Peter G. Szilagyi

Long-term Consistency in Rotavirus Vaccine Protection: RV5 and RV1 Vaccine Effectiveness in US Children, 2012–2013

BACKGROUNDnUsing a multicenter, active surveillance network from 2 rotavirus seasons (2012 and 2013), we assessed the vaccine effectiveness of RV5 (RotaTeq) and RV1 (Rotarix) rotavirus vaccines in preventing rotavirus gastroenteritis hospitalizations and emergency department (ED) visits for numerous demographic and secular strata.nnnMETHODSnWe enrolled children hospitalized or visiting the ED with acute gastroenteritis (AGE) for the 2012 and 2013 seasons at 7 medical institutions. Stool specimens were tested for rotavirus by enzyme immunoassay and genotyped, and rotavirus vaccination histories were compared for rotavirus-positive cases and rotavirus-negative AGE controls. We calculated the vaccine effectiveness (VE) for preventing rotavirus associated hospitalizations and ED visits for each vaccine, stratified by vaccine dose, season, clinical setting, age, predominant genotype, and ethnicity.nnnRESULTSnRV5-specific VE analyses included 2961 subjects, 402 rotavirus cases (14%) and 2559 rotavirus-negative AGE controls. RV1-specific VE analyses included 904 subjects, 100 rotavirus cases (11%), and 804 rotavirus-negative AGE controls. Over the 2 rotavirus seasons, the VE for a complete 3-dose vaccination with RV5 was 80% (confidence interval [CI], 74%-84%), and VE for a complete 2-dose vaccination with RV1 was 80% (CI, 68%-88%).Statistically significant VE was observed for each year of life for which sufficient data allowed analysis (7 years for RV5 and 3 years for RV1). Both vaccines provided statistically significant genotype-specific protection against predominant circulating rotavirus strains.nnnCONCLUSIONSnIn this large, geographically and demographically diverse sample of US children, we observed that RV5 and RV1 rotavirus vaccines each provided a lasting and broadly heterologous protection against rotavirus gastroenteritis.

Child Poverty in the United States Today: Introduction and Executive Summary

From the Department of Pediatrics, Developmental-Behavioral Pediatrics, NYU School of Medicine, Bellevue Hospital Center, New York, NY (Dr Dreyer); Departments of Pediatrics and Health Policy and Management, University of California (Dr Chung), Children’s Discovery & Innovation Institute, Mattel Children’s Hospital, UCLA, Los Angeles, Calif (Dr Chung); RAND Health, The RAND Corporation, Santa Monica, Calif (Dr Chung); Department of Pediatrics, University of California, Mattel Children’s Hospital, UCLA, Los Angeles, Calif (Dr Szilagyi); and Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital, Aurora, Colo (Dr Wong) The authors declare that they have no conflict of interest. Address correspondence to Benard Dreyer, MD, Department of Pediatrics, Bellevue Hospital Center, 462 1st Ave, New York, NY 10016 (e-mail: Benard.Dreyer@nyumc.org).

Rotavirus Strain Trends During the Postlicensure Vaccine Era: United States, 2008–2013

BACKGROUNDnGroup A rotaviruses (RVA) are a significant cause of pediatric gastroenteritis worldwide. The New Vaccine Surveillance Network (NVSN) has conducted active surveillance for RVA at pediatric hospitals and emergency departments at 3-7 geographically diverse sites in the United States since 2006.nnnMETHODSnOver 6 consecutive years, from 2008 to 2013, 1523 samples from NVSN sites that were tested positive by a Rotaclone enzyme immunoassay were submitted to the Centers for Disease Control and Prevention for genotyping.nnnRESULTSnIn the 2009, 2010, and 2011 seasons, genotype G3P[8] was the predominant genotype throughout the network, with a 46%-84% prevalence. In the 2012 season, G12P[8] replaced G3P[8] as the most common genotype, with a 70% prevalence, and this trend persisted in 2013 (68.0% prevalence). Vaccine (RotaTeq; Rotarix) strains were detected in 0.6%-3.4% of genotyped samples each season. Uncommon and unusual strains (eg, G8P[4], G3P[24], G2P[8], G3P[4], G3P[6], G24P[14], G4P[6], and G9P[4]) were detected sporadically over the study period. Year, study site, and race were found to be significant predictors of genotype.nnnCONCLUSIONSnContinued active surveillance is needed to monitor RVA genotypes in the United States and to detect potential changes since vaccine licensure.

Neurocognitive Function in Children with Primary Hypertension

Objective To compare neurocognitive test performance of children with primary hypertension with that of normotensive controls. Study design Seventy‐five children (10‐18 years of age) with newly diagnosed, untreated hypertension and 75 frequency‐matched normotensive controls had baseline neurocognitive testing as part of a prospective multicenter study of cognition in primary hypertension. Subjects completed tests of general intelligence, attention, memory, executive function, and processing speed. Parents completed rating scales of executive function and the Sleep‐Related Breathing Disorder scale of the Pediatric Sleep Questionnaire (PSQ‐SRBD). Results Hypertension and control groups did not differ significantly in age, sex, maternal education, income, race, ethnicity, obesity, anxiety, depression, cholesterol, glucose, insulin, and C‐reactive protein. Subjects with hypertension had greater PSQ‐SRBD scores (P = .04) and triglycerides (P = .037). Multivariate analyses showed that hypertension was independently associated with worse performance on the Rey Auditory Verbal Learning Test (List A Trial 1, P = .034; List A Total, P = .009; Short delay recall, P = .013), CogState Groton Maze Learning Test delayed recall (P = .002), Grooved Pegboard dominant hand (P = .045), and Wechsler Abbreviated Scales of Intelligence Vocabulary (P = .016). Results indicated a significant interaction between disordered sleep (PSQ‐SRBD score) and hypertension on ratings of executive function (P = .04), such that hypertension heightened the association between increased disordered sleep and worse executive function. Conclusions Youth with primary hypertension demonstrated significantly lower performance on neurocognitive testing compared with normotensive controls, in particular, on measures of memory, attention, and executive functions.

Patient reminder and recall interventions to improve immunization rates

BACKGROUNDnImmunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.nnnOBJECTIVESnTo evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.nnnSEARCH METHODSnWe searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017.nnnSELECTION CRITERIAnWe included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period.nnnDATA COLLECTION AND ANALYSISnWe used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model.nnnMAIN RESULTSnThe 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).nnnAUTHORS CONCLUSIONSnPatient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

Effects of Phone and Text Message Reminders on Completion of the Human Papillomavirus Vaccine Series

PURPOSEnTo assess the effect of phone or text message reminders to parents of adolescents on human papillomavirus (HPV) vaccine series completion in Rochester, NY.nnnMETHODSnWe performed parallel randomized controlled trials of phone and text reminders for HPV vaccine for parents of 11- to 17-year olds in three urban primary care clinics. The main outcome measures were time to receipt of the third dose of HPV vaccine and HPV vaccination rates.nnnRESULTSnWe enrolled 178 phone intervention (180 control) and 191 text intervention (200 control) participants. In multivariate survival analysis controlling for gender, age, practice, insurance, race, and ethnicity, the time from enrollment to receipt of the third HPV dose for those receiving a phone reminder compared with controls was not significant overall (hazard ratio [HR]xa0= 1.30, pxa0=xa0.12) but was for those enrolling at dose 1 (HRxa0= 1.91, pxa0= .007). There was a significant difference in those receiving a text reminder compared with controls (HRxa0= 2.34, p < .0001; an average of 71xa0days earlier). At the end of the study, 48% of phone intervention versus 40% of phone control (pxa0= .34), and 49% of text intervention versus 30% of text control (pxa0= .001) adolescents had received 3 HPV vaccine doses.nnnCONCLUSIONSnIn this urban population of parents of adolescents, text message reminders for HPV vaccine completion for those who had already started the series were effective, whereas phone message reminders were only effective for those enrolled at dosexa01.

Predictors of Poor School Readiness in Children Without Developmental Delay at Age 2

BACKGROUND AND OBJECTIVES: Current recommendations emphasize developmental screening and surveillance to identify developmental delays (DDs) for referral to early intervention (EI) services. Many young children without DDs, however, are at high risk for poor developmental and behavioral outcomes by school entry but are ineligible for EI. We developed models for 2-year-olds without DD that predict, at kindergarten entry, poor academic performance and high problem behaviors. METHODS: Data from the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B), were used for this study. The analytic sample excluded children likely eligible for EI because of DDs or very low birth weight. Dependent variables included low academic scores and high problem behaviors at the kindergarten wave. Regression models were developed by using candidate predictors feasibly obtainable during typical 2-year well-child visits. Models were cross-validated internally on randomly selected subsamples. RESULTS: Approximately 24% of all 2-year-old children were ineligible for EI at 2 years of age but still had poor academic or behavioral outcomes at school entry. Prediction models each contain 9 variables, almost entirely parental, social, or economic. Four variables were associated with both academic and behavioral risk: parental education below bachelor’s degree, little/no shared reading at home, food insecurity, and fair/poor parental health. Areas under the receiver-operating characteristic curve were 0.76 for academic risk and 0.71 for behavioral risk. Adding the mental scale score from the Bayley Short Form–Research Edition did not improve areas under the receiver-operating characteristic curve for either model. CONCLUSIONS: Among children ineligible for EI services, a small set of clinically available variables at age 2 years predicted academic and behavioral outcomes at school entry.

Decomposing racial/ethnic disparities in influenza vaccination among the elderly.

While persistent racial/ethnic disparities in influenza vaccination have been reported among the elderly, characteristics contributing to disparities are poorly understood. This study aimed to assess characteristics associated with racial/ethnic disparities in influenza vaccination using a nonlinear Oaxaca-Blinder decomposition method. We performed cross-sectional multivariable logistic regression analyses for which the dependent variable was self-reported receipt of influenza vaccine during the 2010-2011 season among community dwelling non-Hispanic African-American (AA), non-Hispanic White (W), English-speaking Hispanic (EH) and Spanish-speaking Hispanic (SH) elderly, enrolled in the 2011 Medicare Current Beneficiary Survey (MCBS) (un-weighted/weighted N=6,095/19.2 million). Using the nonlinear Oaxaca-Blinder decomposition method, we assessed the relative contribution of seventeen covariates - including socio-demographic characteristics, health status, insurance, access, preference regarding healthcare, and geographic regions - to disparities in influenza vaccination. Unadjusted racial/ethnic disparities in influenza vaccination were 14.1 percentage points (pp) (W-AA disparity, p<0.001), 25.7 pp (W-SH disparity, p<0.001) and 0.6 pp (W-EH disparity, p>.8). The Oaxaca-Blinder decomposition method estimated that the unadjusted W-AA and W-SH disparities in vaccination could be reduced by only 45% even if AA and SH groups become equivalent to Whites in all covariates in multivariable regression models. The remaining 55% of disparities were attributed to (a) racial/ethnic differences in the estimated coefficients (e.g., odds ratios) in the regression models and (b) characteristics not included in the regression models. Our analysis found that only about 45% of racial/ethnic disparities in influenza vaccination among the elderly could be reduced by equalizing recognized characteristics among racial/ethnic groups. Future studies are needed to identify additional modifiable characteristics causing disparities in influenza vaccination.

Patient-Centered Medical Home and Family Burden in Attention-Deficit Hyperactivity Disorder.

Objective: Attention-deficit hyperactivity disorder (ADHD) can impair child health and functioning, but its effects on the familys economic burden are not well understood. The authors assessed this burden in US families of children with ADHD, and the degree to which access to a patient-centered medical home (PCMH) might reduce this burden. Methods: We conducted cross-sectional analyses of 2005–2006 and 2009–2010 National Surveys of Children with Special Health Care Needs, focusing on families of children with ADHD. They defined family economic burden as (1) family financial problems (annual expenses for the childs health care or illness-related financial problems for the family) and/or (2) family employment problems (job loss, work time loss, or failure to change jobs to avoid insurance loss). Relative risk models assessed associations between PCMH and family economic burden, adjusted for child age, sex, ethnicity, ADHD severity, poverty status, caregiver education, and insurance. Results: In 2009, 26% of families reported financial problems because of the childs ADHD, 2.1% reported out-of-pocket expenses >5% of income, and 36% reported employment problems. Only 38% reported care that met all 5 criteria for a PCMH (similar to rates in 2005–2006). In multivariable analysis, care in a PCMH was associated with 48% lower relative risk (RR) of financial problems (RR = 0.52, p < .001) and 36% lower relative risk of employment problems (RR = 0.64, p < .001). Among PCMH components, family-centered care and care coordination were more strongly associated with lower burden. Conclusions: The economic burdens of families with ADHD are significant but may be alleviated by family-centered care and care coordination in a medical home.

Parent Preferences for Communicating With Their Adolescent's Provider Using New Technologies

PURPOSEnBecause adolescents make few health care visits, we assessed the views of parents of adolescents on various means to communicate with their adolescents physicians about vaccine reminders and appointments, medication refills and test results-including phone, mail, e-mail, text messages, and personal health records (PHRs).nnnMETHODSnWe performed a cross-sectional survey of 400 parents of adolescents presenting to four pediatric offices (two urban, two suburban) in Rochester, NY in 2011 before vaccine reminders occurring in these practices.nnnRESULTSnRoughly half of parents (60% urban, 52% suburban, p = .11) were accepting of teens receiving their own vaccine reminders. Urban parents preferred communicating with the provider via telephone, whereas suburban parents preferred e-mail for most issues and a PHR for receipt of test results. In adjusted analyses, being younger was associated with preferring text message vaccine reminders (41 to <51 years: adjusted relative risk [aRR] = .8, p = .02; ≥51 years, aRR = .5, p < .001), and being a suburban parent was associated with preferring e-mail reminders (aRR = 1.6, p < .001). Those who were younger (41 to <51 years: aRR = .6, p = .007; ≥51 years: aRR = .4, p < .001) and suburban (aRR = 2.4, p < .001) were most likely to be interested in general use of a PHR.nnnCONCLUSIONSnOur study shows that some, but not all, parents are ready for electronic (text message, e-mail, PHR) communications for their adolescents health care and that a parent age and socioeconomic divide exists. Providing options in the means in which parents communicate with an adolescents provider is ideal.