Search

OBJECTIVES: Central to the debate over school and child care reopening is whether children are efficient coronavirus disease 2019 (COVID-19) transmitters and are likely to increase community spread when programs reopen. We compared COVID-19 outcomes in child care providers who continued to provide direct in-person child care during the first 3 months of the US COVID-19 pandemic with outcomes in those who did not. METHODS: Data were obtained from US child care providers (N = 57 335) reporting whether they had ever tested positive or been hospitalized for COVID-19 (n = 427 cases) along with their degree of exposure to child care. Background transmission rates were controlled statistically, and other demographic, programmatic, and community variables were explored as potential confounders. Logistic regression analysis was used in both unmatched and propensity score–matched case-control analyses. RESULTS: No association was found between exposure to child care and COVID-19 in both unmatched (odds ratio [OR], 1.06; 95% confidence interval [CI], 0.82–1.38) and matched (OR, 0.94; 95% CI, 0.73–1.21) analyses. In matched analysis, being a home-based provider (as opposed to a center-based provider) was associated with COVID-19 (OR, 1.59; 95% CI, 1.14–2.23) but revealed no interaction with exposure. CONCLUSIONS: Within the context of considerable infection mitigation efforts in US child care programs, exposure to child care during the early months of the US pandemic was not associated with an elevated risk for COVID-19 transmission to providers. These findings must be interpreted only within the context of background transmission rates and the considerable infection mitigation efforts implemented in child care programs.

OBJECTIVES: To estimate (1) the proportion of children not adhering to the Advisory Committee on Immunization Practices (ACIP) recommended early childhood immunization schedule and (2) associations between schedule adherence, sociodemographic characteristics, and up-to-date immunization status by 19 to 35 months of age. METHODS: We used 2014 National Immunization Survey provider-verified vaccination data to classify vaccination patterns as “recommended” (ie, in line with ACIP dose- and age-specific recommendations), “alternate” (ie, in line with either limiting the number of shots per visit or skipping at least 1 vaccine series), or “unknown or unclassifiable” (ie, not in line with ACIP recommendations or clearly limiting shots per visit or vaccine series). We evaluated the association between vaccination patterns and up-to-date status for all ACIP-recommended vaccinations (including rotavirus and hepatitis A vaccines) using Poisson regression. RESULTS: The majority of children’s patterns were classified as “recommended” (63%), with 23% and 14% following alternate or unknown or unclassifiable patterns, respectively; 58% of children were up-to-date with all ACIP-recommended immunizations by 19 to 35 months. Not being up-to-date was associated with alternate (prevalence ratio = 4.2, 95% confidence interval: 3.9–4.5) and unknown or unclassifiable (prevalence ratio = 2.4, 95% confidence interval: 2.2–2.7) patterns. CONCLUSIONS: High vaccine coverage by 19 to 35 months of age may miss nonadherence to the recommended immunization schedule in the first 18 months of life, leaving children vulnerable to preventable diseases. With more than one-third of US children not following the ACIP schedule, targeted interventions are needed to minimize vaccine delays and disease susceptibility.

BACKGROUND: Mandatory vaccination has been effective in maintaining high vaccination coverage in countries such as the United States. However, there are no peer-reviewed analyses of the association between mandates and both coverage and subsequent incidence of vaccine-preventable disease in Europe. METHODS: Using data from the European Centre for Disease Prevention and Control and the World Health Organization, we evaluated the relationship between country-level mandatory vaccination policies and (1) measles and pertussis vaccine coverage and (2) the annual incidence of these diseases in 29 European countries. Multivariate negative binomial and linear regression models were used to quantify these associations. RESULTS: Mandatory vaccination was associated with a 3.71 (95% confidence interval [CI]: 1.68 to 5.74) percentage point higher prevalence of measles vaccination and a 2.14 (95% CI: 0.13 to 4.15) percentage point higher prevalence of pertussis vaccination when compared with countries that did not have mandatory vaccination. Mandatory vaccination was only associated with decreased measles incidence for countries without nonmedical exemptions (adjusted incidence rate ratio = 0.14; 95% CI: 0.05 to 0.36). We did not find a significant association between mandatory vaccination and pertussis incidence. CONCLUSIONS: Mandatory vaccination and the magnitude of fines were associated with higher vaccination coverage. Moreover, mandatory vaccination was associated with lower measles incidence for countries with mandatory vaccination without nonmedical exemptions. These findings can inform legislative policies aimed at increasing vaccination coverage.

OBJECTIVES: In 2015, California passed Senate Bill 227 (SB277), eliminating nonmedical vaccine exemptions for school entry. Our objective for this study was to describe the experiences of health officers and immunization staff addressing medical exemption requests under SB277. METHODS: We conducted semistructured telephone interviews between August 2017 and September 2017 with health officers and immunization staff from local health jurisdictions in California. Interviews were recorded, transcribed, and analyzed for key themes. RESULTS: We conducted 34 interviews with 40 health officers and immunization staff representing 35 of the 61 local health jurisdictions in California. Four main themes emerged related to experiences with medical exemptions: (1) the role of stakeholders, (2) reviewing medical exemptions received by schools, (3) medical exemptions that were perceived as problematic, and (4) frustration and concern over medical exemptions. Generally, local health jurisdictions described a narrow role in providing support and technical assistance to schools. Only 5 jurisdictions actively tracked medical exemptions received by schools, with 1 jurisdiction facing a lawsuit as a result. Examples were provided of medical exemptions that listed family history of allergies and autoimmune diseases as contraindications for immunization and of physicians charging steep fees for medical exemptions. Participants also reported concerns about the increase in medical exemptions after the implementation of SB277. CONCLUSIONS: Participants reported many challenges and concerns with medical exemptions under SB277. Without additional legal changes, including a standardized review of medical exemptions, some physicians may continue to write medical exemptions for vaccine-hesitant parents, potentially limiting the long-term impact of SB277.

BACKGROUND: Interventions to address vaccine hesitancy and increase vaccine acceptance are needed. This study sought to determine if a Web-based, social media intervention increases early childhood immunization. METHODS: A 3-arm, randomized controlled trial was conducted in Colorado from September 2013 to July 2016. Participants were pregnant women, randomly assigned (3:2:1) to a Web site with vaccine information and interactive social media components (VSM), a Web site with vaccine information (VI), or usual care (UC). Vaccination was assessed in infants of participants from birth to age 200 days. The primary outcome was days undervaccinated, measured as a continuous and dichotomous variable. RESULTS: Infants of 888 participants were managed for 200 days. By using a nonparametric rank-based analysis, mean ranks for days undervaccinated were significantly lower in the VSM arm versus UC (P = .02) but not statistically different between the VI and UC (P = .08) or between VSM and VI arms (P = .63). The proportions of infants up-to-date at age 200 days were 92.5, 91.3, and 86.6 in the VSM, VI, and UC arms, respectively. Infants in the VSM arm were more likely to be up-to-date than infants in the UC arm (odds ratio [OR] = 1.92; 95% confidence interval [CI], 1.07–3.47). Up-to-date status was not statistically different between VI and UC arms (OR = 1.62; 95% CI, 0.87–3.00) or between the VSM and VI arms (OR = 1.19, 95% CI, 0.70–2.03). CONCLUSIONS: Providing Web-based vaccine information with social media applications during pregnancy can positively influence parental vaccine behaviors.

BACKGROUND: In 2010, 9120 cases of pertussis were reported in California, more than any year since 1947. Although this resurgence has been widely attributed to waning immunity of the acellular vaccine, the role of vaccine refusal has not been explored in the published literature. Many factors likely contributed to the outbreak, including the cyclical nature of pertussis, improved diagnosis, and waning immunity; however, it is important to understand if clustering of unvaccinated individuals also played a role. METHODS: We analyzed nonmedical exemptions (NMEs) for children entering kindergarten from 2005 through 2010 and pertussis cases with onset in 2010 in California to determine if NMEs increased in that period, if children obtaining NMEs clustered spatially, if pertussis cases clustered spatially and temporally, and if there was statistically significant overlap between clusters of NMEs and cases. RESULTS: Kulldorff’s scan statistics identified 39 statistically significant clusters of high NME rates and 2 statistically significant clusters of pertussis cases in this time period. Census tracts within an exemptions cluster were 2.5 times more likely to be in a pertussis cluster (odds ratio = 2.47, 95% confidence interval: 2.22–2.75). More cases occurred within as compared with outside exemptions clusters (incident rate ratios = 1.20, 95% confidence interval: 1.10–1.30). The association remained significant after adjustment for demographic factors. NMEs clustered spatially and were associated with clusters of pertussis cases. CONCLUSIONS: Our data suggest clustering of NMEs may have been 1 of several factors in the 2010 California pertussis resurgence.

BACKGROUND AND OBJECTIVE: An increased risk of febrile seizure (FS) was identified with concomitant administration of trivalent inactivated influenza vaccine (IIV3) and pneumococcal conjugate vaccine (PCV) 13-valent during the 2010–2011 influenza season. Our objective was to determine whether concomitant administration of IIV3 with other vaccines affects the FS risk. METHODS: We examined the risk of FS 0 to 1 day postvaccination for all routinely recommended vaccines among children aged 6 through 23 months during a period encompassing 5 influenza seasons (2006–2007 through 2010–2011). We used a population-based self-controlled risk interval analysis with a control interval of 14 to 20 days postvaccination. We used multivariable regression to control for receipt of concomitant vaccines and test for interaction between vaccines. RESULTS: Only PCV 7-valent had an independent FS risk (incidence rate ratio [IRR], 1.98; 95% confidence interval [CI], 1.00 to 3.91). IIV3 had no independent risk (IRR, 0.46; 95% CI, 0.21 to 1.02), but risk was increased when IIV3 was given with either PCV (IRR, 3.50; 95% CI, 1.13 to 10.85) or a diphtheria-tetanus-acellular-pertussis (DTaP)-containing vaccine (IRR, 3.50; 95% CI, 1.52 to 8.07). The maximum estimated absolute excess risk due to concomitant administration of IIV3, PCV, and DTaP-containing vaccines compared with administration on separate days was 30 FS per 100 000 persons vaccinated. CONCLUSIONS: The administration of IIV3 on the same day as either PCV or a DTaP-containing vaccine was associated with a greater risk of FS than when IIV3 was given on a separate day. The absolute risk of postvaccination FS with these vaccine combinations was small.

OBJECTIVE: We sought to understand pandemic 2009 influenza A (H1N1) vaccine acceptance in a minority community including correlates of vaccine hesitancy and refusal. We identified intervention points to increase H1N1 vaccine coverage. PATIENTS AND METHODS: Minority parents and caregivers of children ≤18 years participated in a cross-sectional survey. Statistical analyses included bivariate correlations, exploratory factor analyses, internal-consistency assessment, and logistic regressions. RESULTS: The sample (N = 223) included mostly lower-income (71% [n = 159]) and black (66% [n = 147]) participants. Potential and actual receipt of pediatric H1N1 vaccination was low (36% [n = 80]). Pediatric H1N1 vaccine acceptance was associated with lack of insurance (odds ratio [OR]: 3.04 [95% confidence interval (CI): 1.26–7.37]), perceived H1NI pediatric susceptibility (OR: 1.66 [95% Cl: 1.41–1.95]), child vaccination prioritization in family (OR: 3.34 [95% CI: 1.33–8.38]), believing that H1N1 is a greater community concern than other diseases (OR: 1.77 [95% CI: 1.01–3.09]), believing that other methods of containment (eg, hand-washing, masks) are not as effective as the H1N1 vaccine (OR: 1.73 [95% CI: 1.06–2.83]), and a desire to promote influenza vaccination in the community (OR: 2.35 [95% CI: 1.53–3.61]). CONCLUSIONS: We found low acceptance of the H1N1 vaccine in our study population. Perceived influenza susceptibility, concern about H1N1 disease, and confidence in vaccinations as preventive methods were associated with vaccine acceptance. Physician support for HIN1 vaccination will aid in increasing immunization coverage for this population, and health departments are perceived as ideal community locations for vaccine administration.

BACKGROUND: The success of health care provider counseling–based interventions to address vaccine hesitancy is not clear. In 2011, Washington State implemented Senate Bill 5005 (SB5005), requiring counseling and a signed form from a licensed health care provider to obtain an exemption. Evaluating the impact of a counseling intervention can provide important insight into population-level interventions that focus on interpersonal communication by a health care provider. METHODS: We used segmented regression and interaction and aggregation indices to assess the impact of SB5005 on immunization coverage and exemption rates in Washington State from school years 1997–1998 through 2013–2014. RESULTS: After SB5005 was implemented, there was a significant relative decrease of 40.2% (95% confidence interval: −43.6% to −36.6%) in exemption rates. This translates to a significant absolute reduction of 2.9 percentage points (95% confidence interval: −4.2% to −1.7%) in exemption rates. There were increases in vaccine coverage for all vaccines required for school entrance, with the exception of the hepatitis B vaccine. The probability that kindergarteners without exemptions would encounter kindergarteners with exemptions (interaction index) decreased, and the probability that kindergarteners with exemptions would encounter other such kindergarteners (aggregation index) also decreased after SB5005. Moreover, SB5005 was associated with a decline in geographic clustering of vaccine exemptors. CONCLUSIONS: States in the United States and jurisdictions in other countries should consider adding parental counseling by health care provider as a requirement for obtaining exemptions to vaccination requirements.

Many primary care pediatricians find vaccine hesitancy to be one of the most frustrating situations that they face. Parents who refuse to vaccinate their children implicitly call into question an intervention that most pediatricians see as one of the safest and most effective health care interventions of all time. Many pediatricians respond by refusing to care for children whose parents refuse vaccines, and some may consider that the parent’s refusal warrants referral to child protective services. We present a case in which a pediatrician faces this dilemma, with responses from pediatricians in academia and private practice.

OBJECTIVE: Previous surveys on hypothesized sexual activity changes after human papillomavirus (HPV) vaccination may be subject to self-response biases. To date, no studies measured clinical markers of sexual activity after HPV vaccination. This study evaluated sexual activity–related clinical outcomes after adolescent vaccination. METHODS: We conducted a retrospective cohort study utilizing longitudinal electronic data from a large managed care organization. Girls enrolled in the managed care organization, aged 11 through 12 years between July 2006 and December 2007, were classified by adolescent vaccine (HPV; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed; quadrivalent meningococcal conjugate) receipt. Outcomes (pregnancy/sexually transmitted infection testing or diagnosis; contraceptive counseling) were assessed through December 31, 2010, providing up to 3 years of follow-up. Incidence rate ratios comparing vaccination categories were estimated with multivariate Poisson regression, adjusting for health care–seeking behavior and demographic characteristics. RESULTS: The cohort included 1398 girls (493 HPV vaccine–exposed; 905 HPV vaccine–unexposed). Risk of the composite outcome (any pregnancy/sexually transmitted infection testing or diagnosis or contraceptive counseling) was not significantly elevated in HPV vaccine–exposed girls relative to HPV vaccine–unexposed girls (adjusted incidence rate ratio: 1.29, 95% confidence interval [CI]: 0.92 to1.80; incidence rate difference: 1.6/100 person-years; 95% CI: −0.03 to 3.24). Incidence rate difference for Chlamydia infection (0.06/100 person-years [95% CI: −0.30 to 0.18]) and pregnancy diagnoses (0.07/100 person-years [95% CI: −0.20 to 0.35]), indicating little clinically meaningful absolute risk differences. CONCLUSIONS: HPV vaccination in the recommended ages was not associated with increased sexual activity–related outcome rates.

OBJECTIVE: To identify and describe vaccine safety in US newspaper articles. METHODS: Articles (1147) from 44 states and Washington, DC, between January 1, 1995, and July 15, 2005, were identified by using the search terms “immunize or vaccine” and “adverse events or safety or exemption or danger or risk or damage or injury or side effect” and were coded by using a standardized data-collection instrument. RESULTS: The mean number of vaccine-safety articles per state was 26. Six (not mutually exclusive) topics were identified: vaccine-safety concerns (46%); vaccine policy (44%); vaccines are safe (20%); immunizations are required (10%); immunizations are not required (8%); and state/school exemption (8%). Three spikes in the number of newspaper articles about vaccine-safety issues were observed: in 1999 regarding rotavirus vaccine and in 2002 and 2003 regarding smallpox vaccine. Excluding articles that referred to rotavirus and smallpox vaccines, 37% of the articles had a negative take-home message. CONCLUSION: Ongoing monitoring of news on vaccine safety may help the content and framing of vaccine-safety messages.

Objectives. We studied school personnel involved in the review of student's immunization status to determine whether personnel training, immunization-related knowledge, attitudes, and beliefs, use of alternative medicine, and sources of vaccine information were associated with the vaccination status of school children. Methods. Surveys were mailed to a stratified and random sample of 1000 schools in Colorado, Massachusetts, Missouri, and Washington. School personnel reported their training and perceptions of disease susceptibility/severity, vaccine efficacy/safety, key immunization beliefs, use of alternative medicine, confidence in organizations, sources, and credibility of vaccine information, and the rates of vaccine exemptors in their schools. Logistic regression analysis was used to explore associations between personnel factors and beliefs (independent variables) with the likelihood of a child having an exemption (dependent variable). Regression models were adjusted for clustering of children in schools, type of school (public versus private), and state. Results. Surveys were returned by 69.6% of eligible participants. A child attending a school with a respondent who was a nurse was significantly less likely to be have an exemption than a child attending a school with a respondent who was not a nurse (odds ratio [OR]: 0.39; 95% confidence interval [CI]: 0.28–0.56). The majority of respondents believed that children (95.6%) and the community (96.1%) benefit when children are vaccinated. Nurses were more likely than nonnurses to hold beliefs supporting the utility and safety of vaccination. Greater perceived disease susceptibility and severity and vaccine efficacy and safety were associated with a decreased likelihood of a child in the school having an exemption. Vaccine misconceptions were relatively common. For example, 19.0% of respondents were concerned that children's immune systems could be weakened by too many immunizations, and this belief was associated with an increased likelihood of a child in the school having an exemption (OR: 1.51; 95% CI: 1.00–2.28). Most respondents had a moderate amount or great deal of confidence in state health departments (91.4%), the Centers for Disease Control and Prevention (CDC) (93.9%), local health departments (88.8%), health care providers (88.5%), the Food and Drug Administration (73.6%), and the health care system (65.2%). Fewer respondents had a moderate amount or great deal of confidence in the media (17.4%). A child attending a school with a respondent who had a moderate amount or great deal of confidence in local and state health departments was less likely to have an exemption (OR: 0.47 and 0.44; 95% CI: 0.27–0.80 and 0.25–0.80, respectively) than a child attending a school with a respondent who did not have a moderate amount or great deal of confidence in local and state health departments. Confidence in other groups was not associated with the likelihood of a child in the school having an exemption. Nearly half (45.5%) of the respondents or their immediate family members had used some form of alternative medicine in the last 5 years. A child attending a school with a respondent who had (or had a family member[s] who) used an alternative medicine practitioner was more likely to have an exemption than a child attending a school with a respondent who had not used an alternative medicine practitioner. There were significant associations between sources used and perception of reliability for vaccine information with the likelihood of a child in the school having an exemption. Use of professional organizations, government resources, vaccine companies, and pharmacists for vaccine information were associated with a decreased likelihood of a child in the school having an exemption. Perceiving health departments and the CDC as a good or excellent source for vaccine information was associated with a decreased likelihood of a child in the school having an exemption. Conclusions. The training, knowledge, attitudes, and beliefs of school personnel who work with parents on immunization issues were associated with the likelihood of a child in the school having an exemption. Although respondents generally believed in vaccinations, misconceptions were common. Many school personnel seem to be unaware of the seriousness of some vaccine-preventable diseases and that unimmunized children are highly susceptible to diseases. These misperceptions were associated with an increased likelihood of a child having an exemption. This study of associations cannot determine causal associations. Nonetheless, the frequency of vaccine misconceptions among school personnel warrants vaccine communication programs for school employees who work with parents on immunization issues. An intervention study could determine whether such programs have an impact on parental decisions to claim exemptions for their children. Personnel without formal health care training who advice parents on immunization issues could be passing on misinformation to parents. Nurses or properly trained health personnel should be the primary school contacts for parents on immunization issues. Health departments and health care providers were used most often by school personnel for vaccine information. Providers, professional organizations, health departments, and the CDC were considered most credible. The CDC may be an underutilized source, given its high credibility; only 58.1% of respondents reported using the CDC for vaccine information. Greater visibility of CDC on vaccine information statements and communication efforts from the CDC directly to school personnel will likely be well received. Respondents who do not consider health departments and the CDC as credible sources were associated with a greater likelihood of a child in their school having an exemption. The CDC may need to consider working with other reliable sources to communicate with these personnel. Studies are needed to understand why some parents choose to forgo vaccination for children who do not have true medical contraindications to vaccines. School personnel trained in vaccine safety may serve as a valuable source of vaccine information for parents. Parents who have misconceptions about vaccines would likely benefit from discussions with health care providers. Additional public-information campaigns regarding misconceptions and the value of vaccination may be needed.