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Parental Vaccine Hesitancy and Risk of Pediatric Influenza Under-Vaccination in a Safety-Net Health Care System

  • Joshua T.B. Williams
    Correspondence
    Address correspondence to Joshua T.B. Williams, MD, Denver Health Medical Center, 301 W. 6th Ave, MC #1911, Denver, CO 80204
    Affiliations
    Department of Ambulatory Care Services, Denver Health and Hospital Authority (JTB Williams, SG Federico, and SJ Hambidge), Denver, Colo

    Department of Pediatrics, The University of Colorado Denver Anschutz Medical Campus (JTB Williams, SG Federico, SJ Hambidge, and ST O'Leary), Aurora, Colo
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  • John D. Rice
    Affiliations
    Department of Biostatistics and Informatics, Colorado School of Public Health (JD Rice), Aurora, Colo

    Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS) (JD Rice and ST O'Leary), Aurora, Colo
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  • Yingbo Lou
    Affiliations
    Ambulatory Care Services, Denver Health and Hospital Authority (Y Lou and SJ Hambidge), Denver, Colo
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  • Taylor K. Soderborg
    Affiliations
    University of Colorado Denver School of Medicine (TK Soderborg), Aurora, Colo
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  • Elizabeth A. Bayliss
    Affiliations
    Institute for Health Research, Kaiser Permanente (EA Bayliss), Denver, Colo

    Department of Family Medicine, University of Colorado Anschutz Medical Campus (EA Bayliss), Aurora, Colo
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  • Steven G. Federico
    Affiliations
    Department of Ambulatory Care Services, Denver Health and Hospital Authority (JTB Williams, SG Federico, and SJ Hambidge), Denver, Colo

    Department of Pediatrics, The University of Colorado Denver Anschutz Medical Campus (JTB Williams, SG Federico, SJ Hambidge, and ST O'Leary), Aurora, Colo
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  • Simon J. Hambidge
    Affiliations
    Department of Ambulatory Care Services, Denver Health and Hospital Authority (JTB Williams, SG Federico, and SJ Hambidge), Denver, Colo

    Department of Pediatrics, The University of Colorado Denver Anschutz Medical Campus (JTB Williams, SG Federico, SJ Hambidge, and ST O'Leary), Aurora, Colo

    Ambulatory Care Services, Denver Health and Hospital Authority (Y Lou and SJ Hambidge), Denver, Colo
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  • Sean T. O'Leary
    Affiliations
    Department of Pediatrics, The University of Colorado Denver Anschutz Medical Campus (JTB Williams, SG Federico, SJ Hambidge, and ST O'Leary), Aurora, Colo

    Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS) (JD Rice and ST O'Leary), Aurora, Colo

    Section of Pediatric Infectious Diseases, Department of Pediatrics, The University of Colorado Anschutz Medical Campus (ST O'Leary), Aurora, Colo
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      Abstract

      Objective

      To measure the risk of influenza under-vaccination in children of vaccine-hesitant parents, referent to children of nonhesitant parents, in a sample of disadvantaged families in one influenza season.

      Study Design

      A prospective observational cohort study of English- and Spanish-speaking parents of 2-year-olds presenting at random for well, sick, or specialty visit care from August 1, 2019 to February 28, 2020. Parents answered demographic questions and the Parent Attitudes about Childhood Vaccines survey. We followed children until season's end, extracting vaccination data on April 30, 2020. We dichotomized vaccination status as unvaccinated or partially/fully vaccinated, analyzing data with multivariable Poisson regression; in secondary analyses, we conducted adjusted time-to-event analyses.

      Results

      Overall, 263 parents consented (response rate: 90%); our final sample included 255 dyads. Thirty-three (13%) parents were vaccine hesitant. In adjusted analyses, children of hesitant parents (n = 33) had a 195% increased risk (adjusted Risk Ratio 2.95; 95% confidence interval 1.91, 4.56) of being unvaccinated at season's end, referent to children of nonhesitant parents (n = 222). In time-to-event analyses, children of vaccine-hesitant parents were also more likely to be unvaccinated before influenza activity peaked (P = .02).

      Conclusions

      Parental vaccine hesitancy tripled the risk of pediatric influenza nonvaccination in a sample of poor and minority families during the 2019 to 2020 influenza season. As parental vaccine hesitancy appears to exacerbate pediatric influenza vaccination disparities, future work should explore parental hesitancy with poor and minority stakeholders and tailor evidence-based interventions to benefit children from these communities who receive care at all practice sites.

      Keywords

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      References

        • Centers for Disease Control and Prevention
        Disease burden of influenza.
        2020 (Available at:https://www.cdc.gov/flu/about/burden/index.html. Accessed April 27, 2020)
        • Yousey-Hindes KM
        • Hadler JL
        Neighborhood socioeconomic status and influenza hospitalizations among children: New Haven County, Connecticut, 2003-2010.
        Am J Public Health. 2011; 101: 1785-1789https://doi.org/10.2105/AJPH.2011.300224
        • Iwane MK
        • Chaves SS
        • Szilagyi PG
        • et al.
        Disparities between black and white children in hospitalizations associated with acute respiratory illness and laboratory-confirmed influenza and respiratory syncytial virus in 3 US counties—2002-2009.
        Am J Epidemiol. 2013; 177: 656-665https://doi.org/10.1093/aje/kws299
        • Dee DL
        • Bensyl DM
        • Gindler J
        • et al.
        Racial and ethnic disparities in hospitalizations and deaths associated with 2009 pandemic influenza A (H1N1) virus infections in the United States.
        Ann Epidemiol. 2011; 21: 623-630https://doi.org/10.1016/j.annepidem.2011.03.002
        • Kenneth D.
        • Kochanek M.A.
        • Sherry L.
        • et al.
        National vital statistics reports.
        Deaths. 2017; 68: 2017https://doi.org/10.1111/mec.13536.Application
        • Zhai Y
        • Santibanez TA
        • Kahn KE
        • et al.
        Parental-reported full influenza vaccination coverage of children in the U.S.
        Am J Prev Med. 2017; 52: e103-e113https://doi.org/10.1016/j.amepre.2016.10.040
        • Hill HA
        • Singleton JA
        • Yankey D
        • et al.
        Vaccination coverage by age 24 months among children born in 2015 and 2016—national immunization survey-child, United States, 2016-2018.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 913-918https://doi.org/10.15585/mmwr.mm6841e2
        • Hofstetter AM
        • Natarajan K
        • Rabinowitz D
        • et al.
        Timeliness of pediatric influenza vaccination compared with seasonal influenza activity in an urban community, 2004-2008.
        Am J Public Health. 2013; 103: 2004-2008https://doi.org/10.2105/AJPH.2013.301351
        • Rao S
        • Williams JTB
        • Torok MR
        • et al.
        Missed opportunities for influenza vaccination among hospitalized children with influenza at a tertiary care facility.
        Hosp Pediatr. 2016; 6: 513-519https://doi.org/10.1542/hpeds.2015-0112
        • Hofstetter AM
        • Robinson JD
        • Lepere K
        • et al.
        Clinician-parent discussions about influenza vaccination of children and their association with vaccine acceptance.
        Vaccine. 2017; 35: 2709-2715https://doi.org/10.1016/j.vaccine.2017.03.077
        • Kempe A
        • Saville AW
        • Albertin C
        • et al.
        Centralized reminder/recall to increase influenza vaccination rates: a two-state pragmatic randomized trial.
        Acad Pediatr. 2020; 20: 374-383
        • Saville AW
        • Szilagyi P
        • Helmkamp L
        • et al.
        Potential strategies to achieve universal influenza vaccination for children: provider attitudes in two states.
        Acad Pediatr. 2018; 18: 873-881
        • Brenner RA
        • Simons-Morton BG
        • Bhaskar B
        • et al.
        Prevalence and predictors of immunization among inner-city infants: a birth cohort study.
        Pediatrics. 2001; 108: 661-670https://doi.org/10.1542/peds.108.3.661
        • Wood D
        • Donald-Sherbourne C
        • Halfon N
        • et al.
        Factors related to immunization status among inner-city Latino and African-American preschoolers.
        Pediatrics. 1995; 96: 295-301
        • Bobo JK
        • Gale JL
        • Thapa PB
        • et al.
        Risk factors for delayed immunization in a random sample of 1163 children from Oregon and Washington.
        Pediatrics. 1993; 91: 308-314
        • Miller LA
        • Hoffman RE
        • Baron AE
        • et al.
        Risk factors for delayed immunization against measles, mumps, and rubella in Colorado two-year-olds.
        Pediatrics. 1994; 94: 213-219
      1. Ten Threats to Global Health in 2019. World Health Organization. 2019. Available at: https://www.who.int/news-room/feature-stories/ten-threats-to-global-health-in-2019. Accessed February 20, 2020.

        • Kempe A
        • Saville AW
        • Albertin C
        • et al.
        Parental hesitancy about routine childhood and influenza vaccinations: a national survey.
        Pediatrics. 2020; 146https://doi.org/10.1542/peds.2019-3852
        • Hofstetter AM
        • Simon TD
        • Lepere K
        • et al.
        Parental vaccine hesitancy and declination of influenza vaccination among hospitalized children.
        Hosp Pediatr. 2018; 8: 628-635https://doi.org/10.1542/hpeds.2018-0025
        • Strelitz B
        • Gritton J
        • Klein EJ
        • et al.
        Parental vaccine hesitancy and acceptance of seasonal influenza vaccine in the pediatric emergency department.
        Vaccine. 2015; 33: 1802-1807https://doi.org/10.1016/j.vaccine.2015.02.034
        • Maldonado YA
        • Zaoutis TE
        • Banerjee R
        • et al.
        Recommendations for prevention and control of influenza in children, 2019–2020.
        Pediatrics. 2019; 144: 2019-2020https://doi.org/10.1542/peds.2019-2478
        • Williams JTB
        • Rice JD
        • Lou Y
        • et al.
        Parental vaccine hesitancy and vaccination disparities in a safety-net system.
        Pediatrics. 2021; 147e2020010710https://doi.org/10.1542/peds.2020-010710
        • Gabow P
        • Eisert S
        • Wright R
        Denver health: a model for the integration of a public hospital and community health centers.
        Ann Intern Med. 2003; 138: 143-149https://doi.org/10.7326/0003-4819-138-2-200301210-00016
        • Becker MH
        The Health Belief Model and Personal Health Behavior.
        C.B. Slack, 1974
        • Coe AB
        • Gatewood SBS
        • Moczygemba LR
        • et al.
        The use of the health belief model to assess predictors of intent to receive the novel (2009) H1N1 influenza vaccine.
        Inov Pharm. 2012; 3 (Available at:http://www.ncbi.nlm.nih.gov/pubmed/22844651%5Cnhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3405550): 1-11
        • Cheney MK
        • John R
        Underutilization of influenza vaccine: a test of the Health Belief Model.
        SAGE Open. 2013; 3: 1-12https://doi.org/10.1177/2158244013484732
        • Opel DJ
        • Taylor JA
        • Mangione-Smith R
        • et al.
        Development of a survey to identify vaccine-hesitant parents.
        Hum Vaccin. 2011; 7: 419-425https://doi.org/10.1016/j.vaccine.2011.06.115
        • Cunningham RM
        • Kerr GB
        • Orobio J
        • et al.
        Development of a Spanish version of the parent attitudes about childhood vaccines survey.
        Hum Vaccines Immunother. 2019; 15: 1106-1110https://doi.org/10.1080/21645515.2019.1578599
        • Opel DJ
        • Taylor JA
        • Mangione-Smith R
        • et al.
        Validity and reliability of a survey to identify vaccine-hesitant parents.
        Vaccine. 2011; 29: 6598-6605https://doi.org/10.1016/j.vaccine.2011.06.115
        • Harris P
        • Taylor R
        • Thielke R
        • et al.
        Research Electronic Data Capture (REDCap)—a metadata driven methodology and workflow process for providing translational research informatict support.
        J Biomed Inform. 2009; 42: 377-381https://doi.org/10.1016/j.jbi.2008.08.010.Research
        • Zou G
        A modified Poisson regression approach to prospective studies with binary data.
        Am J Epidemiol. 2004; 159: 702-706https://doi.org/10.1093/aje/kwh090
        • Colorado Department of Public Health & Environment
        Colorado flu report.
        2020 (Available at:https://www.colorado.gov/pacific/cdphe/influenza. Accessed June 23, 2020)
        • Schmid P
        • Rauber D
        • Betsch C
        • et al.
        Barriers of influenza vaccination intention and behavior—a systematic review of influenza vaccine hesitancy, 2005-2016.
        PLoS One. 2017; 12e0170550https://doi.org/10.1371/journal.pone.0170550
        • Fitch P
        • Racine A
        Parental beliefs about vaccination among an ethnically diverse inner-city population.
        J Natl Med Assoc. 2004; 96: 1047-1050
        • Hofstetter AM
        • Barrett A
        • Stockwell MS
        Factors impacting influenza vaccination of urban low-income Latino children under nine years requiring two doses in the 2010 –2011 season.
        J Community Health. 2015; 40: 227-234https://doi.org/10.1007/s10900-014-9921-z
        • Shui IM
        • Weintraub ES
        • Gust DA
        Parents concerned about vaccine safety. Differences in race/ethnicity and attitudes.
        Am J Prev Med. 2006; 31: 244-251https://doi.org/10.1016/j.amepre.2006.04.006
        • Centers for Disease Control and Prevention
        Vaccinate with confidence.
        2020 (Available at:https://www.cdc.gov/vaccines/partners/vaccinate-with-confidence.html. Accessed April 27, 2021)
        • Mbaeyi S
        • Cohn A
        • Messonier N
        A call to action: strengthening vaccine confidence in the United States.
        Pediatrics. 2020; 145e20200390
        • Nowalk MP
        • Lin CJ
        • Hannibal K
        • et al.
        Increasing childhood influenza vaccination: a cluster randomized trial.
        Am J Prev Med. 2014; 47: 435-443https://doi.org/10.1016/j.amepre.2014.07.003