Gary L. Freed

Effective Messages in Vaccine Promotion: A Randomized Trial

OBJECTIVES: To test the effectiveness of messages designed to reduce vaccine misperceptions and increase vaccination rates for measles-mumps-rubella (MMR). METHODS: A Web-based nationally representative 2-wave survey experiment was conducted with 1759 parents age 18 years and older residing in the United States who have children in their household age 17 years or younger (conducted June–July 2011). Parents were randomly assigned to receive 1 of 4 interventions: (1) information explaining the lack of evidence that MMR causes autism from the Centers for Disease Control and Prevention; (2) textual information about the dangers of the diseases prevented by MMR from the Vaccine Information Statement; (3) images of children who have diseases prevented by the MMR vaccine; (4) a dramatic narrative about an infant who almost died of measles from a Centers for Disease Control and Prevention fact sheet; or to a control group. RESULTS: None of the interventions increased parental intent to vaccinate a future child. Refuting claims of an MMR/autism link successfully reduced misperceptions that vaccines cause autism but nonetheless decreased intent to vaccinate among parents who had the least favorable vaccine attitudes. In addition, images of sick children increased expressed belief in a vaccine/autism link and a dramatic narrative about an infant in danger increased self-reported belief in serious vaccine side effects. CONCLUSIONS: Current public health communications about vaccines may not be effective. For some parents, they may actually increase misperceptions or reduce vaccination intention. Attempts to increase concerns about communicable diseases or correct false claims about vaccines may be especially likely to be counterproductive. More study of pro-vaccine messaging is needed.

Getting heavier, younger: Trajectories of obesity over the life course

Context:Although recent trends in obesity have been well documented, generational patterns of obesity from early childhood through adulthood across birth cohorts, which account for the recent epidemic of childhood obesity, have not been well described. Such trends may have implications for the prevalence of obesity-associated conditions among population subgroups, including type 2 diabetes.Objective:Our objective was to evaluate trajectories of obesity over the life course for the US population, overall and by gender and race.Design, Setting and Participants:We conducted an age, period and birth cohort analysis of obesity for US individuals who participated in the National Health and Nutrition Examination Surveys (NHANES) (1971–2006).Main Outcome Measures:Obesity was defined as a body mass index ⩾95th percentile for individuals aged 2–16 years or ⩾30 kg  m–2 among individuals older than 16 years. Age was represented by the age of the individual at each NHANES, period was defined by the year midpoint of each survey, and cohort was calculated by subtracting age from period.Results:Recent birth cohorts are becoming obese in greater proportions for a given age, and are experiencing a greater duration of obesity over their lifetime. For example, although the 1966–1975 and 1976–1985 birth cohorts had reached an estimated obesity prevalence of at least 20% by 20–29 years of age, this level was only reached by 30–39 years for the 1946–1955 and 1956–1965 birth cohorts, by 40–49 years for the 1936–1945 birth cohort and by 50–59 years of age for the 1926–1935 birth cohort. Trends are particularly pronounced for female compared with male, and black compared with white cohorts.Conclusions:The increasing cumulative exposure to excess weight over the lifetime of recent birth cohorts will likely have profound implications for future rates of type 2 diabetes, and mortality within the US population.

Immunization Programs for Infants, Children, Adolescents, and Adults: Clinical Practice Guidelines by the Infectious Diseases Society of America

Evidence-based guidelines for immunization of infants, children, adolescents, and adults have been prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). These updated guidelines replace the previous immunization guidelines published in 2002. These guidelines are prepared for health care professionals who care for either immunocompetent or immunocompromised people of all ages. Since 2002, the capacity to prevent more infectious diseases has increased markedly for several reasons: new vaccines have been licensed (human papillomavirus vaccine; live, attenuated influenza vaccine; meningococcal conjugate vaccine; rotavirus vaccine; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap] vaccine; and zoster vaccine), new combination vaccines have become available (measles, mumps, rubella and varicella vaccine; tetanus, diphtheria, and pertussis and inactivated polio vaccine; and tetanus, diphtheria, and pertussis and inactivated polio/Haemophilus influenzae type b vaccine), hepatitis A vaccines are now recommended universally for young children, influenza vaccines are recommended annually for all children aged 6 months through 18 years and for adults aged > or = 50 years, and a second dose of varicella vaccine has been added to the routine childhood and adolescent immunization schedule. Many of these changes have resulted in expansion of the adolescent and adult immunization schedules. In addition, increased emphasis has been placed on removing barriers to immunization, eliminating racial/ethnic disparities, addressing vaccine safety issues, financing recommended vaccines, and immunizing specific groups, including health care providers, immunocompromised people, pregnant women, international travelers, and internationally adopted children. This document includes 46 standards that, if followed, should lead to optimal disease prevention through vaccination in multiple population groups while maintaining high levels of safety.

Assessment of transition readiness skills and adherence in pediatric liver transplant recipients

Fredericks EM, Dore‐Stites D, Well A, Magee JC, Freed GL, Shieck V, Lopez MJ. Assessment of transition readiness skills and adherence in pediatric liver transplant recipients.
Pediatr Transplantation 2010: 14:944–953.

A National Survey of Pediatric Critical Care Resources in the United States

Objective. To characterize resources available for the care of critically ill and injured children in the United States. Study Design. In January through May 2004, we conducted a cross-sectional survey of medical directors of intensive care facilities for children. Results. Pediatric critical care medical directors from 257 of 337 eligible hospitals responded to the survey (response rate: 76%). The median number of beds was 12 (interquartile range: 8–17 beds), with a median of 58 admissions per PICU bed (interquartile range: 44–70 admissions per PICU bed) in 2003. The median numbers of admissions per PICU bed were not statistically different among PICUs of different sizes. Fewer than 6% of hospitals shared PICU space with space for critically ill adults. The smallest units (1–6 beds) had higher physician and nurse staffing ratios per PICU bed. Advanced therapeutic technology, particularly renal replacement and inhaled nitric oxide therapy, was significantly more likely to be available in larger PICUs (≥7 beds). Conclusions. PICUs with the fewest beds had higher physician and nurse staffing ratios per PICU bed and lower resource capacity for high-intensity renal and respiratory therapy. The impact of PICU resource availability on referral patterns and outcomes of pediatric critical illnesses warrants additional study.

Primary care physician perspectives on reimbursement for childhood immunizations

OBJECTIVES. The purpose of this research was to explore physicians’ attitudes and behaviors related to vaccine financing issues within their practice. Amid the increasing number of vaccine doses recommended for children and adolescents, anecdotal reports suggest that physicians are facing increasing financial pressures from vaccine purchase and administration and may stop providing vaccines altogether to privately insured children. Whether these sentiments are widely held among immunization providers is unknown. METHODS. We conducted a cross-sectional mail survey from July to September 2007 of a random sample of 1280 US pediatricians and family physicians engaged in direct patient care. Main outcome measures included delay in the purchase of specific vaccines for financial reasons; reported decrease in profit margin from immunizations; and practice consideration of whether to stop providing all vaccines to privately insured children. RESULTS. The response rate was 70% for pediatricians and 60% for family physicians. Approximately half of the respondents reported that their practice had delayed the purchase of specific vaccines for financial reasons (49%) and experienced decreased profit margin from immunizations (53%) in the previous 3 years. Twenty-one percent of respondents strongly disagreed that “reimbursement for vaccine purchase is adequate,” and 17% strongly disagreed that “reimbursement for vaccine administration is adequate.” Eleven percent of respondents said their practice had seriously considered whether to stop providing all vaccines to privately insured children in the previous year. CONCLUSIONS. Physicians who provide vaccines to children and adolescents report dissatisfaction with reimbursement levels and increasing financial strain from immunizations. Although large-scale withdrawal of immunization providers does not seem to be imminent, efforts to address root causes of financial pressures should be undertaken.

Risk Factors for Delay in Age-Appropriate Vaccination

Objective. To estimate the risk factors of children experiencing delay in age-appropriate vaccination using a nationally representative population of children, and to compare risk factors for vaccination delay with those based on up-to-date vaccination status models. Methods. The authors compared predictors of delay in age-appropriate vaccination with those for children who were not up-to-date, using a nationally representative sample of children from five years of pooled data (1992–1996) from the National Health Interview Survey (NHIS) Immunization Supplement. Duration of delay was calculated for the DTP4, Polio3, MMR1 doses and 4:3:1 series using age-appropriate vaccination standards; up-to-date status (i.e., whether or not a dose was received) was also determined. Adjusted odds ratios were estimated using multivariate logistic regression for models of vaccination delay and up-to-date vaccination status. Results. Absence of a two-parent household, large family size, parental education, Medicaid enrollment, absence of a usual provider, no insurance coverage, and households without a telephone were significantly related to increased odds of a child experiencing vaccination delay (p≤0.05). Conclusions. Many of the risk factors observed in models of vaccination delay were not found to be significant in risk models based upon up-to-date status. Consequently, risk models of delays in age-appropriate vaccination may foster identification of children at increased risk for inadequate vaccination. Populations at increased risk of inadequate vaccination can be more clearly identified through risk models of delays in age-appropriate vaccination.

Recently Trained General Pediatricians: Perspectives on Residency Training and Scope of Practice

OBJECTIVE. Because of the increase in both the prevalence and complexity of chronic diseases in children, there is heightened awareness of the need for general pediatricians to be prepared to comanage their patients with chronic disorders with subspecialists. It is not known currently how well prepared general pediatricians believe themselves to be for these roles after residency training. This study was conducted to determine the perspectives of recently trained general pediatricians in practice regarding their decisions on residency choice, career choice, and adequacy of training. METHODS. A random sample of 600 generalists whose initial application for general pediatric certification occurred between 2002 and 2003 (4–5 years out of training) and 600 generalists who applied for board certification between 2005 and 2006 and who were not currently enrolled in or had completed subspecialty training (1–2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency programs, strength of residency training in preparation for clinical care, and scope of practice. RESULTS. The overall response rate was 76%. The majority of generalists reported that their residency training was adequate in most subspecialty areas. However, a large proportion of generalists indicated that they could have used additional training in mental health (62% [n = 424]), sports medicine (51% [n = 345]), oral health (52% [n = 356]), and developmental/behavioral pediatrics (48% [n = 326]). Most generalist respondents reported that they are comfortable comanaging cases requiring subspecialty care with a subspecialist. However, generalist respondents without local access to subspecialists were more likely to report that they are comfortable managing patients who require subspecialty care. CONCLUSIONS. The training of general pediatricians, and the needs for their adequate preparation to care for patients, should be a dynamic process. As the nature and epidemiology of pediatric care change, our educational system must change as well.

The need for surveillance of delay in age-appropriate immunization

BACKGROUND Vaccination status is assessed nationally in terms of up-to-date status without regard to the age at which recommended doses were actually received. Our study was conducted in 2000-2001 using the most current National Health Interview Survey (NHIS) public use files available. METHODS Retrospective analysis to determine up-to-date and age-appropriate vaccination status for children aged 25 to 72 months. Five years of pooled data (1992-1996) were obtained from the NHIS Immunization Supplement for children aged 25 to 72 months with immunization data based on written records. The outcome measures used were months of vaccination delay relative to age-appropriate vaccination standard as well as up-to-date vaccination status for the fourth diphtheria-tetanus-pertussis (DTP 4), Polio3, the first measles-mumps-rubella (MMR1) doses, and the 4:3:1 series. RESULTS Of the 9223 eligible children, 80% were up-to-date for the 4:3:1 vaccination series, but 48% had experienced delays relative to age-appropriate standards. For the DTP4 dose, 85% were up-to-date, although only 46% had received this dose at the appropriate age. Similarly, 90% of children were up-to-date with their Polio3 dose, with 64% receiving this dose at the appropriate age; 96% were up-to-date for the MMR1, and 58% received this dose at the appropriate age. Age-appropriate DTP4 vaccination increased by 17 percentage points from 1992 to 1996, whereas up-to-date DTP4 status increased by only 6% during the same period. CONCLUSIONS Children with up-to-date vaccination status often experienced considerable delay relative to age-appropriate vaccination standards. Consequently, vaccination status measures based solely on up-to-date status tend to understate the degree of underimmunization in a population. National surveillance of age-appropriate vaccination is necessary to identify subpopulations with the greatest prevalence of vaccination delay and to reveal underlying trends that may not be evident through assessments of up-to-date status.

Breast-feeding education of obstetrics-gynecology residents and practitioners☆

OBJECTIVE Our purpose was to assess breast-feeding education, knowledge, attitudes, and practices among resident and practicing obstetrician-gynecologists. STUDY DESIGN A mailed survey was administered to a national sample of resident and practicing obstetrician-gynecologists. RESULTS Response rates were 64% for residents and 69% for practitioners. Residency training included limited opportunity for direct patient interaction regarding breast-feeding; 60% of practitioners recommended that training devote more time to breast-feeding counseling skills. Only 38% of residents reported that obstetric faculty presented breast-feeding topics; more common sources were nursing staff and other residents. Practitioners rated themselves as more effective in meeting the needs of breast-feeding patients than were residents; prior personal breast-feeding experience was a significant influence on perceived effectiveness. Almost all respondents agreed that obstretician-gynecologists have a role in breast-feeding promotion, but significant deficits in knowledge of breast-feeding benefits and clinical management were found. CONCLUSION Residency training and continuing education programs should create opportunities to practice breast-feeding promotion skills and emphasize management of common lactation problems.