Trends in Vaccine Refusal and Acceptance Using Electronic Health Records from a Large Pediatric Hospital Network, 2013-2020: Strategies for Change.

2022

10/2022

2076-393X

Understanding trends in vaccine refusal is critical to monitor as small declines in vaccination coverage can lead to outbreaks of vaccine-preventable diseases. Using electronic heath record (EHR) data from the Children's Hospital of Philadelphia's 31 outpatient primary care sites, we created a cohort of 403,448 children less than age 20 years who received at least one visit from 1 January 2013 through 31 December 2020. The sample represented 1,449,061 annualized patient and 181,131 annualized preventive vaccination visits per year. We characterized trends in vaccine refusal and acceptance using a repeated cross-sectional observational analysis of electronic health records (EHR) data using a single annual merged observation measure for patients seen multiple times for preventive healthcare within a calendar year. Refusals were identified for 212,900 annualized patient-visit year observations, which represented 14.6% of annualized patient-visit year observations and 25.1% of annualized vaccine patient-year observations. The odds of having a refusal marker were significantly increased in patients seen in suburban practices (aOR [CI]: 2.35 [2.30-2.40, < 0.001]), in patients with increased age 11-17 years (aOR [CI]: 3.85 [3.79-3.91], < 0.001), and those eligible for the VFC program (aOR [CI]: 1.10 [1.08-1.11]. Parental refusal (61.0%) and provider decisions (32.0%) were the most common documented in progress notes for not administering vaccines, whereas contraindications (2.5%) and supply issues (1.8%) were the least common. When offered, vaccine acceptance increased for human papillomavirus, hepatitis B, measles-mumps-rubella-containing and varicella-containing vaccines and decreased for hepatitis A and meningococcal vaccines. Repeated offering of vaccines was central to increasing acceptance, in part due to increased opportunities to address specific concerns.

10.3390/vaccines10101688

Vaccines (Basel)

36298553

Factors Influencing Parental and Individual COVID-19 Vaccine Decision Making in a Pediatric Network.

2022

08/2022

2076-393X

Aspects of the COVID-19 vaccination campaign differed from routine vaccines, including emergency use authorizations, the prioritization of access, and the politicization of messaging. Subsequently, many parents reported lower vaccine confidence relative to routine vaccines, and vaccination coverage stalled below targets. This study aimed to understand parental vaccine decision making and compare COVID-19 versus routine vaccine decision making. We conducted nine virtual focus groups between 25 February 2022-11 March 2022 with parents ( = 41) of the Children's Hospital of Philadelphia's patients, recruited via email and stratified by vaccine hesitancy status (non-hesitant vs. hesitant). Transcripts were analyzed using the vaccine hesitancy matrix domains. Of 41 total participants, 25 (61.0%) were non-hesitant, 16 (39.0%) were hesitant or their children were not up-to-date on adolescent vaccines, and most self-identified as female (95.1%) and White/Caucasian (61.0%). Most participants (87.5%) were fully vaccinated against COVID-19 and many of their first children ( = 26, 63.4%) were vaccinated against influenza. Several themes emerged regarding decision making: individual influences, group influences, vaccine and vaccine program influences, and contextual influences. While some influences were similar for routine and COVID-19 vaccine decision making (e.g., needing evidence-based information), other factors were vaccine- or situation-specific. Building trust requires a multi-faceted concerted effort that involves addressing the complex vaccine decision-making process.

10.3390/vaccines10081277

Vaccines (Basel)

36016165

COVID-19 Vaccine Hesitancy among Physicians, Physician Assistants, Nurse Practitioners, and Nurses in Two Academic Hospitals in Philadelphia.

2021

1-24

2021 Sep 20

1559-6834

<p><strong>OBJECTIVE: </strong>To evaluate COVID-19 vaccine hesitancy among health care personnel (HCP) with significant clinical exposure to COVID-19 at two large, academic hospitals in Philadelphia.</p>

<p><strong>DESIGN, SETTING AND PARTICIPANTS: </strong>HCP were surveyed between November-December 2020 about their intention to receive the COVID-19 vaccine.</p>

<p><strong>METHODS: </strong>The survey measured the intent among HCP to receive a COVID-19 vaccine, timing of vaccination, and reasons for or against vaccination. Among patient-facing HCP, multivariate regression evaluated the associations between healthcare positions (MD, NP/PA, RN) and vaccine hesitancy (intending to decline, delay, or were unsure about vaccination), adjusting for demographic characteristics, reasons why or why not to receive the vaccine, and prior receipt of routine vaccines.</p>

<p><strong>RESULTS: </strong>Among 5,929 HCP (2,253 MDs/DOs, 582 NPs, 158 PAs, and 2,936 nurses), a higher proportion of nurses (47.3%) were COVID-vaccine hesitant compared with 30.0% of PAs/NPs and 13.1% of MDs/DOs. The most common reasons for vaccine hesitancy included concerns about side effects, the newness of the vaccines, and lack of vaccine knowledge. Regardless of position, Black HCP were more hesitant than White HCP (OR∼5) and females were more hesitant than males (OR∼2).</p>

<p><strong>CONCLUSION: </strong>Although a majority of clinical HCP intended to receive a COVID-19 vaccine, intention varied by healthcare position. Consistent with other studies, hesitancy was also significantly associated with race/ethnicity across all positions. These results underline the importance of understanding and effectively addressing reasons for hesitancy, especially among frontline HCP who are at increased risk of COVID exposure and play a critical role in recommending vaccines to patients.</p>

10.1017/ice.2021.410

Infect Control Hosp Epidemiol

34538290

Shared clinical decision-making on vaccines: out of sight, out of mind.

2021

2021 Aug 02

1527-974X

<p>Clinical decision support systems, which provide automated reminders in electronic health systems, are designed to provide physicians and other health professionals support in clinical decision-making. New clinical guidance from the Advisory Committee on Immunization Practices on a new category of recommendations referred to as "shared clinical decision-making" have left providers struggling to interpret how to best implement recommendations for adult vaccines. The issue at hand is how to ensure that a conversation between the patient and provider occurs. While traditional clinical decision support systems have driven immunization for years, these systems support a binary default opt-in process. The goal for shared decision-making is the discussion rather than the vaccination. The recommended provider-patient conversations need to be supported with both provider guidance as well as tools to ensure vaccines are not omitted from the conversations, particularly as future vaccine candidates progress through the vaccine development pipeline.</p>

10.1093/jamia/ocab147

J Am Med Inform Assoc

34338789

Racial/Ethnic Differences in COVID-19 Vaccine Hesitancy Among Health Care Workers in 2 Large Academic Hospitals.

2021

e2121931

2021 Aug 02

2574-3805

<p><strong>Importance: </strong>Significant differences in hesitancy to receive COVID-19 vaccination by race/ethnicity have been observed in several settings. Racial/ethnic differences in COVID-19 vaccine hesitancy among health care workers (HCWs), who face occupational and community exposure to COVID-19, have not been well described.</p>

<p><strong>Objective: </strong>To assess hesitancy to COVID-19 vaccination among HCWs across different racial/ethnic groups and assess factors associated with vaccine hesitancy.</p>

<p><strong>Design, Setting, and Participants: </strong>This survey study was conducted among HCWs from 2 large academic hospitals (ie, a children's hospital and an adult hospital) over a 3-week period in November and December 2020. Eligible participants were HCWs with and without direct patient contact. A 3-step hierarchical multivariable logistic regression was used to evaluate associations between race/ethnicity and vaccine hesitancy controlling for demographic characteristics, employment characteristics, COVID-19 exposure risk, and being up to date with routine vaccinations. Data were analyzed from February through March 2021.</p>

<p><strong>Main Outcomes and Measures: </strong>Vaccine hesitancy, defined as not planning on, being unsure about, or planning to delay vaccination, served as the outcome.</p>

<p><strong>Results: </strong>Among 34 865 HCWs eligible for this study, 12 034 individuals (34.5%) completed the survey and 10 871 individuals (32.2%) completed the survey and reported their race/ethnicity. Among 10 866 of these HCWs with data on sex, 8362 individuals (76.9%) were women, and among 10 833 HCWs with age data, 5923 individuals (54.5%) were younger than age 40 years. (Percentages for demographic and clinical characteristics are among the number of respondents for each type of question.) There were 8388 White individuals (77.2%), 882 Black individuals (8.1%), 845 Asian individuals (7.8%), and 449 individuals with other or mixed race/ethnicity (4.1%), and there were 307 Hispanic or Latino individuals (2.8%). Vaccine hesitancy was highest among Black HCWs (732 individuals [83.0%]) and Hispanic or Latino HCWs (195 individuals [63.5%]) (P &lt; .001). Among 5440 HCWs with vaccine hesitancy, reasons given for hesitancy included concerns about side effects (4737 individuals [87.1%]), newness of the vaccine (4306 individuals [79.2%]), and lack of vaccine knowledge (4091 individuals [75.2%]). The adjusted odds ratio (aOR) for vaccine hesitancy was 4.98 (95% CI, 4.11-6.03) among Black HCWs, 2.10 (95% CI, 1.63-2.70) among Hispanic or Latino HCWs, 1.48 (95% CI, 1.21-1.82) among HCWs with other or mixed race/ethnicity, and 1.47 (95% CI, 1.26-1.71) among Asian HCWs compared with White HCWs (P &lt; .001). The aOR was decreased among Black HCWs when adjusting for employment characteristics and COVID-19 exposure risk (aOR, 4.87; 95% CI, 3.96-6.00; P &lt; .001) and being up to date with prior vaccines (aOR, 4.48; 95% CI, 3.62-5.53; P &lt; .001) but not among HCWs with other racial/ethnic backgrounds.</p>

<p><strong>Conclusions and Relevance: </strong>This study found that vaccine hesitancy before the authorization of the COVID-19 vaccine was increased among Black, Hispanic or Latino, and Asian HCWs compared with White HCWs. These findings suggest that interventions focused on addressing vaccine hesitancy among HCWs are needed.</p>

10.1001/jamanetworkopen.2021.21931

JAMA Netw Open

34459907

Perspectives on the receipt of a COVID-19 vaccine: A survey of employees in two large hospitals in Philadelphia.

2021

2021 Feb 16

1873-2518

<p><strong>BACKGROUND: </strong>Health care personnel have been identified by the ACIP as a priority group for COVID-19 vaccination. We conducted a survey in November-December 2020 at two large, academic hospitals in Philadelphia to evaluate the intention of hospital employees to be vaccinated.</p>

<p><strong>METHODS: </strong>The survey was sent electronically to all employees (clinical and nonclinical staff) at a children's hospital and an adult hospital. The survey was voluntary and confidential. Questions focused on plans to receive a COVID-19 vaccine when available, reasons why employees would/would not get vaccinated, when employees planned to be vaccinated, vaccine safety and efficacy features that would be acceptable, and past history of receipt of other vaccines by the employee and family. Responses were analyzed using univariate and multiple logistic regression methods.</p>

<p><strong>RESULTS: </strong>A total of 12,034 hospital employees completed the survey (a 34.5% response rate). Overall, 63.7% of employees reported that they planned to receive a COVID-19 vaccine, 26.3% were unsure, and 10.0% did not plan to be vaccinated. Over 80% of those unsure or unwilling to be vaccinated expressed concerns about vaccine side effects and the vaccines' newness. In multivariable logistic regression, persons planning to take a COVID-19 vaccine were more likely to be older, male, more educated, Asian or White, up-to-date on vaccinations, without direct patient contact, and tested for COVID-19 in the past. No significant difference in intention to be vaccinated was found between those with higher versus lower levels of exposure to COVID-19 patients or the number of previous exposures to patients with COVID-19.</p>

<p><strong>CONCLUSIONS: </strong>While the majority of hospital employees are planning to receive a COVID-19 vaccine, many are unsure or not planning to do so. Further education of hospital employees about the safety, efficacy, and value of the currently available COVID-19 vaccines is critical to vaccine acceptance in this population.</p>

10.1016/j.vaccine.2021.02.029

Vaccine

33632563

Chimeric antigen receptor T cells for sustained remissions in leukemia.

2014

1507-17

2014 Oct 16

1533-4406

<p><strong>BACKGROUND: </strong>Relapsed acute lymphoblastic leukemia (ALL) is difficult to treat despite the availability of aggressive therapies. Chimeric antigen receptor-modified T cells targeting CD19 may overcome many limitations of conventional therapies and induce remission in patients with refractory disease.</p>

<p><strong>METHODS: </strong>We infused autologous T cells transduced with a CD19-directed chimeric antigen receptor (CTL019) lentiviral vector in patients with relapsed or refractory ALL at doses of 0.76×10(6) to 20.6×10(6) CTL019 cells per kilogram of body weight. Patients were monitored for a response, toxic effects, and the expansion and persistence of circulating CTL019 T cells.</p>

<p><strong>RESULTS: </strong>A total of 30 children and adults received CTL019. Complete remission was achieved in 27 patients (90%), including 2 patients with blinatumomab-refractory disease and 15 who had undergone stem-cell transplantation. CTL019 cells proliferated in vivo and were detectable in the blood, bone marrow, and cerebrospinal fluid of patients who had a response. Sustained remission was achieved with a 6-month event-free survival rate of 67% (95% confidence interval [CI], 51 to 88) and an overall survival rate of 78% (95% CI, 65 to 95). At 6 months, the probability that a patient would have persistence of CTL019 was 68% (95% CI, 50 to 92) and the probability that a patient would have relapse-free B-cell aplasia was 73% (95% CI, 57 to 94). All the patients had the cytokine-release syndrome. Severe cytokine-release syndrome, which developed in 27% of the patients, was associated with a higher disease burden before infusion and was effectively treated with the anti-interleukin-6 receptor antibody tocilizumab.</p>

<p><strong>CONCLUSIONS: </strong>Chimeric antigen receptor-modified T-cell therapy against CD19 was effective in treating relapsed and refractory ALL. CTL019 was associated with a high remission rate, even among patients for whom stem-cell transplantation had failed, and durable remissions up to 24 months were observed. (Funded by Novartis and others; CART19 ClinicalTrials.gov numbers, NCT01626495 and NCT01029366.).</p>

10.1056/NEJMoa1407222

N. Engl. J. Med.

25317870