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Autism risk not increased by maternal influenza infection during pregnancy
Maternal influenza infection during pregnancy does not increase the risk for autism spectrum disorder (ASD) in children, according to Ousseny Zerbo, PhD, and associates.
In a study of 196,929 mother-child pairs (the children were born at Kaiser Permanente Northern California between Jan. 1, 2000, and Dec. 31, 2010), 1.6% of the children were diagnosed with ASD. Influenza was diagnosed in 0.7% of mothers during their pregnancy, and 23% received an influenza vaccination during pregnancy.
Overall, maternal influenza vaccination did not effect likelihood of ASD diagnosis, with 1.7% of children in this group receiving an ASD diagnosis. A small association between ASD diagnosis and maternal influenza vaccination, however, was seen in the first trimester of pregnancy, with an adjusted hazard ratio of 1.2, translating to a potential extra 4 cases of autism per 1,000 births. But further analysis suggested that this could be caused by bias and chance, and “the association was insignificant after statistical correction for multiple comparisons,” the investigators said.
“While we do not advocate changes in vaccine policy or practice, we believe that additional studies are warranted to further evaluate any potential associations between first-trimester maternal influenza vaccination and autism,” the investigators concluded.
Find the full study in JAMA Pediatrics (doi: 10.1001/jamapediatrics.2016.3609).
Maternal influenza infection during pregnancy does not increase the risk for autism spectrum disorder (ASD) in children, according to Ousseny Zerbo, PhD, and associates.
In a study of 196,929 mother-child pairs (the children were born at Kaiser Permanente Northern California between Jan. 1, 2000, and Dec. 31, 2010), 1.6% of the children were diagnosed with ASD. Influenza was diagnosed in 0.7% of mothers during their pregnancy, and 23% received an influenza vaccination during pregnancy.
Overall, maternal influenza vaccination did not effect likelihood of ASD diagnosis, with 1.7% of children in this group receiving an ASD diagnosis. A small association between ASD diagnosis and maternal influenza vaccination, however, was seen in the first trimester of pregnancy, with an adjusted hazard ratio of 1.2, translating to a potential extra 4 cases of autism per 1,000 births. But further analysis suggested that this could be caused by bias and chance, and “the association was insignificant after statistical correction for multiple comparisons,” the investigators said.
“While we do not advocate changes in vaccine policy or practice, we believe that additional studies are warranted to further evaluate any potential associations between first-trimester maternal influenza vaccination and autism,” the investigators concluded.
Find the full study in JAMA Pediatrics (doi: 10.1001/jamapediatrics.2016.3609).
Maternal influenza infection during pregnancy does not increase the risk for autism spectrum disorder (ASD) in children, according to Ousseny Zerbo, PhD, and associates.
In a study of 196,929 mother-child pairs (the children were born at Kaiser Permanente Northern California between Jan. 1, 2000, and Dec. 31, 2010), 1.6% of the children were diagnosed with ASD. Influenza was diagnosed in 0.7% of mothers during their pregnancy, and 23% received an influenza vaccination during pregnancy.
Overall, maternal influenza vaccination did not effect likelihood of ASD diagnosis, with 1.7% of children in this group receiving an ASD diagnosis. A small association between ASD diagnosis and maternal influenza vaccination, however, was seen in the first trimester of pregnancy, with an adjusted hazard ratio of 1.2, translating to a potential extra 4 cases of autism per 1,000 births. But further analysis suggested that this could be caused by bias and chance, and “the association was insignificant after statistical correction for multiple comparisons,” the investigators said.
“While we do not advocate changes in vaccine policy or practice, we believe that additional studies are warranted to further evaluate any potential associations between first-trimester maternal influenza vaccination and autism,” the investigators concluded.
Find the full study in JAMA Pediatrics (doi: 10.1001/jamapediatrics.2016.3609).
FROM JAMA PEDIATRICS
Cultural approach to vaccine hesitancy essential for ethnic communities
ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.
Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.
A 2000 study had shown Somali parents were generally supportive of immunization, but that perception had changed by summer of 2008, explained co-presenter Lynn Bahta, RN, PHN, an immunization clinical consultant at the Minnesota Department of Health Immunization Program. A local TV station ran a story about Somali parents’ concern that a disproportionately higher number of Somali children were in early childhood special education programs for autism.
“In the middle of the report, a parent stated, ‘It’s the vaccines,’ ” Ms. Bahta said. Because they did not have a word for autism in Somali, parents’ online searches led them to groups promoting the misconception that the MMR vaccine and autism were linked. Clinicians in Minnesota began to report Somali parents’ refusal to get their children’s 12-month vaccines. Then a 2011 measles outbreak led the Minnesota Department of Health to look at MMR vaccination rates among local Somalis.
Somalis had a higher rate of MMR coverage in 24-month-old children than did non-Somalis in 2004 – 90%, compared with 84% – according to the Minnesota Immunization Information Connection. But MMR rates among Somali 24-month-olds began dropping in 2005, reaching 82% in 2007 and 63% in 2009.
“The data we got instilled a bit of panic in the immunization team,” Ms. Bahta said. “Parents were still supporting immunizations, but they weren’t getting that MMR.”
Traditional strategies to increase vaccination – distributing travel immunization information, promoting YouTube videos about immunization and autism, using diverse media for information campaigns – failed.
So they joined with the community and family health department, where co-presenter Asli Ashkir, RN, MPH, is a senior nurse consultant in the Children & Youth with Special Health Needs program. They also hired Somali staff and began to improve their cultural knowledge and competence.
With Somalis, social life revolves around family ties, the community, and faith, explained Ms. Ashkir, a Somali woman herself. Somali culture is based on oral tradition, one that shares information among themselves and provides unsolicited advice to one another, and they persuade each other easily. But issues of health, life, and death are in the hands of Allah only, she said.
“There is a time you will die, whether you are vaccinated or not,” Ms. Ashkir explained. “That doesn’t mean we don’t practice preventive service or health promotion – we do – but at the back of our head, when our time is over, you’re going to go. These are the people we are working with.”
Two other potential obstacles involve Somali beliefs about sin and mental illness.
“We believe if someone is ill, their sins will be cleansed,” she said, explaining why Somalis with minor health problems don’t seek health care. “Parents with kids who have autism keep kids in their apartment until they are 8 years old because mental illness has a negative stigma.”
The Minnesota Department of Health conducted a study on the experience of having a child with autism in the Somali community and discovered four key themes. First, the parents greatly feared autism: Every Somali interviewed said they did not get the MMR because they wanted to avoid autism. Second, parents lacked information about normal child development, autism, and the diseases that vaccines prevent.
“We were expecting parents to identify developmental delays, but parents look not at the development but the growth, at the physical size of the child,” Ms. Ashkir said. And when they learned that the MMR prevented measles – the No. 3 killer of children in Somalia – parents often wanted the shot immediately.
The other two discoveries were that it was impossible to talk about immunization issues in isolation – they were too intricately entwined with discussions about autism – and that Somalis wanted to hear information from respected community sources.
These findings were applied in a pilot program that aimed to improve parents’ knowledge about child growth and development, autism, and vaccine-preventable diseases. Six mothers attended the training program, and tracking their contacts revealed that the information had traveled to 82 other family, friends, and neighbors within the first 3 months. All the women found the program “very helpful” with no negative responses.
The success of this program led to a more comprehensive approach that included training and outreach, engaging the community, disease mitigation and control, and creating and expanding partnerships with organizations such as the state American Academy of Pediatrics chapter, the Somali American Parent Association, the Minnesota Medical Association, and Parents in Community Action.
Training included all-Somali speakers with messages from spiritual leaders and parents of children with autism. Community outreach involved one-on-one conversations among Somalis at information tables in places such as malls, mosques, community centers, and libraries.
“Among this group, there are four parents who have children with autism,” Ms. Ashkir said. “Two of these parents are very, very vocal and talk about their children who have autism, and that they did not give them the MMR. They tell people ‘You have wrong information.’ ”
As of March 2016, the decline in MMR vaccination rates among Somalis had started to flatten. The annual drop of 5%-7% a year in MMR rates became 0.89% last year, which the Minnesota Department of Health finds encouraging.
“Our initial efforts, which included a typical repertoire of public health interventions, were ineffective, so we had to go back and dig deep to understand the core concerns,” Ms. Bahta said. “Our information had to address the core concerns of the community, not what we assumed to be the issue.”
Credibility came from the cultural relevancy of the message, and the fact that those providing the message were parents who had vaccinated their children, she said.
“Each cultural group needs unique approaches, and this is certainly true in this situation – to understand the unique perspective of the community and develop an effective approach required bringing in culturally competent staff and engaging the community,” Ms. Bahta said.
ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.
Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.
A 2000 study had shown Somali parents were generally supportive of immunization, but that perception had changed by summer of 2008, explained co-presenter Lynn Bahta, RN, PHN, an immunization clinical consultant at the Minnesota Department of Health Immunization Program. A local TV station ran a story about Somali parents’ concern that a disproportionately higher number of Somali children were in early childhood special education programs for autism.
“In the middle of the report, a parent stated, ‘It’s the vaccines,’ ” Ms. Bahta said. Because they did not have a word for autism in Somali, parents’ online searches led them to groups promoting the misconception that the MMR vaccine and autism were linked. Clinicians in Minnesota began to report Somali parents’ refusal to get their children’s 12-month vaccines. Then a 2011 measles outbreak led the Minnesota Department of Health to look at MMR vaccination rates among local Somalis.
Somalis had a higher rate of MMR coverage in 24-month-old children than did non-Somalis in 2004 – 90%, compared with 84% – according to the Minnesota Immunization Information Connection. But MMR rates among Somali 24-month-olds began dropping in 2005, reaching 82% in 2007 and 63% in 2009.
“The data we got instilled a bit of panic in the immunization team,” Ms. Bahta said. “Parents were still supporting immunizations, but they weren’t getting that MMR.”
Traditional strategies to increase vaccination – distributing travel immunization information, promoting YouTube videos about immunization and autism, using diverse media for information campaigns – failed.
So they joined with the community and family health department, where co-presenter Asli Ashkir, RN, MPH, is a senior nurse consultant in the Children & Youth with Special Health Needs program. They also hired Somali staff and began to improve their cultural knowledge and competence.
With Somalis, social life revolves around family ties, the community, and faith, explained Ms. Ashkir, a Somali woman herself. Somali culture is based on oral tradition, one that shares information among themselves and provides unsolicited advice to one another, and they persuade each other easily. But issues of health, life, and death are in the hands of Allah only, she said.
“There is a time you will die, whether you are vaccinated or not,” Ms. Ashkir explained. “That doesn’t mean we don’t practice preventive service or health promotion – we do – but at the back of our head, when our time is over, you’re going to go. These are the people we are working with.”
Two other potential obstacles involve Somali beliefs about sin and mental illness.
“We believe if someone is ill, their sins will be cleansed,” she said, explaining why Somalis with minor health problems don’t seek health care. “Parents with kids who have autism keep kids in their apartment until they are 8 years old because mental illness has a negative stigma.”
The Minnesota Department of Health conducted a study on the experience of having a child with autism in the Somali community and discovered four key themes. First, the parents greatly feared autism: Every Somali interviewed said they did not get the MMR because they wanted to avoid autism. Second, parents lacked information about normal child development, autism, and the diseases that vaccines prevent.
“We were expecting parents to identify developmental delays, but parents look not at the development but the growth, at the physical size of the child,” Ms. Ashkir said. And when they learned that the MMR prevented measles – the No. 3 killer of children in Somalia – parents often wanted the shot immediately.
The other two discoveries were that it was impossible to talk about immunization issues in isolation – they were too intricately entwined with discussions about autism – and that Somalis wanted to hear information from respected community sources.
These findings were applied in a pilot program that aimed to improve parents’ knowledge about child growth and development, autism, and vaccine-preventable diseases. Six mothers attended the training program, and tracking their contacts revealed that the information had traveled to 82 other family, friends, and neighbors within the first 3 months. All the women found the program “very helpful” with no negative responses.
The success of this program led to a more comprehensive approach that included training and outreach, engaging the community, disease mitigation and control, and creating and expanding partnerships with organizations such as the state American Academy of Pediatrics chapter, the Somali American Parent Association, the Minnesota Medical Association, and Parents in Community Action.
Training included all-Somali speakers with messages from spiritual leaders and parents of children with autism. Community outreach involved one-on-one conversations among Somalis at information tables in places such as malls, mosques, community centers, and libraries.
“Among this group, there are four parents who have children with autism,” Ms. Ashkir said. “Two of these parents are very, very vocal and talk about their children who have autism, and that they did not give them the MMR. They tell people ‘You have wrong information.’ ”
As of March 2016, the decline in MMR vaccination rates among Somalis had started to flatten. The annual drop of 5%-7% a year in MMR rates became 0.89% last year, which the Minnesota Department of Health finds encouraging.
“Our initial efforts, which included a typical repertoire of public health interventions, were ineffective, so we had to go back and dig deep to understand the core concerns,” Ms. Bahta said. “Our information had to address the core concerns of the community, not what we assumed to be the issue.”
Credibility came from the cultural relevancy of the message, and the fact that those providing the message were parents who had vaccinated their children, she said.
“Each cultural group needs unique approaches, and this is certainly true in this situation – to understand the unique perspective of the community and develop an effective approach required bringing in culturally competent staff and engaging the community,” Ms. Bahta said.
ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.
Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.
A 2000 study had shown Somali parents were generally supportive of immunization, but that perception had changed by summer of 2008, explained co-presenter Lynn Bahta, RN, PHN, an immunization clinical consultant at the Minnesota Department of Health Immunization Program. A local TV station ran a story about Somali parents’ concern that a disproportionately higher number of Somali children were in early childhood special education programs for autism.
“In the middle of the report, a parent stated, ‘It’s the vaccines,’ ” Ms. Bahta said. Because they did not have a word for autism in Somali, parents’ online searches led them to groups promoting the misconception that the MMR vaccine and autism were linked. Clinicians in Minnesota began to report Somali parents’ refusal to get their children’s 12-month vaccines. Then a 2011 measles outbreak led the Minnesota Department of Health to look at MMR vaccination rates among local Somalis.
Somalis had a higher rate of MMR coverage in 24-month-old children than did non-Somalis in 2004 – 90%, compared with 84% – according to the Minnesota Immunization Information Connection. But MMR rates among Somali 24-month-olds began dropping in 2005, reaching 82% in 2007 and 63% in 2009.
“The data we got instilled a bit of panic in the immunization team,” Ms. Bahta said. “Parents were still supporting immunizations, but they weren’t getting that MMR.”
Traditional strategies to increase vaccination – distributing travel immunization information, promoting YouTube videos about immunization and autism, using diverse media for information campaigns – failed.
So they joined with the community and family health department, where co-presenter Asli Ashkir, RN, MPH, is a senior nurse consultant in the Children & Youth with Special Health Needs program. They also hired Somali staff and began to improve their cultural knowledge and competence.
With Somalis, social life revolves around family ties, the community, and faith, explained Ms. Ashkir, a Somali woman herself. Somali culture is based on oral tradition, one that shares information among themselves and provides unsolicited advice to one another, and they persuade each other easily. But issues of health, life, and death are in the hands of Allah only, she said.
“There is a time you will die, whether you are vaccinated or not,” Ms. Ashkir explained. “That doesn’t mean we don’t practice preventive service or health promotion – we do – but at the back of our head, when our time is over, you’re going to go. These are the people we are working with.”
Two other potential obstacles involve Somali beliefs about sin and mental illness.
“We believe if someone is ill, their sins will be cleansed,” she said, explaining why Somalis with minor health problems don’t seek health care. “Parents with kids who have autism keep kids in their apartment until they are 8 years old because mental illness has a negative stigma.”
The Minnesota Department of Health conducted a study on the experience of having a child with autism in the Somali community and discovered four key themes. First, the parents greatly feared autism: Every Somali interviewed said they did not get the MMR because they wanted to avoid autism. Second, parents lacked information about normal child development, autism, and the diseases that vaccines prevent.
“We were expecting parents to identify developmental delays, but parents look not at the development but the growth, at the physical size of the child,” Ms. Ashkir said. And when they learned that the MMR prevented measles – the No. 3 killer of children in Somalia – parents often wanted the shot immediately.
The other two discoveries were that it was impossible to talk about immunization issues in isolation – they were too intricately entwined with discussions about autism – and that Somalis wanted to hear information from respected community sources.
These findings were applied in a pilot program that aimed to improve parents’ knowledge about child growth and development, autism, and vaccine-preventable diseases. Six mothers attended the training program, and tracking their contacts revealed that the information had traveled to 82 other family, friends, and neighbors within the first 3 months. All the women found the program “very helpful” with no negative responses.
The success of this program led to a more comprehensive approach that included training and outreach, engaging the community, disease mitigation and control, and creating and expanding partnerships with organizations such as the state American Academy of Pediatrics chapter, the Somali American Parent Association, the Minnesota Medical Association, and Parents in Community Action.
Training included all-Somali speakers with messages from spiritual leaders and parents of children with autism. Community outreach involved one-on-one conversations among Somalis at information tables in places such as malls, mosques, community centers, and libraries.
“Among this group, there are four parents who have children with autism,” Ms. Ashkir said. “Two of these parents are very, very vocal and talk about their children who have autism, and that they did not give them the MMR. They tell people ‘You have wrong information.’ ”
As of March 2016, the decline in MMR vaccination rates among Somalis had started to flatten. The annual drop of 5%-7% a year in MMR rates became 0.89% last year, which the Minnesota Department of Health finds encouraging.
“Our initial efforts, which included a typical repertoire of public health interventions, were ineffective, so we had to go back and dig deep to understand the core concerns,” Ms. Bahta said. “Our information had to address the core concerns of the community, not what we assumed to be the issue.”
Credibility came from the cultural relevancy of the message, and the fact that those providing the message were parents who had vaccinated their children, she said.
“Each cultural group needs unique approaches, and this is certainly true in this situation – to understand the unique perspective of the community and develop an effective approach required bringing in culturally competent staff and engaging the community,” Ms. Bahta said.
AT THE NATIONAL IMMUNIZATION CONFERENCE
Key clinical point:
Major finding: The decline in MMR vaccination among Somali children in Minnesota went from a 5%-7% annual drop to a 0.89% drop in 2015.
Data source: The findings are based on a comprehensive training and outreach program developed at the Minnesota Department of Health.
Disclosures: The initiative was funded by the Minnesota Department of Health. Ms. Ashkir and Ms. Bahta reported they had no conflicts to disclose.
HPV vaccination rates tripled with practice’s comprehensive intervention
ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.
Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.
She described the critical components of a vaccination quality improvement project: set specific goals, know your practice’s actual rates, identify areas of weakness and/or opportunity, and then implement effective and sustainable processes for improvement. Their initial goal was to show any improvement at all in the first year and then to meet the highest national rates 2 years later.
“We started by agreeing we would become transparent to one another,” Dr. Casler explained. “This is called peer influence. What we didn’t want to be was the one who deviated from standard practice.”
As they got further along into their initiative, this transparency led physicians to ask others with better rates for help. “It’s not just a motivator in terms of not wanting to be the worse; it’s also a motivator in knowing how to get help,” said Dr. Casler, also at Florida State College of Medicine in Tallahassee and the University of Central Florida in Orlando.
Individual physicians’ rates were first shared privately with that physician, then shared with the department, and then published monthly and eventually only quarterly.
Then they developed the interventions to improve rates: verification and clean-up of their data, physician and staff education, physician incentives, previsit planning, electronic follow-up orders for the second and third doses, reminder calls, manufacturer tools, and clinical summaries.
The physician education program involved first making HPV vaccination a priority even when multiple competing priorities exist at each well visit.
“Our doctors felt, as all doctors feel, that we have 75 things to do and it’s not possible to do them all,” Dr. Casler said. “If we don’t have a fast and dirty way of doing something, it won’t get done.”
Part of prioritizing the vaccine was making physicians aware of how common HPV and HPV diseases were, which many did not realize. Then the training addressed providers’ discomfort about discussing the vaccine. They provided a script that included a clear recommendation for the HPV vaccine – sandwiched between the recommendations for the meningitis and Tdap vaccines – without adding unnecessary extra information unless the parent requested it.
During staff training, her practice found similar obstacles as with the doctors. “They had different competing priorities, they didn’t really know what HPV was, and they didn’t want to talk about sex,” Dr. Casler said.
Following training, they distributed tools such as posters and fact sheets to physicians and developed incentives: competition among each other, a quality bonus structure, and wine. “It’s amazing what will motivate people,” Dr. Casler said with a smile. “Again, this is the real world.”
Daily previsit planning meant documenting on patient lists the priorities for each patient, including the HPV vaccine as well as needs such as flu shots; other vaccines; screening for asthma, depression, and STIs; smoking assessment; diet and exercise counseling; and risk factor assessments.
“That is one of the most valuable interventions and got a tremendous amount of feedback from the staff,” Dr. Casler said. “Any practice can do this for free. I look at every metric that needs to be covered with that patient during that visit.”
Patients then are required to schedule their second and third doses on their way out. “If someone no-shows or doesn’t reschedule, my secretary knows what HPV is and what it does,” Dr. Casler said. “She will call the parents and leave a message, ‘Call me tomorrow to reschedule your appointment... so that your child doesn’t get cancer.”
In evaluating the program, Dr. Casler said the most popular interventions were the physician and staff education programs, scheduling subsequent doses in real time, and using manufacturer-supplied tools such as magnets and cling posters. Staff involvement turned out to be a critical resource in the overall intervention as well.
As a result of the program begun in August 2013, the practice’s rates of girls and boys receiving one dose of the HPV vaccine increased to 65% and 57%, respectively, by the end of 2014. Further, 43% of girls and 30% of boys received all three doses. By June 2016, 75% of girls and 72% of boys were receiving their first dose of HPV vaccine, and 55% of girls and 47% of boys were receiving all three doses.
Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.
Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.
She described the critical components of a vaccination quality improvement project: set specific goals, know your practice’s actual rates, identify areas of weakness and/or opportunity, and then implement effective and sustainable processes for improvement. Their initial goal was to show any improvement at all in the first year and then to meet the highest national rates 2 years later.
“We started by agreeing we would become transparent to one another,” Dr. Casler explained. “This is called peer influence. What we didn’t want to be was the one who deviated from standard practice.”
As they got further along into their initiative, this transparency led physicians to ask others with better rates for help. “It’s not just a motivator in terms of not wanting to be the worse; it’s also a motivator in knowing how to get help,” said Dr. Casler, also at Florida State College of Medicine in Tallahassee and the University of Central Florida in Orlando.
Individual physicians’ rates were first shared privately with that physician, then shared with the department, and then published monthly and eventually only quarterly.
Then they developed the interventions to improve rates: verification and clean-up of their data, physician and staff education, physician incentives, previsit planning, electronic follow-up orders for the second and third doses, reminder calls, manufacturer tools, and clinical summaries.
The physician education program involved first making HPV vaccination a priority even when multiple competing priorities exist at each well visit.
“Our doctors felt, as all doctors feel, that we have 75 things to do and it’s not possible to do them all,” Dr. Casler said. “If we don’t have a fast and dirty way of doing something, it won’t get done.”
Part of prioritizing the vaccine was making physicians aware of how common HPV and HPV diseases were, which many did not realize. Then the training addressed providers’ discomfort about discussing the vaccine. They provided a script that included a clear recommendation for the HPV vaccine – sandwiched between the recommendations for the meningitis and Tdap vaccines – without adding unnecessary extra information unless the parent requested it.
During staff training, her practice found similar obstacles as with the doctors. “They had different competing priorities, they didn’t really know what HPV was, and they didn’t want to talk about sex,” Dr. Casler said.
Following training, they distributed tools such as posters and fact sheets to physicians and developed incentives: competition among each other, a quality bonus structure, and wine. “It’s amazing what will motivate people,” Dr. Casler said with a smile. “Again, this is the real world.”
Daily previsit planning meant documenting on patient lists the priorities for each patient, including the HPV vaccine as well as needs such as flu shots; other vaccines; screening for asthma, depression, and STIs; smoking assessment; diet and exercise counseling; and risk factor assessments.
“That is one of the most valuable interventions and got a tremendous amount of feedback from the staff,” Dr. Casler said. “Any practice can do this for free. I look at every metric that needs to be covered with that patient during that visit.”
Patients then are required to schedule their second and third doses on their way out. “If someone no-shows or doesn’t reschedule, my secretary knows what HPV is and what it does,” Dr. Casler said. “She will call the parents and leave a message, ‘Call me tomorrow to reschedule your appointment... so that your child doesn’t get cancer.”
In evaluating the program, Dr. Casler said the most popular interventions were the physician and staff education programs, scheduling subsequent doses in real time, and using manufacturer-supplied tools such as magnets and cling posters. Staff involvement turned out to be a critical resource in the overall intervention as well.
As a result of the program begun in August 2013, the practice’s rates of girls and boys receiving one dose of the HPV vaccine increased to 65% and 57%, respectively, by the end of 2014. Further, 43% of girls and 30% of boys received all three doses. By June 2016, 75% of girls and 72% of boys were receiving their first dose of HPV vaccine, and 55% of girls and 47% of boys were receiving all three doses.
Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.
Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.
She described the critical components of a vaccination quality improvement project: set specific goals, know your practice’s actual rates, identify areas of weakness and/or opportunity, and then implement effective and sustainable processes for improvement. Their initial goal was to show any improvement at all in the first year and then to meet the highest national rates 2 years later.
“We started by agreeing we would become transparent to one another,” Dr. Casler explained. “This is called peer influence. What we didn’t want to be was the one who deviated from standard practice.”
As they got further along into their initiative, this transparency led physicians to ask others with better rates for help. “It’s not just a motivator in terms of not wanting to be the worse; it’s also a motivator in knowing how to get help,” said Dr. Casler, also at Florida State College of Medicine in Tallahassee and the University of Central Florida in Orlando.
Individual physicians’ rates were first shared privately with that physician, then shared with the department, and then published monthly and eventually only quarterly.
Then they developed the interventions to improve rates: verification and clean-up of their data, physician and staff education, physician incentives, previsit planning, electronic follow-up orders for the second and third doses, reminder calls, manufacturer tools, and clinical summaries.
The physician education program involved first making HPV vaccination a priority even when multiple competing priorities exist at each well visit.
“Our doctors felt, as all doctors feel, that we have 75 things to do and it’s not possible to do them all,” Dr. Casler said. “If we don’t have a fast and dirty way of doing something, it won’t get done.”
Part of prioritizing the vaccine was making physicians aware of how common HPV and HPV diseases were, which many did not realize. Then the training addressed providers’ discomfort about discussing the vaccine. They provided a script that included a clear recommendation for the HPV vaccine – sandwiched between the recommendations for the meningitis and Tdap vaccines – without adding unnecessary extra information unless the parent requested it.
During staff training, her practice found similar obstacles as with the doctors. “They had different competing priorities, they didn’t really know what HPV was, and they didn’t want to talk about sex,” Dr. Casler said.
Following training, they distributed tools such as posters and fact sheets to physicians and developed incentives: competition among each other, a quality bonus structure, and wine. “It’s amazing what will motivate people,” Dr. Casler said with a smile. “Again, this is the real world.”
Daily previsit planning meant documenting on patient lists the priorities for each patient, including the HPV vaccine as well as needs such as flu shots; other vaccines; screening for asthma, depression, and STIs; smoking assessment; diet and exercise counseling; and risk factor assessments.
“That is one of the most valuable interventions and got a tremendous amount of feedback from the staff,” Dr. Casler said. “Any practice can do this for free. I look at every metric that needs to be covered with that patient during that visit.”
Patients then are required to schedule their second and third doses on their way out. “If someone no-shows or doesn’t reschedule, my secretary knows what HPV is and what it does,” Dr. Casler said. “She will call the parents and leave a message, ‘Call me tomorrow to reschedule your appointment... so that your child doesn’t get cancer.”
In evaluating the program, Dr. Casler said the most popular interventions were the physician and staff education programs, scheduling subsequent doses in real time, and using manufacturer-supplied tools such as magnets and cling posters. Staff involvement turned out to be a critical resource in the overall intervention as well.
As a result of the program begun in August 2013, the practice’s rates of girls and boys receiving one dose of the HPV vaccine increased to 65% and 57%, respectively, by the end of 2014. Further, 43% of girls and 30% of boys received all three doses. By June 2016, 75% of girls and 72% of boys were receiving their first dose of HPV vaccine, and 55% of girls and 47% of boys were receiving all three doses.
Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
AT THE NATIONAL IMMUNIZATION CONFERENCE
Key clinical point: A multifaceted comprehensive intervention significantly improved HPV vaccination rates in a pediatric health care group practice.
Major finding: Girls and boys receiving any HPV vaccine dose increased from 23% and 12% in 2013 to 75% and 72% in June 2016, respectively. Rates of three doses increased from 14% of girls and 3% of boys in 2013 to 55% of girls and 47% of boys in June 2016.
Data source: The findings are based on internal assessment of an intervention at a large multispecialty health care group with 22 pediatricians and with 23,000 patients at least 11 years old.
Disclosures: Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
Pediatric update: 2 vaccine changes and the latest word on media time
The art of persuasion
With the advent of the Internet, many parents and teen patients come in armed with information and sometimes even a diagnosis. Much of our time is spent dispelling falsehoods that were posted on the Internet or clarifying information that was misinterpreted. Although generally more information is a good thing, too much false information can result in limiting health care.
Vaccine administration has suffered significantly because of this. With a simple Google search, you can find articles that do everything just short of proving that vaccines are harmful, and tear-jerking stories about children who were harmed by the administration of vaccines. Many sites – Vaxtruth.org, healthwyze.org, naturalnews.com – all present convincing data that would scare any concerned parent to not vaccinate their child. So how do medical professionals regain the trust of their parents and/or patients?
The strategies put forth by the Centers for Disease Control and Prevention for talking to parents about vaccines begin with listening.1 Many parents come with fears that are unfounded and unrealistic that can simply be discussed and resolved. Others present with information from the Internet that discourages vaccines or life experiences such as another family member who was thought to be harmed by vaccines; this discussion is more complex.
It is imperative to become familiar with the most popular information sources on the Internet so that you can speak directly to the validity of the source. As well, countering with a more reliable source will substantiate your position. Healthychildren.org2 is an excellent reference for the AAP recommendations and further references. Vaccinesafety.edu is an independent source that reviews vaccine safety and current research.
Being proactive also builds trust. Provide families with the list of ingredients (vaccinesafety.edu), what their role is in keeping vaccines safe (tell them to go to cdc.gov and search under “vaccines for parents”), and help them understand how vaccines work. Parents then see that you are well informed and are passionate about the health of their children. The AAP provides physicians with a tool kit for the HPV vaccine, and the CDC has an HPV tipsheet entitled “Addressing Parents’ Top Questions about HPV Vaccine” that gives suggestions for what you can say or that can save you time if you provide it while the family waits to be seen.
Probably the most important strategy is believing in what you’re doing. No matter what you’re promoting, if you truly believe in it, then you will encourage others to believe in it as well. This requires educating yourself on current research and recommendations, as well as what is being reported in the news so you can be armed with factual data when parents have questions.
Today, health care is a partnership, and we must embrace our role as educators to empower patients to make good choices for themselves as well as their families.
References
1. http://www.cdc.gov/vaccines/hcp/conversations/conv-materials.html
2. https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Safety-The-Facts.aspx
3. http://www.immunize.org
Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at pdnews@frontlinemedcom.com.
With the advent of the Internet, many parents and teen patients come in armed with information and sometimes even a diagnosis. Much of our time is spent dispelling falsehoods that were posted on the Internet or clarifying information that was misinterpreted. Although generally more information is a good thing, too much false information can result in limiting health care.
Vaccine administration has suffered significantly because of this. With a simple Google search, you can find articles that do everything just short of proving that vaccines are harmful, and tear-jerking stories about children who were harmed by the administration of vaccines. Many sites – Vaxtruth.org, healthwyze.org, naturalnews.com – all present convincing data that would scare any concerned parent to not vaccinate their child. So how do medical professionals regain the trust of their parents and/or patients?
The strategies put forth by the Centers for Disease Control and Prevention for talking to parents about vaccines begin with listening.1 Many parents come with fears that are unfounded and unrealistic that can simply be discussed and resolved. Others present with information from the Internet that discourages vaccines or life experiences such as another family member who was thought to be harmed by vaccines; this discussion is more complex.
It is imperative to become familiar with the most popular information sources on the Internet so that you can speak directly to the validity of the source. As well, countering with a more reliable source will substantiate your position. Healthychildren.org2 is an excellent reference for the AAP recommendations and further references. Vaccinesafety.edu is an independent source that reviews vaccine safety and current research.
Being proactive also builds trust. Provide families with the list of ingredients (vaccinesafety.edu), what their role is in keeping vaccines safe (tell them to go to cdc.gov and search under “vaccines for parents”), and help them understand how vaccines work. Parents then see that you are well informed and are passionate about the health of their children. The AAP provides physicians with a tool kit for the HPV vaccine, and the CDC has an HPV tipsheet entitled “Addressing Parents’ Top Questions about HPV Vaccine” that gives suggestions for what you can say or that can save you time if you provide it while the family waits to be seen.
Probably the most important strategy is believing in what you’re doing. No matter what you’re promoting, if you truly believe in it, then you will encourage others to believe in it as well. This requires educating yourself on current research and recommendations, as well as what is being reported in the news so you can be armed with factual data when parents have questions.
Today, health care is a partnership, and we must embrace our role as educators to empower patients to make good choices for themselves as well as their families.
References
1. http://www.cdc.gov/vaccines/hcp/conversations/conv-materials.html
2. https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Safety-The-Facts.aspx
3. http://www.immunize.org
Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at pdnews@frontlinemedcom.com.
With the advent of the Internet, many parents and teen patients come in armed with information and sometimes even a diagnosis. Much of our time is spent dispelling falsehoods that were posted on the Internet or clarifying information that was misinterpreted. Although generally more information is a good thing, too much false information can result in limiting health care.
Vaccine administration has suffered significantly because of this. With a simple Google search, you can find articles that do everything just short of proving that vaccines are harmful, and tear-jerking stories about children who were harmed by the administration of vaccines. Many sites – Vaxtruth.org, healthwyze.org, naturalnews.com – all present convincing data that would scare any concerned parent to not vaccinate their child. So how do medical professionals regain the trust of their parents and/or patients?
The strategies put forth by the Centers for Disease Control and Prevention for talking to parents about vaccines begin with listening.1 Many parents come with fears that are unfounded and unrealistic that can simply be discussed and resolved. Others present with information from the Internet that discourages vaccines or life experiences such as another family member who was thought to be harmed by vaccines; this discussion is more complex.
It is imperative to become familiar with the most popular information sources on the Internet so that you can speak directly to the validity of the source. As well, countering with a more reliable source will substantiate your position. Healthychildren.org2 is an excellent reference for the AAP recommendations and further references. Vaccinesafety.edu is an independent source that reviews vaccine safety and current research.
Being proactive also builds trust. Provide families with the list of ingredients (vaccinesafety.edu), what their role is in keeping vaccines safe (tell them to go to cdc.gov and search under “vaccines for parents”), and help them understand how vaccines work. Parents then see that you are well informed and are passionate about the health of their children. The AAP provides physicians with a tool kit for the HPV vaccine, and the CDC has an HPV tipsheet entitled “Addressing Parents’ Top Questions about HPV Vaccine” that gives suggestions for what you can say or that can save you time if you provide it while the family waits to be seen.
Probably the most important strategy is believing in what you’re doing. No matter what you’re promoting, if you truly believe in it, then you will encourage others to believe in it as well. This requires educating yourself on current research and recommendations, as well as what is being reported in the news so you can be armed with factual data when parents have questions.
Today, health care is a partnership, and we must embrace our role as educators to empower patients to make good choices for themselves as well as their families.
References
1. http://www.cdc.gov/vaccines/hcp/conversations/conv-materials.html
2. https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Vaccine-Safety-The-Facts.aspx
3. http://www.immunize.org
Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at pdnews@frontlinemedcom.com.
Which Health Care Providers Are Most Likely to Get Vaccinated?
Making it easier for employees to get free flu vaccinations on site—and requiring vaccinations—has helped bump up coverage, according to an online survey conducted for the CDC.
Of 2,316 health care personnel who responded, 79% reported having gotten a flu shot for the 2015-2016 season, up 15.5 percentage points from the 2010-2011 estimate but similar to the 77.3% coverage for 2014-2015.
Physicians are most likely to get vaccinated (95.6%), whereas assistants and aides have the lowest coverage, although it was well above half (64.1%). Nurse practitioners and physician assistants also had a high rate of vaccination (90.3%), followed by nurses (90.1%) and pharmacists (86.5%), and Allied health professionals/technicians/technologists (84.7%).
Related: The Ads Say ‘Get Your Flu Shot Today,’ But It May Be Wiser To Wait
Coverage among staff in long-term care settings was up—from 63.9% in 2014-2015 to 69.2% for 2015-2016—but still consistently lower than the coverage in hospitals and ambulatory care. Coverage in those settings was similar in both seasons. Employer requirements “likely contributed” to the gradual increase in vaccination among health care staff in settings with lowest coverage, the researchers say.
In facilities where vaccination was required, coverage was nearly total (96.5%). But only 61% of health care personnel work in hospitals with vaccination requirements—and that’s at least 27 percentage points higher than the proportion in any other work setting, the researchers say. Aides and assistants reported the lowest prevalence of vaccination requirements (22.5%).
Related: New Vaccination Data & Trends
Next to requirements, cost influenced vaccination response. The majority of vaccinated health care staff got the shots at their workplace. Coverage was highest when free vaccination was available on-site for a day or more.
To boost vaccination among long-term care staff, the CDC and the National Vaccine Program Office offer a web-based tool kit that includes access to resources, strategies, and educational material (www.cdc/gov/flu/toolkit/long-term-care/index.htm). Employers and health care administrators can also check out the Guide to Community Preventive Services, which presents evidence to support on-site vaccination at no or low cost.
Related: Health Care Providers Impact on HPV Vaccination Rates
Source:
Black CL, Yue X, Ball SW, et al. MMWR. 2016;65(38):1026-1031.
Making it easier for employees to get free flu vaccinations on site—and requiring vaccinations—has helped bump up coverage, according to an online survey conducted for the CDC.
Of 2,316 health care personnel who responded, 79% reported having gotten a flu shot for the 2015-2016 season, up 15.5 percentage points from the 2010-2011 estimate but similar to the 77.3% coverage for 2014-2015.
Physicians are most likely to get vaccinated (95.6%), whereas assistants and aides have the lowest coverage, although it was well above half (64.1%). Nurse practitioners and physician assistants also had a high rate of vaccination (90.3%), followed by nurses (90.1%) and pharmacists (86.5%), and Allied health professionals/technicians/technologists (84.7%).
Related: The Ads Say ‘Get Your Flu Shot Today,’ But It May Be Wiser To Wait
Coverage among staff in long-term care settings was up—from 63.9% in 2014-2015 to 69.2% for 2015-2016—but still consistently lower than the coverage in hospitals and ambulatory care. Coverage in those settings was similar in both seasons. Employer requirements “likely contributed” to the gradual increase in vaccination among health care staff in settings with lowest coverage, the researchers say.
In facilities where vaccination was required, coverage was nearly total (96.5%). But only 61% of health care personnel work in hospitals with vaccination requirements—and that’s at least 27 percentage points higher than the proportion in any other work setting, the researchers say. Aides and assistants reported the lowest prevalence of vaccination requirements (22.5%).
Related: New Vaccination Data & Trends
Next to requirements, cost influenced vaccination response. The majority of vaccinated health care staff got the shots at their workplace. Coverage was highest when free vaccination was available on-site for a day or more.
To boost vaccination among long-term care staff, the CDC and the National Vaccine Program Office offer a web-based tool kit that includes access to resources, strategies, and educational material (www.cdc/gov/flu/toolkit/long-term-care/index.htm). Employers and health care administrators can also check out the Guide to Community Preventive Services, which presents evidence to support on-site vaccination at no or low cost.
Related: Health Care Providers Impact on HPV Vaccination Rates
Source:
Black CL, Yue X, Ball SW, et al. MMWR. 2016;65(38):1026-1031.
Making it easier for employees to get free flu vaccinations on site—and requiring vaccinations—has helped bump up coverage, according to an online survey conducted for the CDC.
Of 2,316 health care personnel who responded, 79% reported having gotten a flu shot for the 2015-2016 season, up 15.5 percentage points from the 2010-2011 estimate but similar to the 77.3% coverage for 2014-2015.
Physicians are most likely to get vaccinated (95.6%), whereas assistants and aides have the lowest coverage, although it was well above half (64.1%). Nurse practitioners and physician assistants also had a high rate of vaccination (90.3%), followed by nurses (90.1%) and pharmacists (86.5%), and Allied health professionals/technicians/technologists (84.7%).
Related: The Ads Say ‘Get Your Flu Shot Today,’ But It May Be Wiser To Wait
Coverage among staff in long-term care settings was up—from 63.9% in 2014-2015 to 69.2% for 2015-2016—but still consistently lower than the coverage in hospitals and ambulatory care. Coverage in those settings was similar in both seasons. Employer requirements “likely contributed” to the gradual increase in vaccination among health care staff in settings with lowest coverage, the researchers say.
In facilities where vaccination was required, coverage was nearly total (96.5%). But only 61% of health care personnel work in hospitals with vaccination requirements—and that’s at least 27 percentage points higher than the proportion in any other work setting, the researchers say. Aides and assistants reported the lowest prevalence of vaccination requirements (22.5%).
Related: New Vaccination Data & Trends
Next to requirements, cost influenced vaccination response. The majority of vaccinated health care staff got the shots at their workplace. Coverage was highest when free vaccination was available on-site for a day or more.
To boost vaccination among long-term care staff, the CDC and the National Vaccine Program Office offer a web-based tool kit that includes access to resources, strategies, and educational material (www.cdc/gov/flu/toolkit/long-term-care/index.htm). Employers and health care administrators can also check out the Guide to Community Preventive Services, which presents evidence to support on-site vaccination at no or low cost.
Related: Health Care Providers Impact on HPV Vaccination Rates
Source:
Black CL, Yue X, Ball SW, et al. MMWR. 2016;65(38):1026-1031.
Two doses of HPV vaccine may be noninferior to three
A two-dose schedule of the 9-valent human papillomavirus (HPV) vaccine in children aged 9-14 years is noninferior to a three-dose schedule in adolescent girls and women (aged 16-26 years), based on immunogenicity measurements.
Many countries have poor HPV vaccination rates, in part because the current regimen requires three doses over a 6-month span, and it can be challenging in some areas for children to make three health care visits in the required time span. “Using an effective two-dose regimen entailing fewer visits could improve adherence to HPV vaccination programs. Coadministration of the 9-valent HPV vaccine with diphtheria, tetanus, pertussis, polio, and meningococcal vaccines could also be completed at the same visit,” reported Ole-Erik Iversen, MD, PhD, of the University of Bergen (Norway) and his colleagues (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.17615).
The researchers measured serum anti-HPV antibodies 1 month after the final dose. At least 98% of the participants in each group seroconverted to a response against all 9 HPV subtypes, and analysis of the antibody geometric mean titers revealed that the groups who received two doses had noninferior responses to the control group of adolescent girls and young women who received three doses.
Antibody geometric mean titers against all 9 HPV types were higher in subgroups of boys and girls (aged 9-10 years, aged 11-12 years, and aged 13-14 years) who received two doses, compared with girls and young women who received three doses. “These observations suggest that the overall results of the primary immunogenicity analyses may be applicable across the entire studied age range of girls and boys,” Dr. Iversen and his associates wrote.
The study cannot prove that the two-dose regimen has equal efficacy to the three-dose regimen in preventing HPV infection, only that the immunogenicity is noninferior, they said.
The study was sponsored by Merck, which manufactures the vaccine. Study authors have financial ties to Merck and a number of other pharmaceutical companies.
Evidence now supports a two-dose schedule in adolescents (aged 9-14 years) for all three licensed HPV vaccines. When the vaccination series is initiated before the age of 15 years, two doses administered at a 0- and 6-month interval or at a 0- and 12-month interval were found to be just as immunogenic as (or even better than) three doses.
The coverage of HPV vaccination in the United States is lower than that for other vaccines recommended for adolescents, such as quadrivalent meningococcal conjugate vaccine and tetanus, diphtheria, and acellular pertussis vaccine. In 2015, three-dose HPV vaccination coverage among 13- to 17-year-olds was only 41.9% for girls and 28.1% for boys; at least one-dose coverage was 62.8% for girls and 49.8% for boys.
Going forward, a two-dose schedule should make it easier to complete the recommended vaccination series. A two-dose schedule (at 0 and 6-12 months) will decrease health care appointments needed for HPV vaccination and facilitate clinicians’ ability to deliver vaccine at preventive health visits. Nevertheless, efforts will be needed to increase vaccine initiation and ensure delivery of the second dose.
Lauri E. Markowitz, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, Atlanta. Elizabeth R. Unger, MD, MPH, is at the division of high-consequence pathogens and pathology, National Center for Emerging and Zoonotic Infectious Diseases at the CDC. Elissa Meites, PhD, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the CDC. Their comments were excerpted from an editorial accompanying the article by Iversen et al. (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.16393). The authors declared no financial conflicts of interest.
Evidence now supports a two-dose schedule in adolescents (aged 9-14 years) for all three licensed HPV vaccines. When the vaccination series is initiated before the age of 15 years, two doses administered at a 0- and 6-month interval or at a 0- and 12-month interval were found to be just as immunogenic as (or even better than) three doses.
The coverage of HPV vaccination in the United States is lower than that for other vaccines recommended for adolescents, such as quadrivalent meningococcal conjugate vaccine and tetanus, diphtheria, and acellular pertussis vaccine. In 2015, three-dose HPV vaccination coverage among 13- to 17-year-olds was only 41.9% for girls and 28.1% for boys; at least one-dose coverage was 62.8% for girls and 49.8% for boys.
Going forward, a two-dose schedule should make it easier to complete the recommended vaccination series. A two-dose schedule (at 0 and 6-12 months) will decrease health care appointments needed for HPV vaccination and facilitate clinicians’ ability to deliver vaccine at preventive health visits. Nevertheless, efforts will be needed to increase vaccine initiation and ensure delivery of the second dose.
Lauri E. Markowitz, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, Atlanta. Elizabeth R. Unger, MD, MPH, is at the division of high-consequence pathogens and pathology, National Center for Emerging and Zoonotic Infectious Diseases at the CDC. Elissa Meites, PhD, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the CDC. Their comments were excerpted from an editorial accompanying the article by Iversen et al. (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.16393). The authors declared no financial conflicts of interest.
Evidence now supports a two-dose schedule in adolescents (aged 9-14 years) for all three licensed HPV vaccines. When the vaccination series is initiated before the age of 15 years, two doses administered at a 0- and 6-month interval or at a 0- and 12-month interval were found to be just as immunogenic as (or even better than) three doses.
The coverage of HPV vaccination in the United States is lower than that for other vaccines recommended for adolescents, such as quadrivalent meningococcal conjugate vaccine and tetanus, diphtheria, and acellular pertussis vaccine. In 2015, three-dose HPV vaccination coverage among 13- to 17-year-olds was only 41.9% for girls and 28.1% for boys; at least one-dose coverage was 62.8% for girls and 49.8% for boys.
Going forward, a two-dose schedule should make it easier to complete the recommended vaccination series. A two-dose schedule (at 0 and 6-12 months) will decrease health care appointments needed for HPV vaccination and facilitate clinicians’ ability to deliver vaccine at preventive health visits. Nevertheless, efforts will be needed to increase vaccine initiation and ensure delivery of the second dose.
Lauri E. Markowitz, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, Atlanta. Elizabeth R. Unger, MD, MPH, is at the division of high-consequence pathogens and pathology, National Center for Emerging and Zoonotic Infectious Diseases at the CDC. Elissa Meites, PhD, MD, is at the division of viral diseases, National Center for Immunization and Respiratory Diseases at the CDC. Their comments were excerpted from an editorial accompanying the article by Iversen et al. (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.16393). The authors declared no financial conflicts of interest.
A two-dose schedule of the 9-valent human papillomavirus (HPV) vaccine in children aged 9-14 years is noninferior to a three-dose schedule in adolescent girls and women (aged 16-26 years), based on immunogenicity measurements.
Many countries have poor HPV vaccination rates, in part because the current regimen requires three doses over a 6-month span, and it can be challenging in some areas for children to make three health care visits in the required time span. “Using an effective two-dose regimen entailing fewer visits could improve adherence to HPV vaccination programs. Coadministration of the 9-valent HPV vaccine with diphtheria, tetanus, pertussis, polio, and meningococcal vaccines could also be completed at the same visit,” reported Ole-Erik Iversen, MD, PhD, of the University of Bergen (Norway) and his colleagues (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.17615).
The researchers measured serum anti-HPV antibodies 1 month after the final dose. At least 98% of the participants in each group seroconverted to a response against all 9 HPV subtypes, and analysis of the antibody geometric mean titers revealed that the groups who received two doses had noninferior responses to the control group of adolescent girls and young women who received three doses.
Antibody geometric mean titers against all 9 HPV types were higher in subgroups of boys and girls (aged 9-10 years, aged 11-12 years, and aged 13-14 years) who received two doses, compared with girls and young women who received three doses. “These observations suggest that the overall results of the primary immunogenicity analyses may be applicable across the entire studied age range of girls and boys,” Dr. Iversen and his associates wrote.
The study cannot prove that the two-dose regimen has equal efficacy to the three-dose regimen in preventing HPV infection, only that the immunogenicity is noninferior, they said.
The study was sponsored by Merck, which manufactures the vaccine. Study authors have financial ties to Merck and a number of other pharmaceutical companies.
A two-dose schedule of the 9-valent human papillomavirus (HPV) vaccine in children aged 9-14 years is noninferior to a three-dose schedule in adolescent girls and women (aged 16-26 years), based on immunogenicity measurements.
Many countries have poor HPV vaccination rates, in part because the current regimen requires three doses over a 6-month span, and it can be challenging in some areas for children to make three health care visits in the required time span. “Using an effective two-dose regimen entailing fewer visits could improve adherence to HPV vaccination programs. Coadministration of the 9-valent HPV vaccine with diphtheria, tetanus, pertussis, polio, and meningococcal vaccines could also be completed at the same visit,” reported Ole-Erik Iversen, MD, PhD, of the University of Bergen (Norway) and his colleagues (JAMA. 2016 Nov 21. doi: 10.1001/jama.2016.17615).
The researchers measured serum anti-HPV antibodies 1 month after the final dose. At least 98% of the participants in each group seroconverted to a response against all 9 HPV subtypes, and analysis of the antibody geometric mean titers revealed that the groups who received two doses had noninferior responses to the control group of adolescent girls and young women who received three doses.
Antibody geometric mean titers against all 9 HPV types were higher in subgroups of boys and girls (aged 9-10 years, aged 11-12 years, and aged 13-14 years) who received two doses, compared with girls and young women who received three doses. “These observations suggest that the overall results of the primary immunogenicity analyses may be applicable across the entire studied age range of girls and boys,” Dr. Iversen and his associates wrote.
The study cannot prove that the two-dose regimen has equal efficacy to the three-dose regimen in preventing HPV infection, only that the immunogenicity is noninferior, they said.
The study was sponsored by Merck, which manufactures the vaccine. Study authors have financial ties to Merck and a number of other pharmaceutical companies.
FROM JAMA
Key clinical point:
Major finding: Antibody geometric mean titers against all 9 HPV types were higher in subgroups of boys and girls (aged 9-10 years, aged 11-12 years, and aged 13-14 years) who received two doses, compared with girls and young women who received three doses.
Data source: Prospective, randomized trial of 1,377 children and young adults.
Disclosures: The study was sponsored by Merck, which manufactures the vaccine. Study authors have financial ties to Merck and a number of other pharmaceutical companies.
Challenges of influenza, measles, pertussis guide outbreak management
SAN FRANCISCO – Recent U.S. outbreaks of pertussis, influenza, and measles have revealed shifts in the diseases’ epidemiology, shifts that pose new prevention and management challenges, explained Yvonne Maldonado, MD, at the annual meeting of the American Academy of Pediatrics.
Routine immunizations prevent 33,000 child deaths a year in the United States, having reduced vaccine-preventable diseases by more than 90%, but outbreaks still occur, she said. The recent announcement that measles was eliminated from the Western Hemisphere, for example, doesn’t mean we won’t see cases, said Dr. Maldonado, vice chair of the AAP Committee on Infectious Diseases and chief of the division of pediatric infectious diseases at Stanford (Calif.) University.
Dr. Maldonado reviewed specific challenges for flu, pertussis, and measles.
Influenza
The biggest challenges with controlling influenza are the failure to vaccinate children and the variable circulating strains each season, which can impact the performance of that year’s vaccine. Those changing strains and other factors also mean that the populations most at risk for serious complications also vary each season.
The two new mechanisms of change in influenza strains are antigenic drift and antigenic shift. Antigenic drift involves mutations that occur during repeated replications in the RNA strains of the virus, shifting its configuration over time so that it may not respond to the same antigens that the original strain responded to. Antigenic shift, however, is responsible for the periodic pandemics, when a complete genetic reassortment abruptly occurs because a new major protein from a strain jumps from an animal population into the human population, forming a new hybrid strain in humans.
Pertussis
Unlike flu, pertussis did become very uncommon because of widespread vaccination up until the early 2000s. But rates have begun to climb again, largely because of problems with the vaccine over time. Until the 1990s, the DTP vaccine, which includes a whole pertussis bacterium, was highly effective at preventing pertussis but could cause febrile seizures, an adverse event that proved too intolerable for many families.
It was replaced with the acellular pertussis vaccine DTaP, but research in the past 5-10 years has revealed that the effectiveness of DTaP and Tdap vaccines wanes much more quickly than anticipated. Subsequently, pertussis rates have almost continuously climbed from the early 2000s through the present, reaching an incidence of more than 100 cases per 100,000 among children younger than 1 year.
One of the biggest challenges now is improving vaccination rates among pregnant women, who were recommended in 2015 to get the Tdap vaccine in every pregnancy so that the newborn would have some passively acquired protection during the first few months of life.
Ongoing outbreaks then become exacerbated by pockets of lower vaccination rates among children in general.
Measles
The only chink in the armor against measles is failure to vaccinate against it, Dr. Maldonado said. Though the disease was eliminated from the United States in 2000, measles cases peaked recently in 2014, when 31 outbreaks involving 667 cases occurred because of imported cases from the Philippines. The next year, 60% of the 189 cases in 2015 resulted from the multistate measles outbreak starting at Disneyland in California.
Most of the individuals in both those years’ outbreaks were not vaccinated or had an unknown vaccination status. Of the 110 individuals with measles in California from the Disneyland outbreak, 45% were not immunized. Twelve were too young for vaccination, but 37 were eligible to have been vaccinated, and 67% of these were not vaccinated because of personal beliefs.
Vaccination rates for measles must be considerably higher, around 92%-94% of the population, to prevent outbreaks than for most other diseases, because the virus is so incredibly contagious.
“Measles is so infectious because it can exist in tiny microdroplets less than 5 mcg that can sit in the air up to 2 hours,” Dr. Maldonado explained. Yet only 92.6% of kindergartners had had both their MMR doses in 2014, compared with the peak of 97% between 2002 to 2007.
When children across all ages who have not received both doses of the vaccine are taken into account, 12.5% of all U.S. children and adolescents are currently susceptible to measles – and a quarter of those aged 3 years and younger are, Maldonado said.
The keys to preventing measles are high national coverage rates, an aggressive public health response (because early diagnosis can limit transmission), and improved implementation of health care worker recommendations.
“We have to keep measles in mind whenever we see fevers and rashes,” Dr. Maldonado cautioned. “Unfortunately, we see fevers and rashes all the time, so what really helps is a history of international travel or a parent with international travel.”
For families planning overseas travel, parents are recommended to give their infants the MMR as young as 6 months. But that dose does not count toward the child’s two doses recommended by the Centers for Disease Control and Prevention schedule.
“It’s a very tough call with measles, because we never know when it might pop up,” Dr. Maldonado said. “Measles will be sporadic, but when it happens, it’s a really big deal. You basically have to reach out to your entire patient log for several days before the child came in.”
Managing suspected/confirmed outbreaks
To prepare for and manage suspected outbreaks of an infectious disease, Dr. Maldonado advised taking the following steps:
• Establish a plan for evaluating suspected or confirmed infectious disease outbreaks in your office setting.
• Identify and eliminate the source of the infection, such as providing a separate waiting room for coughing children.
• Prevent additional cases using screening questions at the front desk.
• Provide prompt and consistent ongoing evaluation to prevent or minimize transmission to others.
• Track disease trends and advice from the AAP, CDC, and local county public health officials and disease experts to engage in ongoing surveillance and communication.
• Identify the initial source and route of exposure to understand why an outbreak occurred and how to prevent similar ones in the future.
Dr. Maldonado reporting being a member of a data safety monitoring board for Pfizer.
SAN FRANCISCO – Recent U.S. outbreaks of pertussis, influenza, and measles have revealed shifts in the diseases’ epidemiology, shifts that pose new prevention and management challenges, explained Yvonne Maldonado, MD, at the annual meeting of the American Academy of Pediatrics.
Routine immunizations prevent 33,000 child deaths a year in the United States, having reduced vaccine-preventable diseases by more than 90%, but outbreaks still occur, she said. The recent announcement that measles was eliminated from the Western Hemisphere, for example, doesn’t mean we won’t see cases, said Dr. Maldonado, vice chair of the AAP Committee on Infectious Diseases and chief of the division of pediatric infectious diseases at Stanford (Calif.) University.
Dr. Maldonado reviewed specific challenges for flu, pertussis, and measles.
Influenza
The biggest challenges with controlling influenza are the failure to vaccinate children and the variable circulating strains each season, which can impact the performance of that year’s vaccine. Those changing strains and other factors also mean that the populations most at risk for serious complications also vary each season.
The two new mechanisms of change in influenza strains are antigenic drift and antigenic shift. Antigenic drift involves mutations that occur during repeated replications in the RNA strains of the virus, shifting its configuration over time so that it may not respond to the same antigens that the original strain responded to. Antigenic shift, however, is responsible for the periodic pandemics, when a complete genetic reassortment abruptly occurs because a new major protein from a strain jumps from an animal population into the human population, forming a new hybrid strain in humans.
Pertussis
Unlike flu, pertussis did become very uncommon because of widespread vaccination up until the early 2000s. But rates have begun to climb again, largely because of problems with the vaccine over time. Until the 1990s, the DTP vaccine, which includes a whole pertussis bacterium, was highly effective at preventing pertussis but could cause febrile seizures, an adverse event that proved too intolerable for many families.
It was replaced with the acellular pertussis vaccine DTaP, but research in the past 5-10 years has revealed that the effectiveness of DTaP and Tdap vaccines wanes much more quickly than anticipated. Subsequently, pertussis rates have almost continuously climbed from the early 2000s through the present, reaching an incidence of more than 100 cases per 100,000 among children younger than 1 year.
One of the biggest challenges now is improving vaccination rates among pregnant women, who were recommended in 2015 to get the Tdap vaccine in every pregnancy so that the newborn would have some passively acquired protection during the first few months of life.
Ongoing outbreaks then become exacerbated by pockets of lower vaccination rates among children in general.
Measles
The only chink in the armor against measles is failure to vaccinate against it, Dr. Maldonado said. Though the disease was eliminated from the United States in 2000, measles cases peaked recently in 2014, when 31 outbreaks involving 667 cases occurred because of imported cases from the Philippines. The next year, 60% of the 189 cases in 2015 resulted from the multistate measles outbreak starting at Disneyland in California.
Most of the individuals in both those years’ outbreaks were not vaccinated or had an unknown vaccination status. Of the 110 individuals with measles in California from the Disneyland outbreak, 45% were not immunized. Twelve were too young for vaccination, but 37 were eligible to have been vaccinated, and 67% of these were not vaccinated because of personal beliefs.
Vaccination rates for measles must be considerably higher, around 92%-94% of the population, to prevent outbreaks than for most other diseases, because the virus is so incredibly contagious.
“Measles is so infectious because it can exist in tiny microdroplets less than 5 mcg that can sit in the air up to 2 hours,” Dr. Maldonado explained. Yet only 92.6% of kindergartners had had both their MMR doses in 2014, compared with the peak of 97% between 2002 to 2007.
When children across all ages who have not received both doses of the vaccine are taken into account, 12.5% of all U.S. children and adolescents are currently susceptible to measles – and a quarter of those aged 3 years and younger are, Maldonado said.
The keys to preventing measles are high national coverage rates, an aggressive public health response (because early diagnosis can limit transmission), and improved implementation of health care worker recommendations.
“We have to keep measles in mind whenever we see fevers and rashes,” Dr. Maldonado cautioned. “Unfortunately, we see fevers and rashes all the time, so what really helps is a history of international travel or a parent with international travel.”
For families planning overseas travel, parents are recommended to give their infants the MMR as young as 6 months. But that dose does not count toward the child’s two doses recommended by the Centers for Disease Control and Prevention schedule.
“It’s a very tough call with measles, because we never know when it might pop up,” Dr. Maldonado said. “Measles will be sporadic, but when it happens, it’s a really big deal. You basically have to reach out to your entire patient log for several days before the child came in.”
Managing suspected/confirmed outbreaks
To prepare for and manage suspected outbreaks of an infectious disease, Dr. Maldonado advised taking the following steps:
• Establish a plan for evaluating suspected or confirmed infectious disease outbreaks in your office setting.
• Identify and eliminate the source of the infection, such as providing a separate waiting room for coughing children.
• Prevent additional cases using screening questions at the front desk.
• Provide prompt and consistent ongoing evaluation to prevent or minimize transmission to others.
• Track disease trends and advice from the AAP, CDC, and local county public health officials and disease experts to engage in ongoing surveillance and communication.
• Identify the initial source and route of exposure to understand why an outbreak occurred and how to prevent similar ones in the future.
Dr. Maldonado reporting being a member of a data safety monitoring board for Pfizer.
SAN FRANCISCO – Recent U.S. outbreaks of pertussis, influenza, and measles have revealed shifts in the diseases’ epidemiology, shifts that pose new prevention and management challenges, explained Yvonne Maldonado, MD, at the annual meeting of the American Academy of Pediatrics.
Routine immunizations prevent 33,000 child deaths a year in the United States, having reduced vaccine-preventable diseases by more than 90%, but outbreaks still occur, she said. The recent announcement that measles was eliminated from the Western Hemisphere, for example, doesn’t mean we won’t see cases, said Dr. Maldonado, vice chair of the AAP Committee on Infectious Diseases and chief of the division of pediatric infectious diseases at Stanford (Calif.) University.
Dr. Maldonado reviewed specific challenges for flu, pertussis, and measles.
Influenza
The biggest challenges with controlling influenza are the failure to vaccinate children and the variable circulating strains each season, which can impact the performance of that year’s vaccine. Those changing strains and other factors also mean that the populations most at risk for serious complications also vary each season.
The two new mechanisms of change in influenza strains are antigenic drift and antigenic shift. Antigenic drift involves mutations that occur during repeated replications in the RNA strains of the virus, shifting its configuration over time so that it may not respond to the same antigens that the original strain responded to. Antigenic shift, however, is responsible for the periodic pandemics, when a complete genetic reassortment abruptly occurs because a new major protein from a strain jumps from an animal population into the human population, forming a new hybrid strain in humans.
Pertussis
Unlike flu, pertussis did become very uncommon because of widespread vaccination up until the early 2000s. But rates have begun to climb again, largely because of problems with the vaccine over time. Until the 1990s, the DTP vaccine, which includes a whole pertussis bacterium, was highly effective at preventing pertussis but could cause febrile seizures, an adverse event that proved too intolerable for many families.
It was replaced with the acellular pertussis vaccine DTaP, but research in the past 5-10 years has revealed that the effectiveness of DTaP and Tdap vaccines wanes much more quickly than anticipated. Subsequently, pertussis rates have almost continuously climbed from the early 2000s through the present, reaching an incidence of more than 100 cases per 100,000 among children younger than 1 year.
One of the biggest challenges now is improving vaccination rates among pregnant women, who were recommended in 2015 to get the Tdap vaccine in every pregnancy so that the newborn would have some passively acquired protection during the first few months of life.
Ongoing outbreaks then become exacerbated by pockets of lower vaccination rates among children in general.
Measles
The only chink in the armor against measles is failure to vaccinate against it, Dr. Maldonado said. Though the disease was eliminated from the United States in 2000, measles cases peaked recently in 2014, when 31 outbreaks involving 667 cases occurred because of imported cases from the Philippines. The next year, 60% of the 189 cases in 2015 resulted from the multistate measles outbreak starting at Disneyland in California.
Most of the individuals in both those years’ outbreaks were not vaccinated or had an unknown vaccination status. Of the 110 individuals with measles in California from the Disneyland outbreak, 45% were not immunized. Twelve were too young for vaccination, but 37 were eligible to have been vaccinated, and 67% of these were not vaccinated because of personal beliefs.
Vaccination rates for measles must be considerably higher, around 92%-94% of the population, to prevent outbreaks than for most other diseases, because the virus is so incredibly contagious.
“Measles is so infectious because it can exist in tiny microdroplets less than 5 mcg that can sit in the air up to 2 hours,” Dr. Maldonado explained. Yet only 92.6% of kindergartners had had both their MMR doses in 2014, compared with the peak of 97% between 2002 to 2007.
When children across all ages who have not received both doses of the vaccine are taken into account, 12.5% of all U.S. children and adolescents are currently susceptible to measles – and a quarter of those aged 3 years and younger are, Maldonado said.
The keys to preventing measles are high national coverage rates, an aggressive public health response (because early diagnosis can limit transmission), and improved implementation of health care worker recommendations.
“We have to keep measles in mind whenever we see fevers and rashes,” Dr. Maldonado cautioned. “Unfortunately, we see fevers and rashes all the time, so what really helps is a history of international travel or a parent with international travel.”
For families planning overseas travel, parents are recommended to give their infants the MMR as young as 6 months. But that dose does not count toward the child’s two doses recommended by the Centers for Disease Control and Prevention schedule.
“It’s a very tough call with measles, because we never know when it might pop up,” Dr. Maldonado said. “Measles will be sporadic, but when it happens, it’s a really big deal. You basically have to reach out to your entire patient log for several days before the child came in.”
Managing suspected/confirmed outbreaks
To prepare for and manage suspected outbreaks of an infectious disease, Dr. Maldonado advised taking the following steps:
• Establish a plan for evaluating suspected or confirmed infectious disease outbreaks in your office setting.
• Identify and eliminate the source of the infection, such as providing a separate waiting room for coughing children.
• Prevent additional cases using screening questions at the front desk.
• Provide prompt and consistent ongoing evaluation to prevent or minimize transmission to others.
• Track disease trends and advice from the AAP, CDC, and local county public health officials and disease experts to engage in ongoing surveillance and communication.
• Identify the initial source and route of exposure to understand why an outbreak occurred and how to prevent similar ones in the future.
Dr. Maldonado reporting being a member of a data safety monitoring board for Pfizer.
FROM AAP 16
Inhaled laninamivir reduces risk of influenza in young children
The inhaled neuraminidase inhibitor laninamivir has been shown to significantly reduce the likelihood of developing influenza among children exposed to a family member with the infection, according to a study recently published in Pediatrics.
In a double-blind, placebo-controlled study, researchers randomized 343 children under 10 years old – who had an influenza-infected family member – to a single 20-mg dose of inhaled laninamivir octanoate or placebo.
Subgroup analyses suggested the treatment was more effective in children under 7 years old, with a relative risk reduction of 64%, compared with a non–statistically significant 28% reduction in those aged 7-10 years (Pediatrics. 2016 Nov 2. doi: 10.1542/peds.2016-0109).
The treatment was also effective among children where the index case was infected with influenza A (H3N2).
Dr. Takashi Nakano, from Kawasaki Hospital in Okayama, Japan, and coauthors reported a similar incidence of adverse events in the laninamivir and placebo groups, with no serious adverse events and no withdrawals due to adverse events. However, the authors noted that there were very few study participants considered at high risk, such as patients with chronic respiratory disease, and suggested further studies of the impact and efficacy of treatment in high-risk groups.
The researchers noted that, despite increasing rates of influenza vaccination and the availability of other neuraminidase inhibitors, such as oseltamivir and peramivir, pandemic outbreaks of influenza are still occurring. There has also been evidence of resistance to both oseltamivir and peramivir, for example, in the 2013/2014 outbreak of influenza A (H1N1) in Japan. “Given the limitations of vaccination, extensive variations in the option for antiinfluenza prophylaxis are desirable as an adjunct to influenza vaccine,” the researchers wrote.
Laninamivir has been studied in adults and children and shown to be effective at treating influenza infection, but its efficacy as prophylaxis in children under 10 years old had not previously been studied.
“Since a single 20-mg dose of laninamivir octanoate revealed prophylactic effect, the regimen in the current study is a highly user-friendly option,” the researchers wrote. “Although the numbers of infected individuals may differ by season, the number needed to treat based on the incidence of clinical influenza for the two groups in the current study was 11.”
The study was funded by Daiichi Sankyo. Two of the study authors reported being consultants for Daiichi Sankyo, as well as having financial relationships with other pharmaceutical companies. The other study authors are employees of Daiichi Sankyo.
Although vaccination remains the preferred approach for influenza prevention, additional options for influenza prophylaxis in children are important, given concerns for the emergence of resistance, the known antiviral adverse side effect profiles, possible limited supplies, and the potential for spotty patient compliance. This drug was well tolerated, without significant adverse events reported, and there were no neurologic symptoms or abnormal behavior, which have occurred with influenza illness and with other neuraminidase inhibitors in Japan.
Prompt initiation of influenza prophylaxis is necessary to ensure efficacy, which hinges on proper and prompt identification of index cases. Therefore, efforts to educate parents and families on the early signs and symptoms of influenza and the importance of seeking medical attention to confirm the diagnosis in the index case are crucial for timely initiation of prophylaxis in household contacts.
Flor M. Munoz, MD, is from the department of pediatrics at the Baylor College of Medicine and Texas Children’s Hospital in Houston, and Henry H. Bernstein, DO, is from the department of pediatrics, Hofstra Northwell School of Medicine, Hempstead, N.Y., and Cohen Children’s Medical Center of New York in New Hyde Park. These comments are adapted from an accompanying editorial (Pediatrics. 2016 Nov 2. doi: 10.1542/peds.2016-2371). The authors reported having no relevant financial disclosures.
Although vaccination remains the preferred approach for influenza prevention, additional options for influenza prophylaxis in children are important, given concerns for the emergence of resistance, the known antiviral adverse side effect profiles, possible limited supplies, and the potential for spotty patient compliance. This drug was well tolerated, without significant adverse events reported, and there were no neurologic symptoms or abnormal behavior, which have occurred with influenza illness and with other neuraminidase inhibitors in Japan.
Prompt initiation of influenza prophylaxis is necessary to ensure efficacy, which hinges on proper and prompt identification of index cases. Therefore, efforts to educate parents and families on the early signs and symptoms of influenza and the importance of seeking medical attention to confirm the diagnosis in the index case are crucial for timely initiation of prophylaxis in household contacts.
Flor M. Munoz, MD, is from the department of pediatrics at the Baylor College of Medicine and Texas Children’s Hospital in Houston, and Henry H. Bernstein, DO, is from the department of pediatrics, Hofstra Northwell School of Medicine, Hempstead, N.Y., and Cohen Children’s Medical Center of New York in New Hyde Park. These comments are adapted from an accompanying editorial (Pediatrics. 2016 Nov 2. doi: 10.1542/peds.2016-2371). The authors reported having no relevant financial disclosures.
Although vaccination remains the preferred approach for influenza prevention, additional options for influenza prophylaxis in children are important, given concerns for the emergence of resistance, the known antiviral adverse side effect profiles, possible limited supplies, and the potential for spotty patient compliance. This drug was well tolerated, without significant adverse events reported, and there were no neurologic symptoms or abnormal behavior, which have occurred with influenza illness and with other neuraminidase inhibitors in Japan.
Prompt initiation of influenza prophylaxis is necessary to ensure efficacy, which hinges on proper and prompt identification of index cases. Therefore, efforts to educate parents and families on the early signs and symptoms of influenza and the importance of seeking medical attention to confirm the diagnosis in the index case are crucial for timely initiation of prophylaxis in household contacts.
Flor M. Munoz, MD, is from the department of pediatrics at the Baylor College of Medicine and Texas Children’s Hospital in Houston, and Henry H. Bernstein, DO, is from the department of pediatrics, Hofstra Northwell School of Medicine, Hempstead, N.Y., and Cohen Children’s Medical Center of New York in New Hyde Park. These comments are adapted from an accompanying editorial (Pediatrics. 2016 Nov 2. doi: 10.1542/peds.2016-2371). The authors reported having no relevant financial disclosures.
The inhaled neuraminidase inhibitor laninamivir has been shown to significantly reduce the likelihood of developing influenza among children exposed to a family member with the infection, according to a study recently published in Pediatrics.
In a double-blind, placebo-controlled study, researchers randomized 343 children under 10 years old – who had an influenza-infected family member – to a single 20-mg dose of inhaled laninamivir octanoate or placebo.
Subgroup analyses suggested the treatment was more effective in children under 7 years old, with a relative risk reduction of 64%, compared with a non–statistically significant 28% reduction in those aged 7-10 years (Pediatrics. 2016 Nov 2. doi: 10.1542/peds.2016-0109).
The treatment was also effective among children where the index case was infected with influenza A (H3N2).
Dr. Takashi Nakano, from Kawasaki Hospital in Okayama, Japan, and coauthors reported a similar incidence of adverse events in the laninamivir and placebo groups, with no serious adverse events and no withdrawals due to adverse events. However, the authors noted that there were very few study participants considered at high risk, such as patients with chronic respiratory disease, and suggested further studies of the impact and efficacy of treatment in high-risk groups.
The researchers noted that, despite increasing rates of influenza vaccination and the availability of other neuraminidase inhibitors, such as oseltamivir and peramivir, pandemic outbreaks of influenza are still occurring. There has also been evidence of resistance to both oseltamivir and peramivir, for example, in the 2013/2014 outbreak of influenza A (H1N1) in Japan. “Given the limitations of vaccination, extensive variations in the option for antiinfluenza prophylaxis are desirable as an adjunct to influenza vaccine,” the researchers wrote.
Laninamivir has been studied in adults and children and shown to be effective at treating influenza infection, but its efficacy as prophylaxis in children under 10 years old had not previously been studied.
“Since a single 20-mg dose of laninamivir octanoate revealed prophylactic effect, the regimen in the current study is a highly user-friendly option,” the researchers wrote. “Although the numbers of infected individuals may differ by season, the number needed to treat based on the incidence of clinical influenza for the two groups in the current study was 11.”
The study was funded by Daiichi Sankyo. Two of the study authors reported being consultants for Daiichi Sankyo, as well as having financial relationships with other pharmaceutical companies. The other study authors are employees of Daiichi Sankyo.
The inhaled neuraminidase inhibitor laninamivir has been shown to significantly reduce the likelihood of developing influenza among children exposed to a family member with the infection, according to a study recently published in Pediatrics.
In a double-blind, placebo-controlled study, researchers randomized 343 children under 10 years old – who had an influenza-infected family member – to a single 20-mg dose of inhaled laninamivir octanoate or placebo.
Subgroup analyses suggested the treatment was more effective in children under 7 years old, with a relative risk reduction of 64%, compared with a non–statistically significant 28% reduction in those aged 7-10 years (Pediatrics. 2016 Nov 2. doi: 10.1542/peds.2016-0109).
The treatment was also effective among children where the index case was infected with influenza A (H3N2).
Dr. Takashi Nakano, from Kawasaki Hospital in Okayama, Japan, and coauthors reported a similar incidence of adverse events in the laninamivir and placebo groups, with no serious adverse events and no withdrawals due to adverse events. However, the authors noted that there were very few study participants considered at high risk, such as patients with chronic respiratory disease, and suggested further studies of the impact and efficacy of treatment in high-risk groups.
The researchers noted that, despite increasing rates of influenza vaccination and the availability of other neuraminidase inhibitors, such as oseltamivir and peramivir, pandemic outbreaks of influenza are still occurring. There has also been evidence of resistance to both oseltamivir and peramivir, for example, in the 2013/2014 outbreak of influenza A (H1N1) in Japan. “Given the limitations of vaccination, extensive variations in the option for antiinfluenza prophylaxis are desirable as an adjunct to influenza vaccine,” the researchers wrote.
Laninamivir has been studied in adults and children and shown to be effective at treating influenza infection, but its efficacy as prophylaxis in children under 10 years old had not previously been studied.
“Since a single 20-mg dose of laninamivir octanoate revealed prophylactic effect, the regimen in the current study is a highly user-friendly option,” the researchers wrote. “Although the numbers of infected individuals may differ by season, the number needed to treat based on the incidence of clinical influenza for the two groups in the current study was 11.”
The study was funded by Daiichi Sankyo. Two of the study authors reported being consultants for Daiichi Sankyo, as well as having financial relationships with other pharmaceutical companies. The other study authors are employees of Daiichi Sankyo.
FROM PEDIATRICS
Key clinical point:
Major finding: Children treated with laninamivir showed a 45.8% reduction in the risk of influenza, compared with the placebo group.
Data source: Randomized, double-blind, placebo-controlled trial in 343 children under 10 years old.
Disclosures: The study was funded by Daiichi Sankyo. Two of the study authors reported being consultants for Daiichi Sankyo, as well as having financial relationships with other pharmaceutical companies. The other study authors are employees of Daiichi Sankyo.
Research yields 5 key points about vaccine hesitancy
ATLANTA – While there is no question about the need to address pockets of increasing vaccine refusals, determining how to address it requires a better understanding of the forces underlying vaccine hesitancy.
This area of research is still young, but Glen Nowak, PhD, a visiting communication scientist at the National Vaccine Program Office and director of the Grady College Center for Health & Risk Communication at the University of Georgia in Athens, drew on multiple recent studies and an in-progress review of vaccine hesitancy and confidence literature to distill five key findings from recent research into vaccine hesitancy. He presented that summary at a conference sponsored by the Centers for Disease Control and Prevention.
The first insight: There is a lot of interest in understanding vaccine hesitancy and confidence. But the rub is that many inconsistencies and uncertainties exist, because efforts remain in the early stages of research.
Dr. Nowak referenced the November 2014 report of the World Health Organization’s Strategic Advisory Group of Experts (SAGE) on Immunization to define vaccine hesitancy as the “delay in acceptance or refusal of vaccines despite availability of vaccine services.” But that hesitancy is complex and context specific, varying across time, place, and type of vaccine, the report found.
Those who are hesitant about vaccines are not a homogeneous group, Dr. Nowak said. Their degree of indecision ranges from refusing all vaccines, refusing some and accepting others, or delaying some but not others, to full acceptance of all vaccines despite hesitancy. Their attitudes also vary about vaccination overall and about specific vaccines.
“Vaccines hesitancy is influenced by several factors: complacency, convenience, and confidence,” Dr. Nowak said.
“Generally speaking, the end goal of all of our efforts is vaccine coverage, and before that is vaccine acceptance,” he said. “Before acceptance is hesitancy, and confidence is considered the precursor to hesitancy.” But no clear definition or measure of “vaccine confidence” exists yet.
Dr. Nowak next highlighted the second key finding: that research has identified an association between vaccine hesitancy or vaccine-related hesitancy and vaccine acceptance.
A 2016 study found that scores from the Attitudes about Childhood Vaccines Survey predicted under-immunization in children at 19 months of age, and three studies from 2008 through 2012 found a greater likelihood to delay or refuse vaccines among parents who had vaccine-related doubts.
Focus groups have found that parents who express hesitation or a lack of trust in vaccines also tend to mention using “alternative schedules,” including delaying vaccines or only vaccinating their children with select vaccines instead of all the recommended immunizations.
The third key finding Dr. Nowak discussed returned to the idea of “vaccine confidence,” which has aroused more interest in research but which requires refinement before it can become a truly helpful concept. Studies have already found links between confidence and parents vaccinating their children, but the field lacks standard measures.
“There are all different definitions that are out there, but they have not been measured,” Dr. Nowak said.
For example, the 2015 National Vaccine Advisory Committee report defined vaccine confidence as parents’ or health care providers’ trust in three areas: the immunizations recommended by the CDC’s Advisory Committee on Immunization Practices, the providers who administer the vaccines, and the processes that lead to vaccine licensure and vaccine recommendations.
But other definitions might include having faith that a person will benefit from a vaccine or that they won’t experience harm, or lacking any concerns about potential adverse outcomes.
The fourth key finding of recent research delivered positive news, Dr. Nowak noted: “Vaccines do relatively well compared to other health-related products that parents of young children have to make decisions about, such as antibiotics, over-the-counter medicines and vitamins.”
For example, in one study, the mean score (scale 1-10) of parents’ confidence that their child will not have a bad or serious adverse reaction to a recommended vaccine was 6.6, the same as the confidence level for antibiotics and only slightly below the scores of 6.8 for OTC medications and 7.3 for vitamins. Vaccines and antibiotics tied for the highest score for parents’ confidence in their effectiveness: 7.1, compared with 6.3 for OTC medications and 5.8 for vitamins. And of all four products, parents had the highest faith in vaccines as benefiting their children’s health.
But it was the final finding Dr. Nowak discussed that can present some of the greatest challenges to addressing vaccine hesitancy: Parents’ direct and indirect experiences play a significant role in their confidence about vaccines.
One study found that nearly a quarter of parents reported knowing someone who had a “bad reaction” to a vaccine (aside from soreness, fever, redness, or swelling), compared with 16.7% reporting that someone they knew had a bad reaction to an OTC medication. About one-third of parents reported the same for antibiotics.
Similarly, the measles outbreak at Disneyland in 2015 increased parents’ confidence in the safety and effectiveness of the CDC-recommended childhood vaccination schedule, and in the belief that their child’s health would benefit from receiving all the recommended vaccines.
Dr. Nowak reported no disclosures.
ATLANTA – While there is no question about the need to address pockets of increasing vaccine refusals, determining how to address it requires a better understanding of the forces underlying vaccine hesitancy.
This area of research is still young, but Glen Nowak, PhD, a visiting communication scientist at the National Vaccine Program Office and director of the Grady College Center for Health & Risk Communication at the University of Georgia in Athens, drew on multiple recent studies and an in-progress review of vaccine hesitancy and confidence literature to distill five key findings from recent research into vaccine hesitancy. He presented that summary at a conference sponsored by the Centers for Disease Control and Prevention.
The first insight: There is a lot of interest in understanding vaccine hesitancy and confidence. But the rub is that many inconsistencies and uncertainties exist, because efforts remain in the early stages of research.
Dr. Nowak referenced the November 2014 report of the World Health Organization’s Strategic Advisory Group of Experts (SAGE) on Immunization to define vaccine hesitancy as the “delay in acceptance or refusal of vaccines despite availability of vaccine services.” But that hesitancy is complex and context specific, varying across time, place, and type of vaccine, the report found.
Those who are hesitant about vaccines are not a homogeneous group, Dr. Nowak said. Their degree of indecision ranges from refusing all vaccines, refusing some and accepting others, or delaying some but not others, to full acceptance of all vaccines despite hesitancy. Their attitudes also vary about vaccination overall and about specific vaccines.
“Vaccines hesitancy is influenced by several factors: complacency, convenience, and confidence,” Dr. Nowak said.
“Generally speaking, the end goal of all of our efforts is vaccine coverage, and before that is vaccine acceptance,” he said. “Before acceptance is hesitancy, and confidence is considered the precursor to hesitancy.” But no clear definition or measure of “vaccine confidence” exists yet.
Dr. Nowak next highlighted the second key finding: that research has identified an association between vaccine hesitancy or vaccine-related hesitancy and vaccine acceptance.
A 2016 study found that scores from the Attitudes about Childhood Vaccines Survey predicted under-immunization in children at 19 months of age, and three studies from 2008 through 2012 found a greater likelihood to delay or refuse vaccines among parents who had vaccine-related doubts.
Focus groups have found that parents who express hesitation or a lack of trust in vaccines also tend to mention using “alternative schedules,” including delaying vaccines or only vaccinating their children with select vaccines instead of all the recommended immunizations.
The third key finding Dr. Nowak discussed returned to the idea of “vaccine confidence,” which has aroused more interest in research but which requires refinement before it can become a truly helpful concept. Studies have already found links between confidence and parents vaccinating their children, but the field lacks standard measures.
“There are all different definitions that are out there, but they have not been measured,” Dr. Nowak said.
For example, the 2015 National Vaccine Advisory Committee report defined vaccine confidence as parents’ or health care providers’ trust in three areas: the immunizations recommended by the CDC’s Advisory Committee on Immunization Practices, the providers who administer the vaccines, and the processes that lead to vaccine licensure and vaccine recommendations.
But other definitions might include having faith that a person will benefit from a vaccine or that they won’t experience harm, or lacking any concerns about potential adverse outcomes.
The fourth key finding of recent research delivered positive news, Dr. Nowak noted: “Vaccines do relatively well compared to other health-related products that parents of young children have to make decisions about, such as antibiotics, over-the-counter medicines and vitamins.”
For example, in one study, the mean score (scale 1-10) of parents’ confidence that their child will not have a bad or serious adverse reaction to a recommended vaccine was 6.6, the same as the confidence level for antibiotics and only slightly below the scores of 6.8 for OTC medications and 7.3 for vitamins. Vaccines and antibiotics tied for the highest score for parents’ confidence in their effectiveness: 7.1, compared with 6.3 for OTC medications and 5.8 for vitamins. And of all four products, parents had the highest faith in vaccines as benefiting their children’s health.
But it was the final finding Dr. Nowak discussed that can present some of the greatest challenges to addressing vaccine hesitancy: Parents’ direct and indirect experiences play a significant role in their confidence about vaccines.
One study found that nearly a quarter of parents reported knowing someone who had a “bad reaction” to a vaccine (aside from soreness, fever, redness, or swelling), compared with 16.7% reporting that someone they knew had a bad reaction to an OTC medication. About one-third of parents reported the same for antibiotics.
Similarly, the measles outbreak at Disneyland in 2015 increased parents’ confidence in the safety and effectiveness of the CDC-recommended childhood vaccination schedule, and in the belief that their child’s health would benefit from receiving all the recommended vaccines.
Dr. Nowak reported no disclosures.
ATLANTA – While there is no question about the need to address pockets of increasing vaccine refusals, determining how to address it requires a better understanding of the forces underlying vaccine hesitancy.
This area of research is still young, but Glen Nowak, PhD, a visiting communication scientist at the National Vaccine Program Office and director of the Grady College Center for Health & Risk Communication at the University of Georgia in Athens, drew on multiple recent studies and an in-progress review of vaccine hesitancy and confidence literature to distill five key findings from recent research into vaccine hesitancy. He presented that summary at a conference sponsored by the Centers for Disease Control and Prevention.
The first insight: There is a lot of interest in understanding vaccine hesitancy and confidence. But the rub is that many inconsistencies and uncertainties exist, because efforts remain in the early stages of research.
Dr. Nowak referenced the November 2014 report of the World Health Organization’s Strategic Advisory Group of Experts (SAGE) on Immunization to define vaccine hesitancy as the “delay in acceptance or refusal of vaccines despite availability of vaccine services.” But that hesitancy is complex and context specific, varying across time, place, and type of vaccine, the report found.
Those who are hesitant about vaccines are not a homogeneous group, Dr. Nowak said. Their degree of indecision ranges from refusing all vaccines, refusing some and accepting others, or delaying some but not others, to full acceptance of all vaccines despite hesitancy. Their attitudes also vary about vaccination overall and about specific vaccines.
“Vaccines hesitancy is influenced by several factors: complacency, convenience, and confidence,” Dr. Nowak said.
“Generally speaking, the end goal of all of our efforts is vaccine coverage, and before that is vaccine acceptance,” he said. “Before acceptance is hesitancy, and confidence is considered the precursor to hesitancy.” But no clear definition or measure of “vaccine confidence” exists yet.
Dr. Nowak next highlighted the second key finding: that research has identified an association between vaccine hesitancy or vaccine-related hesitancy and vaccine acceptance.
A 2016 study found that scores from the Attitudes about Childhood Vaccines Survey predicted under-immunization in children at 19 months of age, and three studies from 2008 through 2012 found a greater likelihood to delay or refuse vaccines among parents who had vaccine-related doubts.
Focus groups have found that parents who express hesitation or a lack of trust in vaccines also tend to mention using “alternative schedules,” including delaying vaccines or only vaccinating their children with select vaccines instead of all the recommended immunizations.
The third key finding Dr. Nowak discussed returned to the idea of “vaccine confidence,” which has aroused more interest in research but which requires refinement before it can become a truly helpful concept. Studies have already found links between confidence and parents vaccinating their children, but the field lacks standard measures.
“There are all different definitions that are out there, but they have not been measured,” Dr. Nowak said.
For example, the 2015 National Vaccine Advisory Committee report defined vaccine confidence as parents’ or health care providers’ trust in three areas: the immunizations recommended by the CDC’s Advisory Committee on Immunization Practices, the providers who administer the vaccines, and the processes that lead to vaccine licensure and vaccine recommendations.
But other definitions might include having faith that a person will benefit from a vaccine or that they won’t experience harm, or lacking any concerns about potential adverse outcomes.
The fourth key finding of recent research delivered positive news, Dr. Nowak noted: “Vaccines do relatively well compared to other health-related products that parents of young children have to make decisions about, such as antibiotics, over-the-counter medicines and vitamins.”
For example, in one study, the mean score (scale 1-10) of parents’ confidence that their child will not have a bad or serious adverse reaction to a recommended vaccine was 6.6, the same as the confidence level for antibiotics and only slightly below the scores of 6.8 for OTC medications and 7.3 for vitamins. Vaccines and antibiotics tied for the highest score for parents’ confidence in their effectiveness: 7.1, compared with 6.3 for OTC medications and 5.8 for vitamins. And of all four products, parents had the highest faith in vaccines as benefiting their children’s health.
But it was the final finding Dr. Nowak discussed that can present some of the greatest challenges to addressing vaccine hesitancy: Parents’ direct and indirect experiences play a significant role in their confidence about vaccines.
One study found that nearly a quarter of parents reported knowing someone who had a “bad reaction” to a vaccine (aside from soreness, fever, redness, or swelling), compared with 16.7% reporting that someone they knew had a bad reaction to an OTC medication. About one-third of parents reported the same for antibiotics.
Similarly, the measles outbreak at Disneyland in 2015 increased parents’ confidence in the safety and effectiveness of the CDC-recommended childhood vaccination schedule, and in the belief that their child’s health would benefit from receiving all the recommended vaccines.
Dr. Nowak reported no disclosures.