Charitha Gowda

The rise (and fall?) of parental vaccine hesitancy

Parental vaccine hesitancy is a growing problem affecting the health of children and the larger population. This article describes the evolution of the vaccine hesitancy movement and the individual, vaccine-specific and societal factors contributing to this phenomenon. In addition, potential strategies to mitigate the rising tide of parent vaccine reluctance and refusal are discussed.

Understanding attitudes toward adolescent vaccination and the decision-making dynamic among adolescents, parents and providers

BackgroundWith several new vaccine recommendations specifically targeting adolescents, improving adolescent vaccination rates has become a major health priority. Vaccination attitudes are an important, modifiable target for new interventions. Prior research has examined primarily the attitudes and beliefs of adolescents, parents or healthcare providers separately without exploring the decision-making dynamic among these stakeholders. We sought to identify potentially modifiable barriers in the vaccine decision process among adolescents, parents and healthcare providers that could be addressed through interventions implemented within the adolescent’s medical home.MethodsWe conducted a qualitative study of adolescents, their parents and healthcare providers, recruited from four primary care practices in Michigan. For each practice, three separate focus group discussions (adolescents, parents and healthcare providers, for a total of 12 focus groups) were conducted to explore vaccination attitudes, possible interventions to improve vaccine uptake and access to and use of technology for vaccination interventions. Themes that emerged from the focus group discussions were categorized using an inductive, iterative process, and analysis focused on highlighting similarities and differences among the three perspectives.ResultsParticipants included 32 adolescents, 33 parents and 28 providers. The majority of parents and adolescents were female. Lack of knowledge about recommended adolescent vaccinations was universally recognized among the three groups and was perceived to be the underlying driver of low immunization rates. Notably, each group did not appear to fully appreciate the challenges faced by the other stakeholders with respect to adolescent vaccination. Adolescents were seen as having a greater role in the vaccine decision-making dynamic than previously suggested. Provider-based interventions such as educational tools and reminder-recall notices were identified as important components of any immunization program. Overall, there was high receptivity among all stakeholders toward integrating technology such as email and Internet into new vaccination interventions.ConclusionsWe identified potentially modifiable attitudinal barriers to adolescent vaccination among the three key stakeholders. However, there were notable differences in attitudes and preferences across the three perspectives, indicating that for an intervention to be successful it will require a dynamic partnership with the target audiences.

A pilot study on the effects of individually tailored education for MMR vaccine-hesitant parents on MMR vaccination intention

Healthcare providers need strategies to better address the concerns of vaccine-hesitant parents. We studied whether individually tailored education was more effective than untailored education at improving vaccination intention among MMR vaccine-hesitant parents. In an intervention pilot study of parents (n = 77) of children < 6 y who screened as hesitant to vaccinate against MMR (first or second dose), parents were randomly assigned to receive either (1) educational web pages that were individually tailored to address their specific vaccine concerns; or (2) web pages similar in appearance to the intervention but containing untailored information. The main outcome, change in vaccination intention before and after the intervention, was assessed using an 11-pt scale (higher values indicated greater intent). We found that a greater proportion of parents in the tailored than untailored arm had positive vaccination intentions after viewing educational information (58% vs. 46%). Furthermore, parents in the tailored group had a greater magnitude of change in vaccination intention (1.08 vs. 0.49 points) than participants in the untailored group. However, neither of these results was statistically significant. From this pilot study we conclude message tailoring may be an effective way to improve vaccine compliance among vaccine hesitant parents. However, larger studies are warranted to further investigate the efficacy of providing tailored education for increasing vaccine acceptance among parents with diverse beliefs.

CHIAS: A standardized measure of parental HPV immunization attitudes and beliefs and its associations with vaccine uptake

Background: Despite the burden of human papillomavirus (HPV)-associated morbidity, less than half of US adolescent females had begun the 3-dose HPV vaccination series as of 2010. Given that parental attitudes significantly influence vaccine uptake, having a standardized measure of parental beliefs that predict HPV vaccine uptake would contribute substantially to the development of effective immunization strategies. We explored whether a modified version of the previously published Carolina HPV Immunization Attitudes and Beliefs Scale (CHIAS) could be applied nationally to identify attitudinal constructs that were associated with HPV vaccine uptake and maternal HPV vaccination intention. Methods: We administered the modified CHIAS as part of a cross-sectional, web-based survey to a nationally representative sample of mothers of adolescent females. Exploratory factor analysis was used to identify underlying attitudinal constructs, which were compared with those identified in the original CHIAS. Bivariate and multivariate analyses determined associations between these attitudinal constructs and HPV vaccine uptake as well as vaccination intention. Results: Overall survey response rate was 57%. The modified CHIAS yielded a factor structure that was similar to the original CHIAS, identifying 3 attitudinal constructs: harms/ineffectiveness, barriers, and social norms. In multivariate models, harms/ineffectiveness and social norms were independently associated with HPV vaccine uptake. Conclusions: The CHIAS seems to be a valid instrument for identifying important factors associated with HPV-vaccine uptake and parental vaccination intention nationally. Longitudinal studies are merited to explore whether these attitudinal constructs also reliably predict HPV-vaccine uptake.

Medicaid reimbursement and the uptake of adolescent vaccines

BACKGROUND In light of low adolescent vaccination rates, state-level policies that could improve vaccine coverage should be evaluated. Approximately 1/3 of adolescents are eligible, primarily through Medicaid enrollment, to receive vaccines from state-administered Vaccines for Children (VFC) programs. We investigated whether Medicaid reimbursement, the scope of implementation of VFC programs (i.e. limited or universal purchase), and/or presence of school-based vaccine mandates were associated with adolescent vaccination levels. METHODS We performed a cross-sectional analysis of state-level associations between these policies and 2009 National Immunization Survey-TEEN vaccination rates for tetanus-containing, meningococcal conjugate (MCV4), and among females only, human papillomavirus (HPV) vaccines. RESULTS Medicaid reimbursement was not associated with vaccine coverage rates after adjusting for presence of vaccine-related school mandates, type of VFC program, proportion of adolescents attending preventive care visits, and state-specific distribution of insurance coverage. Participation in a more expansive VFC program (universal or universal-select) was significantly associated with HPV vaccine coverage, but not tetanus-containing vaccine or MCV4, among states that had mandates for any vaccines. CONCLUSIONS Our results suggest that, contrary to what has been shown for childhood vaccines, raising Medicaid reimbursement rates may not improve adolescent vaccine utilization. Instead, other policy changes may be more effective, such as expansion of VFC programs into universal purchase programs, further implementation of school-based vaccine mandates and efforts to raise preventive care visits among adolescents.

Does the relative importance of MMR vaccine concerns differ by degree of parental vaccine hesitancy?: An exploratory study

Background: There has been a rise in the number of vaccine-hesitant parents (VHPs) in the US, many of whom express reservations about administering the MMR vaccine to their children. We studied the relative importance of attitudinal barriers to MMR vaccination among VHPs with differing levels of MMR vaccine-hesitancy. Methods: We performed a cross-sectional exploratory analysis of a parental survey that assessed common vaccination barriers among MMR vaccine-hesitant parents in Michigan. The outcome of interest was parental MMR vaccination intention, measured on an 11-point scale, with higher numbers corresponding to greater intent. The relative importance of identified barriers to MMR vaccination was assessed across levels of vaccine hesitancy. Exploratory factor analysis was performed to identify underlying attitudinal constructs and assess if these constructs’ importance varied depending on the degree of parental vaccine hesitancy. Results: Our study population included 79 Michigan parents who initially screened positive for MMR vaccine-hesitancy. Within this sample, 47% of parents were unsure about their vaccination intentions and 20% expressed negative intentions, while a third (33%) of parents had positive vaccination intentions when further questioned. After grouping the barriers in our study into four underlying factors, parents with negative vaccination intentions had statistically significant higher factor score for the factor “risks versus benefits” and a statistically significant lower mean score for “vaccine importance,” compared with parents with unsure or positive intentions. Conclusions: In this exploratory study we found that vaccine-specific concerns have varying salience for parents based on their vaccination intention. Thus, future educational programs likely should tailor messages based on the degree of vaccine hesitancy expressed in their target populations in order to improve their overall effectiveness.

Association between chronic hepatitis C virus infection and low muscle mass in US adults

Given that low muscle mass can lead to worse health outcomes in patients with chronic infections, we assessed whether chronic hepatitis C virus (HCV) infection was associated with low muscle mass among US adults. We performed a cross‐sectional study of the National Health Examination and Nutrition Study (1999–2010). Chronic HCV‐infected patients had detectable HCV RNA. Low muscle mass was defined as <10th percentile for mid‐upper arm circumference (MUAC). Multivariable logistic regression was used to determine adjusted odds ratios (aORs) with 95% confidence intervals (CIs) of low muscle mass associated with chronic HCV. Among 18 513 adults, chronic HCV‐infected patients (n = 303) had a higher prevalence of low muscle mass than uninfected persons (13.8% vs 6.7%; aOR, 2.22; 95% CI, 1.39–3.56), and this association remained when analyses were repeated among persons without significant liver fibrosis (aOR, 2.12; 95% CI, 1.30–3.47). This study demonstrates that chronic HCV infection is associated with low muscle mass, as assessed by MUAC measurements, even in the absence of advanced liver disease.

A Systematic Evaluation of Different Methods for Calculating Adolescent Vaccination Levels Using Immunization Information System Data

Objective. Immunization information systems (IISs) are valuable surveillance tools; however, population relocation may introduce bias when determining immunization coverage We explored alternative methods for estimating the vaccine-eligible population when calculating adolescent immunization levels using a statewide IIS. Methods. We performed a retrospective analysis of the Michigan State Care Improvement Registry (MCIR) for all adolescents aged 11–18 years registered in the MCIR as of October 2010. We explored four methods for determining denominators: (1) including all adolescents with MCIR records, (2) excluding adolescents with out-of-state residence, (3) further excluding those without MCIR activity ≥10 years prior to the evaluation date, and (4) using a denominator based on U.S. Census data. We estimated state- and county-specific coverage levels for four adolescent vaccines. Results. We found a 20% difference in estimated vaccination coverage between the most inclusive and restrictive denominator populations. Although there was some variability among the four methods in vaccination at the state level (2%–11%), greater variation occurred at the county level (up to 21%). This variation was substantial enough to potentially impact public health assessments of immunization programs. Generally, vaccines with higher coverage levels had greater absolute variation, as did counties with smaller populations. Conclusion. At the county level, using the four denominator calculation methods resulted in substantial differences in estimated adolescent immunization rates that were less apparent when aggregated at the state level. Further research is needed to ascertain the most appropriate method for estimating vaccine coverage levels using IIS data.

A Population-Level Assessment of Factors Associated With Uptake of Adolescent-Targeted Vaccines in Michigan

PURPOSE Increases in adolescent vaccine coverage are needed. The aim of this study was to identify population-level clinical and demographic factors associated with adolescent vaccination. METHODS A retrospective analysis of data from the Michigan Care Improvement Registry (MCIR), a statewide immunization registry, was performed for 2006-2010. The sample included 1,252,655 adolescents aged 11-18 years. Vaccine coverage levels were calculated for tetanus-diphtheria-acellular pertussis (Tdap), meningococcal conjugate (MCV4), flu (seasonal influenza), and human papillomavirus, females only (HPV) vaccines. For the subset of adolescents enrolled in Medicaid, claims data were used to obtain information about the type of visits in which vaccines were administered. RESULTS As of 2010, statewide coverage levels for Tdap and MCV4 vaccines were 46.0% and 46.5%, respectively whereas only 15% of females had completed the HPV vaccine series. Only one in four female adolescents were up to date for all three of these vaccines. Statewide coverage among adolescents for flu vaccine during the 2009-2010 season was 8%. Age was the most significant predictor of HPV vaccination, whereas health care-associated factors (provider type and childhood immunization history) were the strongest predictors for the other three vaccines. Older adolescents were less likely to have received the flu vaccine but more likely to have receive HPV vaccine doses than younger adolescents. Among Medicaid-enrolled adolescents, most Tdap, MCV, and first-dose HPV vaccines, but only 29% of flu doses, were administered during preventive visits. CONCLUSIONS Noted variability in adolescent vaccine coverage by age, vaccine type, and health care-associated factors provides a framework for developing future outreach activities to increase adolescent vaccine use.

Absolute Insurer Denial of Direct-Acting Antiviral Therapy for Hepatitis C: A National Specialty Pharmacy Cohort Study

Abstract Background Despite the availability of new direct-acting antiviral (DAA) regimens, changes in DAA reimbursement criteria, and a public health focus on hepatitis C virus (HCV) elimination, it remains unclear if public and private insurers have increased access to these therapies over time. We evaluated changes in the incidence of absolute denial of DAA therapy over time and by insurance type. Methods We conducted a prospective cohort study among patients who had a DAA prescription submitted from January 2016 to April 2017 to Diplomat Pharmacy, Inc., which provides HCV pharmacy services across the United States. The main outcome was absolute denial of DAA prescription, defined as lack of fill approval by the insurer. We calculated the incidence of absolute denial, overall and by insurance type (Medicaid, Medicare, commercial), for the 16-month study period and each quarter. Results Among 9025 patients from 45 states prescribed a DAA regimen (4702 covered by Medicaid, 1821 Medicare, 2502 commercial insurance), 3200 (35.5%; 95% confidence interval, 34.5%–36.5%) were absolutely denied treatment. Absolute denial was more common among patients covered by commercial insurance (52.4%) than Medicaid (34.5%, P < .001) or Medicare (14.7%, P < .001). The incidence of absolute denial increased across each quarter of the study period, overall (27.7% in first quarter to 43.8% in last quarter; test for trend, P < .001) and for each insurance type (test for trend, P < .001 for each type). Conclusions Despite the availability of new DAA regimens and changes in restrictions of these therapies, absolute denials of DAA regimens by insurers have remained high and increased over time, regardless of insurance type.