<p>Increases in vaccine hesitancy and vaccine-preventable disease outbreaks have focused attention on state laws governing school-entry vaccine mandates and the allowable exemptions (medical and nonmedical) from those mandates. There is substantial variation in the type of exemptions available in each state, and states with more rigorous or burdensome exemption requirements generally have lower exemption rates. States have little evidence, however, about how vaccine-hesitant parents respond to different requirements. Despite recent efforts to formulate "model legislation" templates for states to follow, policy evidence about optimal exemption regimes is limited to observational studies in states that have changed exemption laws. We conducted two online experiments to explore how parental attitudes and intentions responded to different school-entry vaccine mandate exemption requirements. We randomly assigned online participants to one of four hypothetical vaccine exemption application scenarios: parental signature only, a checklist of vaccines for which an exemption is requested, a lengthy (10-30+ min) video-based vaccine education module, and a requirement to write a statement justifying the exemption. Among parents with high vaccine hesitancy, a required vaccine education module led to significant decreases in vaccine hesitancy, while checklist and justification requirements increased vaccine hesitancy slightly. Among parents with low vaccine hesitancy, we observed a potential backfire effect when parents were required to write a justification statement. Our findings warrant replication in a larger, fully-powered trial to accelerate knowledge about how parents across the vaccine hesitancy spectrum respond to exemption regimes.</p>

<p><strong>OBJECTIVE: </strong>Human papillomavirus (HPV) vaccine has been recommended for males for prevention of genital warts and precancerous anal lesions since 2009. Our objective was to characterize race and insurance-based disparities in HPV vaccine completion among males who initiated the HPV vaccine series.</p>

<p><strong>METHODS: </strong>Retrospective cohort study of adolescent males in a primary care network who initiated the HPV vaccine series 10/09-12/13. We measured vaccine series completion as the primary outcome. We evaluated associations between outcomes and race and insurance status, controlling for potential confounders and effect modification with multivariable logistic regression. Analyses were stratified by vaccine recommendation era (permissive vs. routine).</p>

<p><strong>RESULTS: </strong>42% of males in the cohort (16,691) completed the vaccine series. In the permissive vaccine era (2009 - 2011), non-black patients (53%) were more likely to complete than Black patients (32%), and non-Medicaid were more likely to complete than Medicaid patients (33%). These differences persisted in the routine recommendation era (2012 - 2013). In both the permissive and routine eras Medicaid insurance was associated with a larger reduction in the predicted probability of vaccine series completion for non-black patients. Adherence to the recommended vaccination schedule was low with a median time to completion of 8.9 months. Using the updated completion schedule (2016), completion rates were higher (54.1%) with continued differences based on race (60% vs. 45.7% for non-black vs. black patients) and insurance (57.4% vs. 46.4% completion for non-Medicaid vs. Medicaid patients).</p>

<p><strong>CONCLUSIONS: </strong>There are significant disparities in HPV vaccine series completion rates among males based on race and insurance, unchanged based on era of initiation or visit frequency.</p>

<p>Pediatric clinical practice often involves improving child health by changing parents' behavior. Strategies from behavioral economics - a field that leverages predictable patterns in human decision-making to overcome barriers to behavior change - can improve health outcomes in adults. Though more research is needed, the application of these approaches to parent behavior change in pediatric settings has the potential to improve the clinical effectiveness of child healthcare. We review the foundational concepts of behavioral economics and identify the unique role of pediatricians in motivating parent behavior change. We then discuss how to apply four key strategies in practice - message framing, use of defaults, enhanced active choice, and harnessing social forces - to support parent decision-making to improve child health. Leveraging behavioral economic principles around parental decision-making has the potential to supercharge program effectiveness and improve patient and family health.</p>

<p>The objective of this study was to describe how a sample of pediatricians were impacted by and responded to the Disneyland measles outbreak in the United States. We conducted three repeated cross-sectional, online surveys in 2014 (before the outbreak), 2015, and 2016 (after the outbreak) among members of three state chapters of the American Academy of Pediatrics. We assessed pediatricians' level of willingness and length of time comfortable delaying the measles-mumps-rubella (MMR) vaccine before and after the outbreak. Frequency of alternative immunization schedule requests and creation of office immunization policies due to the outbreak were measured. The sample included 304 pediatricians in 2014, 270 in 2015, and 221 in 2016. We found no significant changes in willingness or comfort delaying the MMR vaccine before and after the outbreak. In 2015, 38% of pediatricians reported fewer requests for alternative immunization schedules and 20% created stricter office immunization policies. A subsample of pediatricians reported administering the MMR vaccine earlier in the recommended time frame and taking extra precautions in waiting rooms due to the outbreak. Our results suggest that this measles outbreak did not lead to significant changes in attitudes or practices among this sample, but did modestly affect office immunization policies and practices.</p>

<p>Vaccine-preventable deaths amongst adults remain a major public health concern, despite continued efforts to increase vaccination rates in this population. Alternative approaches to immunization delivery may help address under-vaccination amongst adults. This systematic review assesses the feasibility, acceptability, and effectiveness of community pharmacies as sites for adult vaccination. We searched 5 electronic databases (PubMed, EMBASE, Scopus, Cochrane, LILACS) for studies published prior to June 2016 and identified 47 relevant articles. We found that pharmacy-based immunization services (PBIS) have been facilitated by state regulatory changes and training programs that allow pharmacists to directly provide vaccinations. These services are widely accepted by both patients and pharmacy staff, and are capable of improving access and increasing vaccination rates. However, political and organizational barriers limit the feasibility and effectiveness of vaccine delivery in pharmacies. These studies provide evidence to inform policy and organizational efforts that promote the efficacy and sustainability of PBIS.</p>

<p><strong>OBJECTIVES: </strong>The incidence of pertussis has tripled in the past five years. Infants can be protected by "cocooning," or vaccinating household contacts with the Tdap vaccine. However, Tdap coverage for adult caregivers of infants is low. This study evaluated the feasibility and impact of interventions informed by behavioral economics (retail pharmacy vouchers for Tdap vaccines and a celebrity public service announcement) to increase Tdap vaccination among caregivers of young infants.</p>

<p><strong>METHODS: </strong>We conducted a randomized controlled feasibility trial among adults attending newborn well-child visits at an urban Philadelphia pediatric primary care clinic who were not previously vaccinated with Tdap. Participants were randomized to one of four conditions: ($5-off Tdap voucher vs. free voucher)×(watching a 1min video public service announcement (PSA) about Tdap vaccination vs. no PSA). Tdap vaccination was assessed by tracking voucher redemption and following up with participants by phone.</p>

<p><strong>RESULTS: </strong>Ninety-five adult caregivers of 74 infants were enrolled in the study (mean age 29.3 years; 61% male; relationship to newborn: 54% father, 33% mother, 13% grandparent or other; caregiver insurance status: 35% Medicaid, 34% private insurance, 32% uninsured). Only 1 subject redeemed the retail pharmacy Tdap voucher. Follow-up interviews suggest that, even with the voucher, significant barriers to vaccination remained including: delaying planned vaccination, perceived inconvenient pharmacy locations, and beliefs about pertussis risk and severity.</p>

<p><strong>CONCLUSIONS: </strong>Despite leveraging existing infrastructure for adult vaccination, results suggest that retail pharmacy vouchers delivered during a newborn visit are not an effective strategy for promoting Tdap. Alternate approaches are needed that prioritize convenience and provide an immediate opportunity to vaccinate when motivation is high.</p>

<p><strong>PURPOSE: </strong>The purpose of this study was to describe patterns of human papillomavirus (HPV) vaccine initiation by males and characterize sociodemographic differences.</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study of 11- to 18-year-old males in a large primary care network who had a preventive or acute visit between October 2009 and December 2013. Outcomes measured were HPV vaccine series initiation and initiation at the first eligible visit. Logistic regression measured independent associations between outcomes and sociodemographic characteristics, adjusting for potential confounders including visit frequency, insurance changes, and the presence of complex medical conditions.</p>

<p><strong>RESULTS: </strong>Of 58,757 eligible patients, most were white (57%) with private insurance (77%). During the study period, 39% of the cohort initiated the vaccine series, and 7% initiated at their first eligible visit. Black patients with private (adjusted odds ratio [aOR], 1.99; 95% confidence interval [CI], 1.73-2.30) and Medicaid insurance (aOR, 2.90; 95% CI, 2.56-3.30) had significantly higher odds of HPV vaccine initiation compared with white patients with private insurance. A similar trend was found for Hispanic patients with private (aOR, 1.45; 95% CI, 1.26-1.67) and Medicaid insurance (aOR, 2.15; 95% CI, 1.78-2.60). These differences were present both in the preroutine recommendation period (2009-2011) and the postroutine recommendation period (2012-2013).</p>

<p><strong>CONCLUSIONS: </strong>Traditionally marginalized populations have higher odds of HPV vaccine initiation, both at the first eligible visit and overall. Although the true mechanism underlying these differences remains unknown, potential candidates include provider recommendation patterns and differential vaccine acceptance within these groups.</p>