Maternal Recall of Obstetric Office-Based Activities That Promote Antepartum Tetanus-Diphtheria-Acellular-Pertussis Vaccination.

Objective: To explore associations between maternal characteristics and recall of obstetric provider actions in promoting antepartum tetanus-diphtheria-acellular-pertussis (Tdap) vaccination. Methods: A convenience sample of 1,682 postpartum women was surveyed in this cross-sectional study. Maternal characteristics and recall of four obstetric provider actions (recommending antepartum Tdap vaccine, offering it in clinic, providing written information, and referring patients elsewhere for vaccination) were collected. Univariate and multivariable logistic regression analyses were performed to characterize the association between maternal characteristics and each provider action. Results: Among 1,604 surveys (95% of total collected), maternal recall of an obstetric provider recommending Tdap vaccination, offering it in clinic, providing written information, or referring patients elsewhere was 68%, 59%, 53%, and 15%, respectively. Multivariable analysis revealed specific maternal characteristics that increased odds of recalling at least one obstetric provider action promoting Tdap vaccination, including receipt of first trimester prenatal care (adjusted odds ratio [aOR] 1.77, 95% confidence interval [CI] = 1.06-2.97), primiparity (aOR 1.35, 95% CI = 1.05-1.75), private health insurance (aOR 1.56, 95% CI = 1.16-2.04), higher household income (aOR ranging from 1.71 to 2.10 for ≥$150,000 for two actions), and non-White, non-Hispanic race/ethnicity (aOR ranging from 1.49 to 1.74 for Asian non-Hispanic for two actions and aOR 1.71 for Black non-Hispanic). Conclusion: Prenatal care, parity, insurance type, household income, and race/ethnicity are associated with recall of obstetric provider activities that impact antepartum Tdap vaccine promotion. Obstetric providers should recommend this potentially life-saving vaccine with each pregnancy, irrespective of differences in maternal characteristics, and policymakers should work to combat systemic factors that may cause disparities in uptake.

Developing a novel screening tool to address pediatric COVID-19 vaccine hesitancy at point of care.

Many children are still not vaccinated against COVID-19, often attributed to rising pediatric vaccine hesitancy. To address this complex public health issue, interventions that uncover parental thinking at point of care are needed to help facilitate discussions in the exam room. The cognitive science framework of Rule Developing Experimentation helps distinguish how people think about day-to-day topics by presenting respondents with a systematic combination of messages that determines the ideas primarily driving their decisions. We hypothesized that Rule Developing Experimentation can empirically assess and identify parental mind-sets in deciding to vaccinate their children to prevent COVID-19. Artificial intelligence was also incorporated to more efficiently help formulate messages. Through an iterative process, surveying a total of 600 participants, three mind-sets emerged regarding the types of messages which parents believe would convince them to vaccinate their children to prevent COVID-19. These three mind-sets are summarized by the following phrases - "Covid is Serious," "Science Says Vaccine Works," and "Vaccine Returns Kids to Normalcy". Using these mind-sets, a simple six-question instrument (i.e., Personal Viewpoint Identifier) was then created to quickly discern at point of care a parent's mind-set surrounding pediatric COVID-19 vaccination. By quickly identifying a parent's mindset at point of care, providers can then utilize the results of the assessment to deliver individualized messaging to parents about the benefits of COVID-19 vaccination. A future study is planned to evaluate the impact of incorporating the Personal Viewpoint Identifier into routine pediatric care settings on COVID-19 vaccination rates.

International Travel Vaccine Recommendations for Children.

Children are at risk of contracting diseases while traveling internationally. Beyond the importance of receiving routine vaccinations, physicians should also discuss with parents the effectiveness of vaccination as a strategy to protect their child against disease before travel. This article (1) explores the universally recommended routine vaccines that are particularly important for children to be up to date before travel (ie, measles, mumps, rubella; hepatitis A and B; polio; meningococcal; coronavirus disease 2019 [COVID-19]; and influenza) and (2) explains the travel-specific vaccination recommendations (ie, dengue, cholera, typhoid, tick-borne encephalitis, yellow fever, Japanese encephalitis, and rabies). Physicians can encourage parents to consult the Centers for Disease Control and Prevention website for travel vaccine recommendations (https://wwwnc.cdc.gov/travel). Children must remain up to date on universally recommended vaccines and receive the appropriate vaccines before international travel to prevent serious illness and limit the spread of diseases in the United States. [Pediatr Ann. 2023;52(3):e106-e113.].

COVID-19 Vaccines for Children: An Update.

The coronavirus disease 2019 (COVID-19) pandemic has had a large effect on the pediatric population, with 16,000,000 cases and counting. Currently, there are two messenger RNA (mRNA)-based and a single adjuvanted, protein-based COVID-19 vaccine approved for use in children and adolescents in the United States. Multiple studies have highlighted that these vaccines are safe for use in children and adolescents and are effective at reducing COVID-19 infection and complications. Given the risk of the SARS-CoV-2 virus to the pediatric population and ongoing global viral transmission, it is advised that providers emphasize the value of COVID-19 vaccination for children and adolescents. [Pediatr Ann. 2023;52(3):e83-e88.].

Association of Severe Acute Respiratory Syndrome Coronavirus 2 Infection With Early Breastfeeding.

OBJECTIVE: The association of maternal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) status before delivery with breastfeeding is unknown. This study compares breastfeeding initiation, exclusivity, and duration between SARS-CoV-2-positive (+) and SARS-CoV-2-negative (-) mothers during the first 2 months of their newborns' lives. METHODS: A single center, retrospective cohort study of pediatric contacts during the first 2 months in a diverse mother-infant population (n = 285) compared breastfeeding outcomes by maternal SARS-CoV-2 status during a pandemic surge. Infants of SARS-CoV-2 positive mothers were also tested before discharge. Comparison of maternal demographics (age, race, ethnicity), maternal/infant characteristics (parity, insurance, delivery mode, infant sex, hospital length of stay), and pediatric contacts by maternal SARS-CoV-2 status included Fisher's exact and Wilcoxon tests and Poisson regression for count outcomes. Logistic regression compared breastfeeding outcomes between the 2 groups, adjusting for potential confounders and effect modifiers. RESULTS: Maternal demographics and maternal/infant characteristics were similar. While 19% of mothers tested positive for SARS-CoV-2 (n = 54), their infants were all negative. SARS-CoV-2 positive mothers had fewer in-person, but more virtual pediatric contacts. After controlling for the above variables, SARS-CoV-2 positive mothers had lower odds of breastfeeding initiation within 1 to 7 days of life (78% vs 88%; adjusted odds ratio [aOR] = 0.40, 95% confidence interval [CI]: 0.17, 0.96) and of any breastfeeding during month 2 (54% vs 76%; aOR = 0.37, 95% CI: 0.16, 0.86) compared with SARS-CoV-2 negative mothers. CONCLUSIONS: Maternal SARS-CoV-2 positivity at delivery was independently associated with less initiation and shorter duration of any breastfeeding during month 2. SARS-CoV-2 positive women would likely benefit from additional breastfeeding support during pandemic surges.

Factors Influencing Maternal Antepartum Tdap Vaccination.

INTRODUCTION: Antepartum Tdap remains low despite national recommendations. This prospective observational study aims to identify factors associated with lower antepartum Tdap rates. METHODS: Maternal demographics, personal health beliefs, Tdap vaccination status, and recall of in-office obstetric provider actions were collected from a convenience sample of postpartum women in a New York metropolitan hospital. Bivariate and multivariable logistic regression were used to identify significant factors and adjusted odds ratios (OR) for recorded Tdap; OR > 1 reflects elements with increased odds of not receiving antepartum Tdap, while OR < 1 demonstrates increased odds of receipt. RESULTS: Surveys were collected (n = 1682) from a study population demographically similar to New York City and more diverse in race/ethnicity than the national population. Demographic analysis showed Hispanic women less likely than white, non-Hispanic women to vaccinate (OR 2.44, CI 1.54-3.88). Health beliefs associated with non-receipt of antepartum Tdap included "It is dangerous for pregnant women to get vaccines" (OR 1.68, CI 1.01-2.77), and "I worry about the safety of the Tdap vaccine" (OR 1.59, CI 1.12-2.24). Obstetric provider actions associated with vaccination included receiving an OB recommendation (OR 0.39, CI 0.23-0.65), getting written information about Tdap (OR 0.44, CI 0.30-0.64), and having Tdap offered in office (OR 0.24, CI 0.15-0.37). Health beliefs associated with antepartum Tdap included "I generally do what my OB/GYN provider recommends" (OR 0.49, CI 0.30-0.80), and "Pregnant women should get the Tdap (pertussis) vaccine" (OR 0.17, CI 0.09-0.33). DISCUSSION: Maternal race/ethnicity, personal health beliefs, and obstetric provider actions predict antepartum Tdap.

The Power of Connections: AAP COVID-19 ECHO Accelerates Responses During a Public Health Emergency.

CONTEXT: Pediatric providers across the United States have sought guidance on how to care for the nation's children during the uncertain historic times of the COVID-19 pandemic. The health care community has been challenged by the unprecedented burden of caring for patients when they have evolving guidelines and limited information about the effects of the virus on children. PROGRAM: In response, the American Academy of Pediatrics (AAP) rapidly launched a national initiative to increase child health professionals' knowledge, skills, and self-efficacy. This COVID-19 ECHO (Extension for Community Healthcare Outcomes) program created communities of learners among child health professionals and subject matter expert faculty using didactic and case-based presentations that foster an "all-teach, all-learn" approach. IMPLEMENTATION: The initial AAP COVID-19 ECHO program hosted more than 900 participants in 127 individual virtual sessions, with approximately 25 participants per session. The evolving nature of the pandemic necessitated dynamic and continuous bidirectional flow of concerns and information relevant to participants. Session topics were selected in a "just-in-time" fashion based on participant feedback from the prospective postsession surveys and faculty recommendations; speakers brought data and expert recommendations. EVALUATION: To assess impact, the AAP used a mixed-methods approach to evaluate the program's effectiveness in meeting its educational objectives. The 2-phase evaluation collected quantitative and qualitative data through an integrated feedback structure that utilized prospective postsession and retrospective postprogram surveys, along with postprogram focus groups. DISCUSSION: As the COVID-19 pandemic surges and another influenza season is upon us, the ECHO model is an effective strategy for facilitating bidirectional communication and education to build child health professionals' knowledge, skills, and self-efficacy during an unprecedented and ongoing public health emergency. KEY POINTS: The ECHO model is an effective strategy for health care organizations to facilitate bidirectional communication and education in building health professionals' clinical knowledge, skills, and self-efficacy during the unprecedented and ongoing public health emergency of the COVID-19 pandemic.

Maternal Self-Report of Tetanus Diphtheria Pertussis Vaccination during Pregnancy Correlates with Patient-Specific Electronic Medical Records.

OBJECTIVES: To evaluate the concordance between maternal report of antepartum tetanus, diphtheria, pertussis (Tdap) vaccination and vaccination status documented in the electronic medical record (EMR), as well as factors associated with discordance. STUDY DESIGN: A survey was completed by a convenience sample of postpartum patients in a New York metropolitan hospital. The survey collected patients' demographic information, health beliefs, and whether they received Tdap vaccine during this pregnancy. The patient's Tdap vaccination status was abstracted from the EMR, a combination of data gathered from the obstetrician and patient's hospital record. Kappa statistics measured the agreement between maternal report and EMR on antepartum Tdap vaccination. Univariate and multivariable logistic regression analyses were performed to identify maternal characteristics associated with discordance. RESULTS: Of the 1571 patients with Tdap status available in the EMR, 1549 patients (92%) reported on receipt status for Tdap vaccination during pregnancy; 1328 maternal reports (86%) agreed with the EMR for Tdap status (kappa = 0.72, 95% CI 0.68-0.75). Several factors were statistically significant in multivariable analyses: lower income was associated with greater discordance (ie, overreporting; P = .02), as well as certain health beliefs including "Pregnant women should be concerned about the possibility of pertussis in their babies" (aOR 2.86, 95% CI 1.02-8.04) and "My friends would probably think getting a Tdap vaccine is a good idea" (aOR 2.36, 95% CI 1.11-4.99). CONCLUSIONS: Maternal recall of Tdap vaccination during pregnancy is consistent with the EMR. This supports the value of maternal report in determining Tdap vaccination status, which is especially important when vaccination records are not available.

The Effect of the COVID-19 Pandemic on Childhood Immunizations: Ways to Strengthen Routine Vaccination.

Primary care providers play key roles in ensuring that children and the community receive vaccines on time. Sometimes, this role includes the task of reassuring parents who are vaccine hesitant that vaccines are safe and effective. Now, because of coronavirus disease 2019 (COVID-19), providers are presented with the additional challenge of maintaining and strengthening routine vaccination during a pandemic. As COVID-19 cases increased and states implemented stay-at-home orders, outpatient visits declined significantly. As a result, childhood immunization rates also declined. Increasing communication efforts regarding the importance of vaccination will be worthwhile, as the effect of the COVID-19 pandemic has highlighted the threat of an infectious disease and has increased awareness of the vaccine development process. Prior to 2020, many parents had not seen the devastating consequences of an infectious disease. The pandemic may change a parent's perspective, particularly as it relates to the influenza vaccine. Providers should continue to promote the importance of well-child and vaccination visits. [Pediatr Ann. 2020;49(12):e516-e522.].

COVID-19 Vaccines: A Primer for Clinicians.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the identified cause of coronavirus disease 2019 (COVID-19), continues unabated. This fact, coupled with recurrence of COVID-19 in areas where it had been controlled, highlights the critical need for a safe and effective vaccine to prevent and mitigate this novel virus. The spike protein of SARS-CoV-2 is important in its lifecycle as well as in the development of immunity after human infection. This has prompted the selection of this antigen as a focus in developing COVID-19 vaccines. This article provides (1) a summary of the host immune responses to SARS-CoV-2 infection, (2) the vaccine platforms being used with COVID-19 vaccine candidates undergoing, or about to undergo, Phase III clinical trial testing, and (3) an overview of the key criteria necessary for COVID-19 vaccine efficacy and safety. In addition, the unique concept of vaccine-enhanced disease will be discussed. [Pediatr Ann. 2020;49(12):e532-e536.].

Increasing antepartum Tdap vaccine administration: A quality improvement initiative.

The Centers for Disease Control and Prevention (CDC) recommends antepartum Tdap vaccination for women with each pregnancy to protect themselves and their vulnerable infants through transplacental transfer of maternal antibodies. Our aim was to increase the rate of antepartum Tdap vaccine administration by 20%. Obstetricians were surveyed to identify their present approaches and barriers to antepartum Tdap vaccine administration to help guide the development of our intervention. Limited staff training, lack of vaccine on site, and cost were the most commonly identified barriers. Using these survey responses, existing literature, and brainstorming conversations with colleagues, an interdisciplinary workgroup then created a fishbone analysis and developed a 5-step intervention to address these barriers: (1) educate providers and patients on Tdap and pertussis; (2) increase Tdap availability to all pregnant women; (3) remind staff of the established Tdap standing order to facilitate administration; (4) encourage obstetricians to offer Tdap; (5) transfer documentation of Tdap administration from office to hospital. To monitor changes in the process over 15 months of pre- and post-intervention, data were collected from monthly chart audits and a two-phase control chart was created. The main outcome measure was proportion of eligible women who received Tdap during current pregnancy. In the pre-intervention period, 362 of 636 eligible women (56.9%) received Tdap during their current pregnancy; in the post-intervention period, 457 of 708 eligible women (64.5%) received Tdap during their current pregnancy. This absolute difference of 7.6% (64.5% vs. 56.9%, p < 0.01) represents a 13.4% relative increase (64.5%/56.9%) in the proportion of clinically eligible pregnant women who received Tdap. This represents a clinically and statistically significant increase in the rate of antepartum Tdap immunization. More research is needed to further understand obstetric barriers and maternal refusal of antepartum Tdap administration.

Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa.

These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.

Hib antibody responses in infants following diphtheria, tetanus, acellular pertussis, and conjugated Haemophilus influenzae type b (Hib) combination vaccines with decreasing amounts of tetanus toxoid.

BACKGROUND: While combination vaccines have contributed to improved vaccine uptake rates in children, studies have documented varied immunogenicity to specific vaccine components. We studied whether varying the amount of tetanus toxoid (TT) in a DTaP and Hib combination vaccine would result in immunogenicity comparable with separate, concurrent administration. METHODS: We evaluated the immunogenicity of Massachusetts Biologic Laboratories (MBL) diphtheria, tetanus, and acellular pertussis (mDTaP) vaccine combined with tetanus-conjugated MBL Haemophilus influenzae type b vaccine (mHib) in a single injection (DTaPH). We compared four DTaPH vaccines containing varying concentrations of TT. We also evaluated the immune response to the DTaP vaccine manufactured by Connaught Laboratories (now known as Sanofi Pasteur) given with mHib and with Wyeth Hib-CRM197 (HbOC) as separate injections. Vaccines were administered to 240 healthy infants at 2, 4, and 6 months of age, and blood specimens for antibody determination were obtained before each immunization and one month after the third immunization. RESULTS: We found no significant differences in immune response to the vaccines between the four DTaPH groups. Hib antibody responses were similar in the mHib and the HbOC groups but significantly lower in the DTaPH groups, as measured by Chinese Hamster Ovary (CHO) cell neutralization titers and filamentous hemagglutinin antigen (FHA) geometric mean concentrations (GMC) of anti-Hib antibodies. There were no significant differences between the groups in pertussis or tetanus toxoid antibody levels. CONCLUSION: Reducing tetanus toxoid amounts did not produce comparable immunogenicity for Hib. The nature of the interaction between immune responses to DTaPH components should be explored further to enable the development of better Hib-containing combination vaccines.

Oral Health Promotion During Well Visits.

Training pediatric residents in Bright Futures and oral health concepts is critical to improving oral health. This study's objective was to determine the skill level of pediatric residents in integrating oral health promotion during health supervision visits of 12- to 35-month-old children. One hundred forty-three pediatric residents participated in an evaluation of the effectiveness of a Bright Futures oral health curriculum. Competencies assessed preintervention included partnership building, communication, and integration of oral health concepts. Pediatric residents' abilities to integrate oral health promotion into health supervision visits varied considerably. Residents demonstrated greater skill in communication and partnership building compared with oral health promotion behaviors and performance of an oral examination. Further education is needed at a national level if we are to meet Healthy People 2020 goals.

Increasing Tdap Coverage Among Postpartum Women: A Quality Improvement Intervention.

BACKGROUND AND OBJECTIVE: Infants are at greatest risk for severe disease and death from pertussis; most acquire it from household contacts. Centers for Disease Control and Prevention guidelines recommend tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap) vaccination for infant caregivers, especially postpartum women who did not receive it during pregnancy. Our objective was to increase the percentage of women receiving Tdap vaccine before postpartum discharge. METHODS: An interdisciplinary workgroup identified barriers to improvement of postpartum Tdap vaccination from which a 5-step intervention was created: (1) provide education on Tdap and pertussis; (2) offer Tdap throughout hospitalization; (3) create a Tdap standing order; (4) keep Tdap as floor stock; and (5) document administration. Pre- and postintervention data were collected from monthly chart reviews. Our main outcome measures were the proportion of postpartum women eligible for Tdap and the proportion of those eligible who received Tdap. RESULTS: Preintervention baseline data (202 charts) described 166 postpartum women eligible to receive Tdap. Of the eligible women, 91 (55%) received the Tdap vaccine. During the 9-month postintervention period, 844 charts were reviewed (average, 93 per month; range, 82-104). Of the 632 women eligible to receive the Tdap vaccine, 462 (73% overall [range, 67%-79%]) received it. Thirty-three percent more postpartum mothers received the Tdap vaccine before discharge in the postintervention period (P < .01). The percentage of women eligible decreased from 82% to 75%. CONCLUSIONS: This quality improvement initiative substantially increased Tdap immunization in the immediate postpartum period. Efforts to increase immunization during pregnancy for passive transfer of maternal antibodies remain preferable.

Practical Approaches to Optimize Adolescent Immunization.

With the expansion of the adolescent immunization schedule during the past decade, immunization rates notably vary by vaccine and by state. Addressing barriers to improving adolescent vaccination rates is a priority. Every visit can be viewed as an opportunity to update and complete an adolescent's immunizations. It is essential to continue to focus and refine the appropriate techniques in approaching the adolescent patient and parent in the office setting. Health care providers must continuously strive to educate their patients and develop skills that can help parents and adolescents overcome vaccine hesitancy. Research on strategies to achieve higher vaccination rates is ongoing, and it is important to increase the knowledge and implementation of these strategies. This clinical report focuses on increasing adherence to the universally recommended vaccines in the annual adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. This will be accomplished by (1) examining strategies that heighten confidence in immunizations and address patient and parental concerns to promote adolescent immunization and (2) exploring how best to approach the adolescent and family to improve immunization rates.