Stewin Camargo

Effect of a Text Messaging Intervention on Influenza Vaccination in an Urban, Low-Income Pediatric and Adolescent Population: A Randomized Controlled Trial

CONTEXT Influenza infection results in substantial costs, morbidity, and mortality. Vaccination against influenza is particularly important in children and adolescents who are a significant source of transmission to other high-risk populations, yet pediatric and adolescent vaccine coverage remains low. Traditional vaccine reminders have had a limited effect on low-income populations; however, text messaging is a novel, scalable approach to promote influenza vaccination. OBJECTIVE To evaluate targeted text message reminders for low-income, urban parents to promote receipt of influenza vaccination among children and adolescents. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial of 9213 children and adolescents aged 6 months to 18 years receiving care at 4 community-based clinics in the United States during the 2010-2011 influenza season. Of the 9213 children and adolescents, 7574 had not received influenza vaccine prior to the intervention start date and were included in the primary analysis. INTERVENTION Parents of children assigned to the intervention received up to 5 weekly immunization registry-linked text messages providing educational information and instructions regarding Saturday clinics. Both the intervention and usual care groups received the usual care, an automated telephone reminder, and access to informational flyers posted at the study sites. MAIN OUTCOME MEASURES Receipt of an influenza vaccine dose recorded in the immunization registry via an electronic health record by March 31, 2011. Receipt was secondarily assessed at an earlier fall review date prior to typical widespread influenza activity. RESULTS Study children and adolescents were primarily minority, 88% were publicly insured, and 58% were from Spanish-speaking families. As of March 31, 2011, a higher proportion of children and adolescents in the intervention group (43.6%; n = 1653) compared with the usual care group (39.9%; n = 1509) had received influenza vaccine (difference, 3.7% [95% CI, 1.5%-5.9%]; relative rate ratio [RRR], 1.09 [95% CI, 1.04-1.15]; P = .001). At the fall review date, 27.1% (n = 1026) of the intervention group compared with 22.8% (n = 864) of the usual care group had received influenza vaccine (difference, 4.3% [95% CI, 2.3%-6.3%]; RRR, 1.19 [95% CI, 1.10-1.28]; P < .001). CONCLUSIONS Among children and adolescents in a low-income, urban population, a text messaging intervention compared with usual care was associated with an increased rate of influenza vaccination. However, the overall influenza vaccination rate remained low. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01146912.

Influenza Vaccine Text Message Reminders for Urban, Low-Income Pregnant Women: A Randomized Controlled Trial

OBJECTIVES We evaluated the impact of influenza vaccine text message reminders in a low-income obstetric population. METHODS We conducted a randomized controlled trial that enrolled 1187 obstetric patients from 5 community-based clinics in New York City. The intervention group received 5 weekly text messages regarding influenza vaccination starting mid-September 2011 and 2 text message appointment reminders. Both groups received standard automated telephone appointment reminders. The prespecified endpoints were receipt of either pre- or postpartum influenza vaccination calculated cumulatively at the end of each month (September-December 2011). RESULTS After adjusting for gestational age and number of clinic visits, women who received the intervention were 30% more likely to be vaccinated as of December 2011 (adjusted odds ratio [AOR] = 1.30; 95% confidence interval [CI] = 1.003, 1.69 end of September: AOR = 1.34; 95% CI = 0.98, 1.85; October: AOR = 1.35; 95% CI = 1.05, 1.75; November: AOR = 1.27; 95% CI = 0.98, 1.65). The subgroup of women early in the third trimester at randomization showed the greatest intervention effect (December 31: 61.9% intervention vs 49.0% control; AOR = 1.88; 95% CI = 1.12, 3.15). CONCLUSIONS In this low-income obstetric population, text messaging was associated with increased influenza vaccination, especially in those who received messages early in their third trimester.

Text Message Reminders for Second Dose of Influenza Vaccine: A Randomized Controlled Trial

OBJECTIVE: To determine whether provision of vaccine-health-literacy-promoting information in text message vaccine reminders improves receipt and timeliness of the second dose of influenza vaccine within a season for children in need of 2 doses. METHODS: During the 2012–2013 season, families of eligible 6-month through 8-year-old children were recruited at the time of their first influenza vaccination from 3 community clinics in New York City. Children (n = 660) were randomly assigned to “educational” text message, “conventional” text message, and “written reminder-only” arms. At enrollment, all arms received a written reminder with next dose due date. Conventional messages included second dose due date and clinic walk-in hours. Educational messages added information regarding the need for a timely second dose. Receipt of second dose by April 30 was assessed by using χ2 tests. Timeliness was assessed by receipt of second dose by 2 weeks after due date (day 42) using χ2 and over time using a Kaplan-Meier analysis. RESULTS: Most families were Latino and publicly insured with no significant between-arm differences between groups. Children in the educational arm were more likely to receive a second dose by April 30 (72.7%) versus conventional (66.7%) versus written reminder-only arm (57.1%; P = .003). They also had more timely receipt by day 42 (P < .001) and over time (P < .001). CONCLUSIONS: In this low-income, urban, minority population, embedding health literacy information improved the effectiveness of text message reminders in promoting timely delivery of a second dose of influenza vaccine, compared with conventional text messages and written reminder only.

Text message reminders for timely routine MMR vaccination: A randomized controlled trial ☆

OBJECTIVE Measles-mumps-rubella (MMR) vaccination is important for preventing disease outbreaks, yet pockets of under-vaccination persist. Text message reminders have been employed successfully for other pediatric vaccines, but studies examining their use for MMR vaccination are limited. This study assessed the impact of text message reminders on timely MMR vaccination. STUDY DESIGN Parents (n=2054) of 9.5-10.5-month-old children from four urban academically-affiliated pediatric clinics were randomized to scheduling plus appointment text message reminders, appointment text message reminder-only, or usual care. The former included up to three text reminders to schedule the one-year preventive care visit. Both text messaging arms included a text reminder sent 2 days before that visit. Outcomes included appointment scheduling, appointment attendance, and MMR vaccination by age 13 months, the standard of care at study sites. RESULTS Children of parents in the scheduling plus appointment text message reminders arm were more likely to have a scheduled one-year visit than those in the other arms (71.9% vs. 67.4%, relative risk ratio (RRR) 1.07 [95% CI 1.005-1.13]), particularly if no appointment was scheduled before randomization (i.e., no baseline appointment) (62.1% vs. 54.7%, RRR 1.14 [95% CI 1.04-1.24]). One-year visit attendance and timely MMR vaccination were similar between arms. However, among children without a baseline appointment, those with parents in the scheduling plus appointment text message reminders arm were more likely to undergo timely MMR vaccination (61.1% vs. 55.1%, RRR 1.11 [95% CI 1.01-1.21]). CONCLUSION Text message reminders improved timely MMR vaccination of high-risk children without a baseline one-year visit.

Registry-linked electronic influenza vaccine provider reminders: a cluster-crossover trial.

OBJECTIVE: To determine the impact of a vaccination reminder in an electronic health record supplemented with data from an immunization information system (IIS). METHODS: A noninterruptive influenza vaccination reminder, based on a real-time query of hospital and city IIS, was used at 4 urban, academically affiliated clinics serving a low-income population. Using a randomized cluster-crossover design, each study site had “on” and “off” period during the fall and winter of 2011–2012. Influenza vaccination during a clinic visit was assessed for 6-month to 17-year-old patients. To assess sustainability, the reminder was active at all sites during the 2012–2013 season. RESULTS: In the 2011–2012 season, 8481 unique non-up-to-date children had visits. Slightly more non–up-to-date children seen when the reminder was ‘on’ were vaccinated than when ‘off’ (76.2% vs 73.8%; P = .027). Effects were seen in the winter (67.9% vs 62.2%; P = .005), not fall (76.8% vs 76.5%). The reminder also increased documentation of the reason for vaccine non-administration (68.1% vs 41.5%; P < .0001). During the 2011–2012 season, the reminder displayed for 8630 unique visits, and clinicians interacted with it in 83.1% of cases where patients required vaccination. During the 2012–2013 season, it displayed for 22 248 unique visits; clinicians interacted with it in 84.8% of cases. CONCLUSIONS: An IIS-linked influenza vaccination reminder increased vaccination later in the winter when fewer vaccine doses are usually given. Although the reminder did not require clinicians to interact with it, they frequently did; utilization did not wane over time.

MoSAIC: Mobile Surveillance for Acute Respiratory Infections and Influenza-Like Illness in the Community

Surveillance for acute respiratory infection (ARI) and influenza-like illness (ILI) relies primarily on reports of medically attended illness. Community surveillance could mitigate delays in reporting, allow for timely collection of respiratory tract samples, and characterize cases of non–medically attended ILI representing substantial personal and economic burden. Text messaging could be utilized to perform longitudinal ILI surveillance in a community-based sample but has not been assessed. We recruited 161 households (789 people) in New York City for a study of mobile ARI/ILI surveillance, and selected reporters received text messages twice weekly inquiring whether anyone in the household was ill. Home visits were conducted to obtain nasal swabs from persons with ARI/ILI. Participants were primarily female, Latino, and publicly insured. During the 44-week period from December 2012 through September 2013, 11,282 text messages were sent. In responses to 8,250 (73.1%) messages, a household reported either that someone was ill or no one was ill; 88.9% of responses were received within 4 hours. Swabs were obtained for 361 of 363 reported ARI/ILI episodes. The median time from symptom onset to nasal swab was 2 days; 65.4% of samples were positive for a respiratory pathogen by reverse-transcriptase polymerase chain reaction. In summary, text messaging promoted rapid ARI/ILI reporting and specimen collection and could represent a promising approach to timely, community-based surveillance.

Impacting Delayed Pediatric Influenza Vaccination: A Randomized Controlled Trial of Text Message Reminders

BACKGROUND Influenza vaccination coverage is low, especially among low-income populations. Most doses are generally administered early in the influenza season, yet sustained vaccination efforts are crucial for achieving optimal coverage. The impact of text message influenza vaccination reminders was recently demonstrated in a low-income population. Little is known about their effect on children with delayed influenza vaccination or the most effective message type. PURPOSE To determine the impact of educational plus interactive text message reminders on influenza vaccination of urban low-income children unvaccinated by late fall. DESIGN Randomized controlled trial. SETTING/PARTICIPANTS Parents of 5,462 children aged 6 months-17 years from four academically affiliated pediatric clinics who were unvaccinated by mid-November 2011. INTERVENTION Eligible parents were stratified by their childs age and pediatric clinic site and randomized using a 1:1:1 allocation to educational plus interactive text message reminders, educational-only text message reminders, or usual care. Using an immunization registry-linked text messaging system, parents of intervention children received up to seven weekly text message reminders. One of the messages sent to parents in the educational plus interactive text message arm allowed selection of more information about influenza and influenza vaccination. MAIN OUTCOME MEASURES Influenza vaccination by March 31, 2012. Data were collected and analyzed between 2012 and 2014. RESULTS Most children were publicly insured and Spanish speaking. Baseline demographics were similar between groups. More children of parents in the educational plus interactive text message arm were vaccinated (38.5%) versus those in the educational-only text message (35.3%; difference=3.3%, 95% CI=0.02%, 6.5%; relative risk ratio (RRR)=1.09, 95% CI=1.002, 1.19) and usual care (34.8%; difference=3.8%, 95% CI=0.6%, 7.0%; RRR=1.11, 95% CI=1.02-1.21) arms. CONCLUSIONS Text message reminders with embedded educational information and options for interactivity have a small positive effect on influenza vaccination of urban, low-income, minority children who remain unvaccinated by late fall.

Vaccination Coverage of Adolescents With Chronic Medical Conditions

INTRODUCTION Adolescents with chronic medical conditions (CMCs) are at increased risk of vaccine-preventable infections. Little is known about their vaccine uptake. METHODS This retrospective cohort study included 3,989 adolescents aged 11-17 years receiving care at academically affiliated pediatric clinics between August 2011 and June 2013. Data were abstracted from the medical centers electronic health record and immunization registry in 2014. Vaccination coverage, timeliness, and missed opportunities were evaluated and analyzed in 2015-2016. RESULTS Adolescents with CMCs had lower human papillomavirus vaccination initiation than those without CMCs (81.3% vs 85.0%), although this difference was only observed in stratified analysis among males (adjusted relative risk=0.90, 95% CI=0.85, 0.96), aged 13-17 years (adjusted relative risk=0.94, 95% CI=0.91, 0.98), and those with more primary care visits (adjusted relative risk=0.94, 95% CI=0.91, 0.98). Adolescents with CMCs had greater influenza vaccination coverage and timeliness than those without CMCs (2011-2012 season: 66.9% vs 50.1%; adjusted hazards ratio=1.27, 95% CI=1.15, 1.40; 2012-2013 season: 73.8% vs 64.5%; adjusted hazards ratio=1.20, 95% CI=1.10, 1.31). Only 32.1% and 18.2% of eligible adolescents had received pneumococcal polysaccharide and 13-valent pneumococcal conjugate vaccines, respectively. Missed opportunities were higher among adolescents with versus without CMCs for human papillomavirus vaccination initiation (4.2 vs 2.7, p<0.001), meningococcal vaccination (4.0 vs 2.9, p<0.001), and influenza vaccination (2011-2012 season: 2.1 vs 1.7, p<0.001; 2012-2013 season: 2.0 vs 1.6, p<0.001). Missed opportunities for pneumococcal vaccination were common. CONCLUSIONS Pockets of undervaccination and missed opportunities exist among adolescents with CMCs. Greater, more timely influenza vaccination suggests that optimal vaccination of high-risk adolescents is possible.