normal activities was a reason to not receive the second dose. The top reported barrier to recommending RZV was experience with patients declining RZV due to cost concerns (67%). Most physicians reported they would be likely to recommend RZV to immunocompromised patients. CONCLUSION: Most primary care physicians welcome updated ACIP RZV recommendations for immunocompromised adults. Knowledge gaps, communication issues, and financial barriers need to be addressed to optimize vaccination delivery.

Survey of pediatric transplant center practices regarding COVID-19 vaccine mandates for transplant candidates and living donors and use of COVID-19-positive deceased organs.

BACKGROUND: COVID-19 vaccine is recommended for individuals ages ≥6 months; however, whether vaccination should be mandated for transplant candidates and living donors remains controversial. This study assessed COVID-19 policies at US pediatric solid organ transplant centers. METHODS: A 79-item survey was emailed between March and April 2022 to 200 UNOS Medical Directors detailing center COVID-19 vaccine policies for transplant candidates and living donors and use of grafts from COVID-19-positive deceased donors. RESULTS: The response rate was 77% (154/200). For children aged 5-15 years, 23% (35/154 centers) have a COVID-19 vaccine mandate, 27% (42/154) anticipate implementing a future mandate, and 47% (72/154) have not considered or do not anticipate implementing a mandate. For children ≥16 years, 32% (50/154 centers) have a COVID-19 vaccine mandate, 25% (39/154) anticipate implementing a future mandate, and 40% (62/154) have not considered or do not anticipate implementing a mandate. The top two reasons for not implementing a COVID-19 vaccine mandate were concerns about penalizing a child for their parent's decision and worsening inequities in transplant. Of 85 kidney and liver living donor centers, 32% (27/85) require vaccination of donors. Twenty percent (31/154) of centers accept organs from COVID-19-positive deceased donors. CONCLUSIONS: There is great variation among pediatric SOT centers in both the implementation and details of COVID-19 vaccine mandates for candidates and living donors. To guide more uniform policies, further data are needed on COVID-19 disease, vaccine efficacy, and use of grafts from donors positive for COVID-19 in the pediatric transplant population.

A coordinated approach for managing polypharmacy among children with medical complexity: rationale and design of the Pediatric Medication Therapy Management (pMTM) randomized controlled trial.

BACKGROUND: Children with medical complexity (CMC) often rely upon the use of multiple medications to sustain quality of life and control substantial symptom burden. Pediatric polypharmacy (≥ 5 concurrent medications) is prevalent and increases the risk of medication-related problems (MRPs). Although MRPs are associated with pediatric morbidity and healthcare utilization, polypharmacy is infrequently assessed during routine clinical care for CMC. The aim of this randomized controlled trial is to determine if a structured pharmacist-led Pediatric Medication Therapy Management (pMTM) intervention reduces MRP counts, as well as the secondary outcomes of symptom burden and acute healthcare utilization. METHODS: This is a hybrid type 2 randomized controlled trial assessing the effectiveness of pMTM compared to usual care in a large, patient-centered medical home for CMC. Eligible patients include all children ages 2-18 years old, with ≥ 1 complex chronic condition, and with ≥ 5 active medications, as well as their English-speaking primary caregivers. Child participants and their primary parental caregivers will be randomized to pMTM or usual care before a non-acute primary care visit and followed for 90 days. Using generalized linear models, the overall effectiveness of the intervention will be evaluated using total MRP counts at 90 days following pMTM intervention or usual care visit. Following attrition, a total of 296 CMC will contribute measurements at 90 days, which provides > 90% power to detect a clinically significant 1.0 reduction in total MRPs with an alpha level of 0.05. Secondary outcomes include Parent-Reported Outcomes of Symptoms (PRO-Sx) symptom burden scores and acute healthcare visit counts. Program replication costs will be assessed using time-driven activity-based scoring. DISCUSSION: This pMTM trial aims to test hypotheses that a patient-centered medication optimization intervention delivered by pediatric pharmacists will result in lower MRP counts, stable or improved symptom burdens, and fewer cumulative acute healthcare encounters at 90 days following pMTM compared to usual care. The results of this trial will be used to quantify medication-related outcomes, safety, and value for a high-utilization group of CMC, and outcomes may elucidate the role of integrated pharmacist services as a key component of outpatient complex care programs for this priority pediatric population. TRIAL REGISTRATION: This trial was prospectively registered at clinicaltrials.gov (NCT05761847) on Feb 25, 2023.

Measles Experience, Practice, and Knowledge by Pediatricians in the Context of Resurgent US Outbreaks.

OBJECTIVE: To assess measles experience, practice, and knowledge by pediatricians in the context of resurgent US outbreaks in 2018-2019. STUDY DESIGN: A nationally representative network of pediatricians were surveyed by email and mail from January to April 2020. RESULTS: The response rate was 67% (297 of 444). In the 3 years preceding the survey, 52% of the respondents reported awareness of measles cases in/near their community. Most thought that media reports about recent measles outbreaks had decreased delay/refusal of measles, mumps, and rubella (MMR) vaccine (6% "greatly decreased"; 66% "moderately decreased"). More than 60% of the pediatricians responded correctly for 6 of 9 true/false measles knowledge items. Less than 50% responded correctly for 3 true/false items, including statements about pretravel MMR recommendations for a preschooler and measles isolation precautions. The most common resources that the pediatricians would "sometimes" or "often/always" consult for measles information were those from the American Academy of Pediatrics (72%), a state or local public health department (70%), and the Centers for Disease Control and Prevention (63%). More than 90% of the pediatricians reported correct clinical practice for MMR vaccination of a 9-month-old before international travel. More than one-third of the respondents did not have a plan for measles exposures in their clinic. Pediatricians aware of measles cases in/near their community in the previous 3 years and those working in a hospital/clinic or Health Maintenance Organization setting were more likely to have a plan for measles exposures. CONCLUSIONS: During this time of heightened risk for measles outbreaks, there are opportunities to strengthen the knowledge and implementation of measles pretravel vaccination and infection prevention and control recommendations among pediatricians.

"These Are Our Kids": Qualitative Interviews With Clinical Leaders in General Emergency Departments on Motivations, Processes, and Guidelines in Pediatric Sepsis Care.

STUDY OBJECTIVE: Sepsis is a leading cause of pediatric death requiring emergency resuscitation. Most children with sepsis are treated in general emergency departments (EDs); however, research has focused on pediatric EDs. We sought to identify barriers and facilitators to pediatric sepsis care in general EDs, including care processes, the role of guidelines, and incentivized metrics. METHODS: In this qualitative study, we conducted semistructured interviews with key informant physician and nurse leaders overseeing pediatric sepsis in general EDs in 2021, including medical directors, nurse managers, and quality coordinators. Interviews were audio-recorded, transcribed, and coded using deductive domains based on steps of sepsis care, pediatric readiness, and structural dynamics. Domains were analyzed across interviews in matrices, using thematic analysis within domains. RESULTS: Twenty-one clinical leaders representing 26 hospitals, including trauma levels I to IV, were interviewed. The themes included the following: (1) motivation to improve pediatric sepsis care based on moral imperative and location; (2) need for actionable pediatric sepsis guidelines; (3) children's hospitals' role in education, protocols, transfer, and consultation; and (4) mixed feelings about reportable metrics, particularly in EDs with low pediatric volume. Sepsis care process challenges included diagnosis, intravenous access, and antibiotic delivery but varied among hospitals. CONCLUSION: Leaders in general EDs were motivated to provide high-quality pediatric sepsis care but disagreed on whether reportable metrics would drive improvements. They universally sought direct support from their nearest children's hospitals and actionable guidelines. Efforts to address pediatric sepsis quality in general EDs should prioritize guideline design, responsive pediatric transfer and consultation systems, and locally specific process improvement.

Changes in Strength of Recommendation and Perceived Barriers to Human Papillomavirus Vaccination: Longitudinal Analysis of Primary Care Physicians, 2008-2018.

OBJECTIVES: To evaluate among pediatricians and family physicians human papillomavirus (HPV) vaccination recommendation practices for 11- to 12-year-old youth; report parental refusal/deferral of HPV vaccination; and report barriers to HPV vaccination changed over time. STUDY DESIGN: We surveyed nationally representative networks of pediatricians and family physicians in 2008, 2010, 2013-2014, and 2018. Male vaccination questions were not asked in 2008; barriers and parental vaccine refusal questions were not asked in 2010. RESULTS: Response rates were 80% in 2008 (680/848), 72% in 2010 (609/842), 70% in 2013-2014 (582/829), and 65% in 2018 (588/908). The proportion of physicians strongly recommending HPV vaccination for 11- to 12-year-old patients increased from 53% in 2008 to 79% in 2018 for female patients and from 48% in 2014 to 76% in 2018 for male patients (both P < .0001). The proportion of physicians indicating ≥50% of parents refused/deferred HPV vaccination remained steady for female patients (24% in 2008 vs 22% in 2018, P = .40) and decreased for male patients (42% in 2014 vs 28% in 2018, P < .001). Physician barriers to providing HPV vaccination were rare and decreased over time. Increasing numbers of physicians reported perceived parental barriers of vaccine safety concerns (5% "major barrier" in 2008 vs 35% in 2018, P < .0001) and moral/religious concerns (5% in 2008 vs 25% in 2018, P < .0001). CONCLUSIONS: Between 2008 and 2018, more primary care physicians reported recommending HPV vaccination for adolescents, fewer reported barriers, and more physicians reported parents who had vaccine safety or moral/religious concerns.

Pediatricians' Knowledge and Practices Related to Mumps Diagnosis and Prevention.

OBJECTIVES: To assess pediatricians' mumps knowledge and testing practices, to identify physician and practice characteristics associated with mumps testing practices, and to assess reporting and outbreak response knowledge and practices. STUDY DESIGN: Between January and April 2020, we surveyed a nationally representative network of pediatricians. Descriptive statistics were generated for all items. The χ2 test, t tests, and Poisson regression were used to compare physician and practice characteristics between respondents who would rarely or never versus sometimes or often/always test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting. RESULTS: The response rate was 67% (297 of 444). For knowledge, more than one-half of the pediatricians responded incorrectly or "don't know" for 6 of the 9 true/false statements about mumps epidemiology, diagnosis, and prevention, and more than one-half reported needing additional guidance on mumps buccal swab testing. For testing practices, 59% of respondents reported they would sometimes (35%) or often/always (24%) test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting; older physicians, rural physicians, and physicians from the Northeast or Midwest were more likely to test for mumps. Thirty-six percent of the pediatricians reported they would often/always report a patient with suspected mumps to public health authorities. CONCLUSIONS: Pediatricians report mumps knowledge gaps and practices that do not align with public health recommendations. These gaps may lead to underdiagnosis and underreporting of mumps cases, delaying public health response measures and contributing to ongoing disease transmission.

Use of High-Dose Influenza and Live Attenuated Influenza Vaccines by US Primary Care Physicians.

BACKGROUND: Several different types of influenza vaccine are licensed for use in adults in the USA including high-dose inactivated influenza vaccine (HD-IIV) and live attenuated influenza vaccine (LAIV). HD-IIV is licensed for use in adults ≥ 65 years, and recommendations for use of LAIV have changed several times in recent years. OBJECTIVE: We sought to examine family physicians' (FPs) and general internal medicine physicians' (GIMs) perceptions, knowledge, and practices for use of HD-IIV and LAIV during the 2016-2017 and 2018-2019 influenza seasons. DESIGN: E-mail and mail surveys conducted February-March 2017, January-February 2019. PARTICIPANTS: Nationally representative samples of FPs and GIMs. MAIN MEASURES: Surveys assessed HD-IIV practices (2017), knowledge and perceptions (2019), and LAIV knowledge and practices (2017, 2019). KEY RESULTS: Response rates were 67% (620/930) in 2017 and 69% (642/926) in 2019. Many physicians believed HD-IIV is more effective than standard dose IIV in patients ≥ 65 years (76%) and reported their patients ≥ 65 years believe they need HD-IIV (67%). Most respondents incorrectly thought ACIP preferentially recommends HD-IIV for adults ≥ 65 years (88%); 65% "almost always/always" recommended HD-IIV for adults ≥ 65 years. Some physicians incorrectly thought ACIP preferentially recommends HD-IIV for adults < 65 years with cardiopulmonary disease (38%) or immunosuppression (48%); some respondents recommended HD-IIV for these groups (25% and 28% respectively). In 2017, 88% of respondents knew that ACIP recommended against using LAIV during the 2016-2017 influenza season, and 4% recommended LAIV to patients. In 2019, 63% knew that ACIP recommended that LAIV could be used during the 2018-2019 influenza season, and 8% recommended LAIV. CONCLUSIONS: Many physicians incorrectly thought ACIP had preferential recommendations for HD-IIV. Physicians should be encouraged to use any available age-appropriate influenza vaccine to optimize influenza vaccination particularly among older adults and patients with chronic conditions who are more vulnerable to severe influenza disease.

Shared Clinical Decision-Making Recommendations for Adult Immunization: What Do Physicians Think?

BACKGROUND: In 2019, the Advisory Committee on Immunization Practices (ACIP) incorporated the terminology "shared clinical decision-making" (SDM) into recommendations for two adult vaccines. OBJECTIVE: To assess among general internal medicine physicians (GIMs) and family physicians (FPs) nationally (1) attitudes about and experience with ACIP SDM recommendations, (2) knowledge of insurance reimbursement for vaccines with SDM recommendations, (3) how SDM recommendations are incorporated into vaccine forecasting software, and (4) physician and practice characteristics associated with not knowing how to implement SDM. DESIGN: Survey conducted in October 2019-January 2020 by mail or internet based on preference. PARTICIPANTS: Networks of GIMs and FPs recruited from American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) who practice ≥ 50% in primary care. Post-stratification quota sampling performed to ensure networks similar to ACP and AAFP memberships. MAIN MEASURES: Responses on 4-point Likert scales (attitudes/experiences), true/false options (knowledge), and categorical response options (forecasting). Multivariable modeling with outcome of "not knowing how to implement SDM" conducted. KEY RESULTS: Response rate was 64% (617/968). Most physicians strongly/somewhat agreed SDM requires more time than routine recommendations (90%FP; 95%GIM, p = 0.02) and that they need specific talking points to guide SDM discussions (79%FP; 84%GIM, p = NS). There was both support for SDM recommendations for certain vaccines (81%FP; 75%GIM, p = 0.06) and agreement that SDM creates confusion (64%FP; 76%GIM, p = 0.001). Only 41%FP and 43%GIM knew vaccines recommended for SDM would be covered by most health insurance. Overall, 38% reported SDM recommendations are displayed as "recommended" and 23% that they did not result in any recommendation in forecasting software. In adjusted multivariable models, GIMs [risk ratio 1.44 (1.15-1.81)] and females [1.28 (1.02-1.60)] were significantly associated with not knowing how to implement SDM recommendations CONCLUSIONS: To be successful in a primary care setting, SDM for adult vaccination will require thoughtful implementation with decision-making support for patients and physicians.

Barriers to Pretransplant Immunization: A Qualitative Interview Study of Pediatric Solid Organ Transplant Stakeholders.

OBJECTIVES: To describe the experiences and beliefs of pediatric transplant stakeholders regarding factors that contribute to low pretransplant immunization rates. STUDY DESIGN: Semistructured interviews were conducted with transplant team members (hepatologists, cardiologists, nephrologists, transplant nurse coordinators, and transplant infectious diseases physicians), primary care physicians, and parents of heart, liver, and kidney transplant recipients at 3 geographically diverse large pediatric transplant centers in the US. Interviews were conducted between July 2017 and February 2020 until thematic saturation was reached within each stakeholder subgroup. Content analysis methodology was used to identify themes. RESULTS: Stakeholders participated in 30- to 60-minute interviews (16 transplant subspecialists, 3 transplant infectious diseases physicians, 11 transplant nurse coordinators, 12 primary care physicians, and 40 parents). Five central themes emerged: (1) gaps in knowledge about timing and safety of pretransplant immunizations, (2) lack of communication, coordination, and follow-up between team members regarding immunizations, (3) lack of centralized immunization records, (4) subspecialty clinic functioning as the medical home for transplant candidates but unable to provide all needed immunizations, and (5) differences between organ type in prioritization and completion of pretransplant immunization. CONCLUSIONS: There are multiple factors that contribute to low immunization rates among pediatric transplant candidates. New tools are needed to overcome these barriers and increase immunization rates in transplant candidates.

Development and Validation of a Predictive Model of the Risk of Pediatric Septic Shock Using Data Known at the Time of Hospital Arrival.

OBJECTIVE: To derive and validate a model of risk of septic shock among children with suspected sepsis, using data known in the electronic health record at hospital arrival. STUDY DESIGN: This observational cohort study at 6 pediatric emergency department and urgent care sites used a training dataset (5 sites, April 1, 2013, to December 31, 2016), a temporal test set (5 sites, January 1, 2017 to June 30, 2018), and a geographic test set (a sixth site, April 1, 2013, to December 31, 2018). Patients 60 days to 18 years of age in whom clinicians suspected sepsis were included; patients with septic shock on arrival were excluded. The outcome, septic shock, was systolic hypotension with vasoactive medication or ≥30 mL/kg of isotonic crystalloid within 24 hours of arrival. Elastic net regularization, a penalized regression technique, was used to develop a model in the training set. RESULTS: Of 2464 included visits, septic shock occurred in 282 (11.4%). The model had an area under the curve of 0.79 (0.76-0.83) in the training set, 0.75 (0.69-0.81) in the temporal test set, and 0.87 (0.73-1.00) in the geographic test set. With a threshold set to 90% sensitivity in the training set, the model yielded 82% (72%-90%) sensitivity and 48% (44%-52%) specificity in the temporal test set, and 90% (55%-100%) sensitivity and 32% (21%-46%) specificity in the geographic test set. CONCLUSIONS: This model estimated the risk of septic shock in children at hospital arrival earlier than existing models. It leveraged the predictive value of routine electronic health record data through a modern predictive algorithm and has the potential to enhance clinical risk stratification in the critical moments before deterioration.

Effect of State Immunization Information System Based Reminder/Recall for Influenza Vaccinations: A Randomized Trial of Autodialer, Text, and Mailed Messages.

OBJECTIVE: To evaluate the effect of different modalities of centralized reminder/recall (autodialer, text, mailed reminders) on increasing childhood influenza vaccination. STUDY DESIGN: Two simultaneous randomized clinical trials conducted from October 2017 to April 1, 2018, in New York State and Colorado. There were 61 931 children in New York (136 practices) and 23 845 children in Colorado (42 practices) who were randomized to different centralized reminder/recall modalities-4 arms in New York (autodialer, text, mailed, and no reminder control) and 3 arms in Colorado (autodialer, mailed, and no reminder control). The message content was similar across modalities. Up to 3 reminders were sent for intervention arms. The main outcome measure was receipt of ≥1 influenza vaccine. RESULTS: In New York, compared with the control arm (26.6%), postintervention influenza vaccination rates in the autodialer arm (28.0%) were 1.4 percentage points higher (adjusted risk ratio, 1.06; 95% CI, 1.02-1.10), but the rates for text (27.6%) and mail (26.8%) arms were not different from controls. In Colorado, compared with the control arm (29.9%), postintervention influenza vaccination rates for the autodialer (32.9%) and mail (31.5%) arms were 3.0 percentage points (adjusted risk ratio, 1.08; 95% CI, 1.03-1.12) and 1.6 percentage points (adjusted risk ratio, 1.06; 95% CI, 1.02-1.10) higher, respectively. Compared with the control arm, the incremental cost per additional vaccine delivered was $20 (New York) and $16 (Colorado) for autodialer messages. CONCLUSIONS: Centralized reminder/recall for childhood influenza vaccine was most effective via autodialer, less effective via mail, and not effective via text messages. The impact of each modality was modest. Compared with no reminders, the incremental cost per additional vaccine delivered was also modest for autodialer messages. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03294473 and NCT03246100.

Under-immunization of pediatric transplant recipients: a call to action for the pediatric community.

Vaccine-preventable infections (VPIs) are a common and serious complication following transplantation. One in six pediatric solid organ transplant recipients is hospitalized with a VPI in the first 5 years following transplant and these hospitalizations result in significant morbidity, mortality, graft injury, and cost. Immunizations are a minimally invasive, cost-effective approach to reducing the incidence of VPIs. Despite published recommendations for transplant candidates to receive all age-appropriate immunizations, under-immunization remains a significant problem, with the majority of transplant recipients not up-to-date on age-appropriate immunizations at the time of transplant. This is extremely concerning as the rate for non-medical vaccine exemptions in the United States (US) is increasing, decreasing the reliability of herd immunity to protect patients undergoing transplant from VPIs. There is an urgent need to better understand barriers to vaccinating this population of high-risk children and to develop effective interventions to overcome these barriers and improve immunization rates. Strengthened national policies requiring complete age-appropriate immunization for non-emergent transplant candidates, along with improved multi-disciplinary immunization practices and tools to facilitate and ensure complete immunization delivery to this high-risk population, are needed to ensure that we do everything possible to prevent infectious complications in pediatric transplant recipients.

Survey of Adult Influenza Vaccination Practices and Perspectives Among US Primary Care Providers (2016-2017 Influenza Season).

BACKGROUND: Seasonal influenza vaccination is recommended for all adults; however, little is known about how primary care physicians can communicate effectively with patients about influenza vaccination. OBJECTIVE: To assess among general internal medicine (GIM) and family physicians (FP) regarding adult influenza vaccination: (1) recommendation and administration practices, (2) barriers to discussing and perceived reasons for patient refusal, and (3) factors associated with physician self-efficacy in convincing patients to be vaccinated. DESIGN: Email and mail survey conducted in February-March 2017 PARTICIPANTS: Nationally representative sample of GIM and FP MAIN MEASURES: Factor analysis was used to group similar items for multivariable analysis of barriers and strategies associated with high physician self-efficacy about convincing patients to be vaccinated (defined as disagreeing that they could do nothing to change resistant patients' minds). KEY RESULTS: Response rate was 67% (620/930). Ninety-eight percent always/almost always recommended influenza vaccine to adults ≥ 65 years, 90% for adults 50-64 years, and 75% for adults 19-49 years. Standing orders (76%) and electronic alerts (64%) were the most commonly used practice-based immunization strategies. Frequently reported barriers to discussing vaccination were other health issues taking precedence (41%), time (29%), and feeling they were unlikely to change patients' minds (24%). Fifty-eight percent of physicians reported high self-efficacy about convincing patients to be vaccinated; these providers reported fewer patient belief barriers contributing to vaccine refusal (RR = 0.93 per item; 95% CI (0.89-0.98); Cronbach's α = 0.70), were more likely to report using both fact- (1.08/item; (1.03-1.14); 0.66) and personal experience-based (1.07/item; (1.003-1.15); 0.65) communication strategies, and were more likely to work in practices using patient reminders for influenza vaccine (1.32; (1.16-1.50)). CONCLUSIONS: Physicians identified barriers to successfully communicating about adult influenza vaccination but few effective strategies to counter them. Interventions to promote self-efficacy in communication and under-utilized practice-based immunization strategies are needed.

The Sensitivity of Clinician Diagnosis of Sepsis in Tertiary and Community-Based Emergency Settings.

OBJECTIVES: To assess whether the risk of missed clinician diagnosis of pediatric sepsis requiring care in the intensive care unit (ICU) was greater in community vs tertiary pediatric emergency care settings with sepsis pathways. STUDY DESIGN: An observational cohort study in a tertiary pediatric emergency department (ED) staffed by pediatric emergency physicians and 4 affiliated community pediatric ED/urgent care sites staffed by general pediatricians. Use of an institutional sepsis order set or pathway was considered clinician diagnosis of sepsis. Risk of missed diagnosis was compared for 2 outcomes: suspected infection plus ICU admission (sepsis-ICU) and suspected infection plus vasoactive agent/positive-pressure ventilation (sepsis-VV). RESULTS: From January 1, 2014 to December 31, 2015, there were 141 552 tertiary and 139 332 community emergency visits. Clinicians diagnosed sepsis in 1136 visits; median age was 5.7 (2.4, 12.0) years. In the tertiary ED, there were 306 sepsis-ICU visits (0.2%) and 112 sepsis-VV visits (0.08%). In community sites, there were 46 sepsis-ICU visits (0.03%) and 20 sepsis-VV visits (0.01%). The risk of missed diagnosis in community vs tertiary sites was significantly greater for sepsis-ICU (relative risk 4.30, CI 2.15-8.60) and sepsis-VV (relative risk 14.0, CI 2.91-67.24). Sensitivity for sepsis-ICU was 94.4% (91.3%-96.5%) at the tertiary site and 76.1% (62.1%-86.1%) at community sites. CONCLUSIONS: The risk of missed diagnosis of sepsis-ICU was greater in community vs tertiary emergency care settings despite shared pathways and education, but with differences in resources, providers, and sepsis incidence. More research is needed to optimize diagnostic approaches in all settings.

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger - United States, 2018.

In October 2017, the Advisory Committee on Immunization Practices (ACIP) approved the Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger - United States, 2018. The 2018 child and adolescent immunization schedule summarizes ACIP recommendations, including several changes from the 2017 immunization schedules, in three figures and footnotes to the figures. These documents can be found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules/index.html). These immunization schedules are approved by ACIP (https://www.cdc.gov/vaccines/acip/index.html), the American Academy of Pediatrics (https://www.aap.org), the American Academy of Family Physicians (https://www.aafp.org), and the American College of Obstetricians and Gynecologists (https://www.acog.org). Health care providers are advised to use the figures and the footnotes together. The full ACIP recommendations for each vaccine, including contraindications and precautions, can be found at https://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Providers should be aware that changes in recommendations for specific vaccines can occur between annual updates to the childhood/adolescent immunization schedules. If errors or omissions are discovered within the child and adolescent schedule, CDC posts revised versions on the CDC immunization schedule website.

Hospitalizations for Respiratory Syncytial Virus and Vaccine-Preventable Infections in the First 2 Years After Pediatric Liver Transplant.

OBJECTIVES: To examine in liver transplant recipients at centers participating in the Pediatric Health Information System dataset the number of hospitalizations for respiratory syncytial virus (RSV) and vaccine-preventable infections (VPIs) in the first 2 years after transplantation, morbidity and mortality associated with these hospitalizations, and costs associated with these hospitalizations. STUDY DESIGN: A retrospective cohort study of patients <18 years of age who underwent liver transplantation at a Pediatric Health Information System center between January 1, 2004, and December 31, 2012. Hospitalizations for RSV/VPIs during the first 2 years post-transplant were ascertained using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were collected on clinical care, outcomes, and costs during these hospitalizations. RESULTS: There were 2554 liver transplant recipients identified; 415 patients (16.3%) had 544 cases of RSV/VPIs. RSV, rotavirus, and influenza were the most common infections resulting in hospitalization. Ninety-two patients (3.6%) had RSV/VPI during their transplant hospitalization. Transplant hospitalizations complicated by RSV/VPI were longer (44 days vs. 21 days; P < .001), had higher rejection rates (37% vs. 26%; P = .02), and were more expensive ($259 697 vs. $190 860; P < .001). Multivariate analyses identified age <2 years at transplant (P < .001) and multivisceral recipient (P = .04) as predictors of a hospitalization for RSV. CONCLUSIONS: VPIs occurred in 1 of 6 liver transplant recipients in the first 2 years post-transplant, a significantly higher rate than in the general pediatric population. These hospitalizations had substantial morbidity, mortality, and costs, demonstrating the importance of vaccinating patients before transplantation.

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger - United States, 2017.

In October 2016, the Advisory Committee on Immunization Practices (ACIP) approved the Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger-United States, 2017. The 2017 child and adolescent immunization schedule summarizes ACIP recommendations, including several changes from the 2016 immunization schedules, in three figures, and footnotes for the figures. These documents can be found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules/index.html). These immunization schedules are approved by ACIP (https://www.cdc.gov/vaccines/acip/index.html), the American Academy of Pediatrics (https://www.aap.org), the American Academy of Family Physicians (https://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org). Health care providers are advised to use the figures and the combined footnotes together. The full ACIP recommendations for each vaccine, including contraindications and precautions, can be found at https://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Providers should be aware that changes in recommendations for specific vaccines can occur between annual updates to the childhood/adolescent immunization schedules. If errors or omissions are discovered within the child and adolescent schedule, CDC posts revised versions on the CDC immunization schedule website.