Publications by authors named "Jessica R Cataldi"

26 Publications

  • Page 1 of 1

Rural Adolescent Immunization: Delivery Practices and Barriers to Uptake.

J Am Board Fam Med 2021 Sep-Oct;34(5):937-949

From the ACCORDS, University of Colorado Anschutz Medical Campus, Aurora, CO (JRC, SEB, CP, AF, AN, KS, STO, AFD); Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO (JRC, STO, AFD); Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (SEB, AN); Department of Biostatistics & Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO (KS); Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA (CW).

Background: Rural adolescent vaccination rates lag behind urban. We sought to assess rural-urban differences in barriers to adolescent vaccination, perceived parental vaccine attitudes, and immunization delivery practices among public health nursing (PHN), pediatric (Peds), and family medicine (FM) clinicians.

Methods: Internet and mail survey of Colorado PHN, Peds, and FM clinicians from June-August 2019. Study population was recruited from local health plans and the American Medical Association Physician Masterfile. Rural and urban responses were compared using Cochran Armitage trend, Fisher's exact, and chi-square tests.

Results: Response rate was 38% (163/433; 91 rural, 72 urban). Rural respondents were less likely than urban to agree most patients have insurance that covers vaccination (86% vs 97%; = .02). Rural respondents were less likely than urban to indicate most parents in their practice would agree with statements about vaccine benefits ( = .02) and trust in medical providers ( = .05). Rural respondents were more likely than urban to report adolescents were somewhat/very likely to receive vaccines at public health departments (65% vs 28%; < .0001) and less likely to report adolescents were somewhat/very likely to receive vaccines at pharmacies (26% vs 45%; = .02). Fewer providers strongly recommended HPV vaccine (81% for females, 80% for males 11 to 12 years) than other adolescent immunizations (Tdap: 97%, MenACWY at 11 to 12 years: 87%; influenza at 11 to 17 years: 87%; each < .005, rural-urban responses did not differ).

Conclusions: Rural barriers to adolescent vaccination include logistic issues and parental vaccine attitudes. Efforts to improve rural adolescent vaccination should include public health departments and address vaccine confidence and access barriers.
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http://dx.doi.org/10.3122/jabfm.2021.05.210107DOI Listing
October 2021

Parental vaccine hesitancy: scope, causes, and potential responses.

Curr Opin Infect Dis 2021 10;34(5):519-526

Department of Pediatrics, University of Colorado School of Medicine.

Purpose Of Review: We reviewed the literature about parental vaccine hesitancy, focusing on publications from October 2019 to April 2021 to describe patterns and causes of hesitancy and interventions to address hesitancy.

Recent Findings: Recent studies expand understanding of the prevalence of vaccine hesitancy globally and highlight associated individual and contextual factors. Common concerns underlying hesitancy include uncertainty about the need for vaccination and questions about vaccine safety and efficacy. Sociodemographic factors associated with parental vaccine hesitancy vary across locations and contexts. Studies about psychology of hesitancy and how parents respond to interventions highlight the role of cognitive biases, personal values, and vaccination as a social contract or norm. Evidence-based strategies to address vaccine hesitancy include presumptive or announcement approaches to vaccine recommendations, motivational interviewing, and use of immunization delivery strategies like standing orders and reminder/recall programs. A smaller number of studies support use of social media and digital applications to improve vaccination intent. Strengthening school vaccine mandates can improve vaccination rates, but policy decisions must consider local context.

Summary: Vaccine hesitancy remains a challenge for child health. Future work must include more interventional studies to address hesitancy and regular global surveillance of parental vaccine hesitancy and vaccine content on social media.
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http://dx.doi.org/10.1097/QCO.0000000000000774DOI Listing
October 2021

Pediatricians' Knowledge and Practices Related to Mumps Diagnosis and Prevention.

J Pediatr 2021 12 25;239:81-88.e2. Epub 2021 Aug 25.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO.

Objectives: To assess pediatricians' mumps knowledge and testing practices, to identify physician and practice characteristics associated with mumps testing practices, and to assess reporting and outbreak response knowledge and practices.

Study Design: Between January and April 2020, we surveyed a nationally representative network of pediatricians. Descriptive statistics were generated for all items. The χ test, t tests, and Poisson regression were used to compare physician and practice characteristics between respondents who would rarely or never versus sometimes or often/always test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting.

Results: The response rate was 67% (297 of 444). For knowledge, more than one-half of the pediatricians responded incorrectly or "don't know" for 6 of the 9 true/false statements about mumps epidemiology, diagnosis, and prevention, and more than one-half reported needing additional guidance on mumps buccal swab testing. For testing practices, 59% of respondents reported they would sometimes (35%) or often/always (24%) test for mumps in a vaccinated 17-year-old with parotitis in a non-outbreak setting; older physicians, rural physicians, and physicians from the Northeast or Midwest were more likely to test for mumps. Thirty-six percent of the pediatricians reported they would often/always report a patient with suspected mumps to public health authorities.

Conclusions: Pediatricians report mumps knowledge gaps and practices that do not align with public health recommendations. These gaps may lead to underdiagnosis and underreporting of mumps cases, delaying public health response measures and contributing to ongoing disease transmission.
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http://dx.doi.org/10.1016/j.jpeds.2021.08.036DOI Listing
December 2021

An Examination of Employee Immunization Policies Among Colorado Child Care Providers.

J Pediatric Infect Dis Soc 2021 Jul 28. Epub 2021 Jul 28.

Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Child care employee vaccination policies can protect children and adults from vaccine-preventable diseases (VPDs) in child care programs. We aimed to understand the prevalence and characteristics of employee immunization policies at child care facilities and support among child care administrators for statewide employee vaccination regulations.

Methods: A postal mail survey was distributed to a cross-sectional sample of 300 center-based and 300 home-based child care programs in Colorado. Programs were asked to report whether they had any type of policy requiring employee immunizations and if they would support statewide regulations mandating employee immunizations for influenza, pertussis, and measles.

Results: The response rate was 48% (288/600). About 55% of child care programs reported having an employee immunization policy. Child care centers (73%) were more likely than home-based child care programs (30%, P < .001) to report having a policy. Overall, 62% of respondents reported that they would support one or more statewide regulations requiring child care employees to be vaccinated. Home-based programs (71%) were more likely than center-based programs (53%, P = .001) to support one or more statewide child care employee immunization regulations.

Conclusions: Our findings demonstrate the variability of employee immunization policies at child care programs across Colorado. These results may be used to inform strategies to increase employee immunization uptake and reduce the incidence of VPDs, including developing comprehensive employee immunization policies at the facility and state level. Future research is needed to understand vaccination knowledge, attitudes, and behaviors among child care employees including their perspectives on employee vaccination policies and regulations.
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http://dx.doi.org/10.1093/jpids/piab062DOI Listing
July 2021

Why Aren't We Achieving High Vaccination Rates for Rotavirus Vaccine in the United States?

Acad Pediatr 2021 Jul 10. Epub 2021 Jul 10.

National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (MM Cortese, JE Tate, JL St. Pierre, and MC Lindley), Atlanta, Ga.

Background: Rotavirus vaccine (RV) coverage levels for US infants are <80%.

Methods: We surveyed nationally representative networks of pediatricians by internet/mail from April to June, 2019. Multivariable regression assessed factors associated with difficulty administering the first RV dose (RV#1) by the maximum age.

Results: Response rate was 68% (303/448). Ninety-nine percent of providers reported strongly recommending RV. The most common barriers to RV delivery overall (definite/somewhat of a barrier) were: parental concerns about vaccine safety overall (27%), parents wanting to defer (25%), parents not thinking RV was necessary (12%), and parent concerns about RV safety (6%). The most commonly reported reasons for nonreceipt of RV#1 by 4 to 5 months (often/always) were parental vaccine refusal (9%), hospitals not giving RV at discharge from nursery (7%), infants past the maximum age when discharged from neonatal intensive care unit/nursery (6%), and infant not seen before maximum age for well care visit (3%) or seen but no vaccine given (4%). Among respondents 4% strongly agreed and 25% somewhat agreed that they sometimes have difficulty giving RV#1 before the maximum age. Higher percentage of State Child Health Insurance Program/Medicaid-insured children in the practice and reporting that recommendations for timing of RV doses are too complicated were associated with reporting difficulty delivering the RV#1 by the maximum age.

Conclusions: US pediatricians identified multiple, actionable issues that may contribute to suboptimal RV immunization rates including lack of vaccination prior to leaving nurseries after prolonged stays, infants not being seen for well care visits by the maximum age, missed opportunities at visits and parents refusing/deferring.
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http://dx.doi.org/10.1016/j.acap.2021.07.003DOI Listing
July 2021

Physician attitudes regarding the Advisory Committee on Immunization Practices Adult Immunization Schedule.

Vaccine 2021 06 2;39(29):3799-3802. Epub 2021 Jun 2.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, United States; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.

The Advisory Committee on Immunization Practices (ACIP) was created out of the need to formalize vaccine recommendations for the United States. Annually, ACIP delivers recommendations to the CDC director for guidance about United States vaccine use and publishes the Adult Immunization Schedule. Updated schedules feature changes to vaccine recommendations as well as changes to the schedule's usability for physicians. The objective of this study was to determine physicians' attitudes about the Adult Immunization Schedule. Surveys were administered to a sentinel physician network from October 2019 through January 2020. Physicians that responded were comfortable using the Adult Immunization Schedule, but reported confusion about some medical condition-based indications. Physicians reported a lack engagement with mobile applications, CDC Vaccine Schedules and Shots by STFM (the Society for Teachers of Family Medicine). Future work should focus on increasing clarity regarding the recommendations with medical condition-based indications and increasing knowledge of mobile applications for physicians.
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http://dx.doi.org/10.1016/j.vaccine.2021.05.055DOI Listing
June 2021

Case 2: Early-Onset Neonatal Sepsis in a Term Neonate.

Neoreviews 2021 06;22(6):e402-e405

Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.

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http://dx.doi.org/10.1542/neo.22-6-e402DOI Listing
June 2021

Unraveling Attributes of COVID-19 Vaccine Hesitancy and Uptake in the U.S.: A Large Nationwide Study.

medRxiv 2021 Jul 2. Epub 2021 Jul 2.

SARS-CoV-2 vaccines are powerful tools to combat the COVID-19 pandemic, but vaccine hesitancy threatens these vaccines’ effectiveness. To address COVID-19 vaccine hesitancy and ensure equitable distribution, understanding the extent of and factors associated with vaccine acceptance and uptake is critical. We report the results of a large nationwide study conducted December 2020-May 2021 of 34,470 users from COVID-19-focused smartphone-based app How We Feel on their willingness to receive a COVID-19 vaccine. Nineteen percent of respondents expressed vaccine hesitancy, the majority being undecided. Of those who were undecided or unlikely to get a COVID-19 vaccine, 86% reported they ultimately did receive a COVID-19 vaccine. We identified sociodemographic and behavioral factors that were associated with COVID-19 vaccine hesitancy and uptake, and we found several vulnerable groups at increased risk of COVID-19 burden, morbidity, and mortality were more likely to be vaccine hesitant and had lower rates of vaccination. Our findings highlight specific populations in which targeted efforts to develop education and outreach programs are needed to overcome vaccine hesitancy and improve equitable access, diversity, and inclusion in the national response to COVID-19.
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http://dx.doi.org/10.1101/2021.04.05.21254918DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043469PMC
July 2021

Primary Care Physicians' Perspective on Pharmacists Delivering Vaccines to Adults.

J Am Board Fam Med 2021 Mar-Apr;34(2):392-397

From the Department of Pharmacy, Children's Hospital Colorado, Aurora, (CEM); Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora (LPH, STO, JRC, LAC, CG, MB, BLB, AK); Division of General Internal Medicine, Denver Health, Denver, CO (LPH); Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora (STO, JRC, MB, AK); Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora (LAC).

Introduction: Since 2009, pharmacists in all 50 states have been authorized to provide vaccinations to adults. The objective of this study was to assess primary care physicians' (PCPs) experiences with and attitudes about pharmacists administering vaccinations.

Methods: Internet and mail survey of PCPs representative of American College of Physicians' and American Academy of Family Physicians' memberships.

Results: Response rate was 69% (642/926). Ninety-eight percent of respondents agreed (79% "Strongly," 19% "Somewhat") that it is their responsibility to assure their adult patients receive recommended vaccinations. Most respondents agreed that pharmacists either did not have access to patient medical information (33% "Strongly," 45% "Somewhat") or did not have adequate vaccination history (33% "Strongly," 41% "Somewhat"). The majority also agreed that pharmacists did not inform them when vaccinations were given (35% "Strongly," 39% "Somewhat") and did not enter vaccinations administered into immunization information systems (IISs) (20% "Strongly," 37% "Somewhat"). However, 83% agreed (31% "Strongly," 52% "Somewhat") that it is helpful to have pharmacists share the role of vaccinating adults.

Conclusions: PCPs have mixed feelings about pharmacists delivering vaccines. Universal use of IISs by pharmacists could partially address physicians' concerns by providing a systematic way for pharmacists and physicians to share patient vaccination histories.
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http://dx.doi.org/10.3122/jabfm.2021.02.200486DOI Listing
September 2021

The Many Costs of Measles Outbreaks and Undervaccination: Why We Need to Invest in Public Health.

Pediatrics 2021 04 12;147(4). Epub 2021 Mar 12.

Section of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado

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http://dx.doi.org/10.1542/peds.2020-035303DOI Listing
April 2021

Changes in Strength of Recommendation and Perceived Barriers to Human Papillomavirus Vaccination: Longitudinal Analysis of Primary Care Physicians, 2008-2018.

J Pediatr 2021 Jul 6;234:149-157.e3. Epub 2021 Mar 6.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO.

Objectives: To evaluate among pediatricians and family physicians human papillomavirus (HPV) vaccination recommendation practices for 11- to 12-year-old youth; report parental refusal/deferral of HPV vaccination; and report barriers to HPV vaccination changed over time.

Study Design: We surveyed nationally representative networks of pediatricians and family physicians in 2008, 2010, 2013-2014, and 2018. Male vaccination questions were not asked in 2008; barriers and parental vaccine refusal questions were not asked in 2010.

Results: Response rates were 80% in 2008 (680/848), 72% in 2010 (609/842), 70% in 2013-2014 (582/829), and 65% in 2018 (588/908). The proportion of physicians strongly recommending HPV vaccination for 11- to 12-year-old patients increased from 53% in 2008 to 79% in 2018 for female patients and from 48% in 2014 to 76% in 2018 for male patients (both P < .0001). The proportion of physicians indicating ≥50% of parents refused/deferred HPV vaccination remained steady for female patients (24% in 2008 vs 22% in 2018, P = .40) and decreased for male patients (42% in 2014 vs 28% in 2018, P < .001). Physician barriers to providing HPV vaccination were rare and decreased over time. Increasing numbers of physicians reported perceived parental barriers of vaccine safety concerns (5% "major barrier" in 2008 vs 35% in 2018, P < .0001) and moral/religious concerns (5% in 2008 vs 25% in 2018, P < .0001).

Conclusions: Between 2008 and 2018, more primary care physicians reported recommending HPV vaccination for adolescents, fewer reported barriers, and more physicians reported parents who had vaccine safety or moral/religious concerns.
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http://dx.doi.org/10.1016/j.jpeds.2021.03.002DOI Listing
July 2021

Addressing Vaccine Concerns: A Hopeful Path Forward for Vaccine Confidence.

Am J Public Health 2021 04;111(4):556-558

Both authors are affiliated with the Adult and Child Consortium for Health Outcomes Research and Delivery Science at the University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, and are members of the Department of Pediatrics at the University of Colorado Anschutz Medical Campus.

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http://dx.doi.org/10.2105/AJPH.2020.306150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958069PMC
April 2021

Shared Clinical Decision-Making Recommendations for Adult Immunization: What Do Physicians Think?

J Gen Intern Med 2021 08 2;36(8):2283-2291. Epub 2021 Feb 2.

Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.

Background: In 2019, the Advisory Committee on Immunization Practices (ACIP) incorporated the terminology "shared clinical decision-making" (SDM) into recommendations for two adult vaccines.

Objective: To assess among general internal medicine physicians (GIMs) and family physicians (FPs) nationally (1) attitudes about and experience with ACIP SDM recommendations, (2) knowledge of insurance reimbursement for vaccines with SDM recommendations, (3) how SDM recommendations are incorporated into vaccine forecasting software, and (4) physician and practice characteristics associated with not knowing how to implement SDM.

Design: Survey conducted in October 2019-January 2020 by mail or internet based on preference.

Participants: Networks of GIMs and FPs recruited from American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) who practice ≥ 50% in primary care. Post-stratification quota sampling performed to ensure networks similar to ACP and AAFP memberships.

Main Measures: Responses on 4-point Likert scales (attitudes/experiences), true/false options (knowledge), and categorical response options (forecasting). Multivariable modeling with outcome of "not knowing how to implement SDM" conducted.

Key Results: Response rate was 64% (617/968). Most physicians strongly/somewhat agreed SDM requires more time than routine recommendations (90%FP; 95%GIM, p = 0.02) and that they need specific talking points to guide SDM discussions (79%FP; 84%GIM, p = NS). There was both support for SDM recommendations for certain vaccines (81%FP; 75%GIM, p = 0.06) and agreement that SDM creates confusion (64%FP; 76%GIM, p = 0.001). Only 41%FP and 43%GIM knew vaccines recommended for SDM would be covered by most health insurance. Overall, 38% reported SDM recommendations are displayed as "recommended" and 23% that they did not result in any recommendation in forecasting software. In adjusted multivariable models, GIMs [risk ratio 1.44 (1.15-1.81)] and females [1.28 (1.02-1.60)] were significantly associated with not knowing how to implement SDM recommendations CONCLUSIONS: To be successful in a primary care setting, SDM for adult vaccination will require thoughtful implementation with decision-making support for patients and physicians.
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http://dx.doi.org/10.1007/s11606-020-06456-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8342675PMC
August 2021

Use of High-Dose Influenza and Live Attenuated Influenza Vaccines by US Primary Care Physicians.

J Gen Intern Med 2021 07 22;36(7):2030-2038. Epub 2021 Jan 22.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA.

Background: Several different types of influenza vaccine are licensed for use in adults in the USA including high-dose inactivated influenza vaccine (HD-IIV) and live attenuated influenza vaccine (LAIV). HD-IIV is licensed for use in adults ≥ 65 years, and recommendations for use of LAIV have changed several times in recent years.

Objective: We sought to examine family physicians' (FPs) and general internal medicine physicians' (GIMs) perceptions, knowledge, and practices for use of HD-IIV and LAIV during the 2016-2017 and 2018-2019 influenza seasons.

Design: E-mail and mail surveys conducted February-March 2017, January-February 2019.

Participants: Nationally representative samples of FPs and GIMs.

Main Measures: Surveys assessed HD-IIV practices (2017), knowledge and perceptions (2019), and LAIV knowledge and practices (2017, 2019).

Key Results: Response rates were 67% (620/930) in 2017 and 69% (642/926) in 2019. Many physicians believed HD-IIV is more effective than standard dose IIV in patients ≥ 65 years (76%) and reported their patients ≥ 65 years believe they need HD-IIV (67%). Most respondents incorrectly thought ACIP preferentially recommends HD-IIV for adults ≥ 65 years (88%); 65% "almost always/always" recommended HD-IIV for adults ≥ 65 years. Some physicians incorrectly thought ACIP preferentially recommends HD-IIV for adults < 65 years with cardiopulmonary disease (38%) or immunosuppression (48%); some respondents recommended HD-IIV for these groups (25% and 28% respectively). In 2017, 88% of respondents knew that ACIP recommended against using LAIV during the 2016-2017 influenza season, and 4% recommended LAIV to patients. In 2019, 63% knew that ACIP recommended that LAIV could be used during the 2018-2019 influenza season, and 8% recommended LAIV.

Conclusions: Many physicians incorrectly thought ACIP had preferential recommendations for HD-IIV. Physicians should be encouraged to use any available age-appropriate influenza vaccine to optimize influenza vaccination particularly among older adults and patients with chronic conditions who are more vulnerable to severe influenza disease.
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http://dx.doi.org/10.1007/s11606-020-06397-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8298749PMC
July 2021

US Primary Care Physicians' Viewpoints on HPV Vaccination for Adults 27 to 45 Years.

J Am Board Fam Med 2021 Jan-Feb;34(1):162-170

From Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO (LPH, STO, LAC, JRC, MB, BLB, CG, AK); Division of General Internal Medicine, Denver Health, Denver, CO (LPH); Department of Pediatrics, Children's Hospital-Colorado, Aurora, CO (STO, JRC, MB, AK); National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA (LEM, EM, MCL); Department of Community and Behavioral Health, University of Colorado Anschutz Medical Campus, Aurora, CO (LAC).

Introduction: In June 2019, the Advisory Committee on Immunization Practices (ACIP) recommended shared clinical decision making (SCDM) regarding human papillomavirus (HPV) vaccination for adults 27 to 45 years. Our objectives were to assess among primary care physicians 1) recent practice regarding HPV vaccination for adults 27 to 45 years, 2) knowledge of HPV and the new SCDM recommendation, and 3) attitudes toward and anticipated effect of the new SCDM recommendation.

Methods: From October to December 2019, we administered an Internet and mail survey to national networks of 494 general internist (GIM) and 474 family physician (FP) members of the American College of Physicians and American Academy of Family Physicians, respectively.

Results: Response rate was 64% (617/968; GIM, 57%; FP, 71%). Fifty-eight percent were aware of the new ACIP recommendation; 42% had recommended HPV vaccination to adults 27 to 45 years, but most had administered HPV vaccine to very few of these patients (73% to 0% and 22% to 1 to 3). Fifty-five percent and 63% were unaware that HPV vaccination does not prevent progression of existing HPV-related cancers or infections, respectively and 57% were not sure what to emphasize when having a SCDM conversation about HPV vaccination. A majority reported they will be more likely recommend HPV vaccination to adults in the 27-to-45-year age range as a result of the new recommendation.

Conclusions: Physicians are interested in recommending HPV vaccination for adults age 27 to 45 years despite ACIP not routinely recommending it in this age range. The majority need more education about the optimal use of HPV vaccine in this age group.
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http://dx.doi.org/10.3122/jabfm.2021.01.200408DOI Listing
August 2021

Motivational Interviewing for Maternal Immunisation (MI4MI) study: a protocol for an implementation study of a clinician vaccine communication intervention for prenatal care settings.

BMJ Open 2020 11 17;10(11):e040226. Epub 2020 Nov 17.

Adult and Child Consortium for Health Outcomes Research and Delivery Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

Introduction: Vaccination against influenza and pertussis in pregnancy offers a 'two-for-one' opportunity to protect mother and child. Pregnant patients have increased risk of severe disease from influenza and newborns have increased risk of severe disease from both influenza and pertussis. Obstetricians need communication tools to support their self-efficacy and effectiveness in communicating the importance of immunisation during pregnancy and ultimately improving maternal vaccination rates.

Methods And Analysis: We describe the protocol for a pragmatic study testing the feasibility and potential impact of a clinician communication strategy on maternal vaccination uptake. This study will be conducted in five prenatal care settings in Colorado, USA. The Motivational Interviewing for Maternal Immunisation strategy involves training prenatal care providers to use motivational interviewing in the vaccine conversation with pregnant patients. Our primary outcomes will be the adoption and implementation of the intervention measured using the Enhanced RE-AIM/Practical Robust Implementation and Sustainability Model for dissemination and implementation. Secondary outcomes will include provider time spent, fidelity to Motivational Interviewing and self-efficacy measured through audio recorded visits and provider surveys, patients' visit experience based on audio recorded visits and follow-up interviews, and maternal vaccine uptake as measured through chart reviews.

Ethics And Dissemination: This study is approved by the following institutional review boards: Colorado Multiple Institutional Review Board. Results will be disseminated through peer-reviewed manuscripts and conference presentations.

Trial Registration Number: NCT04302675.
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http://dx.doi.org/10.1136/bmjopen-2020-040226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7674098PMC
November 2020

Policies Among US Pediatricians for Dismissing Patients for Delaying or Refusing Vaccination.

JAMA 2020 09;324(11):1105-1107

Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus, Aurora.

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http://dx.doi.org/10.1001/jama.2020.10658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492908PMC
September 2020

Impact of media reports regarding influenza vaccine on obstetricians' vaccination practices.

Vaccine 2020 04 21;38(18):3474-3479. Epub 2020 Mar 21.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, United States; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.

Background: In 2017, three media stories regarding influenza vaccine may have impacted obstetricians' (OB) influenza vaccination practices: reports of reduced influenza vaccine effectiveness, a severe influenza season, and a possible increased risk of miscarriage among pregnant women receiving 2009 H1N1 vaccine in the 1st trimester who had received H1N1 vaccine the previous season (later disproven).

Objective: Describe OB's: (1) awareness of; (2) attitudes and experiences related to; and (3) reported alterations in practice as a result of these reports.

Methods: A survey among a nationally representative sample of OBs April to June 2018.

Results: Response rate was 65% (302/468). 88% of OBs were "very aware" of the severe season, 74% of lower effectiveness, and 25% of the miscarriage study (47% "completely unaware" of miscarriage study). Among those aware, 58%, 57%, and 16% reported ≥10% of pregnant patients initiated discussions about the severe season, lower effectiveness, and miscarriage study, respectively. Most (83%) agreed reports about increased severity increased their enthusiasm for recommending influenza vaccine; fewer agreed reports about the miscarriage study (18%) and lower vaccine effectiveness (12%) decreased their enthusiasm for recommending influenza vaccine. Providers were more likely to initiate discussion with patients about increased severity of the season than the other reports. However, 35% agreed the miscarriage study reports increased their concerns about influenza vaccine safety; 18% (n = 48) reported changing the way they recommended influenza vaccine. Of those, 17 (6% of all respondents) reported not recommending influenza vaccine to women during the 1st trimester and 26 (10% of all respondents) recommended it but were willing to delay until the 2nd trimester.

Conclusions: During a season in which media stories could have influenced OB influenza vaccination behaviors in different directions, reports underscoring importance of influenza vaccine may have had more impact on OBs' recommendations than reports questioning vaccine safety or effectiveness.
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http://dx.doi.org/10.1016/j.vaccine.2020.02.051DOI Listing
April 2020

The potential population-based impact of an HPV vaccination intervention in Colorado.

Cancer Med 2020 02 23;9(4):1553-1561. Epub 2019 Dec 23.

University of Colorado Cancer Center, Aurora, CO, USA.

Background: Human papillomavirus (HPV) infection is the most common cause of cervical cancer and can be prevented with vaccination, but HPV vaccination rates remain low. An intervention to improve health care provider communication about vaccination has been shown to increase HPV vaccination rates in an initial trial in Colorado, where about 160 cases of cervical cancer are diagnosed each year.

Methods: Census data were combined with Colorado cancer and immunization registry data to identify clinics in locations that would most benefit from implementation of this intervention to improve HPV vaccination rates. ArcGIS Pro was used to map cervical cancer incidence, immunization rates, population data, and location of clinics participating in practice-based research networks (PBRNs). Results from the provider communication intervention trial and published estimates of the number needed to vaccinate to prevent a case of cervical cancer were used to predict the number of cervical cancer cases prevented based on increased vaccination due to the intervention.

Results: Ninety-eight Colorado PBRN clinics were analyzed. For the 10 clinics with the highest predicted number of cervical cancer cases prevented, 5218 additional patients would be vaccinated and 43 cervical cancer cases prevented with implementation of the intervention. If implemented in all 98 clinics, the intervention would lead to 20 490 additional patients vaccinated (range 7-658/clinic) and 171 cases of cervical cancer prevented (range 0.05-5.48/clinic).

Conclusions: Geographic data from cancer and immunization registries can inform the dissemination of evidence-based practices like the provider communication intervention for HPV vaccination to maximize impact on public health.
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http://dx.doi.org/10.1002/cam4.2803DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7013051PMC
February 2020

Evidence-based strategies to increase vaccination uptake: a review.

Curr Opin Pediatr 2020 02;32(1):151-159

Department of Pediatrics, Section of Pediatric Infectious Diseases, University of Colorado School of Medicine.

Purpose Of Review: To summarize evidence-based strategies for improving pediatric immunization rates including physician behaviors, clinic and public health processes, community-based and parent-focused interventions, and legal and policy approaches RECENT FINDINGS: Studies continue to show the effectiveness of audit and feedback, provider reminders, standing orders, and reminder/recall to increase immunization rates. Provider communication strategies may improve immunization rates including use of a presumptive approach and motivational interviewing. Centralized reminder/recall (using a state Immunization Information System) is more effective and cost-effective compared to a practice-based approach. Recent work shows the success of text messages for reminder/recall for vaccination. Web-based interventions, including informational vaccine websites with interactive social media components, have shown effectiveness at increasing uptake of pediatric and maternal immunizations. Vaccination requirements for school attendance continue to be effective policy interventions for increasing pediatric and adolescent vaccination rates. Allowance for and ease of obtaining exemptions to vaccine requirements are associated with increased exemption rates.

Summary: Strategies to increase vaccination rates include interventions that directly impact physician behavior, clinic and public health processes, patient behaviors, and policy. Combining multiple strategies to work across different settings and addressing different barriers may offer the best approach to optimize immunization coverage.
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http://dx.doi.org/10.1097/MOP.0000000000000843DOI Listing
February 2020

Addressing personal parental values in decisions about childhood vaccination: Measure development.

Vaccine 2019 09 14;37(38):5688-5697. Epub 2019 Aug 14.

University of Colorado, Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO, United States; University of Colorado School of Medicine, Department of Family Medicine, United States.

Objective: Evidence-based strategies to address vaccine hesitancy are lacking. Personal values are a measurable psychological construct that could be used to deliver personalized messages to influence vaccine hesitancy and behavior. Our objectives were to develop a valid, reliable self-report survey instrument to measure vaccine values based on the Schwartz theory of basic human values, and to test the hypothesis that vaccine values are distinct from vaccine attitudes and are related to vaccine hesitancy and behavior.

Methods: Parental Vaccine Values (PVV) scale items were generated using formative qualitative research and expert input, yielding 24 items for testing. 295 parents of children aged 14-30 months completed a self-report survey with measures of Schwartz's global values, the PVV, vaccine attitudes, and vaccine hesitancy. Factor analysis was used to determine vaccine values factor structure. Associations between vaccine values, vaccine attitudes, vaccine hesitancy, and vaccination behavior were assessed using linear and logistic regression models. Late vaccination was assessed from electronic medical records.

Results: A six-factor structure for vaccine values was determined with good fit (RMSEA = 0.07, Bentler's CFI = 0.91) with subscales for Conformity, Universalism, Tradition, Self-Direction, Security- Disease Prevention, and Security- Vaccine Risk. Vaccine values were moderately associated with Schwartz global values and vaccine attitudes, indicating discriminant validity from these constructs. Multivariable linear regression showed vaccine hesitancy was associated with vaccine values Conformity (partial R = 0.10) and Universalism (0.04) and vaccine attitudes Vaccine Safety (0.52) and Vaccine Benefit (0.16). Multivariable logistic regression showed that late vaccination was associated with vaccine value Self-direction (OR = 1.80, 95% CI: 1.26-2.65) and vaccine attitude of Vaccine Benefit (OR = 0.44, 95% CI: 0.32-0.60).

Conclusions: The PVV scale had good psychometric properties and appears related to but distinct from Schwartz global values and vaccine attitudes. Vaccine values are associated with vaccine hesitancy and late vaccination and may be useful in tailoring future interventions.
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http://dx.doi.org/10.1016/j.vaccine.2019.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752201PMC
September 2019

Survey of Adult Influenza Vaccination Practices and Perspectives Among US Primary Care Providers (2016-2017 Influenza Season).

J Gen Intern Med 2019 10 19;34(10):2167-2175. Epub 2019 Jul 19.

Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 13123 East 16th Ave, Box 055, Aurora, CO, 80045, USA.

Background: Seasonal influenza vaccination is recommended for all adults; however, little is known about how primary care physicians can communicate effectively with patients about influenza vaccination.

Objective: To assess among general internal medicine (GIM) and family physicians (FP) regarding adult influenza vaccination: (1) recommendation and administration practices, (2) barriers to discussing and perceived reasons for patient refusal, and (3) factors associated with physician self-efficacy in convincing patients to be vaccinated.

Design: Email and mail survey conducted in February-March 2017 PARTICIPANTS: Nationally representative sample of GIM and FP MAIN MEASURES: Factor analysis was used to group similar items for multivariable analysis of barriers and strategies associated with high physician self-efficacy about convincing patients to be vaccinated (defined as disagreeing that they could do nothing to change resistant patients' minds).

Key Results: Response rate was 67% (620/930). Ninety-eight percent always/almost always recommended influenza vaccine to adults ≥ 65 years, 90% for adults 50-64 years, and 75% for adults 19-49 years. Standing orders (76%) and electronic alerts (64%) were the most commonly used practice-based immunization strategies. Frequently reported barriers to discussing vaccination were other health issues taking precedence (41%), time (29%), and feeling they were unlikely to change patients' minds (24%). Fifty-eight percent of physicians reported high self-efficacy about convincing patients to be vaccinated; these providers reported fewer patient belief barriers contributing to vaccine refusal (RR = 0.93 per item; 95% CI (0.89-0.98); Cronbach's α = 0.70), were more likely to report using both fact- (1.08/item; (1.03-1.14); 0.66) and personal experience-based (1.07/item; (1.003-1.15); 0.65) communication strategies, and were more likely to work in practices using patient reminders for influenza vaccine (1.32; (1.16-1.50)).

Conclusions: Physicians identified barriers to successfully communicating about adult influenza vaccination but few effective strategies to counter them. Interventions to promote self-efficacy in communication and under-utilized practice-based immunization strategies are needed.
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http://dx.doi.org/10.1007/s11606-019-05164-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816593PMC
October 2019

A 4-Year-Old Boy With an Unusual Bacterial Meningitis Infection.

J Pediatric Infect Dis Soc 2019 07;8(3):282-283

Divisions of Pediatric Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora.

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http://dx.doi.org/10.1093/jpids/piy096DOI Listing
July 2019

Impact of publicly available vaccination rates on parental school and child care choice.

Vaccine 2018 07 13;36(30):4525-4531. Epub 2018 Jun 13.

Department of Pediatrics, Section of Infectious Diseases, University of Colorado Denver, 13123 East 16th Avenue, Aurora, CO 80045, USA; Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Denver, 13199 East Montview Blvd, Aurora, CO 80045, USA. Electronic address:

Objective: Several states require schools and child cares to report vaccination rates, yet little is known about the impact of these policies. Our objectives were to assess: (1) predicted impact of vaccination rates on school/child care choice, (2) differences between vaccine hesitant and non-hesitant parents, and (3) differences by child's age.

Methods: In 2016, a cross-sectional email survey of Colorado mothers with children ≤12 years old assessed value of vaccination rates in the context of school/child care choice. A willingness-to-pay framework measured preference for schools/child cares with different vaccination rates using tradeoff with commute time.

Results: Response rate was 42% (679/1630). Twelve percent of respondents were vaccine hesitant. On a scale where 1 is "not important at all" and 4 is "very important" parents rated the importance of vaccination rates at 3.08. Respondents (including vaccine-hesitant respondents) would accept longer commutes to avoid schools/child cares with lower vaccination rates. Parents of child-care-age children were more likely to consider vaccination rates important.

Conclusions: This study shows parents highly value vaccination rates in the context of school and child care choice. Both hesitant and non-hesitant parents are willing to accept longer commute times to protect their children from vaccine-preventable diseases.
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http://dx.doi.org/10.1016/j.vaccine.2018.06.013DOI Listing
July 2018

Vaccine Hesitancy: Where We Are and Where We Are Going.

Clin Ther 2017 Aug 31;39(8):1550-1562. Epub 2017 Jul 31.

Department of Pediatrics, Sections of Pediatric Infectious Diseases and General Academic Pediatrics, University of Colorado Denver/Anschutz Medical Campus, Children's Hospital Colorado/University of Colorado School of Medicine, and Adult and Child Consortium for Health Outcomes Research and Delivery Science, Denver, Colorado.

Purpose: Vaccines represent one of the most important aspects of pediatric preventive care. However, parents are increasingly questioning the safety of and need for vaccines, and as a result, vaccination rates have fallen to dangerously low levels in certain communities. The effects of vaccine hesitancy are widespread. Community pediatricians who interact regularly with vaccine-hesitant parents report higher levels of burnout and lower levels of job satisfaction. Not surprisingly, vaccine hesitancy has also had direct influence on vaccination rates, which in turn are linked to increased emergency department use, morbidity, and mortality.

Methods: Literature from 1999 to 2017 regarding vaccines and vaccine hesitancy was reviewed.

Findings: Few evidence-based strategies exist to guide providers in their discussions with vaccines-hesitant parents. Recent research has shown a presumptive approach (ie, the provider uses language that presumes the caregiver will vaccinate his or her child) is associated with higher vaccination uptake. Motivational interviewing is a promising technique for more hesitant parents.

Implications: At the community level, evidence-based communication strategies to address vaccine hesitancy are needed. The practice of dismissing families from pediatric practices who refuse to vaccinate is common, although widely criticized. Other controversial and rapidly evolving topics include statewide vaccination mandates and school exemption policies. Electronic interventions, such as text-messaging services and social media, have recently emerged as effective methods of communication and may become more important in coming years.
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http://dx.doi.org/10.1016/j.clinthera.2017.07.003DOI Listing
August 2017

Measles, the media, and MMR: Impact of the 2014-15 measles outbreak.

Vaccine 2016 12 3;34(50):6375-6380. Epub 2016 Nov 3.

Department of Pediatrics, Section of Infectious Diseases, University of Colorado Denver, 13123 East 16th Avenue, Aurora, CO 80045, USA; Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado Denver, 13199 East Montview Blvd, Aurora, CO 80045, USA. Electronic address:

Objective: In late 2014, a measles outbreak beginning in California received significant media attention. To better understand the impact of this outbreak, we conducted a survey to assess and compare among vaccine hesitant and non-hesitant new mothers how this outbreak affected vaccine knowledge, attitudes, vaccination plans, and media use.

Methods: A cross-sectional email survey of English-speaking women with a child ⩽1year old using a convenience sample of women from nine obstetrics and gynecology (OB/GYN) practices in Colorado assessed vaccine hesitancy, knowledge and attitudes about MMR vaccines and the outbreak, MMR vaccination plans before and after the outbreak, and use of and trust for media sources related to the outbreak.

Results: The response rate was 50% (351/701). Knowledge about the outbreak was high and vaccination attitudes were mostly favorable. Forty-eight percent of respondents thought MMR vaccine was more important after the outbreak. Online news (76%), television news (75%), and social media (68%) were the most frequently used media sources, yet were highly trusted by only 18%, 22%, and 1% of respondents respectively. Government websites (34%) and information from a doctor's office (34%) were infrequently used, but were highly trusted by 62% and 60% of respondents. Knowledge of the outbreak was lower among vaccine-hesitant respondents. Few mothers changed MMR vaccination plans after the outbreak.

Conclusions: New mothers had high levels of knowledge and favorable attitudes about vaccination after the 2014-15 measles outbreak. Media sources used the most are not the most trusted. Communication about outbreaks of vaccine-preventable diseases should include spread of accurate information to new media sources and strengthening of existing trust in traditional media.
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http://dx.doi.org/10.1016/j.vaccine.2016.10.048DOI Listing
December 2016
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