Maintenance of Increased Childhood Influenza Vaccination Rates 1 Year After an Intervention in Primary Care Practices.

OBJECTIVE: Influenza vaccination rates among some groups of children remain below the Healthy People 2020 goal of 70%. Multistrategy interventions to increase childhood influenza vaccination have not been evaluated recently. METHODS: Twenty pediatric and family medicine practices were randomly assigned to receive the intervention in either year 1 or year 2. This study focuses on influenza vaccine uptake in the 10 year 1 intervention sites during intervention and the following maintenance year. The intervention included the 4 Pillars Immunization Toolkit-a practice improvement toolkit, early delivery of donated vaccine for disadvantaged children, staff education, and feedback on progress. During the maintenance year, practices were not assisted or contacted, except to complete follow-up surveys. Student's t tests assessed vaccine uptake of children aged 6 months to 18 years, and multilevel regression modeling in repeated measures determined variables related to the likelihood of vaccination. RESULTS: Influenza vaccine uptake increased 12.4 percentage points (PP; P < .01) during active intervention and uptake was sustained (+0.4 PP; P > .05) during maintenance, for an average change of 12.7 PP over all sites, increasing from 42.2% at baseline to 54.9% (P < .001) during maintenance. In regression modeling that controlled for age, race, and insurance, likelihood of vaccination was greater during intervention than baseline (odds ratio 1.47; 95% confidence interval 1.44-1.50; P < .001) and greater during maintenance than baseline (odds ratio 1.50; 95% confidence interval 1.47-1.54; P < .001). CONCLUSIONS: In primary care practices, a multistrategy intervention that included the 4 Pillars Immunization Toolkit, early delivery of vaccine, and feedback was associated with significant improvements in childhood influenza vaccination rates that were maintained 1 year after active intervention.

Reducing Racial Disparities in Influenza Vaccination Among Children With Asthma.

INTRODUCTION: A multifaceted intervention to raise influenza vaccination rates was tested among children with asthma. METHODS: In a pre/post study design, 18 primary care practices implemented the 4 Pillars Immunization Toolkit along with other strategies. The primary outcome was the difference in influenza vaccination rates at each practice among children with asthma between the baseline year (before the intervention) and at the end of year 2 (after the intervention), both overall and by race (White vs. non-White). RESULTS: Influenza vaccination rates increased significantly in 13 of 18 practices. The percentage of vaccinated non-White children increased from 46% to 61% (p < .01), and the percentage of vaccinated White children increased from 58% to 65% (p < .001). Likelihood of vaccination was significantly lower for non-White children before the intervention (odds ratio = 0.66; 95% confidence interval = 0.59-0.73; p < .001), but this difference was eliminated after the intervention (odds ratio = 0.95; 95% confidence interval = 0.85-1.05; p = .289). DISCUSSION: A multi-strategy, evidence-based intervention significantly increased influenza vaccination uptake and reduced racial disparities among children with asthma.

Increasing childhood influenza vaccination: a cluster randomized trial.

BACKGROUND: Since the 2008 inception of universal childhood influenza vaccination, national rates have risen more dramatically among younger children than older children and reported rates across racial/ethnic groups are inconsistent. Interventions may be needed to address age and racial disparities to achieve the recommended childhood influenza vaccination target of 70%. PURPOSE: To evaluate an intervention to increase childhood influenza vaccination across age and racial groups. METHODS: In 2011-2012, a total of 20 primary care practices treating children were randomly assigned to the intervention and control arms of a cluster randomized controlled trial to increase childhood influenza vaccination uptake using a toolkit and other strategies including early delivery of donated vaccine, in-service staff meetings, and publicity. RESULTS: The average vaccination differences from pre-intervention to the intervention year were significantly larger in the intervention arm (n=10 practices) than the control arm (n=10 practices); for children aged 9-18 years (11.1 pct pts intervention vs 4.3 pct pts control, p<0.05); for non-white children (16.7 pct pts intervention vs 4.6 pct pts control, p<0.001); and overall (9.9 pct pts intervention vs 4.2 pct pts control, p<0.01). In multi-level modeling that accounted for person- and practice-level variables and the interactions among age, race, and intervention, the likelihood of vaccination increased with younger age group (6-23 months); white race; commercial insurance; the practice's pre-intervention vaccination rate; and being in the intervention arm. Estimates of the interaction terms indicated that the intervention increased the likelihood of vaccination for non-white children in all age groups and white children aged 9-18 years. CONCLUSIONS: A multi-strategy intervention that includes a practice improvement toolkit can significantly improve influenza vaccination uptake across age and racial groups without targeting specific groups, especially in practices with large percentages of minority children.

Cluster randomized trial of a toolkit and early vaccine delivery to improve childhood influenza vaccination rates in primary care.

PURPOSE: To increase childhood influenza vaccination rates using a toolkit and early vaccine delivery in a randomized cluster trial. METHODS: Twenty primary care practices treating children (range for n=536-8183) were randomly assigned to Intervention and Control arms to test the effectiveness of an evidence-based practice improvement toolkit (4 Pillars Toolkit) and early vaccine supplies for use among disadvantaged children on influenza vaccination rates among children 6 months-18 years. Follow-up staff meetings and surveys were used to assess use and acceptability of the intervention strategies in the Intervention arm. Rates for the 2010-2011 and 2011-2012 influenza seasons were compared. Two-level generalized linear mixed modeling was used to evaluate outcomes. RESULTS: Overall increases in influenza vaccination rates were significantly greater in the Intervention arm (7.9 percentage points) compared with the Control arm (4.4 percentage points; P<0.034). These rate changes represent 4522 additional doses in the Intervention arm vs. 1390 additional doses in the Control arm. This effect of the intervention was observed despite the fact that rates increased significantly in both arms - 8/10 Intervention (all P<0.001) and 7/10 Control sites (P-values=0.04 to <0.001). Rates in two Intervention sites with pre-intervention vaccination rates >58% did not significantly increase. In regression analyses, a child's likelihood of being vaccinated was significantly higher with: younger age, white race (Odds ratio [OR]=1.29; 95% confidence interval [CI]=1.23-1.34), having commercial insurance (OR=1.30; 95%CI=1.25-1.35), higher pre-intervention practice vaccination rate (OR=1.25; 95%CI=1.16-1.34), and being in the Intervention arm (OR=1.23; 95%CI=1.01-1.50). Early delivery of influenza vaccine was rated by Intervention practices as an effective strategy for raising rates. CONCLUSIONS: Implementation of a multi-strategy toolkit and early vaccine supplies can significantly improve influenza vaccination rates among children in primary care practices but the effect may be less pronounced in practices with moderate to high existing vaccination rates. Clinical trial registry name/number: From Innovation to Solutions: Childhood Influenza/NCT01664793.

Effectiveness of hospital-based postpartum procedures on pertussis vaccination among postpartum women.

OBJECTIVE: Pertussis causes significant morbidity among adults, children, and especially infants. Since 2006, pertussis vaccination has been recommended for women after delivery. We conducted a prospective, controlled evaluation of in-hospital postpartum pertussis vaccination of birth mothers from October 2009 through July 2010 to evaluate the effectiveness of hospital-based procedures in increasing postpartum vaccination. STUDY DESIGN: The intervention and comparison hospitals are private community facilities, each with 2000-6000 births/year. At the intervention hospital, physician opt-in orders for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) before discharge were implemented in November 2009, followed by standing orders in February 2010. The comparison hospital maintained standard practice. Randomly selected hospital charts of women after delivery were reviewed for receipt of Tdap and demographic data. We evaluated postpartum Tdap vaccination rates and conducted multivariate analyses to evaluate characteristics that are associated with vaccination. We reviewed 1264 charts (658 intervention hospital; 606 comparison hospital) from women with completed deliveries. RESULTS: Tdap postpartum vaccination was 0% at both hospitals at baseline. In the intervention hospital, the introduction of the opt-in order was followed by an increase in postpartum vaccination to 18%. The introduction of the standing order approach was followed by a further increase to 69% (P < .0001). No postpartum Tdap vaccinations were documented in the comparison hospital. Postpartum Tdap vaccination in the intervention hospital did not differ by demographic characteristics. CONCLUSION: In-hospital ordering procedures substantially increased Tdap vaccination coverage in women after delivery. Opt-in orders increased coverage that increased substantially with standing orders.

Cost-benefit analysis of hospital based postpartum vaccination with combined tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap).

OBJECTIVE: To assess the economic benefits associated with hospital-based postpartum Tdap (combined tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccination. METHODS: A decision tree model was constructed to calculate the potential cost-benefit of this strategy from both a health care system and a societal perspective. Probabilities and costs were derived from published literature, data reported to Centers for Disease Control and Prevention, and recommendations from expert panels. The maternal vaccination protection period for infants was defined as 7 months, and 10 years of waning immunity following Tdap for birth mothers was estimated in the model. All cost estimates were inflated to year 2012 US dollars and discounted at a 3% annual discount rate. RESULTS: In the base case from a societal perspective, the expected costs per vaccinated and unvaccinated mother were estimated at $129.27 and $187.97, respectively, suggesting an expected net benefit of $58.70 per vaccinated mother. The overall societal benefits in the cohort of 3.6 million U.S. birth mothers ranged from $52.8-126.8 million, depending on the vaccination coverage level. If including direct medical costs only, the strategy would not generate net savings from a health care system perspective. Annual incidence of pertussis in birth mothers and Tdap efficacy exhibited substantial impact on the model as shown in one-way and two-way sensitivity analyses. CONCLUSIONS: Although postpartum Tdap vaccination is not cost-beneficial from a health care system perspective in the base case, this strategy is likely to generate net benefits from a societal perspective.

Feasibility of initiating and sustaining registry-based immunization recall in private practices.

OBJECTIVE: To assess the feasibility of initiating and sustaining immunization recall by private practices, including the barriers and costs, using a statewide immunization information system (IIS). METHODS: Private practices in southeast Michigan were recruited in 2007 to perform IIS-based immunization recalls. Enrolled practices were provided with training and asked to conduct 4 recalls during the course of 12 months of children 19 to 35 months of age. Each practice recorded the time they spent performing recall-related activities; labor costs were estimated. Formative and summative evaluations with semistructured interviews were conducted to identify barriers. RESULTS: Of 97 eligible pediatric and family medicine practices, 44 declined to participate, 32 did not respond to repeated contacts, and 20 agreed to enroll in the study (21%). A total of 56 recalls were conducted during the study period, with 9 practices completing at least 4 recalls and 7 practices completing 1 to 3 recalls; 4 practices conducted no recalls. Common barriers reported included time constraints and executing all steps of the recalls. Practice costs per patient recalled ranged from $0.05 to more than $6 and were primarily driven by the type of personnel who performed recalls. The costs of creating a roster of current patients comprised nearly one-half of total labor costs. CONCLUSIONS: Few private provider practices that we contacted were willing to participate in this study of IIS-based recall, and less than one-half of enrolled practices completed the desired 4 recall cycles in 12 months. Time constraints and other real-world problems should not be underestimated in determining the feasibility of practice-based immunization recall. Efforts to increase the use of a statewide IIS for recall in private practice settings should emphasize ongoing training and technical support to practice staff. Improved interoperability with electronic health record systems may foster practice-based recall by reducing the labor intensity of roster building and other recall activities.

Cost-benefit analysis of in-hospital influenza vaccination of postpartum women.

OBJECTIVE: To estimate the potential economic benefits associated with hospital-based postpartum influenza vaccination. METHODS: We constructed a decision analysis model to estimate the potential cost benefit of this strategy from both a societal perspective and a third-party perspective. We included a hypothetical cohort of 1.47 million U.S. postpartum women, assuming an influenza season beginning September 1 and ending April 30. Probabilities and costs were derived from published literature, Centers for Disease Control and Prevention data, and expert recommendations. We used one-way and two-way sensitivity analyses. All cost estimates were inflated to year 2010 U.S. dollars and discounted at a 3% annual discount rate. RESULTS: From the societal perceptive, the expected costs per vaccinated and unvaccinated mother were $328.45 and $341.02 respectively, resulting in an expected net benefit of $12.57 per vaccinated mother. The overall savings in the cohort were predicted to range from $3.69 to $14.75 million, depending on the vaccination coverage rate. This strategy would be cost-beneficial, holding all other variables to the base case, if the annual maternal influenza attack rate is more than 2.8%, influenza vaccine efficacy is more than 47%, or if vaccine acquisition and administration cost per dose are less than $32.78. The strategy would not generate net savings from the third-party perspective. Sensitivity analyses were robust, but disease incidence and vaccine efficacy were important drivers. CONCLUSION: Our model suggests that postpartum influenza vaccination is a cost-beneficial approach for prevention of maternal and infantile influenza from a societal perspective. LEVEL OF EVIDENCE: III.

The impact of missed opportunities on seasonal influenza vaccination coverage for healthy young children.

OBJECTIVE: To estimate the impact of missed opportunities on influenza vaccination coverage among 6- through 23-month-old children who sought medical care during the 2004-2005 influenza season. DESIGN: Retrospective cohort study. SETTING: Fifty-two primary care practice sites located in Rochester, New York, Nashville, Tennessee, and Cincinnati, Ohio. PARTICIPANTS: Children 6 through 23 months of age. METHODS/OUTCOME MEASURE: Charts were reviewed and data collected on influenza vaccinations, type of health care visit (well child or other), and presence of illness symptoms. Missed opportunity was defined as a practice visit by an eligible child during influenza season, when vaccine was available, but during which the child did not receive an influenza vaccination. Vaccine was assumed to be available between the first and last dates influenza vaccination was recorded at that practice. Each child was classified as fully vaccinated, partially vaccinated, or unvaccinated. RESULTS: Data were analyzed for 1724 children, 6 through 23 months of age. Most children (62.0%) had at least 1 missed opportunity during this period. Among children with any missed opportunities, 12.8% were fully and 29.8% were partially vaccinated. Overall, 33.6% of the missed opportunities occurred during well child visits and 66.4% during other types of visits; 75% occurred when no other vaccines were given. Eliminating all missed opportunities would have increased full vaccination coverage from 30.3% to 49.9%. CONCLUSIONS: Missed opportunities for influenza vaccination are frequent. Reducing missed opportunities could significantly increase influenza vaccination rates and should be a goal in each practice.

Practice and child characteristics associated with influenza vaccine uptake in young children.

OBJECTIVES: The objective of this study was to determine both practice and child characteristics and practice strategies associated with receipt of influenza vaccine in young children during the 2004-2005 influenza season, the first season for the universal influenza vaccination recommendation for all children who are aged 6 to 23 months. METHODS: Clinical and demographic data from randomly selected children who were aged 6 to 23 months were obtained by chart review from a community-based cohort study in 3 US counties. The proportion of children who were vaccinated by April 5, 2005, in each practice was obtained. For assessment of practice characteristics and strategies, sampled practices received a self-administered practice survey. Practice and child characteristics that predicted complete influenza vaccination were determined by using multinomial logistic regression. RESULTS: Forty-six (88%) of 52 sampled practices completed the survey and permitted chart reviews. Of 2384 children who were aged 6 to 23 months and were studied, 27% were completely vaccinated. The proportion of children who were completely vaccinated varied widely among practices (0%-71%). Most (87%) practices implemented ≥1 vaccination strategy. Complete influenza vaccination was associated with 3 practice characteristics: suburban location, lower patient volume, and vaccination strategies of evening/weekend vaccine clinics; with child characteristics of younger age, existing high-risk conditions, ≥6 well visits to the practice by 3 years of age, and any practice visit from October through January. CONCLUSIONS: Modifiable factors that were associated with increased influenza vaccination coverage included October to January practice visits and evening/weekend vaccine clinics.

Influenza vaccination of household contacts of newborns: a hospital-based strategy to increase vaccination rates.

We implemented a hospital-based influenza vaccination program for household contacts of newborns. Among mothers not vaccinated prenatally, 44.7% were vaccinated through the program, as were 25.7% of fathers. A hospital-based program provided opportunities for vaccination of household contacts of newborns, thereby facilitating better adherence to national vaccination guidelines.

Financial barriers to implementing combination vaccines: perspectives from pediatricians and policy makers.

To describe the factors that affect the use of new combination vaccines, the authors conducted qualitative interviews with pediatricians (n = 7), state immunization program managers (n = 7), and health insurance plan representatives (n = 6 plans). Respondents from each group identified reduction in pain and potentially increased immunization coverage as key benefits of new combination vaccines. For several pediatricians, low reimbursement for cost of vaccine doses and potential loss of fees for vaccine administration were barriers to using combination vaccines. For most state immunization programs, the higher cost of combination vaccines relative to separate vaccines was an important consideration but not a barrier to adoption. Most insurers were not aware of the financial issues for providers, but some had changed or were willing to change reimbursement to support the use of new combination vaccines. Financial issues for pediatric practices that purchase and provide vaccines for children may be an important barrier to offering combination vaccines.

The association of health insurance and continuous primary care in the medical home on vaccination coverage for 19- to 35-month-old children.

OBJECTIVE: Our goal was to examine the association of continuous care in the medical home and health insurance on up-to-date vaccination coverage by using data from the National Survey of Children's Health and the National Immunization Survey. METHODS: Interviews were conducted with 5400 parents of 19- to 35-month-old children to collect data on demographics and medically-verified vaccinations. Health insurance coverage was categorized as always, intermittently, or uninsured for the previous 12 months. Insurance types were private, public, or uninsured. Having a personal doctor or nurse and receiving preventive health care in either the past 12 or 24 months constituted continuous primary care in the medical home. Children were up-to-date if they received all vaccinations by 19 to 35 months of age (>or=4 doses of diphtheria and tetanus toxoids and pertussis vaccine, >or=3 doses of poliovirus vaccine, >or=1 dose of any measles-containing vaccine, >or=3 doses of Haemophilus influenzae type b vaccine, and >or=3 doses of hepatitis B vaccine). RESULTS: Bivariate analyses revealed children who were always insured had significantly higher vaccination coverage (83%) than those with lapses or uninsured during the past 12 months (75% and 71%, respectively). Those with continuous primary care in the medical home had significantly higher coverage than those who did not (83% vs 75%, respectively). In multivariate analysis, the same pattern of association was observed for insurance status and medical home, but the only statistically significant association was for children of never-married mothers who had significantly lower coverage (74%) compared with children of married mothers (84%). CONCLUSIONS: Among children with the same insurance status and continuity of care in the medical home, children of single mothers were less likely to be up-to-date than children of married mothers. Interventions assisting single mothers to obtain preventive care for their children should be a priority.

Misperceptions regarding influenza vaccine safety for individuals with chronic medical illness.

BACKGROUND: Influenza immunization is recommended for adults >or=50 years, healthy children 6-59 months and individuals with a chronic medical condition. OBJECTIVES: To compare respondents' perceptions of safety of immunization for children and adults both with and without chronic medical conditions. METHODS: We surveyed parents of 828 randomly selected healthy children aged 6-21 months of age from 5 pediatric practices in Denver, Colorado between August and October of 2003. RESULTS: The survey response rate was 57% (n=472). Although 65% of parents thought influenza immunization was safe for healthy 1 year olds, only 40% considered it safe for 1 year olds with a chronic condition. Similarly, 86% judged it safe in healthy 70 year olds versus 50% in 70 year olds with a chronic condition. CONCLUSIONS: Educational efforts to encourage influenza immunization in individuals with chronic illnesses should highlight the message that a chronic medical condition is an indication for immunization and does not confer additional risk of complications from vaccination. Further research is needed to confirm and better understand the observed perception of vulnerability to adverse events of vaccines in those with chronic illness.

Using registry data to evaluate the 2004 pneumococcal conjugate vaccine shortage.

BACKGROUND: The most recent pneumococcal conjugate vaccine (PCV7) shortage occurred between December 2003 and September 2004. To ensure vaccination of the highest-risk children, the Centers for Disease Control and Prevention recommended that providers delay administration of the third and fourth doses of vaccine to healthy children. We used Michigan Child Immunization Registry (MCIR) data collected from September 1, 2001 to November 30, 2004 to evaluate changes in PCV7 coverage. METHODS: Vaccination and demographic data from MCIR were reviewed for 420,733 children born between September 2001 and August 2004. Main outcome measures were the proportion of children who received the third dose of PCV7 by 7 months of age and the fourth dose of PCV7 by 16 months of age. Vaccine coverage for measles, mumps, and rubella vaccine (MMR) and diphtheria, tetanus, and acellular pertussis vaccine (DTaP) was used for comparison, as these vaccines were abundant during this time period and their administration schedule is the same as the third and fourth doses of PCV7, respectively. Data analysis was conducted in spring 2005. RESULTS: Coverage for the third dose of DTaP and the first dose of MMR remained steady, while PCV7 coverage for the third dose dropped from 29% to 11%, and the fourth dose dropped from 27% to 22% in the month following the recommendations to defer doses. Coverage returned close to pre-shortage levels shortly after the recommendations to resume the normal schedule. PCV7 coverage trends were similar for children seen in the private or public sector. CONCLUSIONS: Registry data can be useful for evaluating vaccination coverage trends during a shortage. Our findings suggest that providers were compliant with recommendations to alter vaccine administration during the shortage.

Responses of US college and university student health services to the 2004 influenza vaccine shortage.

The United States experienced a shortage of influenza vaccine for the 2004--2005 influenza season. The authors surveyed college health programs to determine whether they had targeted vaccine to priority groups and knew how to reallocate remaining vaccine. They used an electronic message to distribute a Web-based survey to the members of 3 college-affiliated organizations--the Association of American Colleges and Universities, American Association of Community Colleges, American College Health Association--and to subscribers of the Student Health Service Listserv. They received 434 completed surveys. Sixty percent (259) of the respondents stated they had received vaccine and planned to vaccinate their high-risk students, staff, and faculty members; 77% (198) planned to reallocate leftover vaccine. Given the potential for future disruptions of the influenza vaccine supply, the authors recommend that college health programs establish policies to identify members of their high-risk population and also consider providing the live attenuated influenza virus vaccine.

Parental vaccine safety concerns: results from the National Immunization Survey, 2001-2002.

BACKGROUND: According to the 2002 National Immunization Survey (NIS), vaccination coverage with recommended vaccines among U.S. children aged 19 to 35 months remained near all-time highs. Sustaining this high coverage requires significant effort, including consideration of parental vaccine safety concerns that have led to decreasing coverage in other countries. METHODS: The Parental Knowledge and Experiences module was administered to a random subset of NIS respondents from July 2001 to December 2002. The module included questions regarding attitudes toward vaccine safety and side effects, simultaneous vaccine administration, and acceptance of new vaccines. Multivariate logistic regression analyses examined associations between attitudes and up-to-date (UTD) vaccination coverage (four or more doses of diphtheria and tetanus toxoids and pertussis vaccine, three or more doses of poliovirus vaccine, one or more doses of any measles-containing vaccine, three or more doses of Haemophilus influenzae type b vaccine, and three or more doses of hepatitis B vaccine), while controlling for demographics. RESULTS: Ninety-three percent of parents rated vaccines as safe, 6% as neither safe nor unsafe, and 1% as unsafe. After adjusting for demographics, parental safety belief was significantly associated with the child's vaccination status. For children whose parents believed vaccines are safe, the odds of being UTD were 2.9 times the odds of being UTD for children of parents who believed vaccines are unsafe (75% vs 53%, respectively). Children whose parents were neutral about the safety of vaccines had vaccination coverage similar to children whose parents believed vaccines are unsafe. CONCLUSIONS: A significant association with vaccine coverage was found for a small group of parents with high vaccine safety concerns. Strategies focused on safety concerns may yield better protection for these children.