Thrombotic risk assessed by PAI-1 in patients with COVID-19: The influence of hyperglycemia and diabetes mellitus.

OBJECTIVE: To assess thrombotic risk with PAI-1 levels in patients with COVID-19, to evaluate PAI-1 differences between hyperglycemic and/or Type 2 Diabetes Mellitus (T2DM) versus non-hyperglycemic patients, and to analyze the association of plasminogen activator inhibitor-1 (PAI-1) with hyperglycemia and T2DM. METHODS: A cross-sectional study carried out in 181 patients hospitalized for COVID-19. Two groups were formed: the patients with hyperglycemia at admission and/or previously diagnosed T2DM group and the non-hyperglycemic group. Fibrinolysis was assessed by measuring PAI-1 levels by ELISA. RESULTS: The mean age was 59.4±16.1 years; 55.8% were male 54.1% of patients presented obesity, 38.1% had pre-existing T2DM and 50.8% had admission hyperglycemia and/or pre-existing T2DM. The patients with admission hyperglycemia and/or preexisting T2DM had higher PAI-1 compared with non-hyperglycemic patients [197.5 (128.8-315.9) vs 158.1 (113.4-201.4) ng/mL; p=0.031]. The glucose levels showed a positive correlation with PAI-1 levels (r=0.284, p=0.041). A multivariate logistic regression analysis showed association of PAI-1 level and hyperglycemia and pre-existing T2DM with severity of COVID-19. CONCLUSION: Patients hospitalized for COVID-19 infection with preexisting T2DM or hyperglycemia detected during their hospitalization presented a greater increase in PAI-1 levels, which suggests that hyperglycemia contributes directly to the hypercoagulable state and probably a worse outcome from the patients.

Planned Out-of-Hospital Birth as a Risk Factor for Nonreceipt of Hepatitis B Immunization.

BACKGROUND: The hepatitis B vaccine (HBV) is recommended at birth to prevent perinatal hepatitis B transmission; however, many newborns still do not receive HBV. The extent to which planned out-of-hospital births, which have increased over the past decade, are associated with nonreceipt of the HBV birth dose is unknown. The purpose of this study was to determine whether a planned out-of-hospital birth location is associated with the nonreceipt of the HBV birth dose. METHODS: We performed a retrospective cohort study of all births from 2007 to 2019 recorded in the Colorado birth registry. χ2 analyses were used to compare maternal demographics by birth location. Univariate and multiple logistic regression were used to evaluate the association of birth location with nonreceipt of the HBV birth dose. RESULTS: In total 1.5% of neonates born in freestanding birth centers and 0.1% of neonates born at a planned home birth received HBV compared to 76.3% of neonates born in a hospital location. After adjusting for confounders, this translated to a large increase in the odds of not receiving HBV compared to in-hospital births [freestanding birth center (aodds ratio (aOR): 172.98, 95% confidence interval (CI): 136.98-219.88); planned home birth (aOR: 502.05, 95% CI: 363.04-694.29)]. Additionally, older maternal age, White/non-Hispanic race and ethnicity, higher income, and private or no insurance were associated with nonreceipt of the HBV birth dose. CONCLUSIONS: Planned out-of-hospital birth is a risk factor for nonreceipt of the HBV birth dose. As births in these locations become more common, targeted policies and education are warranted.

Community perceptions of vaccine advocacy for children under five in rural Guatemala.

Historically, partnerships with community leaders (e.g., religious leaders, teachers) have been critical to building vaccination confidence, but leaders may be increasingly vaccine hesitant. In rural Guatemala, the extent of vaccine hesitancy among community leaders is unclear, as are their perceptions of advocacy for childhood vaccines. We sought to: (i) compare Guatemalan religious leaders' and community leaders' attitudes toward childhood vaccines, (ii) describe leaders' experiences and comfort with vaccination advocacy, and (iii) describe community members' trust in them as vaccination advocates. In 2019, we surveyed religious leaders, other community leaders, and parents of children under five in rural Guatemala. We recorded participant demographic information and assessed participant vaccine hesitancy regarding childhood vaccines. We analyzed data descriptively and via adjusted regression modeling. Our sample included 50 religious leaders, 50 community leaders, and 150 community members (response rate: 99%); 14% of religious leaders and community leaders were vaccine hesitant, similar to community members (P = 0.71). In the prior year, 47% of leaders had spoken about vaccines in their formal role; 85% felt responsible to do so. Only 28% of parents trusted politicians "a lot" for vaccine advice, versus doctors (72%; P < 0.01), nurses (62%; P < 0.01), religious leaders (49%; P < 0.01), and teachers (48%; P < 0.01). In this study, religious leaders and community leaders were willing but incompletely engaged vaccination advocates. Most community members trusted doctors and nurses a lot for vaccination advice; half trusted teachers and religious leaders similarly. Public health officials in rural Guatemala can complement efforts by doctors and nurses through partnerships with teachers and religious leaders to increase vaccination confidence and delivery.

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.

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.

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.

Adapting and piloting a vaccine hesitancy questionnaire in rural Guatemala.

INTRODUCTION: We sought to (i) adapt a Spanish-language vaccine hesitancy (VH) tool to rural Guatemala, (ii) pilot the tool with 150 parents of children ≤ 5 years, and (iii) measure if parent scores associated with child under-vaccination. METHODS: We used implementation science to develop the adapted Guatemalan Vaccine Attitudes (GuaVA) tool, piloting it with 150 parents of children ≤ 5 years, and performing descriptive and adjusted regression analyses. RESULTS: Of 150 parents (response rate 99%), 55% (n = 83) of parents expressed a degree of VH. Children of parents with highly hesitant scores (n = 22) had 2.5 times the odds (OR 2.5; 95% CI: 1.2, 5.4) of being undervaccinated at 19 months, referent children of non-hesitant parents (n = 67). CONCLUSIONS: Vaccine hesitancy may be more prevalent in rural Guatemala than suspected. Implementation science facilitated the adaptation of a VH tool to rural Guatemala and may assist investigators in other settings.

Text message reminders to improve infant immunization in Guatemala: A randomized clinical trial.

OBJECTIVE: Millions of infants worldwide remain under-immunized and at risk for unnecessary morbidity and mortality. Text messaging may offer a low-cost solution. We aimed to evaluate text message reminders to improve infant immunization in Guatemala. METHODS: A randomized clinical trial was conducted at four public health clinics in rural and urban Guatemala. Infants ages six weeks to six months presenting for the first visit of the primary immunization series were randomly and equally allocated to an intervention or usual care group. Intervention participants were sent three text reminders before the second and third vaccine visits. The main outcome was timeliness of the second and third visits of the primary immunization series. RESULTS: Of 1088 families approached for enrollment between March to November 2016, 871 were eligible and 720 (82.7%) participated; only 54 families did not own a cell phone. Due to country-wide vaccine shortages, visit completion was used as a proxy for overall immunization coverage. In intention to treat analysis, both intervention and usual care groups had high rates of visit completion, but intervention participants presented on the scheduled date more often (151 [42.2%] of 358 intervention vs. 111 [30.7%] of 362 usual care participants for visit 2, p = 0.001, and 112 [34.0%] of 329 intervention vs. 90 [27.0%] of 333 usual care participants for visit 3, p = 0.05). Intervention caregivers were significantly more likely to want to receive future text message reminders for vaccines and other appointments and were more willing to pay for these reminders. CONCLUSION: Caregivers who were sent text message reminders in urban and rural Guatemala were less delayed for their child's immunization visits and reported high user satisfaction. Text message reminders may be an effective tool to increase infant vaccination coverage in low-income settings by reminding parents to vaccinate. TRIAL REGISTRATION: NCT02567006 at clinicaltrials.gov.

Timing of Information-Seeking about Infant Vaccines.

OBJECTIVES: To assess among pregnant and recently delivered women the timing of thinking about and seeking information about childhood vaccines and the preferred modes of vaccine education. STUDY DESIGN: An e-mail survey among women in 9 urban and rural obstetrics practices in Colorado was conducted from February to April 2014, timed so that approximately one-half had delivered and one-half were still pregnant, designed to assess the frequency of thinking about and seeking information about vaccines in relation to estimated or actual delivery date. A shortened version of the Parental Attitudes About Childhood Vaccines scale was used to assess vaccine hesitancy. RESULTS: The response rate was 54% (230 of 425); 56% were pregnant, 44% had delivered, and 18% were vaccine-hesitant. Compared with pregnant women, women who had delivered more often reported thinking about vaccines for their infant (pregnant: 19% often, 42% sometimes; delivered: 29% often, 51% sometimes; P < .05) and looking for information about vaccines (pregnant: 6% often, 22% sometimes; delivered: 16% often, 34% sometimes; P < .01). Women most frequently reported seeking information about vaccines 2-4 weeks after delivery, followed by 4-6 weeks after delivery. The most preferred method for vaccine education was their child's doctor (95% acceptable; 92% likely to use) followed by their obstetrician (79% acceptable; 64% likely to use). CONCLUSIONS: Within 6 weeks postdelivery appears to be when the most women seek vaccine information. A child's doctor remains the most acceptable source of vaccine education.

Measuring vaccine hesitancy: Field testing the WHO SAGE Working Group on Vaccine Hesitancy survey tool in Guatemala.

BACKGROUND: Despite safe and effective childhood immunizations, decreased acceptance of vaccines has become an emerging global problem. The WHO SAGE Working Group on Vaccine Hesitancy developed a common diagnostic tool, the Vaccine Hesitancy Scale (VHS), to identify and compare hesitancy in different global settings. We field tested the VHS in rural and urban Guatemala. METHODS: We analyzed data from the enrollment visit of a study conducted at four public health clinics in Guatemala. Infants ages 6 weeks-6 months presenting for their first wellness visit were enrolled March-November 2016. Parents completed a demographic survey that included the 10 dichotomous and 10 Likert scale VHS questions. Chi-square or Fisher's exact for categorical and ANOVA test for continuous variables were used to assess significance levels in survey differences. We conducted a factor analysis to assess the Likert scale questions. RESULTS: Of 1088 families screened, 871 were eligible and 720 (82.7%) participated. No parent had ever refused a vaccination, and only eight parents (1.1%) had been reluctant or hesitated to get a vaccination for their children. However, only 40.8% (n = 294) of parents said that they think most parents like them have their children vaccinated with all the recommended vaccines. Factor analysis identified two underlying constructs that had eigenvalues of 1.0 or greater and a substantive lack of variability in response across the Likert scale. There were consistent differences between how study clinics responded to the ordinal scaling. CONCLUSION: Our results suggest problems with interpretation of the VHS, especially in the presence of vaccine shortages and using a Likert scale that does not resonate across diverse cultural settings. Our factor analysis suggests that the Likert scale items are more one-dimensional and do not represent the multiple constructs of vaccine hesitancy. We suggest more work is needed to refine this survey for improved reliability and validity. Clinical Trial Registry: NCT02567006.

Characteristics of mobile phone access and usage in rural and urban Guatemala: assessing feasibility of text message reminders to increase childhood immunizations.

BACKGROUND: Despite efforts to promote vaccination in low- and middle-income countries (LMICs), over 20 million infants remain under-immunized and at risk for unnecessary morbidity and mortality. Mobile health technologies, such as Short Message Service (SMS) texts, have tremendous and untapped potential for disease management. Patient reminder systems are an important mechanism for improving childhood vaccination coverage and can be easily adapted to SMS platforms. However, current research lacks an understanding of the barriers and facilitators to mHealth program design, implementation, and scale in LMICs. METHODS: We analyzed survey data collected March-November 2016 at the enrollment visit from a randomized controlled trial conducted at public health clinics in urban and rural Guatemala. Participants included eligible infants 6 weeks to 6 months of age receiving the first dose of the primary immunization series. At least one parent needed to own a mobile phone and be capable of deciphering SMS. Chi-square or Fisher's exact and Student's t-test were used to assess significance levels in demographic differences to describe factors that contribute to the feasibility of using an SMS-based vaccination reminder system. RESULTS: Of 1,088 families approached for enrollment, 871 were eligible and 720 (82.7%) participated with equal numbers of urban and rural children enrolled; 54 parents did not own a mobile phone with SMS capability and three parents could not use SMS. There was no significant difference between urban and rural maternal mobile phone ownership (94.4% vs. 93.3%, P=0.53), but more urban fathers owned mobile phones (72.8% vs. 47.1%, P<0.0001) and, overall, more mothers compared to fathers owned mobile phones (93.9% vs. 61.1%, P<0.0001). Most families (90.4%) chose to have reminders sent to the mother. Urban participants reported more mobile phones present in the home (P<0.0001), but rural participants reported more telephone landlines (34.7% vs. 15.6%, P<0.0001). Most participants reported a daily average of ≤5 telephone calls made (87.4%), ≤10 texts sent (91.0%), and ≤10 texts received (89.9%), with urban families reporting greater telephone usage (P=0.006, P<0.001, and P<0.001 respectively). Parents preferred to make calls over sending texts (74.7% vs. 25.3%, P<0.0001), with more urban families preferring text messaging (31.9% vs. 18.6%, P<0.0001). CONCLUSIONS: Our study results provide important insight into mobile phone access, usage, and preferences for voice and text communication across rural and urban populations of an LMIC that can be used to inform future mHealth interventions. Our findings suggest that offering a combination of more traditional communication methods with newer, modern technologies may be more effective at reminding families about vaccination visits, particularly for our rural population, and that targeting mothers for mobile phone interventions may provide the greatest benefits. Overall, our study suggests that using SMS reminders in LMICs can be a feasible tool for public health interventions.

Physician Attitudes Toward Adult Vaccines and Other Preventive Practices, United States, 2012.

OBJECTIVES: We described the following among U.S. primary care physicians: (1) perceived importance of vaccines recommended by the Advisory Committee on Immunization Practices relative to U.S. Preventive Services Task Force (USPSTF) preventive services, (2) attitudes toward the U.S. adult immunization schedule, and (3) awareness and use of Medicare preventive service visits. METHODS: We conducted an Internet and mail survey from March to June 2012 among national networks of general internists and family physicians. RESULTS: We received responses from 352 of 445 (79%) general internists and 255 of 409 (62%) family physicians. For a 67-year-old hypothetical patient, 540/606 (89%, 95% confidence interval [CI] 87, 92) of physicians ranked seasonal influenza vaccine and 487/607 (80%, 95% CI 77, 83) ranked pneumococcal vaccine as very important, whereas 381/604 (63%, 95% CI 59, 67) ranked Tdap/Td vaccine and 288/607 (47%, 95% CI 43, 51) ranked herpes zoster vaccine as very important (p<0.001). All Grade A USPSTF recommendations were considered more important than Tdap/Td and herpes zoster vaccines. For the hypothetical patient aged 30 years, the number and percentage of physicians who reported that the Tdap/Td vaccine (377/604; 62%, 95% CI 59, 66) is very important was greater than the number and percentage who reported that the seasonal influenza vaccine (263/605; 43%, 95% CI 40, 47) is very important (p<0.001), and all Grade A and Grade B USPSTF recommendations were more often reported as very important than was any vaccine. A total of 172 of 587 physicians (29%) found aspects of the adult immunization schedule confusing. Among physicians aware of "Welcome to Medicare" and annual wellness visits, 492/514 (96%, 95% CI 94, 97) and 329/496 (66%, 95% CI 62, 70), respectively, reported having conducted fewer than 10 such visits in the previous month. CONCLUSIONS: Despite lack of prioritization of vaccines by ACIP, physicians are prioritizing some vaccines over others and ranking some vaccines below other preventive services. These attitudes and confusion about the immunization schedule may result in missed opportunities for vaccination. Medicare preventive visits are not being used widely despite offering a venue for delivery of preventive services, including vaccinations.

SMS text message reminders to improve infant vaccination coverage in Guatemala: A pilot randomized controlled trial.

BACKGROUND: Patient reminder systems are an evidence-based way to improve childhood vaccination rates but are difficult to implement in low- and middle-income countries (LMICs). Short Message Service (SMS) texts may offer a potential low-cost solution, especially in LMICs where mobile phones are becoming more ubiquitous. OBJECTIVE: To determine if an SMS-based vaccination reminder system aimed at improving completion of the infant primary immunization series is feasible and acceptable in Guatemala. METHODS: A pilot randomized controlled trial was conducted at two public health clinics in Guatemala City. Infants aged 8-14 weeks presenting for the first dose of the primary immunization series were enrolled in March-April 2013. Participants randomized into the intervention received three SMS reminders one week before the second and third dose. A follow-up acceptability survey was administered to both groups. RESULTS: The participation rate was 86.8% (321/370); 8 did not own a cell phone and 12 could not use SMS. 96.9% of intervention parents were sent at least one SMS reminder prior to visit 2 and 96.3% prior to visit 3. Both intervention and usual care participants had high rates of vaccine and visit completion, with a non-statistically significant higher percentage of children in the intervention completing both visit 2 (95.0% vs. 90.1%, p=.12) and visit 3 (84.4% vs. 80.7%, p=.69). More intervention vs. usual care parents agreed that SMS reminders would be helpful for remembering appointments (p<.0001), agreed to being interested in receiving future SMS reminders (p<.0001), and said that they would be willing to pay for future SMS reminders (p=.01). CONCLUSION: This proof of concept evaluation showed that a new application of SMS technology is feasible to implement in a LMIC with high user satisfaction. Larger studies with modifications in the SMS system are needed to determine effectiveness (Clinical Trial Registry NCT01663636).

Adherence to expanded influenza immunization recommendations among primary care providers.

OBJECTIVE: To assess practices regarding the expanded Advisory Committee on Immunization Practices (ACIP) recommendations for influenza vaccination in children among US pediatricians and family medicine physicians (FMs) and strategies to promote vaccination. STUDY DESIGN: We administered a survey between July and October 2009 to 416 pediatricians and 424 FMs from nationally representative networks. RESULTS: The response rate was 75% (79% pediatricians, 70% FMs). FMs were less likely than pediatricians to report adherence to ACIP recommendations (35% vs 65%; adjusted risk ratio [RR], 0.60; 95% CI, 0.50-0.72). Most physicians (89% pediatricians and 89% FMs) reported using posters or pamphlets to encourage influenza vaccination, and 57% pediatricians and 41% FMs reported offering after hours dedicated influenza vaccination clinics. Only 23% pediatricians and 14% FMs reported providing written, telephone, or e-mail reminders to all children. Having dedicated influenza vaccination clinics after hours or weekends was associated with routine vaccination of all children (adjusted RR, 1.33; 95% CI, 1.15-1.57). CONCLUSION: In the first year of the expanded ACIP recommendations to immunize all eligible children against influenza, two-thirds of pediatricians and one-half of FMs reported adherence, although less than one-quarter were actively engaging in reminder/recall efforts. Practices that adhered to the ACIP recommendations were more likely to put a substantial effort into promoting vaccination opportunities.