Effect of a multi-modal intervention on immunization rates in obstetrics and gynecology clinics

Who are vaccine champions and what implementation strategies do they use to improve adolescent HPV vaccination? Findings from a national survey of primary care professionals

BACKGROUND

Implementation science researchers often cite clinical champions as critical to overcoming organizational resistance and other barriers to the implementation of evidence-based health services, yet relatively little is known about who champions are or how they effect change. To inform future efforts to identify and engage champions to support HPV vaccination, we sought to describe the key characteristics and strategies of vaccine champions working in adolescent primary care.

METHODS

In 2022, we conducted a national survey with a web-based panel of 2527 primary care professionals (PCPs) with a role in adolescent HPV vaccination (57% response rate). Our sample consisted of pediatricians (26%), family medicine physicians (22%), advanced practice providers (24%), and nursing staff (28%). Our survey assessed PCPs' experience with vaccine champions, defined as health care professionals "known for helping their colleagues improve vaccination rates."

RESULTS

Overall, 85% of PCPs reported currently working with one or more vaccine champions. Among these 2144 PCPs, most identified the champion with whom they worked most closely as being a physician (40%) or nurse (40%). Almost all identified champions worked to improve vaccination rates for vaccines in general (45%) or HPV vaccine specifically (49%). PCPs commonly reported that champion implementation strategies included sharing information (79%), encouragement (62%), and vaccination data (59%) with colleagues, but less than half reported that champions led quality improvement projects (39%). Most PCPs perceived their closest champion as being moderately to extremely effective at improving vaccination rates (91%). PCPs who did versus did not work with champions more often recommended HPV vaccination at the earliest opportunity of ages 9-10 rather than later ages (44% vs. 33%, p < 0.001).

CONCLUSIONS

Findings of our national study suggest that vaccine champions are common in adolescent primary care, but only a minority lead quality improvement projects. Interventionists seeking to identify champions to improve HPV vaccination rates can expect to find them among both physicians and nurses, but should be prepared to offer support to more fully engage them in implementing interventions.

Interventions to Improve Knowledge, Attitudes, and Uptake of Recommended Vaccines during Pregnancy and Postpartum: A Scoping Review

Tetanus, pertussis, influenza, and COVID-19 vaccines are recommended for the prevention of related morbidity and mortality during pregnancy and postpartum. Despite the established benefits of vaccination for prenatal and postnatal women, maternal vaccination is not universally included in routine antenatal programs, especially in low- and middle-income countries. Furthermore, the uptake of recommended vaccines among pregnant and postpartum women remains below optimum globally. This review aimed to map the evidence on interventions to improve knowledge, attitudes, and uptake of recommended vaccines among pregnant and postpartum women. We conducted a comprehensive and systematic search for relevant literature in PubMed, Scopus, Web of Science, EBSCOhost, and Google Scholar. Overall, 29 studies published between 2010 and 2023 were included in this review. The majority (n = 27) of these studies were from high-income countries. A total of 14 studies focused on the influenza vaccine, 6 on the Tdap vaccine, 8 on both influenza and Tdap vaccines, and only one study on the COVID-19 vaccine. Patient-centered interventions predominated the evidence base (66%), followed by provider-focused (7%), health system-focused (10%), and multilevel interventions (17%). Overall, the effect of these interventions on knowledge, attitudes, and uptake of maternal vaccines was variable.

Enhancing Hepatitis A and B Vaccinations Through Electronic Clinical Decision Support Systems and Staff Education in a Correctional Facility

BACKGROUND

Despite the prevalence and risks for hepatitis A virus (HAV) and hepatitis B virus (HBV) infection and the availability of safe and effective vaccines, HAV/HBV vaccinations are disproportionately low in jails. This quality improvement project evaluated the effectiveness of clinical decision support systems: electronic standing orders to nurses, clinical alerts to nurses and healthcare providers, and secondarily staff education in enhancing HAV and HBV vaccination and knowledge of hepatitis infection.

METHODS

We distributed a validated self-report hepatitis knowledge questionnaire (α = 0.7-0.8) before and after an educational presentation to nurses, nurse practitioners, and physicians ( N = 26) at a Northeastern state jail and then embedded electronic clinical alerts and standing orders in the electronic medical record. The questionnaire assessed pre- and posteducation knowledge scores. The number of vaccine status screenings and vaccinations was retrieved from the electronic medical record 3 months pre- and post-implementation. Descriptive statistics and the Wilcoxon signed-ranks test were used for data analysis.

RESULTS

Twenty-one participants completed the pretest, 18 attended the educational intervention, and 15 completed the posttest. Vaccine status screening increased by 97.5%, and HAV and HBV vaccinations increased by 8.7%. Knowledge scores improved significantly post-intervention ( p = 0.04), with an effect size of r = 0.67).

DISCUSSION/CONCLUSION

Using the Donabedian quality of care model, we showed that quality initiatives are feasible in a jail setting. Implementing a clinical decision support system and education improved the vaccination rate, which may decrease HAV/HBV incidence in the jail and prevent community spread.

The issue of vaccine refusal: the study of a risky behavior

Purpose

Influenza is the most common seasonal infectious disease that causes permanent social, economic, and medical problems worldwide. Therefore, the most effective way to prevent influenza is through vaccines. The aim of this study is to identify the influence of factors that determine the refusal of influenza vaccine among three subjects groups.

Materials and Methods

A survey was conducted amongst the three high-risk groups in 2018-2019 (Moscow, Russia). The survey involved 1,620 parents and pregnant women (group 1), 324 doctors (group 2), and 433 students (group 3). Poor vaccine uptake was observed among respondents in all three groups.

Results

According to the survey results, only 22.2% of children and 13.8% of adults were vaccinated against influenza. Group 2 showed increased rates with 36.7% of vaccinated adults and 58.7% of children. The lowest adherence to annual vaccinations was recorded in group 3 (only 17.3%). There is also a negative correlation between adherence to vaccination and smoking (-0.66), unhealthy diet (-0.73), poor oral hygiene (-0.61), and insufficient awareness of the need for influenza vaccine as well (-0.81).

Conclusion

Thus, a general lack of vaccination awareness has a fundamental role in forming a negative attitude toward influenza vaccine. It is necessary to conduct research to promote vaccination against influenza to improve vaccine uptake among high-risk groups, particularly students.

Vaccination coverage and immunization safety among children with special health status in Chongqing, China

Vaccination of children with special health status has become one of the most urgent issues in China. We aim to evaluate vaccination coverage and safety as well as its associated factors among children with special health status in China during 2016‒2020. We conducted a retrospective cohort review of all children with special health status recorded in the Electronic Immunization Registries System in Chongqing, China, between 2016 and 2020. Univariate and multivariate logistic regression analyses were used to analyze the influence factors. Among the 2,175 children with special health status enrolled in the study, the overall vaccination coverage rate was lower than that among the general population, and the incidence of adverse event in them following immunization was very rare. Children with congenital heart disease were better vaccinated (aOR = 1.508-6.331), while most of the jaundice children had missed vaccination (aOR = 0.441‒0.556). The purchase of vaccine compensation insurance was associated with higher completion rate of basic immunization for Bacillus Calmette-G vaccine (aOR = 1.706, 95% CI: 1.249‒2.329) and rotavirus vaccine (aOR = 1.346, 95% CI: 1.061‒1.708). Children with special health status can be safely vaccinated. However, the vaccination coverage in these huge and vulnerable group is too low to protect them from vaccine-preventable diseases through immunization. More researches and interventions should be conducted to ensure a higher vaccination rate among the children with special health status.

Multi-tiered intervention to increase maternal immunization coverage: A randomized, controlled trial

OBJECTIVE

To evaluate the impact of a multi-component intervention package of maternal immunization uptake in obstetric care clinics.

METHODS

In a multi-level, cluster- and individually-randomized controlled trial we implemented an evidence-based intervention that targeted practice-, provider- and patient-level barriers to vaccine uptake. Obstetric practices were randomized to receive the practice and provider-level interventions or continue their normal standard of care. We enrolled pregnant women at practices in Georgia and Colorado and randomized women into patient-level intervention and control groups, resulting in four study arms. The primary outcomes were receipt of the influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccines during pregnancy. A sample size of 550 women per arm (2200 total) was planned and enrolled to compare the intervention between the four study arms.

RESULTS

Between June 2017 and July 2018, 4907 women were screened and 2200 women were randomized, 550 to each of the four study arms. We were unable to follow-up with 108 women, for a final sample size of 2092. Sample characteristics and sample size were similar among study arms. There was no significant increase in Tdap or influenza vaccine uptake overall. Among women who had no intention of or were unsure about receiving the influenza vaccine during pregnancy, those who received just the patient-level intervention were 61% more likely to receive the influenza vaccine than those in the control arm (Relative risk: 1.61; 95% Confidence Interval: 1.18-2.21). There was no significant difference in vaccine uptake for either influenza or tetanus, diphtheria and acellular pertussis between the four arms of the study.

CONCLUSIONS

This trial highlights the need for more targeted interventions to improve vaccine uptake. Future work should focus on clinics with low baseline vaccine uptake and the patient-level intervention should be expanded and targeted towards women with low vaccine confidence.

Challenges in Government Inter-Organizational Information Integration in the Context of Measles Rubella Vaccination in India

Most of the countries are heading to Government 3.0 with the advent of Information Communication Technology (ICT). Information Integration has to be done with the support of different stakeholders for an effective e-Governance ecosystem. The use of Artificial Intelligence (AI) and high-end processors had solved the issues to some extent. But the socio-political intervention is making the Government Inter-Organizational Information Integration (GIII) difficult when information turns into misinformation. Misinformation in social network sites (SNS) is increasing alarmingly and is also affecting the healthcare sector. The study is focused on the trends in decreasing vaccination rates in India during the vaccination drive. Twitter data, news reports, and social media posts during the MR vaccination program in India are taken into consideration for the analysis. The vaccine hesitancy is also associated with political, religious, Psychological, and Economic factors. Government 3.0 has got its power to overcome the misinformation in the healthcare programs.

Racial disparities in influenza immunization during pregnancy in the United States: A narrative review of the evidence for disparities and potential interventions

OBJECTIVE

The objectives of this review were to summarize existing data on racial disparities in maternal immunization for influenza in the U.S. and to review the literature on interventions to improve the uptake of the influenza vaccine among Black pregnant women.

DATA SOURCES

U.S. survey data on maternal influenza immunization by racial and ethnic group were summarized in narrative form. To review intervention studies, PubMed, CINAHL, EMBASE, and the Cochrane Library databases were searched for English language articles published 2017 to 2021, in addition to studies identified by a previous systematic review.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed studies conducted in the U.S. and reporting interventions designed to increase the uptake of the influenza vaccine in pregnancy with study populations including at least 20% of participants identifying as Black were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies were grouped and reviewed in a narrative manner according to whether they were conducted in predominantly Black populations or in more racially diverse populations, and whether they tested multicomponent or single-component interventions.

RESULTS

A decade of survey data show that Black women in the U.S. consistently have the lowest rate of influenza immunization in pregnancy. Black women report a lower rate of being recommended or offered the vaccine, and provider recommendation is associated with greater vaccine uptake. Intervention studies to increase influenza immunization among Black pregnant women have reported mixed results. Successful interventions include multicomponent practice-based interventions, group prenatal care, and culturally competent patient educational messages.

CONCLUSIONS

Racial disparities in maternal uptake of the influenza vaccine are long-standing, but not intractable. More research is needed to test interventions to address this disparity, with a focus on increasing provider recommendation and offer of the vaccine, addressing patients' concerns about vaccine safety and efficacy, improving providers' cultural competence, and building trust between providers and patients.

Factors Associated with Initiation of HPV Vaccination Among Young Women and Girls in Urban and Suburban New Orleans

Vaccination coverage against human papilloma virus (HPV) in the United States remains low. This study aimed to identify factors associated with initiation of HPV vaccination among young women and girls in New Orleans, Louisiana. The study was conducted in Pediatrics and Obstetrics & Gynecology clinics in New Orleans between 2014 and 2017. Surveys were administered to women ages 18 through 26, and guardians of girls ages 12 through 17. Demographics, health history, sources of medical information, knowledge of HPV and HPV vaccination, opinions on vaccination, expected support for vaccination, and systems-level barriers were assessed. Participants self-reported discussion of the vaccine with a healthcare provider, and whether they or their child had been vaccinated. Participants were predominantly black and low-income. Among young adults, 61/121 (50%) had received any doses of the HPV vaccine; 71/94 (75%) of girls had received it (p < 0.01). In both groups, knowledge of the HPV vaccine, believing the vaccine was available from their usual healthcare provider, and having discussed the vaccine with their provider were associated with increased odds of vaccination. Among young adults, additional factors associated with vaccination were younger age, distance from a healthcare center, knowledge of HPV, and expectation of support from parents. Among guardians, holding negative views on vaccination was associated with decreased odds of vaccination. Discussion of the vaccine with a healthcare provider was the factor most strongly associated with initiation of HPV vaccination in both groups. The results provided actionable items to increase HPV vaccination uptake in these populations.

Vaccination in pregnancy: Challenges and evidence-based solutions

Vaccination in pregnancy (VIP) is dually beneficial - it protects the mother and the baby from tetanus, influenza, and pertussis. VIP uptake is low in many countries. Vaccine hesitancy, defined by the World Health Organization (WHO) as a "delay in acceptance or refusal of vaccination despite the availability of vaccination services" is one of WHO's ten threats to global health per 2019. According to extensive research, mostly from high-income countries (HIC) and limited to tetanus, influenza and pertussis vaccines, lack of provider recommendations, safety concerns, and limitations in access are the main barriers to VIP. Health care provider recommendation is the leading facilitator for VIP across various socioeconomic status groups. Data on strategies to overcome patient, provider, and system barriers to VIP are inconsistent, contradictory, or lacking. Patient-focused research on evidence-based strategies to overcome provider and system barriers is needed. Furthermore, VIP programs require embedded continuous quality improvement to ensure sustainability.

Factors affecting pregnant women's decisions regarding prenatal pertussis vaccination: A decision-making study in the nationwide Prenatal Pertussis Immunization Program in Taiwan

OBJECTIVE

To examine the factors affecting pregnant women's decisions to accept or decline the prenatal pertussis (Tdap) vaccination in Taiwan.

MATERIALS AND METHODS

We conducted a cross-sectional survey, recruiting pregnant women who had received prenatal care from eight maternity hospitals between January and December 2018. We examined the participants' demographic characteristics, perceptions of pertussis disease risk and vaccination effectiveness, beliefs regarding vaccine information, physician recommendation, and other potential factors affecting decision-making regarding prenatal vaccination.

RESULTS

The complete survey response rate among eligible women was 78%. Among the participants, 74% accepted and 26% declined prenatal Tdap vaccination. Most women accepted Tdap during pregnancy because of perceived severity of pertussis in their infants, perceived effectiveness of the prenatal Tdap in preventing neonatal pertussis, and perceived safety of the prenatal Tdap vaccine for the fetus, as well as a provider's recommendation, which was the factor strongly associated with actual Tdap reception. Most of the participants who accepted Tdap vaccination during pregnancy and who believed that the Tdap vaccine could protect their infants from pertussis reported the receiving sufficient information to make an informed decision and trust in the information. By contrast, a large proportion of the participants who declined Tdap and who did not want to experience possible fetal side effects of Tdap reported not getting sufficient information to make an informed decision and a lack of trust in the information.

CONCLUSION

Developing a comprehensive strategy involving government policy, the health care system, public media, health professionals, and pregnant women to launch a successful campaign may improve the nationwide acceptance of the prenatal pertussis vaccination.

Vaccination coverage of recommended vaccines and determinants of vaccination in at-risk groups

Upon exposure to vaccine-preventable diseases, certain individuals are at increased risk for complications due to preexisting diseases, age or immunosuppressive treatment. Vaccination against influenza, pneumococcal disease and hepatitis B (for some groups) is advised in addition to standard vaccination against diphtheria, tetanus and pertussis. We estimated the vaccination coverage and determinants of recommended vaccinations in patients with diabetes mellitus type 1 (n = 173) and type 2 (n = 177), chronic kidney disease (CKD) (n = 138), heart failure (n = 200), chronic obstructive pulmonary disease (COPD) (n = 187), HIV (n = 201) or solid organ transplantation (SOT) (n = 201) in a monocentric study. Vaccination data were retrieved from documents provided by patients and general practitioners, and from the Flemish vaccination register. Less than 10% had received all recommended vaccines. Overall, 29% of subjects were vaccinated against diphtheria-tetanus, 10% against pertussis, 44% against influenza, 32% against pneumococcal disease and 24% of HIV patients and 31% of CKD patients against hepatitis B. Age was positively associated with vaccination against influenza (OR:2.0, p < .01) and pneumococcal disease (OR:2.6, p < .001). Patients with COPD, HIV and SOT were more likely to be vaccinated against influenza (OR:2.8, p < .001, OR:1.8, p < .05; OR:2.0, p < .001, respectively) and pneumococcal disease (OR:2.9, p < .001, OR:25.0, p < .001; OR:2.6, p < .001, respectively) than patients with heart failure. Reason for non-vaccination were concerns about effectiveness, necessity and side effects of influenza vaccines, and not being aware of the recommendation for pneumococcal disease. Initiatives to monitor the vaccination status of vulnerable patients are needed, which is why we advocate systematic vaccination registration and frequent communication about vaccination.

Maximizing the impact of, and sustaining standing orders protocols for adult immunization in outpatient clinics

BACKGROUND

Low adult immunization rates leave adults at risk from infectious disease, and the resulting complications of vaccine-preventable diseases. Standing orders protocols (SOPs) for adult immunization have not been implemented widely in clinics serving adult patients. Our purpose was to evaluate the impact of SOPs on adult immunization rates and identify challenges to sustaining adult immunization coverage rates after implementation of SOPs.

METHODS

Baseline adult vaccination rates were calculated for the year prior to SOPs implementation in 5 diverse clinics. Vaccines included in the implemented standing orders included Tdap, influenza, pneumococcal, human papillomavirus, herpes zoster, and hepatitis B. Adult vaccination rates were tracked for 1 year after SOPs implementation.

RESULTS

Sites generally sustained modest gains in coverage rates (4%-8% increase) after SOP implementation, but greater success was found in practices that used SOPs as a foundation on which additional interventions were built. Challenges to increasing coverage rates included prioritization of acute and chronic conditions over adult vaccination, Medicare Part D reimbursement policies, electronic medical record issues related to data reporting and programming for patient alerts, and the lack of interoperability between the state immunization information system (missing patient vaccination history) and electronic medical record.

CONCLUSIONS

SOPs may provide a good starting point for increasing adult immunization coverage rates. Using additional interventions, quality-based metrics, or incentives could lead to sustained adult immunization prioritization.

Addressing common barriers in adult immunizations: a review of interventions

Introduction: Low levels of adult vaccination have been documented in the United States and globally. Research has been conducted to identify reasons for low immunization rates; however, the most useful studies are those that implemented interventions for identified barriers to evaluate their impact on rates of immunization. Identifying successful interventions provides immunization providers with evidence-based methods that can be utilized to increase the uptake of recommended vaccines.Areas covered: This review focuses on known barriers to adult immunizations and the interventions available in the literature to overcome these barriers. It outlines interventions that may increase vaccine uptake in the adult population through addressing barriers related to lack of vaccine knowledge, cost, access, provider and practice-based challenges, and racial and ethnic disparities.Expert opinion: Improving adult immunization rates is critical to protecting a population against vaccine-preventable diseases. Those interventions that appeared to increase immunization rates in the adult population included education and reminders about vaccination using text and telephone calls, low-cost or subsidized vaccines, easy access to immunization services, and understanding the cultural and social needs of different racial and ethnic populations. It is likely that an evidence-based multimodal approach using different categories of interventions is necessary to significantly improve adult immunization rates.

Success of an EMR-Driven Postpartum Intervention to Improve HPV Vaccination Rates

Human papillomavirus vaccination (HPV) remains low in the United States. The inpatient postpartum setting provides an innovative opportunity to vaccinate eligible patients. This study evaluated two different interventions to improve HPV vaccination rates in hospitalized postpartum patients: a nurse based protocol and an electronic medical record (EMR) postpartum order prompt. This was a comparative intervention study performed in a prospective cohort of postpartum patients at two affiliated County Hospitals. The intervention was conducted over a 6-month period aimed at increasing HPV vaccination rates through a nurse based protocol at one hospital (H-NBP) and an EMR postpartum order prompt at the second hospital (H-EMR). Outcomes measures included vaccine administration, patient refusal, and vaccine wastage. A multiple logistic regression model was used to compare outcomes. At H-NBP, 143 vaccine-eligible patients (74%) were identified of which 44 (32%) received the HPV vaccine, 66 (46%) refused, and 33 (21%) had missed opportunities. At H-EMR, 169 patients (87%) were identified as vaccine-eligible of which 111 (66%) received the HPV4 vaccine, 24 (14%) refused and 34 (20%) had missed opportunities. After adjusting for sociodemographic variables, patients at H-EMR were nearly 6 times more likely than patients at H-NBP to undergo postpartum HPV vaccination (OR 5.865, CI 3.358-10.245, p value < 0.0001). An EMR prompt offers a greater impact on HPV vaccination rates than a nursing protocol. The feasibility and success of inpatient postpartum HPV vaccination interventions as demonstrated in this study provides insights on how to approach vaccination strategies in nontraditional clinical settings.

Japanese physicians' attitudes and intentions regarding human papillomavirus vaccine compared with other adolescent vaccines

INTRODUCTION

Japan has experienced extremely low human papillomavirus vaccine (HPVV) coverage following the suspension of proactive governmental recommendations in 2013. Several studies have reported that recommendations from physicians increase adolescents' vaccine acceptance. In this survey, we evaluated the attitudes and intentions of Japanese physicians related to adolescent immunizations, particularly HPVV.

METHODS

We conducted a cross-sectional study using a mailed questionnaire targeting 330 Japanese physicians including 78 pediatricians, 225 internists and 27 obstetricians and gynecologists (OB/GYNs) in Kawasaki City, Japan in 2016. The survey measured physicians' reported frequency of educating adolescents about vaccines as well as their own perceptions and intentions related to adolescent immunizations.

RESULTS

Valid responses were obtained from 148 (45%) physicians. Though 53% agreed that the HPVV should be recommended, only 21% reported educating about HPVV. The majority of respondents (90%) agreed that they would restart HPVV for adolescents if the government reinstated its recommendation.

CONCLUSIONS

Although Japanese physicians reported support for adolescent immunizations, they were less likely to recommend or discuss HPVV compared with other adolescent vaccines. Responses indicated this was, at least in part, due to the lack of governmental support for HPVV, indicating that their recommendations would improve with government endorsement of the vaccine.

Development and acceptability of a video-based vaccine promotion tutorial for obstetric care providers

A prenatal care provider's recommendation for maternal vaccines is one of the strongest predictors of vaccine acceptance during pregnancy. Aside from basic talking points, few resources exist to help obstetric care providers effectively navigate conversations with vaccine hesitant patients. This paper describes the development and acceptability of "VaxChat," an hour-long, evidence-based video tutorial aimed at improving obstetric care providers' ability to promote maternal vaccines. Between June and November 2017, 62 obstetric care providers registered to receive continuing medical education credit for viewing VaxChat. Of the post-tutorial responses received, over 90% said VaxChat increased their knowledge of what to say to vaccine hesitant patients, increased their confidence in addressing vaccinations with their pregnant patients, and will help them improve their practice culture regarding maternal vaccine promotion. Eighty percent intend to change how they approach vaccine conversations. These data suggest VaxChat may be a welcome complement to existing provider-to-patient talking points.

A systematic review of interventions to improve uptake of pertussis vaccination in pregnancy

BACKGROUND

Maternal pertussis vaccination has been introduced in several countries to prevent pertussis morbidity and mortality in infants too young to be vaccinated. Our review aimed to systematically collect and summarize the available evidence on the effectiveness of interventions used to improve pertussis vaccination uptake in pregnant women.

METHODS

We conducted a systematic search of MEDLINE/PubMed, PMC and CINAHL. Before and after studies and those with a concurrent control group were considered for inclusion. Standardized effect sizes were described as the ratio of the odds to be vaccinated in the intervention group compared with the standard care group and absolute benefit increase (ABI) were calculated.

RESULTS

Six studies were included in the review, of which three were randomized controlled trials (RCTs). Strategies to improve uptake were focused on healthcare providers, pregnant women, or enhancing vaccine access. Healthcare provider interventions included provider reminder, education, feedback and standing orders. Interventions directed at pregnant women focused solely on education. Observational studies showed: (1) the provision of maternal pertussis vaccination by midwives at the place of antenatal care has improved uptake of pertussis vaccine during pregnancy from 20% to 90%; (2) introduction of an automated reminder within the electronic medical record was associated with an improvement in the pertussis immunization rate from 48% to 97%; (3) an increase in prenatal pertussis vaccine uptake from 36% to 61% after strategies to increase provider awareness of recommendations were introduced. In contrast to these findings, interventions in all three RCTs (2 involved education of pregnant women, 1 had multi-component interventions) did not demonstrate improved vaccination uptake.

CONCLUSIONS

Based on the existing research, we recommend incorporating midwife delivered maternal immunization programs at antenatal clinics, use of a provider reminder system to target unvaccinated pregnant women and include maternal pertussis immunization as part of standard antenatal care.

Improving vaccination rates in older adults: A quality improvement project

Adults age 65 or older are at increased risk for acute and chronic diseases. Patients in this group who are up to date with all CDC-recommended vaccinations can reduce morbidity and mortality. This article discusses a quality improvement project across four NP-owned primary care clinics in which all clinical staff received an educational intervention focused on best vaccination practices and Medicare billing strategies. This project yielded improved vaccination rates in the older adult patient population over a 3-month period.

Vaccination Practices Among Obstetrician/Gynecologists for Non-pregnant Patients

INTRODUCTION

Many non-pregnant women see obstetrician-gynecologists as their sole source of medical care, yet little is known about vaccination practices of obstetrician-gynecologists for non-pregnant patients. The objectives were to assess, among a national sample of obstetrician-gynecologists, practices related to vaccine delivery in non-pregnant patients and factors associated with stocking and administering more than three different vaccines to non-pregnant patients.

METHODS

E-mail and mail surveys were administered July-October 2015, with analyses performed during October-November 2015 and April-June 2018.

RESULTS

The response rate was 73% (353/482). Human papillomavirus (92%); influenza (82%); and tetanus, diphtheria, acellular pertussis vaccines (50%) were the vaccines most commonly assessed, with the remaining vaccines assessed by <40% of respondents. Vaccines most commonly administered by obstetrician-gynecologists to non-pregnant patients included human papillomavirus (81%); influenza (70%); and tetanus, diphtheria, acellular pertussis (54%). The remaining vaccines were administered by <30% of obstetrician-gynecologists. Factors associated with routinely administering more than three vaccines to non-pregnant patients included working in a hospital-, public health-, or university-associated clinic (RR=1.87, 95% CI=1.35, 2.58, referent to private practice); a larger practice (more than five providers; RR=1.54, 95% CI=1.05, 2.27); perceiving fewer financial barriers (RR=0.74, 95% CI=0.57, 0.96); fewer practice-associated barriers (RR=0.71, 95% CI=0.55, 0.92); and greater patient barriers (RR=1.62, 95% CI=1.33, 1.98).

CONCLUSIONS

Human papillomavirus; influenza; and tetanus, diphtheria, acellular pertussis vaccines are the only vaccines routinely assessed and administered to non-pregnant patients by most obstetrician-gynecologists. Given their role as the sole source of care for many women, obstetrician-gynecologists could make a positive impact on the vaccination status of their non-pregnant patients.

Enhancing uptake of influenza maternal vaccine

INTRODUCTION

Influenza vaccination during pregnancy can offer many benefits to both mother and infant. Despite recommendations from the Advisory Committee on Immunization Practices, vaccine coverage rates among pregnant women during pregnancy are below 40% in the United States. There is a need for a greater understanding of what interventions can improve vaccine uptake among pregnant women.

AREAS COVERED

This review synthesizes the existing evidence on the effectiveness of interventions to improve maternal influenza vaccine uptake. These interventions are examined within the framework of the three psychological propositions: thoughts and feelings, social processes and changing behavior directly.

EXPERT COMMENTARY

A number of promising and effective interventions were identified in this review. Nudge-based interventions that build on favorable intentions to vaccinate such as provider prompts and standing orders have demonstrated significant success in improving influenza vaccine uptake. However, substantial gaps in the literature still exist. Provider recommendations are the most important predictor of vaccine receipt among pregnant women, yet few studies evaluated intervening to improve the dialogue between patient and provider. With the potential for even more vaccines to be added to the maternal immunization schedule, it is vitally important to understand how to improve uptake.

Outreach and Reminders to Improve Human Papillomavirus Vaccination in an Integrated Primary Care System

This study evaluated the impact of health system-based outreach and reminders on human papillomavirus (HPV) vaccine series initiation and completion. Parents of 10 to 12 year olds (n = 1805) were randomized to receive either (1) an outreach letter and brochure recommending HPV vaccination followed by automated HPV vaccine reminders or (2) usual care. We interviewed a subset of 50 parents to assess program acceptability. Outcomes were HPV vaccine initiation during the study period and on-time series completion. Rates of HPV vaccine initiation during the study period (July 2015 to August 2016) were similar between the intervention and control groups, but initiation within 120 days of randomization was higher in the intervention group (23.6% and 18.8%, P = .04) as was completion during the study period (10.3% vs 6.8%, P = .04). Reminders for doses 2 and 3 did not affect completion. The program was acceptable to parents. This study provides evidence that health system-based outreach and reminders can improve HPV vaccination.

Influenza and Tdap Vaccination Coverage Among Pregnant Women - United States, April 2018

Vaccinating pregnant women with influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines can reduce the risk for influenza and pertussis for themselves and their infants. The Advisory Committee on Immunization Practices (ACIP) recommends that all women who are or might be pregnant during the influenza season receive influenza vaccine, which can be administered any time during pregnancy (1). The ACIP also recommends that women receive Tdap during each pregnancy, preferably from 27 through 36 weeks' gestation (2). To assess influenza and Tdap vaccination coverage among women pregnant during the 2017-18 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28-April 10, 2018. Among 1,771 survey respondents pregnant during the peak influenza vaccination period (October 2017-January 2018), 49.1% reported receiving influenza vaccine before or during their pregnancy. Among 700 respondents who had a live birth, 54.4% reported receiving Tdap during their pregnancy. Women who reported receiving a provider offer of vaccination had higher vaccination coverage than did women who received a recommendation but no offer and women who did not receive a recommendation. Reasons for nonvaccination included concern about effectiveness of the influenza vaccine and lack of knowledge regarding the need for Tdap vaccination during every pregnancy. Provider offers or referrals for vaccination in combination with patient education could reduce missed opportunities for vaccination and increase vaccination coverage among pregnant women.

RCT of Centralized Vaccine Reminder/Recall for Adults

INTRODUCTION

A proven, but underutilized, method to increase current low vaccination rates is reminder/recall. Centralized reminder/recall using an Immunization Information System reduces the burden of an individual practice conducting reminder/recall. The objectives were to assess the effectiveness of centralized vaccine reminder/recall on improving adult vaccination rates using Colorado's Immunization Information System.

STUDY DESIGN

This study is a pragmatic RCT.

SETTING/PARTICIPANTS

Denver Health patients were divided into three strata: 25,039 individuals aged 19-64 years without a high-risk condition for pneumococcal disease, 16,897 individuals aged 19-64 years with a high-risk condition, and 5,332 individuals aged ≥65 years. Data were collected from October 2015 to April 2016 and analyzed between September 2016 and June 2017.

INTERVENTION

Adults aged 19-64 years without a high-risk condition who needed influenza or tetanus, diphtheria, acellular pertussis vaccine or both, and adults with a high-risk condition and adults aged ≥65 years who needed influenza, or tetanus, diphtheria, acellular pertussis, or pneumococcal vaccine, or all three vaccines were randomized to receive up to three reminder/recalls or usual care.

MAIN OUTCOME MEASURES

Documentation of receipt of any needed vaccine in Immunization Information System ≤6 months after the reminder/recall was the primary outcome. A secondary outcome included implementation costs of the reminder/recall effort. A mixed effects model assessed the association between the intervention and receipt of any needed vaccine while controlling for gender, age, race, ethnicity, insurance type, and history of vaccine refusal.

RESULTS

The intervention was associated with receipt of any needed vaccine in the adults aged ≥65 years population (AOR=1.15, 95% CI=1.02, 1.30), but not the other two populations. Influenza vaccine was the source of this difference, with 32.0% receiving a vaccine in intervention versus 28.6% in usual-care groups (p≤0.01). Start-up and implementation costs per person were $0.86. In the population aged ≥65 years, 29.4 patients would need to be contacted to gain one additional vaccination.

CONCLUSIONS

Centralized reminder/recall was effective at increasing influenza vaccination rates in adults aged ≥65 years over a short time period, without burdening the practices, and at a reasonable cost.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02133391.

Clinician perspectives on strategies to improve patient maternal immunization acceptability in obstetrics and gynecology practice settings

Pregnancy is an ideal time to communicate with women about vaccines for themselves and their infants, yet maternal immunization rates remain suboptimal. This study aimed to identify clinic, provider, and staff-related attributes and facilitators to be utilized for a comprehensive vaccine intervention in ob-gyn clinical settings. We conducted in-depth interviews with 24 providers, both healthcare providers (e.g., physicians, nurse practitioners, midwives) and practice managers, from urban and suburban ob-gyn practices in Georgia and Colorado about their immunization attitudes, practices, and patient experiences. Qualitative analyses included Pearson correlation tests to evaluate patterns and relationships within the data to determine themes. Six major themes emerged: 1) strong provider "buy in" for maternal immunization; 2) the supporting role of clinical/interpersonal cues for vaccine promotion; 3) varying provider-patient communication approaches and its influence on maternal and pediatric uptake; 4) an urgent need for a designated office immunization champion; 5) reimbursement and practice implementation challenges; and 6) region differences in attitudes and values toward maternal immunization. Although providers expressed strong support for maternal immunization practices and offered environmental cues for vaccine promotion, practices often lacked a designated, structured role for an immunization champion equipped to manage delicate conversations with patients. The findings reflect needs for immunization champion identification, training, and support, along with best practices guidelines to improve coordination of vaccine promotion and delivery efforts in ob-gyn provider offices. Additionally, provider training on communication approaches to enhance acceptance and uptake of maternal vaccines is warranted.

Strategies to implement maternal vaccination: A comparison between standing orders for midwife delivery, a hospital based maternal immunisation service and primary care

Maternal vaccination is a safe and effective strategy to reduce maternal and neonatal morbidity and mortality from pertussis and influenza. However, despite recommendations for maternal vaccination since 2010, uptake remains suboptimal. Barriers to uptake have been studied widely and include lack of integration of vaccination into routine pregnancy care and access to vaccination services. Standing orders for administration of vaccines without the need for a physician review or prescription have been demonstrated to improve uptake as part of multi-model interventions to increase antenatal influenza and post-partum pertussis vaccination. Monash Health is a university-affiliated, public healthcare network in Melbourne, Australia providing maternity services across three hospitals. In this study we compared three different immunisation models - an immunisation nurse-led immunisation service, standing orders for midwife-administered pertussis vaccination within pregnancy care clinics, and delivery by general practitioners in primary care. Uptake of maternal pertussis vaccine was measured as recorded in the state-wide perinatal data collection tool. Uptake improved significantly at all three hospitals over the study period with the most significant change (39% to 91%, p < .001) noted at the hospital where standing orders were introduced. Our study highlights the diversity of immunisation service models available in maternity care settings. We demonstrated significant improvement in uptake of maternal pertussis vaccination with introduction of midwife-administered vaccination but each maternity service should consider the model best suited to their needs.

Randomized Controlled Trial of Text Message Reminders for Increasing Influenza Vaccination

PURPOSE

Seasonal influenza vaccine is recommended and funded for groups at higher risk of serious infection, but uptake is suboptimal. We conducted a randomized controlled trial of short message service (SMS) reminders for influenza vaccination.

METHODS

Six weeks after seasonal influenza vaccinations began, we identified high-risk patients who had a mobile telephone number on record at 10 practices in Western Australia. Thirty-two percent of the selected patients had already been vaccinated in the current year and were ineligible. Of the remaining 12,354 eligible patients at each practice one-half were randomly assigned to receive a vaccination reminder by SMS (intervention) and the rest received no SMS (control). Approximately 3 months after the SMS was sent (the study period), vaccination data were extracted from the patients' electronic medical records. Log-binomial regression models were used to calculate the relative risk (RR) of vaccination between the intervention and control group.

RESULTS

Twelve-percent (769 of 6,177) of the intervention group and 9% (548 of 6,177) of the control group were vaccinated during the study period, a 39% relative increase attributable to the SMS (RR = 1.39; 95% CI, 1.26-1.54). For every 29 SMSs sent, costing $3.48, 1 additional high-risk patient was immunized. The greatest effect was observed for children younger than 5 years, whose parents were more than twice as likely to have their child vaccinated if they received a SMS reminder (RR = 2.43; 95% CI, 1.79-3.29).

CONCLUSION

We found SMS reminders to be a modestly effective, low-cost means to increase seasonal influenza vaccine coverage among high-risk patients.

Influenza Vaccination Coverage Among Pregnant Women - United States, 2016-17 Influenza Season

Pregnant women and their infants are at increased risk for severe influenza-associated illness (1), and since 2004, the Advisory Committee on Immunization Practices (ACIP) has recommended influenza vaccination for all women who are or might be pregnant during the influenza season, regardless of the trimester of the pregnancy (2). To assess influenza vaccination coverage among pregnant women during the 2016-17 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28-April 7, 2017. Among 1,893 survey respondents pregnant at any time during October 2016-January 2017, 53.6% reported having received influenza vaccination before (16.2%) or during (37.4%) pregnancy, similar to coverage during the preceding four influenza seasons. Also similar to the preceding influenza season, 67.3% of women reported receiving a provider offer for influenza vaccination, 11.9% reported receiving a recommendation but no offer, and 20.7% reported receiving no recommendation; among these women, reported influenza vaccination coverage was 70.5%, 43.7%, and 14.8%, respectively. Among women who received a provider offer for vaccination, vaccination coverage differed by race/ethnicity, education, insurance type, and other sociodemographic factors. Use of evidence-based practices such as provider reminders and standing orders could reduce missed opportunities for vaccination and increase vaccination coverage among pregnant women.

Facilitators and barriers to the use of standing orders for vaccination in obstetrics and gynecology settings

BACKGROUND

Many young and middle-aged women receive their primary health care from their obstetrician-gynecologists. A recent change to vaccination recommendations during pregnancy has forced the integration of new clinical processes at obstetrician-gynecology practices. Evidence-based best practices for vaccination delivery include the establishment of vaccination standing orders.

OBJECTIVES

As part of an intervention to increase adoption of evidence-based vaccination strategies for women in safety-net and private obstetrician-gynecology settings, we conducted a qualitative study to identify the facilitators and barriers experienced by obstetrician-gynecology sites when establishing vaccination standing orders.

STUDY DESIGN

At 6 safety-net and private obstetrician-gynecology practices, 51 semistructured interviews were completed by trained qualitative researchers over 2 years with clinical staff and vaccination program personnel. Standardized qualitative research methods were used during data collection and team-based data analysis to identify major themes and subthemes within the interview data.

RESULTS

All study practices achieved partial to full implementation of vaccine standing orders for human papillomavirus, tetanus diphtheria pertussis, and influenza vaccines. Facilitating factors for vaccine standing order adoption included process standardization, acceptance of a continual modification process, and staff training. Barriers to vaccine standing order adoption included practice- and staff-level competing demands, pregnant women's preference for medical providers to discuss vaccine information with them, and staff hesitation in determining HPV vaccine eligibility.

CONCLUSIONS

With guidance and commitment to integration of new processes, obstetrician-gynecology practices are able to establish vaccine standing orders for pregnant and nonpregnant women. Attention to certain process barriers can aid the adoption of processes to support the delivery of vaccinations in obstetrician-gynecology practice setting, and provide access to preventive health care for many women.

Adolescent Vaccination Strategies: Interventions to Increase Coverage

While vaccines have decreased the burden of disease, many adolescents still remain under-immunized, particularly for human papillomavirus (HPV) and influenza. We review the most current data regarding adolescent immunizations in the United States and discuss proven strategies that work for increasing vaccination rates. Strategies that have been shown to improve rates include provider feedback, immunization information systems (or registries), and enhanced access outside of provider offices, such as school-based immunization programs. Overall, practices may want to consider multimodal quality improvement approaches to enhance practice vaccination rates. The public health and cost benefits of immunizing adolescents are well known, yet recent measles outbreaks in the United States have highlighted issues with state immunization laws and vaccine refusals. Providers should be clear in their advice regarding vaccines and use effective reminder strategies as parents commonly cite not having enough information or knowledge that a vaccine was needed for their adolescent. Additional research is needed regarding adolescent consent for vaccines, as well as adolescent and parental refusal, in order to design systems that will help inform families and allow for widespread vaccine availability.