Childhood and Adolescent Vaccination in Alternative Settings.

Although pediatric and adolescent vaccination rates are generally high in the United States, delayed and under-vaccination exist within certain patient populations and communities, leaving them vulnerable to vaccine-preventable diseases. One strategy for addressing this major public health concern is to offer vaccinations in nonprimary care settings such as schools, emergency rooms, hospitals, and pharmacies. This article reviews the unique advantages, challenges, and experiences regarding vaccine delivery in each alternative setting.

Who Makes the Choice: Ethical Considerations Regarding Instituting Breastfeeding in a Mother Who Has Compromised Mental Capacity.

This case reports an ethical dilemma in which a mother who had recently delivered a baby through cesarean section after sustaining life-threatening injuries in a car accident did not have documented wishes whether she wanted to breastfeed. Her medical condition rendered her temporarily mentally incapacitated and critically ill, and the lactation medicine team was consulted about whether lactation choice should be preserved by pumping. Complicating considerations in this case were (1) lack of family or designated decision-makers available at the time of injury and emergent delivery, (2) lack of prenatal care, and (3) complex social situation, including prior history of illicit substance use, and state removal of other children into foster care.

The Importance of Supervising Toothbrush Usage for Young Children at Risk of Lead Toxicity.

Lead exposure in childhood causes lasting deleterious health effects through multi-system organ toxicity, including in brain, skeletal system, and oral cavity. We report a case that illustrates the imperative for providers to give specific anticipatory guidance on supervising toothbrush usage for young children. A healthy 18-month-old male presented for routine well-child care and had an unremarkable physical exam and developmental assessment.

Effect of State Immunization Information System Centralized Reminder and Recall on HPV Vaccination Rates.

Background: Although autodialer centralized reminder and recall (C-R/R) from state immunization information systems (IISs) has been shown to raise childhood vaccination rates, its impact on human papillomavirus (HPV) vaccination rates is unclear.

Methods: In a 4-arm pragmatic randomized controlled trial across 2 states, we randomly selected practices representative of the specialty (pediatrics, family medicine, and health center) where children received care. Within each practice, patients 11 to 17.

School-Located Influenza Vaccination: Do Vaccine Clinics at School Raise Vaccination Rates?

Background: Only half of US schoolchildren receive influenza vaccine. School-located influenza vaccination (SLIV) might raise vaccination rates but conducting flu vaccine clinics at schools is challenging to implement. We compared 2 school-based programs designed to raise influenza vaccination rates: parent reminder/educational messages sent to parents from schools which is a low-intensity intervention vs the combination of reminder/educational messages plus SLIV clinics which is a high-intensity intervention.

Cost effectiveness of school-located influenza vaccination programs for elementary and secondary school children.

Background: Studies have noted variations in the cost-effectiveness of school-located influenza vaccination (SLIV), but little is known about how SLIV's cost-effectiveness may vary by targeted age group (e.g., elementary or secondary school students), or vaccine consent process (paper-based or web-based).

Text Message Reminders for Child Influenza Vaccination in the Setting of School-Located Influenza Vaccination: A Randomized Clinical Trial.

Half of US school children receive influenza vaccine. In our previous trials, school-located influenza vaccination (SLIV) raised vaccination rates by 5 to 8 percentage points. We assessed whether text message reminders to parents could raise vaccination rates above those observed with SLIV.

Impact of elementary school-located influenza vaccinations: A stepped wedge trial across a community.

Background: Influenza vaccination rates among children are low and novel strategies are needed to raise coverage. We measured the impact of school-located influenza vaccination (SLIV) on coverage, examined whether SLIV substitutes for practice-based influenza vaccination ("substitution"), and estimated whether a second year of experience with SLIV increases its impact.

Methods: We implemented a stepped wedge study design with schools as clusters.

Provider Communication, Prompts, and Feedback to Improve HPV Vaccination Rates in Resident Clinics.

Background And Objectives: Human papillomavirus (HPV) vaccination rates lag behind vaccination rates for other adolescent vaccines; a bundled intervention may improve HPV vaccination rates. Our objective is to evaluate the impact of quality improvement (QI) training plus a bundled practice-based intervention (provider prompts plus communication skills training plus performance feedback) on improving HPV vaccinations in pediatric resident continuity clinics.

Methods: Staff and providers in 8 resident clinics participated in a 12-month QI study.

A Learning Collaborative Model to Improve Human Papillomavirus Vaccination Rates in Primary Care.

Objective: Human papillomavirus (HPV) vaccination rates remain low, in part because of missed opportunities (MOs) for vaccination. We used a learning collaborative quality improvement (QI) model to assess the effect of a multicomponent intervention on reducing MOs.

Methods: Study design: pre-post using a QI intervention in 33 community practices and 14 pediatric continuity clinics over 9 months to reduce MOs for HPV vaccination at all visit types.

School-located Influenza Vaccinations for Adolescents: A Randomized Controlled Trial.

Purpose: We aimed to evaluate the effect of school-located influenza vaccination (SLIV) on adolescents' influenza vaccination rates.

Methods: In 2015-2016, we performed a cluster-randomized trial of adolescent SLIV in middle/high schools. We selected 10 pairs of schools (identical grades within pairs) and randomly allocated schools within pairs to SLIV or usual care control.

School-Located Influenza Vaccinations: A Randomized Trial.

Objective: Assess impact of offering school-located influenza vaccination (SLIV) clinics using both Web-based and paper consent upon overall influenza vaccination rates among elementary school children.

Methods: We conducted a cluster-randomized trial (stratified by suburban/urban districts) in upstate New York in 2014-2015. We randomized 44 elementary schools, selected similar pairs of schools within districts, and allocated schools to SLIV versus usual care (control).

Cost effectiveness analysis of Year 2 of an elementary school-located influenza vaccination program-Results from a randomized controlled trial.

Background: School-located vaccination against influenza (SLV-I) has the potential to improve current suboptimal influenza immunization coverage for U.S. school-aged children.

Effectiveness of centralized text message reminders on human papillomavirus immunization coverage for publicly insured adolescents.

Purpose: We evaluated a managed care organization (MCO)-generated text message reminder-recall system designed to improve human papillomavirus (HPV) vaccination coverage.

Methods: We conducted a randomized controlled trial of text reminder-recall for parents of 3,812 publicly insured adolescents aged 11-16 years with no prior HPV vaccinations who were enrolled in a single MCO and were patients at one of 39 primary care practices. We determined the rate of HPV receipt for intervention versus control with the Kaplan-Meier failure function and determined hazard ratios using a clustered stratified Cox model, clustering on primary care provider and stratified on practice.

Effect of provider prompts on adolescent immunization rates: a randomized trial.

Objective: Adolescent immunization rates are suboptimal. Experts recommend provider prompts at health care visits to improve rates. We assessed the impact of either electronic health record (EHR) or nurse- or staff-initiated provider prompts on adolescent immunization rates.

Seasonal influenza vaccination at school: a randomized controlled trial.

Background: Influenza vaccination coverage for U.S. school-aged children is below the 80% national goal.

Increasing adolescent immunization rates in primary care: strategies physicians use and would consider implementing.

Strategies to increase adolescent immunization rates have been suggested, but little is documented about which strategies clinicians actually use or would consider. In spring 2010, we surveyed primary care physicians from 2 practice-based research networks (PBRNs): Greater Rochester PBRN (GR-PBRN) and national pediatric COntinuity Research NETwork (CORNET). Network clinicians received mailed or online surveys (response rate 76%, n=148).

A randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents.

Objective: To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents.

Methods: We conducted a randomized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11-17 years to one of three groups: mailed letter, telephone reminders, or control. Publicly insured youths (n = 4115) were identified in 37 participating primary care practices.

Cost effectiveness analysis of elementary school-located vaccination against influenza--results from a randomized controlled trial.

School-located vaccination against influenza (SLV-I) has been suggested to help meet the need for annual vaccination of large numbers of school-aged children with seasonal influenza vaccine. However, little is known about the cost and cost-effectiveness of SLV-I. We conducted a cost-analysis and a cost-effectiveness analysis based on a randomized controlled trial (RCT) of an SLV-I program implemented in Monroe County, New York during the 2009-2010 vaccination season.

Parent and adolescent perspectives about adolescent vaccine delivery: practical considerations for vaccine communication.

We surveyed parents of adolescents (n=430) and their adolescents ages 15-17 years (n=208) in 9 primary-care settings in Monroe County, NY to assess perceptions about adolescent vaccine delivery. Parents and adolescents most wanted to discuss vaccine side effects and the diseases prevented with the adolescents' provider. Those who perceived vaccines as very safe were more accepting of adolescent vaccines.

Patient-provider communication and human papillomavirus vaccine acceptance.

The authors performed telephone interviews of parents of adolescents (n = 430) and their older adolescents (n = 208) in Monroe County, New York to measure parent and adolescent acceptance of human papillomavirus (HPV) vaccine, its association with ratings of provider communication, and vaccine-related topics discussed with the adolescent's provider. More than half of adolescent girls had already received an HPV vaccination, with fewer than one quarter refusing. Parent and teen ratings of provider communication was high, and not related to HPV vaccine refusal.

Cost of universal influenza vaccination of children in pediatric practices.

Objectives: The goals were to estimate nationally representative pediatric practices' costs of providing influenza vaccination during the 2006-2007 season and to simulate the costs pediatric practices might incur when implementing universal influenza vaccination for US children aged 6 months to 18 years.

Methods: We surveyed a stratified, random sample of New York State pediatric practices (N = 91) to obtain information from physicians and office managers about all practice resources associated with provision of influenza vaccination. We estimated vaccination costs for 2 practice sizes (small and large) and 3 geographic areas (urban, suburban, and rural).

Health care provider attitudes and practices regarding adolescent immunizations: a qualitative study.

Objective: Assess health care providers' attitudes and practices regarding adolescent immunizations, including factors that either impede or facilitate vaccination.

Methods: Focus groups-In 2005, 3 focus groups were conducted in Monroe County, NY for (1) urban primary care physicians (PCPs); (2) suburban PCPs; and (3) nurses from practices represented in PCP groups. Audiotaped discussions were transcribed and analyzed using Atlas.

How effectively can health care settings beyond the traditional medical home provide vaccines to adolescents?

Objectives: Our goal was to evaluate the capacity of various health care settings to supplement the activities of the traditional medical home by delivering vaccines to adolescents.

Methods: A group of experts in the fields of adolescent-immunization delivery and the provision of preventive care in various health care settings summarized the available literature, considered setting-specific factors, and assessed the ability of various health care settings beyond the traditional medical home to conform to the immunization quality standards set by the National Vaccine Advisory Committee, report vaccination information for the quantitative assessment of vaccine-coverage rates, be likely to offer vaccines to adolescents, and be viewed by adolescents as acceptable sites for receiving vaccinations.

Results: Seven candidate settings were evaluated: pharmacies, obstetrics-gynecology practices, sexually transmitted disease clinics, hospital emergency departments, family planning clinics, teen clinics, and local public health department immunization clinics.