Development and evaluation of virtual simulation games to increase the confidence and self-efficacy of healthcare learners in vaccine communication, advocacy, and promotion.

BACKGROUND: Although healthcare providers (HCPs) are the most trusted source of vaccine information, there is a paucity of easily accessible, multidisciplinary educational tools on vaccine communication for them. Virtual simulation games (VSGs) are innovative yet accessible and effective tools in healthcare education. The objectives of our study were to develop VSGs to increase HCP confidence and self-efficacy in vaccine communication, advocacy, and promotion, and evaluate the VSGs' effectiveness using a pre-post self-assessment pilot study. METHODS: A multidisciplinary team of experts in medicine, nursing, pharmacy, and simulation development created three VSGs for HCP learners focused on addressing conversations with vaccine hesitant individuals. We evaluated the VSGs with 24 nursing students, 30 pharmacy students, and 18 medical residents who completed surveys and 6-point Likert scale pre-post self-assessments to measure changes in their confidence and self-efficacy. RESULTS: There were no significant differences in baseline confidence and self-efficacy across the three HCP disciplines, despite varied levels of education. Post-VSG confidence and self-efficacy (median: 5) were significantly higher than pre-VSG (median: 4-5) for all three HCP disciplines (P ≤ 0.0005), highlighting the effectiveness of the VSGs. Medical residents reported significantly lower post-VSG confidence and self-efficacy than nursing and pharmacy learners despite completing the most significant amount of education. CONCLUSIONS: Following the completion of the VSGs, learners in medicine, nursing, and pharmacy showed significant improvement in their self-assessed confidence and self-efficacy in holding vaccine conversations. The VSGs as an educational tool, in combination with existing clinical immunization training, can be used to increase HCP confidence and engagement in vaccine discussions with patients, which may ultimately lead to increased vaccine confidence among patients.

A mixed-methods needs assessment for an antimicrobial stewardship curriculum in pediatrics.

Objective: Antimicrobial stewardship (AS) education initiatives for multidisciplinary teams are most successful when addressing psychosocial factors driving antimicrobial prescribing (AP) and when they address the needs of the team to allow for a tailored approach to their education. Design: We conducted a mixed-methods embedded study as a needs assessment, involving quantitative analysis of AS concerns observed by pharmacists through an audit while attending clinical team rounds, as well as qualitative semi-structured interviews based on the Theoretical Domain Framework (TDF) to identify psychosocial barriers and facilitators for antimicrobial prescribing for an inpatient general pediatric service. We analyzed the data using deductive and inductive methods by mapping the TDF to a model for social determinants of antimicrobial prescribing (SDAP) in pediatric inpatient health care teams. Setting: The Clinical Teaching Unit (CTU) and Pediatric Intensive Care Unit (PICU), at a tertiary care pediatric hospital in Canada. Participants: Interviews (n = 23) with staff and resident physicians, nurse practitioners, and pharmacists. Results: Psychosocial facilitators and barriers for AS practice in the PICU and CTU which were identified included: collaboration, shared decision-making, locally accessible guidelines, and an overarching goal of doing right by the patient and feeling empowered as a prescriber. Some of the barriers identified included the norm of noninterference, professional comparisons, limited resources, feeling inadequately trained in AS, emotional prescribing, and a pejorative monitoring system. Conclusions: Our findings identified barriers and facilitators to AS decisions on pediatric inpatient teams as well as actionable needs in psychosocial-based AS education.

Normal Infant Immunologic Assessment and Uneventful Live Rotavirus Vaccination Despite Continuous Tofacitinib Exposure In Utero and During Breastfeeding.

Background: Janus kinase (JAK) inhibitors are effective for the treatment of inflammatory bowel disease (IBD). However, this class of medications is not recommended during pregnancy or breastfeeding based on animal data suggesting teratogenesis and recent reports of transmammary transfer after maternal ingestion, raising concerns for immune system development in babies exposed to these drugs. Methods: We present the case of a patient with IBD treated with a JAK inhibitor who decided to continue the medication throughout her pregnancy and during breastfeeding. This is the first reported case of a detailed immunologic profile in a baby exposed to tofacitinib in utero and during lactation. Results: A 30-year-old female with ulcerative colitis with previous exposure to vedolizumab and infliximab achieved complete remission with tofacitinib therapy. The patient became pregnant after 5 months of JAK inhibitor therapy and decided to continue tofacitinib during pregnancy and while breastfeeding. The patient delivered a healthy offspring with no congenital malformations, a normal detailed immunologic profile, and subsequent safe provision of the live oral rotavirus vaccine. Conclusions: This case highlights the importance of individualized counseling for patients of childbearing age who are candidates for JAK inhibition. Those who are pregnant or breastfeeding with refractory disease may have limited medical therapeutic options. Ongoing effective therapy for IBD resulted in complete disease remission in the mother and favorable outcomes in the infant. Further, an in-depth infant immunological assessment can lead to specific vaccination recommendations in exposed infants.

Case report: Blotchy skin in a puffy neonate: is there a new association?

Introduction: Purpura fulminans in the neonatal population is a rare but potentially life-threatening condition complicated by thrombosis, resultant vital organ necrosis, and gangrene of the extremities. Considering the rapid evolution of the pathogenetic mechanism, an index of suspicion, early identification, and prompt intervention are imperative for improved outcomes. The majority of purpura fulminans cases have an infectious etiology, but it is essential to consider other congenital and acquired causes. Case description: We present a clinical case of a female neonate to emphasize the correlation between purpura fulminans, congenital chylothorax, involvement of the PAK2 gene, and the occurrence of retinal detachment in both eyes. After draining the congenital chylothorax, the neonate developed purpura fulminans due to a loss of protein C, S, and antithrombin factors, previously not reported in the literature. The purpuric lesions resolved after the administration of fresh frozen plasma. Subsequently, no recurring purpura fulminans lesions were noted following the normalization of the antithrombotic factor levels in the serum. Subsequently, the child also developed retinal detachment in both eyes.

Antibiotic Prescribing Practices for Urinary Tract Infection in a Pediatric Emergency Department: Is This a Problem Worth Cefix-ing?

Background: Pediatric urinary tract infection (UTI) is associated with diagnostic and therapeutic challenges. Objective: To determine the least-broad-spectrum oral antibiotic that would cover 80% of pathogens from lower (afebrile) and upper (febrile) UTIs in a Canadian pediatric emergency department (ED). Methods: This retrospective case series involved children discharged from the ED between September 2020 and February 2021 with a diagnosis of UTI and collection of a sample for urinalysis that had growth on culture. Results: Of 188 patients who met the inclusion criteria, 184 (97.9%) were discharged on antibiotics. Culture results indicated a UTI in 170 cases (92.4% of those discharged on antibiotics). The 95 urinary isolates from lower UTIs were susceptible to cephalexin (n = 81, 85.3%), cefixime (n = 78, 82.1%), nitrofurantoin (n = 76, 80.0%), trimethoprim-sulfamethoxazole (TMP-SMX) (n = 64, 67.4%), and amoxicillin (n = 55, 57.9%). The 75 urinary isolates from upper UTIs were susceptible to cefixime (n = 71, 94.7%), TMP-SMX (n = 57, 76.0%), and amoxicillin (n = 48, 64.0%). The mean prescribed duration of antibiotic therapy was 8.3 days for patients with a lower UTI and 9.1 days for those with an upper UTI (mean difference 0.80 days, 95% confidence interval 0.05-1.54). Conclusions: Empiric treatment with cephalexin or nitrofurantoin would have been successful for almost all lower UTIs. More complete reporting of cephalexin minimal inhibitory concentrations might have allowed use of this drug for most upper UTIs. Although there was a trend toward shorter duration of therapy for lower versus upper UTI, lower UTIs were always treated for longer than recommended by current guidelines.

Contexte: L'infection des voies urinaires (IVU) pédiatrique présente des défis diagnostiques et thérapeutiques. Objectif: Déterminer l'antibiotique oral à large spectre le moins élevé qui couvrirait 80 % des pathogènes des IVU inférieures (sans fièvre) et des IVU supérieures (avec fièvre) dans un service d'urgences pédiatriques canadien. Méthodes: Cette série de cas rétrospective impliquait des enfants sortis du service des urgences entre septembre 2020 et février 2021 avec un diagnostic d'IVU et la collecte d'un échantillon pour une analyse d'urine avec croissance dans la culture d'urine. Résultats: Parmi les 188 patients répondant aux critères d'inclusion, 184 (97,9 %) ont reçu des antibiotiques au moment du congé. Les résultats de la culture ont indiqué une IVU dans 170 cas (92,4 % des patients ayant reçu des antibiotiques au moment du congé). Les 95 isolats urinaires des IVU inférieures étaient sensibles à la céphalexine (n = 81, 85,3 %), au céfixime (n = 78, 82,1 %), à la nitrofurantoïne (n = 76, 80,0 %), au triméthoprime-sulfaméthoxazole (TMP-SMX) (n = 64, 67,4 %) et à l'amoxicilline (n = 55, 57,9 %). Les 75 isolats urinaires des IVU supérieures étaient sensibles au céfixime (n = 71, 94,7 %), au TMP-SMX (n = 57, 76,0 %) et à l'amoxicilline (n = 48, 64,0 %). La durée moyenne de prescription d'antibiotiques était de 8,3 jours pour les patients atteints d'une IVU inférieure et de 9,1 jours pour ceux atteints d'une IVU supérieure (différence moyenne 0,80 jours, IC à 95 % 0,05­1,54). Conclusions: Un traitement empirique avec la céphalexine ou la nitrofurantoïne aurait été efficace pour la grande majorité des infections urinaires inférieures. Un rapport plus complet des concentrations minimales inhibitrices de la céphalexine aurait peut-être permis d'utiliser ce médicament pour la plupart des infections urinaires supérieures. Bien qu'il y ait eu une tendance vers une durée de traitement plus courte pour les infections urinaires inférieures par rapport aux infections urinaires supérieures, les infections urinaires inférieures étaient toujours traitées plus longtemps que ce qui est recommandé par les lignes directrices actuelles.

Factors associated with intention for revaccination among patients with adverse events following immunization.

OBJECTIVES: Individuals and healthcare providers may be uncertain about the safety of revaccination after an adverse event following immunization (AEFI). We identified factors associated with physician recommendation for revaccination and participant intention to be revaccinated among patients with adverse events following immunization (AEFIs) assessed in the Canadian Special Immunization Clinic (SIC) Network from 2013 to 2019. METHODS: This prospective observational study included patients assessed in the Canadian Special Immunization Clinic Network from 2013 to 2019 for an AEFI who required additional doses of the vaccine temporally associated with their AEFI. Participants underwent standardized assessment and data collection. Physician recommendations regarding revaccination and participant intent for revaccination were recorded. AEFI impact on daily activities and need for medical attention was captured as low, moderate, high impact and serious (e.g., requiring hospitalization). Multivariable logistic regression analysis identified factors associated with physician recommendation and participant intention for revaccination, controlling for province of assessment. RESULTS: Physician recommendation was significantly associated with the type of AEFI and AEFI impact. Compared to large local reaction, physician recommendation for revaccination was reduced for immediate hypersensitivity (aOR: 0.24 [95% CI: 0.08-0.76]) and new onset autoimmune disease (aOR: 0.16; 95% CI: 0.04-0.69). Compared to low impact AEFIs, physician recommendation was reduced for moderate (aOR: 0.22 [95% CI: 0.07-0.65]), high impact (aOR: 0.08 [95% CI: 0.02-0.30]), and serious AEFIs (aOR: 0.11 [95% CI: 0.03-0.37]). Participant intention for revaccination was significantly associated with AEFI impact, with reduced odds for high versus low impact AEFIs (aOR: 0.12 [95% CI: 0.04-0.42]). CONCLUSION: Physicians appear to use AEFI type and impact to guide recommendations while patients use primarily AEFI impact to form intentions for revaccination. The findings may help inform counselling for patients with AEFIs.

Barriers experienced by families new to Alberta, Canada when accessing routine-childhood vaccinations.

BACKGROUND: As Canada and other high-income countries continue to welcome newcomers, we aimed to 1) understand newcomer parents' attitudes towards routine-childhood vaccinations (RCVs), and 2) identify barriers newcomer parents face when accessing RCVs in Alberta, Canada. METHODS: Between July 6th-August 31st, 2022, we recruited participants from Alberta, Canada to participate in moderated focus group discussions. Inclusion criteria included parents who had lived in Canada for < 5 years with children < 18 years old. Focus groups were transcribed verbatim and analyzed using content and deductive thematic analysis. The capability opportunity motivation behaviour model was used as our conceptual framework. RESULTS: Four virtual and three in-person focus groups were conducted with 47 participants. Overall, parents were motivated and willing to vaccinate their children but experienced several barriers related to their capability and opportunity to access RCVs. Five main themes emerged: 1) lack of reputable information about RCVs, 2) language barriers when looking for information and asking questions about RCVs, 3) lack of access to a primary care provider (PCP), 4) lack of affordable and convenient transportation options, and 5) due to the COVID-19 pandemic, lack of available vaccine appointments. Several minor themes were also identified and included barriers such as lack of 1) childcare, vaccine record sharing, PCP follow-up. CONCLUSIONS: Our findings highlight that several barriers faced by newcomer families ultimately stem from issues related to accessing information about RCVs and the challenges families face once at vaccination clinics, highlighting opportunities for health systems to better support newcomers in accessing RCVs.

Immunological effects and safety of live rotavirus vaccination after antenatal exposure to immunomodulatory biologic agents: a prospective cohort study from the Canadian Immunization Research Network.

BACKGROUND: People with inflammatory or autoimmune diseases are recommended to continue immunomodulatory biologic agents throughout pregnancy. However, concerns regarding potential immunosuppression in infants exposed to biologic agents have led to recommendations to avoid live vaccines in the first 6-12 months of life. We aimed to examine whether live rotavirus vaccine could be administered safely to infants exposed to biologic agents, assessed in the Canadian Special Immunization Clinic (SIC) Network. METHODS: In this prospective cohort study, infants exposed to biologic agents in utero were referred to one of six SIC sites in Canada for rotavirus vaccination recommendations. Children with other contraindications to rotavirus vaccination or older than 15 weeks were excluded. Clinical and laboratory evaluations were conducted according to a standard clinical pathway. Data were collected for relevant medical history, pregnancy outcomes, biologic agent exposure history, physical examination, laboratory results of the child, SIC recommendations for rotavirus vaccination, rotavirus vaccine series completion, and adverse events after immunisation. After parental consent, deidentified data were transferred to a central database for analysis. Children recommended for rotavirus vaccination were followed up for 8 months after series initiation to ascertain severe and serious adverse events, including severe diarrhoea, vomiting, and intussusception. FINDINGS: Between May 1, 2017, and Dec 31, 2021, 202 infants were assessed and 191 eligible infants were enrolled (97 [51%] were female and 94 [49%] were male). When including those exposed to multiple agents, the most common biologic agents to which infants were exposed were infliximab (67 [35%] of 191), adalimumab (49 [26%]), ustekinumab (18 [9%]), and vedolizumab (17 [9%]). Biologic agent exposure continued into the third trimester for 178 (93%) infants. No clinically significant abnormalities in lymphocyte subsets, quantitative immunoglobulins, or mitogen responses were detected. After SIC assessment, rotavirus vaccination was recommended for 187 (98%) of 191 infants, all of whom were followed up. By end of follow-up on Aug 19, 2022, 168 (90%) infants had initiated rotavirus vaccination; 150 (80%) completed the series. No serious adverse events after immunisation were reported, but three (2%) infants required medical attention, one for vomiting and change in stools who was subsequently diagnosed with gastroesophageal reflux disease, one for rash on labia unrelated to vaccination, and one for vomiting and diarrhoea associated with a milk allergy. INTERPRETATION: Findings from this study suggest that lymphocyte subsets and the safety of live rotavirus vaccination are generally not affected by in-utero exposure to biologic agents. Rotavirus vaccination can be offered to infants exposed to anti-TNF agents in utero. FUNDING: Public Health Agency of Canada and Canadian Institutes of Health Research through the Canadian Immunization Research Network.

The Alberta Telestewardship Network: Building a platform to enable capacity building in antimicrobial stewardship-results of an initial pilot study.

Background: Resources to improve antimicrobial stewardship (AS) are limited, but a telestewardship platform can enable capacity building and scalability. The Alberta Telestewardship Network (ATeleNet) was designed to focus on outreach across the province of Alberta, Canada, and facilitate AS activities. Methods: Outreach occurred virtually between pharmacists and physicians in hospital and long-term care settings throughout Alberta via secure, enterprise video conferencing software on both desktop and mobile devices. We used a quantitative questionnaire adapted from the telehealth usability questionnaire to capture the health provider's experience during each session. The questionnaire consisted of 39 questions, and a 5-point Likert scale was used to assess the degree of agreement and collate responses into a descriptive analysis. Results: A total of 33 pilot consultations were completed between July 6, 2020 and December 15, 2021. The majority (22, 85%) of respondents agreed that video conference-based virtual sessions are an acceptable means to provide health care and that they were able to express themselves effectively to other health care professionals (23, 88%). Respondents agreed the system was simple to use (23, 96%), and that they could become productive quickly using the system (23, 88%). Overall, 24 (92%) respondents were satisfied or very satisfied with the virtual care platform. Conclusions: We implemented and evaluated a telehealth consultation and collaborative care service between AS providers at multiple centres. AHS has since prioritized similar workflows, including access to specialists in acute care, as part of their virtual health strategy. Evaluation results will be shared with provincial stakeholders for further strategic planning and deployment.

Historique: Les ressources pour améliorer la gérance antimicrobienne (GA) sont limitées, mais une plateforme de télégérance peut favoriser le renforcement des capacités et l'échelonnabilité. L'Alberta Telestewardship Network (réseau de télégérance de l'Alberta, ou ATeleNet) a été conçu pour mettre l'accent sur le rayonnement dans la province de l'Alberta, au Canada et pour faciliter les activités de GA. Méthodologie: Le rayonnement s'est produit virtuellement entre des pharmaciens et des médecins d'établissements hospitaliers et d'établissements de soins de longue durée de l'Alberta par logiciel de visioconférence sécurisé sur des ordinateurs de bureau et des appareils mobiles. Les chercheurs ont utilisé un questionnaire quantitatif adapté du questionnaire sur la convivialité de la télésanté pour saisir l'expérience du dispensateur de soins lors de chaque séance. Le questionnaire était composé de 39 questions, et une échelle de Likert de cinq points a permis d'évaluer le degré d'entente et de recueillir les réponses dans une analyse descriptive. Résultats: Au total, les chercheurs ont effectué 33 consultations pilotes entre le 6 juillet 2020 et le 15 décembre 2021. La majorité des répondants (n = 22, 85 %) ont convenu que les séances en visioconférence représentaient un moyen acceptable de fournir des soins de santé et leur permettaient de s'exprimer avec efficacité auprès des autres professionnels de la santé (n = 23, 88 %). Les répondants ont indiqué que le système était facile à utiliser (n = 23, 96 %), et qu'ils pouvaient vite devenir productifs (n = 23, 88 %). Dans l'ensemble, 24 répondants (92 %) étaient satisfaits ou très satisfaits de la plateforme de soins virtuels. Conclusions: Les chercheurs ont lancé et évalué une consultation en télésanté et un service de soins coopératifs entre fournisseurs de GA de multiples centres. Depuis, les Services de santé de l'Alberta ont priorisé des processus de travail semblables dans leur stratégie de santé virtuelle, y compris pour l'accès à des spécialistes en soins aigus. Les résultats de l'évaluation seront transmis à des intervenants provinciaux en vue d'une planification et d'un déploiement stratégiques.

Persuasive Messages for Improving Adherence to COVID-19 Prevention Behaviors: Randomized Online Experiment.

BACKGROUND: Adherence to nonpharmaceutical interventions for COVID-19, including physical distancing, masking, staying home while sick, and avoiding crowded indoor spaces, remains critical for limiting the spread of COVID-19. OBJECTIVE: The aim of this study was to test the effectiveness of using various persuasive appeals (deontological moral frame, empathy, identifiable victim, goal proximity, and reciprocity) at improving intentions to adhere to prevention behaviors. METHODS: A randomized online experiment using a representative sample of adult Canadian residents with respect to age, ethnicity, and province of residence was performed from March 3 to March 6, 2021. Participants indicated their intentions to follow public health guidelines, saw one of six flyers featuring a persuasive appeal or no appeal, and then rated their intentions a second time. Known correlates of attitudes toward public health measures were also measured. RESULTS: Intentions to adhere to public health measures increased in all appeal conditions. The message featuring an empathy appeal resulted in a greater increase in intentions than the control (no appeal) message. Moreover, the effectiveness of persuasive appeals was moderated by baseline intentions. Deontological, empathy, identifiable victim, and reciprocity appeals improved intentions more than the control message, but only for people with lower baseline intentions to adhere to nonpharmaceutical interventions. CONCLUSIONS: Public health marketing campaigns aiming to increase adherence to COVID-19 protective behaviors could achieve modest gains by employing a range of persuasive appeals. However, to maximize impact, it is important that these campaigns be targeted to the right individuals. TRIAL REGISTRATION: ClinicalTrials.gov NCT05722106; https://clinicaltrials.gov/ct2/show/NCT05722106.

Revaccination and Adverse Event Recurrence in Patients with Adverse Events following Immunization.

OBJECTIVES: To estimate the risk of recurrence of adverse events following immunization (AEFIs) upon revaccination and to determine among patients with suspected vaccine allergy whether allergy skin test positivity was associated with AEFI recurrence. STUDY DESIGN: This prospective observational study included patients assessed in the Canadian Special Immunization Clinic Network from 2013 to 2019 with AEFIs who required revaccination with the vaccine temporally associated with their AEFI. Participants underwent standardized assessment and data collection. Special Immunization Clinic physicians used guidelines to inform their recommendations. Participants were followed up after revaccination to capture AEFI recurrences. Data were transferred to a central database for descriptive analysis. RESULTS: Overall, 588 participants were assessed for 627 AEFIs; 570 (91%) AEFIs occurred in children <18 years of age. AEFIs included immediate hypersensitivity (130/627; 21%), large local reactions (110/627; 18%), nonurticarial rash (51/627; 8%), seizures (26/627; 4%), and thrombocytopenia (11/627; 2%). Revaccination was recommended to 513 of 588 (87%) participants. Among participants recommended and due for revaccination during the study period, 63% (299/477) were revaccinated. AEFI recurrence was 10% (31/299) overall, 31% (15/49) for large local reactions, and 7% (5/66) for immediate hypersensitivity. No recurrence was serious. Among 92 participants with suspected vaccine allergy who underwent skin testing and were revaccinated, the negative predictive value of skin testing for AEFI recurrence was 96% (95% CI 92.5%-99.5%). CONCLUSIONS: Most individuals with AEFIs were safely revaccinated. Among those with suspected vaccine allergy, skin testing may help determine the safety of revaccination.

A behavior change model to address caregiver hesitancy around COVID-19 vaccination in pediatrics.

INTRODUCTION: Many families express hesitancy around immunizing their children against COVID-19. We sought to better understand the perspectives of vaccine hesitant caregivers, and develop targeted recommendations for health care workers and policymakers to engage in more effective vaccine discussions. METHODS: We conducted semi-structured telephone interviews with 23 caregivers recruited from a pediatric infectious diseases clinic, including a subset of patients referred to discuss vaccine hesitancy. Thematic analysis of the interviews identified themes that were mapped using behavior change models to identify perceived barriers and facilitators towards COVID-19 immunization. RESULTS: Barriers and facilitators were mapped to the WHO (World Health Organization) 3C's (confidence, complacency, convenience) model of vaccine hesitancy as well as the COM-B (capability, opportunity, motivation) behavior change model. Barriers included mistrust in authorities, misperception of the risk of COVID-19 in children, and perceived health contraindications and negative previous vaccine experiences. Facilitators included positive relationships with healthcare workers, the promise of a "return to normal", and societal pressures to immunize. CONCLUSIONS: Efforts to increase vaccine uptake in the pediatric population must target specific barriers and facilitators to immunization expressed by caregivers. To address these concerns, we suggest: 1. Educating hesitant caregivers by highlighting the long-term pandemic effects on children and the threat of COVID-19 to children's health, 2. Building on the trust caregivers have in healthcare workers by involving frontline workers in public health policy, and 3. Harnessing the power of peer pressure by mobilization of societal pressures and establishing COVID-19 vaccination as the norm in children.

Kawasaki disease following immunization reported to the Canadian Immunization Monitoring Program ACTive (IMPACT) from 2013 to 2018.

Kawasaki disease (KD) is an acute systemic vasculitis primarily affecting children younger than 5 y of age that has been reported as an adverse event following immunization (AEFI). The Canadian Immunization Monitoring Program ACTive (IMPACT) conducts active surveillance for KD following immunization across Canada. We characterized KD cases reported to IMPACT between 2013 and 2018. Cases admitted to an IMPACT hospital with a physician diagnosis of complete or incomplete KD with onset 0-42 d following vaccination were reviewed. Cases meeting the Brighton Collaboration case definition (BCCD) levels of diagnostic certainty levels 1 a/b, 2a/b or 3a-e were defined as KD cases. Demographic and vaccination characteristics were compared between KD cases and non-cases. Of 84 cases reviewed, 58 met the BCCD: 47 (81%) cases met level 1a (Complete KD), 8 (14%) met level 1b (Incomplete KD), 2 (3%) met level 2a, and 1 (2%) met level 2c (Probable KD). Median age at admission was 13 months (interquartile range 7-26 months). A median of 9.5 cases were reported per year (range 4-14). Thirty-one (53%) KD cases were temporally associated with diphtheria-tetanus acellular pertussis containing vaccinations, followed by 21 (36%) cases with pneumococcal conjugate vaccines. Symptom onset was 0-14 d after vaccination in 32 (55%) cases. Echocardiogram results were available for 43 (74%) cases with 22 reported as abnormal. Age, sex, interval to symptom onset, and vaccines received were similar between KD cases and non-cases. No safety signals were detected in these data.

Challenges and recommendations for COVID-19 public health messaging: a Canada-wide qualitative study using virtual focus groups.

OBJECTIVES: To understand Canadian's attitudes and current behaviours towards COVID-19 public health measures (PHM), vaccination and current public health messaging, to provide recommendations for a public health intervention. DESIGN: Ten focus groups were conducted with 2-7 participants/group in December 2020. Focus groups were transcribed verbatim and analysed using content and inductive thematic analysis. The capability opportunity motivation behaviour Model was used as our conceptual framework. SETTING: Focus groups were conducted virtually across Canada. PARTICIPANTS: Participants were recruited from a pool of individuals who previously completed a Canada-wide survey conducted by our research team. MAIN OUTCOME MEASURE: Key barriers and facilitators towards COVID-19 PHM and vaccination, and recommendations for public health messaging. RESULTS: Several themes were identified (1) participants' desire to protect family and friends was the main facilitator for adhering to PHM, while the main barrier was inconsistent PHM messaging and (2) participants were optimistic that the vaccine offers a return to normal, however, worries of vaccine efficacy and effectiveness were the main concerns. Participants felt that current public health messaging is inconsistent, lacks transparency and suggested that messaging should include scientific data presented by a trustworthy source. CONCLUSIONS: We suggest six public health messaging recommendations to increase adherence to PHM and vaccination (1) use an unbiased scientist as a spokesperson, (2) openly address any unknowns, (3) more is better when sharing data, (4) use personalised stories to reinforce PHM and vaccinations, (5) humanise the message by calling out contradictions and (6) focus on the data and keep politics out.

Suboptimal Vaccination Administration in Mothers With Inflammatory Bowel Disease and Their Biologic-Exposed Infants.

BACKGROUND: Pregnant women with inflammatory bowel disease (IBD) are at increased risk of developing complications from vaccine-preventable infections. We investigated the factors influencing vaccine administration in pregnant women with IBD and their infants, in addition to the safety of vaccination in the infants. METHODS: This retrospective cohort study identified individuals from a tertiary referral clinic whose records were linked to a provincial vaccine database. We conducted χ 2 tests, Fisher exact tests, and logistic regression adjusting for age and disease duration to compare vaccine administration by medication class. Potential rotavirus vaccine adverse events were determined in infants of women with IBD. RESULTS: We included 303 pregnant women and 262 infants. Vaccines were administered to women on biologic therapy as follows: hepatitis B virus (82.9%), diphtheria-tetanus-pertussis (82.1%), and hepatitis A virus (49.3%). The influenza vaccination was provided peripartum in 50.7% of patients. The measles-mumps-rubella-varicella vaccine was provided to 89.3% of women before biologic initiation. Women treated with a biologic (adjusted odds ratio, 2.50; 95% confidence interval, 1.39-4.35) or immunomodulator (adjusted odds ratio, 4.00; 95% confidence interval, 2.22-7.69) were more likely to receive the Prevnar 13 and Pneumovax 23 vaccines than were unexposed individuals, but the overall proportion vaccinated was low (Prevnar 13, 35.7%; Pneumovax 23, 39.3%). At least 90% of infants received the measles-mumps-rubella-varicella vaccine and inactivated vaccines. Fourteen biologic-exposed children (19.2%) received the live rotavirus vaccine with no significant differences in adverse events compared with biologic-unexposed infants (7.1% vs 8.2%, P = 0.99). CONCLUSIONS: Better education surrounding vaccine recommendations is required for both health care providers and individuals with IBD given poor pneumococcal, hepatitis A virus, and influenza vaccination rates. Inadvertent administration of the rotavirus vaccine in biologic-exposed infants did not result in more adverse events, raising the possibility of safety.

COVID-19 Vaccine-Related Attitudes and Beliefs in Canada: National Cross-sectional Survey and Cluster Analysis.

BACKGROUND: There are concerns that vaccine hesitancy may impede COVID-19 vaccine rollout and prevent the achievement of herd immunity. Vaccine hesitancy is a delay in acceptance or refusal of vaccines despite their availability. OBJECTIVE: We aimed to identify which people are more and less likely to take a COVID-19 vaccine and factors associated with vaccine hesitancy to inform public health messaging. METHODS: A Canadian cross-sectional survey was conducted in Canada in October and November 2020, prior to the regulatory approval of the COVID-19 vaccines. Vaccine hesitancy was measured by respondents answering the question "what would you do if a COVID-19 vaccine were available to you?" Negative binomial regression was used to identify the factors associated with vaccine hesitancy. Cluster analysis was performed to identify distinct clusters based on intention to take a COVID-19 vaccine, beliefs about COVID-19 and COVID-19 vaccines, and adherence to nonpharmaceutical interventions. RESULTS: Of 4498 participants, 2876 (63.9%) reported COVID-19 vaccine hesitancy. Vaccine hesitancy was significantly associated with (1) younger age (18-39 years), (2) lower education, and (3) non-Liberal political leaning. Participants that reported vaccine hesitancy were less likely to believe that a COVID-19 vaccine would end the pandemic or that the benefits of a COVID-19 vaccine outweighed the risks. Individuals with vaccine hesitancy had higher prevalence of being concerned about vaccine side effects, lower prevalence of being influenced by peers or health care professionals, and lower prevalence of trust in government institutions. CONCLUSIONS: These findings can be used to inform targeted public health messaging to combat vaccine hesitancy as COVID-19 vaccine administration continues. Messaging related to preventing COVID among friends and family, highlighting the benefits, emphasizing safety and efficacy of COVID-19 vaccination, and ensuring that health care workers are knowledgeable and supported in their vaccination counselling may be effective for vaccine-hesitant populations.

Analyzing Social Media to Explore the Attitudes and Behaviors Following the Announcement of Successful COVID-19 Vaccine Trials: Infodemiology Study.

BACKGROUND: The rollout of COVID-19 vaccines has brought vaccine hesitancy to the forefront in managing this pandemic. COVID-19 vaccine hesitancy is fundamentally different from that of other vaccines due to the new technologies being used, rapid development, and widespread global distribution. Attitudes on vaccines are largely driven by online information, particularly information on social media. The first step toward influencing attitudes about immunization is understanding the current patterns of communication that characterize the immunization debate on social media platforms. OBJECTIVE: We aimed to evaluate societal attitudes, communication trends, and barriers to COVID-19 vaccine uptake through social media content analysis to inform communication strategies promoting vaccine acceptance. METHODS: Social network analysis (SNA) and unsupervised machine learning were used to characterize COVID-19 vaccine content on Twitter globally. Tweets published in English and French were collected through the Twitter application programming interface between November 19 and 26, 2020, just following the announcement of initial COVID-19 vaccine trials. SNA was used to identify social media clusters expressing mistrustful opinions on COVID-19 vaccination. Based on the SNA results, an unsupervised machine learning approach to natural language processing using a sentence-level algorithm transfer function to detect semantic textual similarity was performed in order to identify the main themes of vaccine hesitancy. RESULTS: The tweets (n=636,516) identified that the main themes driving the vaccine hesitancy conversation were concerns of safety, efficacy, and freedom, and mistrust in institutions (either the government or multinational corporations). A main theme was the safety and efficacy of mRNA technology and side effects. The conversation around efficacy was that vaccines were unlikely to completely rid the population of COVID-19, polymerase chain reaction testing is flawed, and there is no indication of long-term T-cell immunity for COVID-19. Nearly one-third (45,628/146,191, 31.2%) of the conversations on COVID-19 vaccine hesitancy clusters expressed concerns for freedom or mistrust of institutions (either the government or multinational corporations) and nearly a quarter (34,756/146,191, 23.8%) expressed criticism toward the government's handling of the pandemic. CONCLUSIONS: Social media content analysis combined with social network analysis provides insights into the themes of the vaccination conversation on Twitter. The themes of safety, efficacy, and trust in institutions will need to be considered, as targeted outreach programs and intervention strategies are deployed on Twitter to improve the uptake of COVID-19 vaccination.