Effect of 2 urban emergency department immunization programs on childhood immunization rates

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Effectiveness of hospital-based strategies for improving childhood immunization coverage: A systematic review

BACKGROUND

Hospital settings represent an opportunity to offer and/or promote childhood vaccination. The purpose of the systematic review was to assess the effectiveness of different hospital-based strategies for improving childhood vaccination coverage.

METHODS

A systematic search of multiple bibliographic databases, thesis databases, and relevant websites was conducted to identify peer-reviewed articles published up to September 20, 2021. Articles were included if they evaluated the impact of a hospital (inpatient or emergency department)-based intervention on childhood vaccination coverage, were published in English or French, and were conducted in high-income countries. High quality studies were included in a narrative synthesis.

RESULTS

We included 25 high quality studies out of 7,845 unique citations. Studies focused on routine, outbreak, and influenza vaccines, and interventions included opportunistic vaccination (i.e. vaccination during hospital visit) (n = 7), patient education (n = 2), community connection (n = 2), patient reminders (n = 2), and opportunistic vaccination combined with patient education and/or reminders (n = 12). Opportunistic vaccination interventions were generally successful at improving vaccine coverage, though results ranged from no impact to vaccinating 71 % of eligible children with routine vaccines and 9-61 % of eligible children with influenza vaccines. Interventions that aimed to increase vaccination after hospital discharge (community connection, patient education, reminders) were less successful.

CONCLUSIONS

Some interventions that provide vaccination to children accessing hospitals improved vaccine coverage; however, the baseline coverage level of the population, as well as implementation strategies used impact success. There is limited evidence that interventions promoting vaccination after hospital discharge are more successful if they are tailored to the individual.

Interventions delivered in secondary or tertiary medical care settings to improve routine vaccination uptake in children and young people: a scoping review

OBJECTIVE

To identify and analyse the interventions delivered opportunistically in secondary or tertiary medical settings, focused on improving routine vaccination uptake in children and young people.

DESIGN

Scoping review.

SEARCH STRATEGY

We searched CINAHL, Web of Science, Medline, Embase and Cochrane Database of Systematic Reviews for studies in English published between 1989 and 2021 detailing interventions delivered in secondary or tertiary care that aimed to improve childhood vaccination coverage. Title, abstract and full-text screening were performed by two independent reviewers.

RESULTS

After deduplication, the search returned 3456 titles. Following screening and discussion between reviewers, 53 studies were included in the review. Most papers were single-centre studies from high-income countries and varied considerably in terms of their study design, population, target vaccination, clinical setting and intervention delivered. To present and analyse the study findings, and to depict the complexity of vaccination interventions in hospital settings, findings were presented and described as a sequential pathway to opportunistic vaccination in secondary and tertiary care comprising the following stages: (1) identify patients eligible for vaccination; (2) take consent and offer immunisations; (3) order/prescribe vaccine; (4) dispense vaccine; (5) administer vaccine; (6) communicate with primary care; and (7) ongoing benefits of vaccination.

CONCLUSIONS

Most published studies report improved vaccination coverage associated with opportunistic vaccination interventions in secondary and tertiary care. Children attending hospital appear to have lower baseline vaccination coverage and are likely to benefit from vaccination interventions in these settings. Checking immunisation status is challenging, however, and electronic immunisation registers are required to enable this to be done quickly and accurately in hospital settings. Further research is required in this area, particularly multicentre studies and cost-effectiveness analysis of interventions.

Facilitators and Barriers to Providing Vaccinations During Hospital Visits

BACKGROUND

Many children are undervaccinated at the time of hospital admission. Our objective was to explore the facilitators and barriers to vaccinating during hospitalization.

METHODS

We conducted qualitative interviews of parents, primary care pediatricians, emergency department (ED) physicians, and pediatric hospitalists. Parents of undervaccinated hospitalized children who were admitted through the ED were invited to participate. We used purposive sampling to identify physician participants. Semistructured interviews querying participants' perspectives on hospital-based vaccination were audiorecorded and transcribed. Parent demographics and physician practice characteristics were collected. Transcripts were analyzed for facilitators and barriers to vaccinating during acute hospital visits by using inductive content analysis. A conceptual framework was developed on the basis of the social ecological model.

RESULTS

Twenty-one parent interviews and 10 physician interviews were conducted. Of parent participants, 86% were female; 76% were white. Physician participants included 3 primary care pediatricians, 3 ED physicians, and 4 hospitalists. Facilitators and barriers fell under 4 major themes: (1) systems-level factors, (2) physician-level factors, (3) parent-provider interactional factors, and (4) parent- and child-level factors. Parent participants reported a willingness to receive vaccines during hospitalizations, which aligned with physician participants' experiences. Another key facilitator identified by parent and physician participants was the availability of shared immunization data. Identified by parent and physician participants included the availability of shared immunization data. Barriers included being unaware that the child was vaccine-eligible, parental beliefs against vaccination, and ED and inpatient physicians' perceived lack of skills to effectively communicate with vaccine-hesitant parents.

CONCLUSIONS

Parents and physicians identified several key facilitators and barriers to vaccinating during hospitalization. Efforts to provide inpatient vaccines need to address existing barriers.

Childhood and Adolescent Vaccination in Alternative Settings

Although pediatric and adolescent vaccination rates are generally high in the United States, delayed and under-vaccination exist within certain patient populations and communities, leaving them vulnerable to vaccine-preventable diseases. One strategy for addressing this major public health concern is to offer vaccinations in nonprimary care settings such as schools, emergency rooms, hospitals, and pharmacies. This article reviews the unique advantages, challenges, and experiences regarding vaccine delivery in each alternative setting. It describes the key components that each must possess as well as other important factors to consider when assessing the ability of each to deliver vaccines to the children and adolescents they serve. It also highlights the need for sufficient funding and reimbursement for vaccine-related costs in these settings, the importance of orienting staff, providers, and practices to offering preventive care services through education and evidenced-based approaches, and the necessity of effective, efficient coordination of vaccination efforts across sites. By expanding the scope of non-primary care settings to include vaccine delivery and striving to capture all vaccination opportunities in these locations, the proportion of children and adolescents receiving on-time doses will undoubtedly increase. It is important to emphasize that these settings should not replace the medical home as the primary location for vaccination, but rather serve as a critical safety net for high-risk individuals and communities and in situations where access to traditional locations may be limited such as during the COVID-19 pandemic.

Knowledge and Acceptability of Human Papillomavirus Vaccination and Text Message Reminders for Adolescents in Urban Emergency Departments: A Pilot Study

Purpose

Cervical, oropharyngeal and anogenital cancers are vaccine-preventable diseases, but human papillomavirus (HPV) vaccination coverage in the US remains poor overall with regional variations in vaccination rates. We explore the acceptability by adolescents and their parents of HPV vaccination and text message reminders in the non-traditional setting of the emergency department (ED).

Patients and Methods

The modified validated Carolina HPV Attitudes and Beliefs Scale (CHIAS) survey was administered at two urban EDs to adolescents aged 13–18 years and their parents. Demographic information was collected for each participating adolescent. Recruitment occurred with consecutive eligible participants on the ED census list approached within 4-hour blocks from 8am to 8pm.

Results

Ninety-six adolescents completed the survey. The mean adolescent and parental knowledge scores were 63% (SD=29.7) and 60% (SD=22.1), respectively. The higher the HPV knowledge score among both adolescents and parents, the more likely they were to accept HPV vaccine in ED. Among the 10 cases where the parents disagreed to the HPV vaccine and the adolescents agreed to the HPV vaccine, the mean knowledge score among parents disagreeing was 47 compared to 62 among the remaining parents (p=0.04). Sixty-seven percent of adolescents and 68% of parents were agreeable to the adolescent receiving vaccination in the ED (kappa = 0.24). Seventy-five percent of adolescents and 71% of parents reported being agreeable to receiving text reminders for HPV vaccines (kappa = 0.20). Adolescent agreement with receiving a text message reminder corresponded with an increased willingness to be vaccinated (OR=3.21, 95% CI=1.07–9.57, p-value=0.0368). Sexually active adolescents were older (mean age, 17 years) than those who reported no sexual activity (mean age, 15 years) (p<0.0001).

Conclusion

Increased knowledge about HPV influences vaccine acceptance. Parents and adolescents may disagree in accepting HPV vaccination. A majority of adolescents and their parents were agreeable to receiving HPV vaccination in the ED and subsequent text message reminders. The ED should be explored further as a non-traditional healthcare setting for HPV vaccination of adolescents.

Accuracy of Provider-Documented Child Immunization Status at Hospital Presentation for Acute Respiratory Illness

OBJECTIVES

To assess (1) the accuracy of child immunization status documented by providers at hospital presentation for acute respiratory illness and (2) the association of provider-documented up-to-date (UTD) status with immunization receipt during and after hospitalization.

METHODS

We conducted a retrospective cohort analysis of children ≤16 years old treated for asthma, croup, bronchiolitis, or pneumonia at a children's hospital between July 2014 and June 2016. Demographics, clinical characteristics, and provider-documented UTD immunization status (yes or no) at presentation were obtained from the medical record. We compared provider-documented UTD status to the gold standard: the child's UTD status as documented in the Washington State Immunization Information System (WAIIS). The sensitivity, specificity, and positive predictive value of provider-documented UTD status were calculated. We assessed the association of provider-documented UTD status and immunization during and within 30 days posthospitalization using multivariable logistic regression.

RESULTS

Among 478 eligible children, 450 (94%) had provider-documented UTD status at hospital presentation and an active WAIIS record. Overall, 92% and 42% were UTD by provider documentation and WAIIS records, respectively, with provider-documented UTD status having 98.4% sensitivity (95% confidence interval [CI]: 95.4%-99.7%), 12.2% specificity (95% CI: 8.5%-16.8%), and 44.6% positive predictive value (95% CI: 39.7%-49.5%). Per WAIIS records, 20% and 44% of children who were due for vaccines received a vaccine during or within 30 days posthospitalization, respectively. There was no significant association between provider-documented UTD status and immunization during or after hospitalization.

CONCLUSIONS

Provider-documented UTD immunization status at hospital presentation for children with respiratory illnesses overestimates UTD status, creating missed opportunities for immunization during and after hospitalization.

Interventions to increase pediatric vaccine uptake: An overview of recent findings

Although much is known about factors contributing to variation in pediatric immunization uptake, there is a need for synthesis of effective vaccine promotion strategies. With growing public health concern on how to best sustain high pediatric immunization rates, and improve where the rates are suboptimal, this review offers evidence gathered from several studies on the achievement of these goals. We identified and analyzed reported findings on childhood (primarily ≤ 7 years) immunization outcomes from tested intervention strategies that focused on parents, guardians, and caregivers, as well as providers, clinics/practices, and communities. The findings suggest that targeted and tailored interventions offer substantial possibilities, especially in a combined manner. We describe promising intervention models that have been operationalized with success and provide evidence for scalability across contexts. Moreover, they are sensitive to parents' and providers' needs, are feasibly integrated in daily clinical practice, and account for broader community concerns and issues.

Cost-effectiveness analysis and emergency medical services for children: issues and applications

Studies to assess the cost-effectiveness of alternative treatment or prevention strategies for children are far fewer than those for adults. This article highlights specific issues relevant to the conduct of cost-effectiveness analysis (CEA) in pediatric populations following the recommendations of the US Panel on Cost-effectiveness in Health and Medicine and discusses CEA applications relevant to emergency medical services for children. The article addresses whether patient time should be included in measures of costs, whether caregiver time costs are included and measured properly, and most importantly, whether the study can use quality adjusted life years (QALYs) as an outcome measure. Pediatric researchers may be unable to follow the panel's recommendations for including QALYs as an outcome measure in CEA studies involving young children. Developing preference weights applicable to young children may be a productive field for pediatric researchers. Without such efforts, the field of child health services research in general and the field of emergency medical services for children in particular will continue to lag behind adult fields in assessing the costs and outcomes of the services they provide.

The importance of outcomes research in pediatric emergency medicine

Applying the methods and tools of outcomes research, "evaluation of the impact of health care on the health outcomes or 'end results' of patients and populations," to the clinical domain of emergency services for children offers an important strategic opportunity for addressing the questions that confront all health care services: What works? For which patients? At what cost? From whose perspective? Although the important questions to address are extensive, much of the intersection between emergency services and outcomes research remains unexplored. Important challenges for researchers intrigued by the opportunities at this intersection of fields include: 1) clear definition of the scope of emergency services; 2) consideration of the appropriate end-point of emergency services-the entire episode of illness and/or services provided within the emergency setting; 3) selection and development of measures that incorporate children's and families' perspectives; and 4) a clear focus on linking research findings with strategies for improving outcomes and informed decision making. This essay will provide an overview of accomplishments and challenges from the field of outcomes research, suggest important opportunities for applying existing methods to emergency medical services for children, and identify potential career paths for current and future investigators.

Effectiveness of compliance with pediatric preventive care guidelines among Medicaid beneficiaries

OBJECTIVE

Because research has not confirmed a relationship between compliance with health supervision in infancy and improved health outcomes, we examined the association between adherence to prevailing guidelines for periodic health supervision and adverse health outcome indicated by incidence of avoidable hospitalizations.

METHODS

This was a historic cohort study of 308 131 children enrolled in Medicaid at birth in California, Georgia, and Michigan in 1990 using Medicaid records linked across 3 years. We used avoidable hospitalizations as indicators of health in a survival analysis. The analysis used variables that represented completeness and timeliness of well-child visits and immunizations using AAP guidelines for health supervision as the gold standard.

RESULTS

When the children in this cohort were up-to-date for age on their schedule of well-child visits, they were less likely to have an avoidable hospitalization (race, illness, and level of poverty adjusted hazard ratios 0.52 [95% confidence interval (CI): 0.50-0.55] in California, 0.54 [95% CI: 0.50-0.55] in Georgia, and 0.7 [95% CI: 0.69-0.79] in Michigan). Among children who were not up-to-date with well-child visits, a sporadic preventive care visit conferred a mild benefit. Immunizations and race/ethnicity had no consistent relationship with incidence of avoidable hospitalizations.

CONCLUSIONS

A series of well-child visits maintained during the first 2 years of life has a positive effect on health outcomes as indicated by a decrease in avoidable hospitalizations among poor and near-poor children, regardless of race, level of poverty, or health status. National efforts to improve the quality of child health services for young children should focus on increasing compliance with periodic preventive care for young children in addition to improving immunization levels.

Pediatric vaccine compliance

Immunization programs have produced a significant trend toward reducing the occurrence of disease in the United States. The resurgence of vaccine-preventable diseases, however, is a reminder that many goals have not yet been achieved. The methods discussed in this article may be useful in delivering vaccines to the pediatric population.

Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services

This paper presents the results of systematic reviews of the effectiveness, applicability, other effects, economic impact, and barriers to use of selected population-based interventions intended to improve vaccination coverage. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis for recommendations by the Task Force on Community Preventive Services (the Task Force) regarding the use of these selected interventions. The Task Force recommendations are presented on pp. 92-96 of this issue.

Immunization status of children enrolled in a hospital-based medicaid managed care practice: the importance of the timing of vaccine administration

OBJECTIVES

To evaluate the immunization status of children enrolled in a hospital-based Medicaid managed care practice and to assess the impact of the timing of vaccine administration on measured immunization rates.

DESIGN AND METHODS

The medical records of all children between the ages of 19 and 35 months who were continuously enrolled in the Medicaid managed care practice for the last 6 months of 1996 were reviewed. Immunization status was determined for the following vaccines: diphtheria-tetanus-pertussis/diphtheria-tetanus-acellular pertussis (4 doses); Haemophilus influenzae type b (3 doses); poliovirus (3 doses); hepatitis B (3 doses); measles-mumps-rubella (1 dose); and overall for the basic series. Two assessment methods were used to determine the immunization status of the study children: (1) a count of all documented vaccines ("count"); and (2) only including vaccines that met minimal age and spacing intervals based on American Academy of Pediatrics and CDC recommendations ("interval assessment").

RESULTS

With the count method vaccine-specific immunization rates ranged from 88 to 95%, with overall coverage of 80% for the basic series. With the interval assessment method vaccine-specific immunization rates ranged from 74 to 92%, with overall coverage of 53% for the basic series.

CONCLUSIONS

When all documented vaccines were included in the assessment, vaccine-specific immunization rates approached national goals, although overall coverage remained below 90% in this Medicaid managed care practice. The substantially lower immunization rates obtained by the interval assessment method demonstrate the importance of considering the issue of vaccine timing when interpreting immunization rates and the need for policies for revaccinating children who were immunized at less than recommended intervals. The results also have implications for provider education regarding the early administration of vaccines.