Impact of state vaccine financing policy on uptake of heptavalent pneumococcal conjugate vaccine

Acceptance of varicella vaccination

Varicella is a common vaccine-preventable disease that usually presents in children as a mild infection; however, severe complications also occur. The burden of varicella is significant in the terms of incidence, complication, and hospitalization rate related to varicella and economic disease burden. Despite the evidence of overall positive effects of varicella vaccination, there are great differences in the implementation of varicella vaccination and in the uptake of the vaccine from country to country. Improving acceptance of varicella vaccination on the national and on the individual level would decrease the burden of the disease on the health of children and on health-care resources. In studies determining factors of parental acceptance of varicella vaccination questions specific for varicella vaccination were highlighted. Addressing these issues with open, evidence based communication is important to improve and maintain the trust of the public in varicella vaccination.

Examination of universal purchase programs as a driver of vaccine uptake among US States, 1995-2014

BACKGROUND

Immunization against numerous potentially life-threatening illnesses has been a great public health achievement. In the United States, the Vaccines for Children (VFC) program has provided vaccines to uninsured and underinsured children since the early 1990s, increasing vaccination rates. In recent years, some states have adopted Universal Purchase (UP) programs with the stated aim of further increasing vaccination rates. Under UP programs, states also purchase vaccines for privately-insured children at federally-contracted VFC prices and bill private health insurers for the vaccines through assessments.

METHODS

In this study, we estimated the effect of UP adoption in a state on children's vaccination rates using state-level and individual-level data from the 1995-2014 National Immunization Survey. For the state-level analysis, we performed ordinary least squares regression to estimate the state's vaccination rate as a function of whether the state had UP in the given year, state demographic characteristics, other vaccination policies, state fixed effects, and a time trend. For the individual analysis, we performed logistic regression to estimate a child's likelihood of being vaccinated as a function of whether the state had UP in the given year, the child's demographic characteristics, state characteristics and vaccine policies, state fixed effects, and a time trend. We performed separate regressions for each of nine recommended vaccines, as well as composite measures on whether a child was up-to-date on all required vaccines.

RESULTS

In the both the state-level and individual-level analyses, we found UP had no significant (p < 0.10) effect on any of the vaccines or composite measures in our base case specifications. Results were similar in alternative specifications.

CONCLUSIONS

We hypothesize that UP was ineffective in increasing vaccination rates. Policymakers seeking to increase vaccination rates would do well to consider other policies such as addressing provider practice issues and vaccine hesitancy.

The 5As: A practical taxonomy for the determinants of vaccine uptake

Suboptimal vaccine uptake in both childhood and adult immunisation programs limits their full potential impact on global health. A recent progress review of the Global Vaccine Action Plan stated that "countries should urgently identify barriers and bottlenecks and implement targeted approaches to increase and sustain coverage". However, vaccination coverage may be determined by a complex mix of demographic, structural, social and behavioral factors. To develop a practical taxonomy to organise the myriad possible root causes of a gap in vaccination coverage rates, we performed a narrative review of the literature and tested whether all non-socio-demographic determinants of coverage could be organised into 4 dimensions: Access, Affordability, Awareness and Acceptance. Forty-three studies were reviewed, from which we identified 23 primary determinants of vaccination uptake. We identified a fifth domain, Activation, which captured interventions such as SMS reminders which effectively nudge people towards getting vaccinated. The 5As taxonomy captured all identified determinants of vaccine uptake. This intuitive taxonomy has already facilitated mutual understanding of the primary determinants of suboptimal coverage within inter-sectorial working groups, a first step towards them developing targeted and effective solutions.

Do Florida Medicaid providers' barriers to HPV vaccination vary based on VFC program participation?

This study aimed to determine if physicians' perceived barriers to human papillomavirus (HPV) vaccination were associated with participation in the federal Vaccines for Children (VFC) program. A sample of 800 Florida Medicaid providers was randomly selected from the Florida Medicaid Master Provider File. A cross-sectional study was conducted using a 27-item survey that included 13 potential barriers to immunizing Medicaid patients against HPV, including concerns about vaccine safety and efficacy, discussing sexuality, vaccinated teens practicing riskier sexual behaviors, cost and reimbursement, ensuring 3-dose series completion, and school attendance requirements associated with HPV vaccination. Pearson χ(2) tests were conducted to investigate differences between each barrier and VFC program participation. Data were analyzed for 449 physicians. Compared to non-VFC providers, VFC providers were significantly less likely to somewhat or strongly agree that the following were barriers to vaccination: the cost of stocking the HPV vaccine (p = 0.0011), lack of adequate reimbursement for HPV vaccination (p < 0.0001), and lack of timely reimbursement for HPV vaccination (p < 0.0001). After adjusting for provider specialty and number of years since completion of residency training, VFC status remained significantly associated with the barrier regarding lack of adequate reimbursement for vaccination such that non-VFC providers had a 2.6-fold (95% confidence interval, 1.1-5.8) greater odds of somewhat or strongly agreeing that this barrier applied to them. Increasing participation in the VFC program may decrease physicians' cost-related barriers, which may increase the number of children vaccinated on time according to the recommended schedule.

Which newborns missed the hepatitis B birth dose vaccination among U.S. children?

OBJECTIVES

Hepatitis B birth dose vaccination is a critical step in preventing perinatal hepatitis B virus infection. This study assesses the prevalence of children who missed the birth dose of hepatitis B vaccination and identifies socio-demographic factors associated with non-receipt of the birth dose among children in the United States.

METHODS

A survey observation study was conducted with the national representative sample of 17,053 U.S. children aged 19-35 months obtained from the 2009 National Immunization Survey. Categorical data analysis and multivariable logistic regression in the context of complex sample survey were applied to evaluate the prevalence and determine the independent risk factors.

RESULTS

39.2% of children missed the birth dose of hepatitis B vaccination. Children who reside in states without a universal hepatitis B vaccine supply policy, are not covered by health insurance, and have only 1 vaccination provider are significantly associated with non-receipt of the birth dose hepatitis B vaccination.

CONCLUSIONS

Children who reside in states without a universal hepatitis B vaccine supply policy, and who are not covered by health insurance are two important modifiable risk factors for not receiving the birth dose hepatitis B vaccination. Future intervention studies could be needed to help control those modifiable risk factors.

A description of barriers and facilitators to childhood vaccinations in the military health system

PURPOSE

To perform a literature review of barriers to and facilitators of parents' decisions to have their children vaccinated. Both differences and similarities between the civilian sector and the military health system (MHS) were explored.

DATA SOURCES

Articles and documents were identified from the following databases: CINAHL, PubMed, Defense Technical Information Center (DTIC), ISI, and Google Scholar. Reference lists from articles were reviewed.

CONCLUSIONS

Common themes identified in the civilian sector and the MHS included an electronic registry, care access issues, provider characteristics, and child illness. Several themes served as a barrier in one system while being a facilitator in the other, such as provider characteristics. Literature addressing the MHS and factors affecting vaccine coverage is scant; however, a large disparity in vaccination coverage exists between the MHS and the civilian sector.

IMPLICATIONS

The theme of provider characteristics was seen as a barrier in both systems; a better understanding of this theme (i.e., provider effectiveness at interacting with parents) would benefit primary care practice. An electronic vaccine registry and targeted education and media campaign used to facilitate vaccinations in the MHS should be piloted in the civilian sector. Additionally, future studies should be performed on identified themes in the MHS.

Medicaid reimbursement and the uptake of adolescent vaccines

BACKGROUND

In light of low adolescent vaccination rates, state-level policies that could improve vaccine coverage should be evaluated. Approximately 1/3 of adolescents are eligible, primarily through Medicaid enrollment, to receive vaccines from state-administered Vaccines for Children (VFC) programs. We investigated whether Medicaid reimbursement, the scope of implementation of VFC programs (i.e. limited or universal purchase), and/or presence of school-based vaccine mandates were associated with adolescent vaccination levels.

METHODS

We performed a cross-sectional analysis of state-level associations between these policies and 2009 National Immunization Survey-TEEN vaccination rates for tetanus-containing, meningococcal conjugate (MCV4), and among females only, human papillomavirus (HPV) vaccines.

RESULTS

Medicaid reimbursement was not associated with vaccine coverage rates after adjusting for presence of vaccine-related school mandates, type of VFC program, proportion of adolescents attending preventive care visits, and state-specific distribution of insurance coverage. Participation in a more expansive VFC program (universal or universal-select) was significantly associated with HPV vaccine coverage, but not tetanus-containing vaccine or MCV4, among states that had mandates for any vaccines.

CONCLUSIONS

Our results suggest that, contrary to what has been shown for childhood vaccines, raising Medicaid reimbursement rates may not improve adolescent vaccine utilization. Instead, other policy changes may be more effective, such as expansion of VFC programs into universal purchase programs, further implementation of school-based vaccine mandates and efforts to raise preventive care visits among adolescents.

Risk factors for invasive pneumococcal disease in children in the era of conjugate vaccine use

OBJECTIVE

We conducted a case-control study to evaluate risk factors for invasive pneumococcal disease (IPD) among children who were aged 3 to 59 months in the era of pneumococcal conjugate vaccine (PCV7).

METHODS

IPD cases were identified through routine surveillance during 2001-2004. We matched a median of 3 control subjects to each case patient by age and zip code. We calculated odds ratios for potential risk factors for vaccine-type and non-vaccine-type IPD by using multivariable conditional logistic regression.

RESULTS

We enrolled 782 case patients (45% vaccine-type IPD) and 2512 matched control subjects. Among children who received any PCV7, children were at increased risk for vaccine-type IPD when they had underlying illnesses, were male, or had no health care coverage. Vaccination with PCV7 did not influence the risk for non-vaccine-type IPD. Presence of underlying illnesses increased the risk for non-vaccine-type IPD, particularly among children who were not exposed to household smoking. Non-vaccine-type case patients were more likely than control subjects to attend group child care, be male, live in low-income households, or have asthma; case patients were less likely than control subjects to live in households with other children.

CONCLUSIONS

Vaccination with PCV7 has reduced the risk for vaccine-type IPD that is associated with race and group child care attendance. Because these factors are still associated with non-vaccine-type IPD risk, additional reductions in disparities should be expected with new, higher valency conjugate vaccines.

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

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

Uptake of pneumococcal conjugate vaccine among children in the 1998-2002 United States birth cohorts

BACKGROUND

Routine childhood immunization with pneumococcal conjugate vaccines (PCV7s) began in 2000 in the United States. Despite vaccine shortages, reductions in invasive pneumococcal disease occurred rapidly during 2000-2002. Age-appropriate PCV7 coverage was estimated and characteristics associated with undervaccination were identified for children in the 1998-2002 birth cohorts.

METHODS

Data were analyzed for 85,135 children aged 19-35 months in the 2001-2004 National Immunization Surveys. To obtain PCV7 coverage estimates by birth cohorts, a pooled analysis was conducted by combining individual survey years that sampled children with appropriate birth dates. Logistic regression models were used to identify factors associated with age-appropriate vaccination.

RESULTS

The proportion of children receiving the primary 3-dose PCV7 series by age 12 months increased from 45.5% (+/-0.6) among children born in 2000 to 62.1% (+/-0.7) among those born in 2002. By age 24 months, an estimated 30.7% (+/-0.6), 38.0% (+/-0.6), and 49.0% (+/-1.1) of children born in 2000, 2001 and 2002, respectively, had received all four PCV7 doses; however, only 15.0% (+/-0.4), 16.1% (+/-0.4) and 24.4% (+/-0.6) of children were age-appropriately immunized. Among children born in 1998 and 1999, 10.1% +/-0.5) and 37.6% (+/-0.7), respectively, received one or more catch-up doses during their second year of life. Lower age-appropriate PCV7 coverage was independently associated with black race, Hispanic ethnicity, receiving vaccinations from public health providers, and low household income.

CONCLUSIONS

The dramatic reductions in pneumococcal-related diseases from direct and indirect vaccine effects occurred when few children had received the recommended complete vaccine schedule, and there were substantial racial and socioeconomic disparities in coverage.