Identification of Spatial Clusters of Undervaccination Patterns Among Children Aged <24 Months Using Immunization Information System Data, Montana, 2015-2019

OBJECTIVE

Spatial clustering of undervaccination leads to increased risk of vaccine-preventable diseases. We identified spatial clustering of undervaccination patterns among children aged <24 months in Montana.

METHODS

We used Montana's immunization information system data to analyze deidentified vaccination records of children aged <24 months born from January 2015 through November 2017. We measured 3 outcomes that were not mutually exclusive: not completing the combined 7-vaccine series by age 24 months, having an undervaccination pattern indicative of parental hesitancy, and having an undervaccination pattern indicative of structural barriers to timely vaccination. Using geomasked residential addresses, we conducted separate Bernoulli spatial scans with a randomization P < .01 to identify spatial clusters consisting of ≥100 children for each outcome and calculated the relative risk of having the undervaccination pattern inside versus outside the cluster.

RESULTS

Of 31 201 children aged <24 months included in our study, 11 712 (37.5%) had not completed the combined 7-vaccine series by age 24 months, and we identified 5 spatial clusters of this outcome across Montana. We identified 4 clusters of undervaccination patterns indicative of parental vaccine hesitancy, all in western Montana. The cluster with the largest relative risk (2.3) had a radius of 23.7 kilometers (n = 762 children, P < .001). We also identified 4 clusters of undervaccination patterns indicative of structural barriers, with 3 of the largest clusters in eastern Montana.

CONCLUSION

In Montana, different strategies to increase routine and timely childhood vaccination are needed in distinct areas of this large and predominantly rural state. Immunization information system data can pinpoint areas where interventions to increase vaccination uptake are needed.

Vaccination Timeliness Among US Children Aged 0-19 Months, National Immunization Survey-Child 2011-2021

Importance

Delays in receiving vaccinations lead to greater vaccine-preventable disease risk. Timeliness of receipt of recommended vaccinations is not routinely tracked in the US, either overall or for populations that have known barriers to accessing routine health care, including lower-income families and children.

Objective

To measure vaccination timeliness among US children aged 0 to 19 months, overall and by socioeconomic indicators.

Design, Setting, and Participants

This serial, cross-sectional study analyzed nationally representative data from the 2011 to 2021 National Immunization Survey-Child (NIS-Child), an annual survey of parents, with immunization histories collected from clinicians administering vaccines. The 2020 and 2021 surveys largely reflected vaccinations in the US before the COVID-19 pandemic. Study participants included US children surveyed at ages 19 to 35 months. Data were analyzed from January to August 2023.

Exposure

Survey year.

Main Outcomes and Measures

The primary outcomes were average days undervaccinated (ADU) and percentage of children who received all vaccine doses on time (ie, 0 days undervaccinated) for the combined 7-vaccine series up to age 19 months. The mean adjusted annual change in on-time vaccination by socioeconomic indicators was calculated by use of multivariable log-linked binomial regression models.

Results

The surveys included 179 154 children (92 248 boys [51.2%]); 74 479 (31.4%, weighted) lived above the federal poverty level with more than $75 000 in annual family income, 58 961 (32.4%) lived at or above the poverty level with $75 000 or less in annual family income, and 39 564 (30.2%) lived below the poverty level. Overall, the median (IQR) ADU for the combined 7-vaccine series in the US decreased from 22.3 (0.4-71.5) days in the 2011 survey to 11.9 (0.0-55.5) days in the 2021 survey. The prevalence of on-time receipt of the combined 7-vaccine series increased from 22.5% (95% CI, 21.4%-23.6%) to 35.6% (95% CI, 34.2%-37.0%). Although children with more than $75 000 in annual family income had a 4.6% (95% CI, 4.0%-5.2%) mean annual increase in on-time vaccination, the mean annual increase was 2.8% (95% CI, 2.0%-3.6%) for children living at or above the poverty level with $75 000 or less in annual family income and 2.0% (95% CI, 1.0%-3.0%) for children living below the poverty level.

Conclusions and Relevance

In this cross-sectional study of NIS-Child data, improvements in vaccination timeliness were observed from the 2011 to the 2021 survey. However, widening disparities by socioeconomic indicators signal that increased efforts to facilitate timely vaccination among children in lower-income families are needed.

Parental Mental Health and Childhood Respiratory Outcomes in a Severe Bronchiolitis Cohort

Parental mental health conditions appear to contribute to the development of childhood respiratory illness. We investigated the relationship between parental mental health and childhood respiratory illness using data from a 17-center prospective cohort study of infants hospitalized with bronchiolitis between 2011 and 2014 (n = 921). Among 779 (84.6%) participants with self-reported parental mental health history data, 184 (23.6%) had parental history of depression and 155 (19.9%) had anxiety. Multivariable analyses found that both parental history of depression (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.01-1.99) and anxiety (HR 1.28, 95% CI 1.08-1.52) were associated with an increased risk of recurrent wheezing by age 3 years. However, only parental history of anxiety was associated with asthma by age 5 years (odds ratio 1.79, 95% CI 1.25-2.55). Further research on exposure severity, other early life stressors, and effective methods of parental psychosocial support is needed to develop targeted risk factor prevention strategies to reduce the burden of childhood respiratory illness.

Failure to Complete Multidose Vaccine Series in Early Childhood

BACKGROUND

Most early childhood immunizations require 3 to 4 doses to achieve optimal protection. Our objective was to identify factors associated with starting but not completing multidose vaccine series.

METHODS

Using 2019 National Immunization Survey-Child data, US children ages 19 to 35 months were classified in 1 of 3 vaccination patterns: (1) completed the combined 7-vaccine series, (2) did not initiate ≥1 of the 7 vaccine series, or (3) initiated all series, but did not complete ≥1 multidose series. Associations between sociodemographic factors and vaccination pattern were evaluated using multivariable log-linked binomial regression. Analyses accounted for the survey's stratified design and complex weighting.

RESULTS

Among 16 365 children, 72.9% completed the combined 7-vaccine series, 9.9% did not initiate ≥1 series, and 17.2% initiated, but did not complete ≥1 multidose series. Approximately 8.4% of children needed only 1 additional vaccine dose from 1 of the 5 multidose series to complete the combined 7-vaccine series. The strongest associations with starting but not completing multidose vaccine series were moving across state lines (adjusted prevalence ratio [aPR] = 1.45, 95% confidence interval [CI]: 1.18-1.79), number of children in the household (2 to 3: aPR = 1.29, 95% CI: 1.05-1.58; 4 or more: aPR = 1.68, 95% CI: 1.30-2.18), and lack of insurance coverage (aPR = 2.03, 95% CI: 1.42-2.91).

CONCLUSIONS

More than 1 in 6 US children initiated but did not complete all doses in multidose vaccine series, suggesting children experienced structural barriers to vaccination. Increased focus on strategies to encourage multidose series completion is needed to optimize protection from preventable diseases and achieve vaccination coverage goals.

Geographic proximity to immunization providers and vaccine series completion among children ages 0-24 months

OBJECTIVES

In the U.S., vaccination coverage is lower in rural versus urban areas. Spatial accessibility to immunization services has been a suspected risk factor for undervaccination in rural children. Our objective was to identify whether geographic factors, including driving distance to immunization providers, were associated with completion of recommended childhood vaccinations.

METHODS

We analyzed records from Montana's immunization information system for children born 2015-2017. Using geolocated address data, we calculated distance in road miles from children's residences to the nearest immunization provider. A multivariable log-linked binomial mixed model was used to identify factors associated with completion of the combined 7-vaccine series by age 24 months.

RESULTS

Among 26,085 children, 16,503 (63.3%) completed the combined 7-vaccine series by age 24 months. Distance to the nearest immunization provider ranged from 0 to 81.0 miles (median = 1.7; IQR = 3.2), with the majority (92.1%) of children living within 10 miles of a provider. Long distances (>10 miles) to providers had modest associations with not completing the combined 7-vaccine series (adjusted prevalence ratio [aPR]: 0.97, 95% confidence interval [CI]: 0.96-0.99). After adjustment for other factors, children living in rural areas (measured by rural-urban commuting area) were significantly less likely to have completed the combined 7-vaccine series than children in metropolitan areas (aPR: 0.88, 95% CI: 0.85-0.92).

CONCLUSIONS

Long travel distances do not appear to be a major barrier to childhood vaccination in Montana. Other challenges, including limited resources for clinic-based strategies to promote timely vaccination and parental vaccine hesitancy, may have greater influence on rural childhood vaccination.

U.S. Emergency Department Telepsychiatry Use in 2019

Introduction: Although many emergency departments (EDs) receive telehealth services for psychiatry, or telepsychiatry, to manage acute psychiatric emergencies, national research on the usage of ED telepsychiatry is limited. To investigate ED telepsychiatry usage in the pre-COVID-19 era, we surveyed a sample of EDs receiving telepsychiatry in 2019, as a follow-up to a survey targeted to similar EDs in 2017. Methods: All U.S. EDs open in 2019 (n = 5,563) were surveyed to characterize emergency care. A more in-depth second survey on telepsychiatry use (2019 ED Telepsychiatry Survey) was then sent to 235 EDs. Of these EDs, 130 were randomly selected from those that reported telepsychiatry receipt in 2019, and 105 were selected based on their participation in a similar survey in 2017 (2017 ED Telepsychiatry Survey). Results: Of the 235 EDs receiving the 2019 Telepsychiatry Survey, 192 (82%) responded and 172 (90% of responding EDs) confirmed 2019 telepsychiatry receipt. Of these, five were excluded for missing data (analytic samplen = 167). Telepsychiatry was the only form of emergency psychiatric services for 92 (55%) EDs. The most common usage of telepsychiatry was for admission or discharge decisions (82%) and transfer coordination (70%). The most commonly reported telepsychiatry mental health consultants were psychiatrists or other physician-level mental health professionals (74%). Discussion: With telepsychiatry as the only form of psychiatric services for most telepsychiatry-receiving EDs, this innovation fills a critical gap in access to emergency psychiatric care. Further research is needed to investigate the impact of the COVID-19 pandemic on usage of ED telepsychiatry.

Evaluating vaccination coverage and timeliness in American Indian/Alaska Native and non-Hispanic White children using state immunization information system data, 2015-2017

Comprehensive estimates of vaccination coverage and timeliness of vaccine receipt among American Indian/Alaska Native (AI/AN) children in the United States are lacking. This study’s objectives were to quantify vaccination coverage and timeliness, as well as the proportion of children with specific undervaccination patterns, among AI/AN and non-Hispanic White (NHW) children ages 0–24 months in Montana, a large and primarily rural U.S. state. Data from Montana’s immunization information system (IIS) for children born 2015–2017 were used to calculate days undervaccinated for all doses of seven recommended vaccine series. After stratifying by race/ethnicity, up-to-date coverage at key milestone ages and the proportion of children demonstrating specific patterns of undervaccination were reported. Among n = 3,630 AI/AN children, only 23.1% received all recommended vaccine doses on-time (i.e., zero days undervaccinated), compared to 40.4% of n = 18,022 NHW children (chi-square p < 0.001). A greater proportion of AI/AN children were delayed at each milestone age, resulting in lower overall combined 7-vaccine series completion, by age 24 months (AI/AN: 56.6%, NHW: 64.3%, chi-square p < 0.001). As compared with NHW children, a higher proportion of AI/AN children had undervaccination patterns suggestive of structural barriers to accessing immunization services and delayed starts to vaccination. More than three out of four AI/AN children experienced delays in vaccination or were missing doses needed to complete recommended vaccine series. Interventions to ensure on-time initiation of vaccine series at age 2 months, as well initiatives to encourage completion of multi-dose vaccine series, are needed to reduce immunization disparities and increase vaccination coverage among AI/AN children in Montana.

Missed opportunities for human papillomavirus vaccine series initiation in a large, rural U.S. state

Human papillomavirus (HPV) vaccination rates are lower in rural versus urban areas of the United States. Our objective was to identify the types of vaccination clinic settings where missed opportunities for HPV vaccine series initiation most frequently occurred in Montana, a large, primary rural U.S. state. We analyzed a limited dataset from Montana’s immunization information system for adolescents who turned 11 years old in 2014–2017. Vaccination visits where the HPV vaccine was due but not administered were missed opportunities. We compared missed opportunities across six types of clinic settings, and calculated adjusted relative risks (RR) using a generalized estimating equation model. Among n = 47,622 adolescents, 53.9% of 71,447 vaccination visits were missed opportunities. After adjusting for sex, age, and rurality of clinic location, receiving vaccines in public health departments was significantly associated with higher risk of missed opportunities (aRR = 1.25, 95% confidence interval = 1.22–1.27, vs. private clinics). Receipt of vaccines in Indian Health Services and Tribal clinics was associated with fewer missed opportunities (aRR = 0.72, 95% CI: 0.69–0.75, vs. private clinics). Our results indicate the need for interventions to promote HPV vaccine uptake in public health departments, which are a critical source of immunization services in rural and medically underserved areas of the U.S.

Vaccine timeliness and prevalence of undervaccination patterns in children ages 0-19 months, U.S., National Immunization Survey-Child 2017

OBJECTIVES

Typically, early childhood vaccination coverage in the U.S. is measured as the proportion of children by age 24 months who completed recommended vaccine series. However, these measures do not reflect whether vaccine doses were received at the ages recommended by the U.S. Advisory Committee on Immunization Practices, or whether children received vaccines concomitantly, per the ACIP recommended schedule. This study's objective was to quantify vaccine timeliness and prevalence of specific patterns of undervaccination in U.S. children ages 0-19 months.

METHODS

Using 2017 National Immunization Survey-Child data, we calculated days undervaccinated for the combined 7-vaccine series and distinguished undervaccination patterns indicative of parental vaccine hesitancy, such as spreading out vaccines across visits ("shot-limiting") or starting some but not all recommended vaccine series ("selective vaccination"), from other non-hesitancy patterns, such as missing final vaccine doses or receiving all doses, with some or all late. We measured associations between demographic, socioeconomic and other characteristics with undervaccination patterns using multivariable log-linked binomial regression. Analyses accounted for the complex survey design.

RESULTS

Among n = 15,333 U.S. children, only 41.2% received all recommended vaccine doses on-time by age 19 months. Approximately 20.9% of children had an undervaccination pattern suggestive of parental vaccine hesitancy, and 36.2% had other undervaccination non-hesitancy patterns. Uninsured children and those with lower levels of maternal education were more likely to exhibit undervaccination patterns suggestive of parental hesitancy. Lower levels of maternal education were also associated with other non-hesitancy undervaccination patterns.

CONCLUSIONS

More than half of children in the U.S. are undervaccinated at some point by 19 months of age. Ongoing assessment of vaccine timeliness and immunization schedule adherence could facilitate timely and targeted public health interventions in populations with high levels of undervaccination.

Receipt of Telepsychiatry and Emergency Department Visit Outcomes in New York State

Telepsychiatry has made psychiatric care more accessible to emergency department (ED) patients. To date, most telepsychiatry studies have focused on specific populations or small groups of EDs. This study sought to examine the potential role of telepsychiatry across a wider range of EDs by comparing visit dispositions for psychiatric visits in EDs that did (versus did not) receive telepsychiatry services. ED telepsychiatry service status was identified from the 2016 National ED Inventory-USA and then linked to psychiatric visits from the 2016 New York State Emergency Department Databases/State Inpatient Databases. Unadjusted analyses and multivariable logistic regression models were used to evaluate associations between an ED's telepsychiatry service status and two clinical outcomes: use of observation services and ED visit disposition. Across all psychiatric ED visits, 712,236 were in EDs without telepsychiatry while 101,025 were in EDs with telepsychiatry. Most (99.8%) visits were in urban EDs. In multivariable logistic regression models, psychiatric visits in EDs with telepsychiatry services had lower odds (adjusted odds ratio 0.30) of using observation services compared to visits in EDs without telepsychiatry. The receipt of ED telepsychiatry is associated with lower usage of observation services for psychiatric visits, likely reducing the amount of time spent in the ED and mitigating the ongoing problem of ED crowding. An overwhelming majority of visits in EDs with telepsychiatry services were in urban hospitals with existing psychiatric services. Factors affecting the delivery and effectiveness of telepsychiatry services to hospitals lacking in psychiatric resources merit further investigation.

Timeliness of Early Childhood Vaccinations and Undervaccination Patterns in Montana

INTRODUCTION

Early childhood vaccination rates are lower in rural areas than those in urban areas of the U.S. This study's objective is to quantify vaccine timeliness and the prevalence of undervaccination patterns in Montana and to measure the associations between timeliness and series completion by age 24 months.

METHODS

Using records from January 2015 to November 2019 in Montana's centralized immunization information system, days undervaccinated were calculated for the combined 7-vaccine series. Undervaccination patterns indicative of certain barriers to vaccination, including parental vaccine hesitancy, were identified. Using multivariable log-linked binomial regression, the association between timing of vaccine delay and not completing the combined 7-vaccine series by age 24 months was assessed. Analyses were conducted in March 2020-August 2020.

RESULTS

Among 31,422 children, 38.0% received all vaccine doses on time; 24.3% received all doses, but some were received late; and 37.7% had not completed the combined 7-vaccine series. Approximately 18.7% had an undervaccination pattern suggestive of parental vaccine hesitancy, and 19.7% started all series but were missing doses needed for multidose series completion. Although falling behind on vaccinations at any age was associated with failing to complete the combined 7-vaccine series, being late at age 12-15 months had the strongest association (adjusted prevalence ratio=3.73, 95% CI=3.56, 3.91) compared with being on time at age 12-15 months.

CONCLUSIONS

Fewer than 2 in 5 Montana children were fully vaccinated on time for the combined 7-vaccine series. To increase vaccination rates, initiatives to increase vaccine confidence and remind parents to complete vaccine series are needed.

Distance From Freestanding Emergency Departments to Nearby Emergency Care

STUDY OBJECTIVE

The number of freestanding emergency departments (EDs) has increased rapidly in the United States, and there is concern that such entities are located near existing EDs rather than in areas lacking emergency care. In 2018, the Medicare Payment Advisory Commission recommended a reduction in Medicare reimbursement rates to freestanding EDs located within 6 miles of the nearest hospital-based ED. We aim to assess the potential effect of this proposal.

METHODS

Using the 2016 National Emergency Department Inventory-USA database, we identified the locations and visit volumes of all US freestanding EDs. Using QGIS, we mapped the distances from all freestanding EDs to both the nearest hospital-based ED and to the nearest ED (either hospital-based or freestanding ED).

RESULTS

We collected location information for all 5,375 EDs open in 2016. Of these EDs, 609 (11%) were freestanding. Few freestanding EDs (1.4%) were located in rural areas and only 11% were located in areas with a median household income of less than $43,000. Overall, 460 freestanding EDs (76%) were within 6 miles of the nearest hospital-based ED, and these had 5.3 million total patient visits, whereas those greater than 6 miles away had 2.6 million visits.

CONCLUSION

We found that most freestanding EDs (76%) are within 6 miles of the nearest hospital-based ED, and most visits (67%) to freestanding EDs are to those within that proximity, indicating that many freestanding EDs would be affected by this Medicare Payment Advisory Commission proposal, if implemented.

National Study of Telepsychiatry Use in U.S. Emergency Departments

OBJECTIVE

The receipt of telemedicine for the management of mental illness, also known as telepsychiatry, is being adopted in emergency departments (EDs), but little is known about this approach. This study investigated the prevalence and applications of telepsychiatry in general EDs in the United States.

METHODS

All 5,375 U.S. EDs were surveyed to characterize emergency care in 2016. From the EDs that reported receiving telepsychiatry services, a 15% random sample was selected for a second survey that confirmed telepsychiatry use in 2017 and collected data on emergency psychiatric services and applications of telepsychiatry in each ED.

RESULTS

The 2016 national survey (4,507 of 5,375; 84% response) showed that 885 (20%) EDs reported receiving telepsychiatry. Characteristics associated with higher likelihood of ED telepsychiatry receipt included higher annual total visit volumes, rural location, and Critical Access Hospital designation. Characteristics associated with lower likelihood of telepsychiatry receipt included being an autonomous freestanding ED. In the second survey (105 of 130; 81% response), 95 (90%) EDs confirmed telepsychiatry use. Most (59%) of these reported telepsychiatry as their ED's only form of emergency psychiatric services, and 25% received services at least once a day. The most common applications of telepsychiatry were in admission or discharge decisions (80%) and transfer coordination (76%).

CONCLUSIONS

In 2016, 20% of EDs received telepsychiatry services, and most receiving telepsychiatry had no other emergency psychiatric services. The latter finding suggests that telepsychiatry is used to fill a critical need. Further studies are warranted to investigate barriers to implementing telepsychiatry in EDs without access to emergency psychiatric services.

The secretion of parotid saliva as stimulated by 10% citric acid is not related to precipitating factors in burning mouth syndrome

Burning mouth syndrome (BMS) is known to have multiple precipitating factors and exists in various clinical subtypes. If salivary gland function was compromised in BMS it could help explain the link with diverse precipitating factors. This study quantified stimulated right and left parotid flow rates (SPFR) in 114 patients with BMS. It also attempted to correlate SPFR with haematinic parameters, oral candidal carriage, concurrent drug therapy and BMS subtype. No relationship was found between haematinic parameters and SPFR nor between SPFR and oral candidal carriage. Patients with Type 2 BMS had a significant reduction in SPFR. Antidepressant medication was associated with reduced SPFR but there was no such association with either tranquillisers or hypnotics. These results provide evidence of reduced parotid gland function in Type 2 BMS and a role for antidepressant medication in reducing SPFR.

Levels of dangerousness: an analysis of Irish dentists' clinical responses to HIV-seropositive patients

Work conducted in the mid-1980s suggested that dentists in the Republic of Ireland felt uncomfortable about treating patients who were HIV-seropositive. It seemed that with greater understanding of the behaviour of the virus, dentists' attitudes would be modified accordingly. The aim of this study was to assess the reactions of Irish dentists to the treatment of HIV-positive patients. All dentists currently on the register were sent a questionnaire to assess their knowledge, attitudes and clinical behaviours. Over 60% of dentists responded. The study highlights dentists' responses to HIV infection suggesting that they are fearful of the virus. They perceive HIV as dangerous to themselves, their other patients and their practice. The findings indicate that attitudes relating to dangerousness remain a significant obstacle in the treatment of this patient group.

Portable tissue equivalent calorimeter

A portable tissue equivalent calorimeter has been constructed and employed to measure absorbed dose in a mixed fast-neutron and gamma-ray field. Design details and measurement techniques are described along with the limits of precision and absolute accuracy. Experiments have been carried out with a cyclotron produced neutron beam using the 9Be(d,n)10B reaction at dose rates ranging from 3 to 25 rad/min. A series of ten measurements at a dose rate of approximately 10 rad/min were performed with a precision of +/- 2% (standard deviation about the mean). The compact design of this calorimetric dosimeter system facilitates transport to other laboratories for the measurement of absorbed dose in several complex radiation fields.

An unusual compressive syndrome of the cauda equina

An unusual case of a capillary hemangioma of the filum terminale is presented. The successful removal returned the patient to an asymptomatic state.