National Vaccination Recommendations Research Articles

Vaccinations in patients diagnosed with an autoimmune disorder receiving an immunosuppressive agent: a best practice implementation project.

Immunosuppressed patients face increased health risks due to infections such as influenza or COVID-19. Scientific evidence supports improved health-related outcomes in this patient population, such as reduced hospitalizations, with up-to-date vaccinations. The project setting, a community-based rheumatology clinic, did not have a vaccination record specific to the needs of immunosuppressed patients, which may lead to a suboptimal immunization status in these patients. This project aimed to promote evidence-based practices regarding the use of vaccinations in patients diagnosed with autoimmune disorders receiving immunosuppressive agents. This project used the JBI evidence implementation framework to promote best practices regarding vaccination. Two audit criteria were identified using a JBI Evidence Summary. Baseline audits identified gaps between the evidence and current practice. Barriers to best practice were then identified, and strategies implemented. Post-implementation audits measured changes in compliance. Baseline audits revealed 67% compliance with the two best practices. Barriers included a lack of provider awareness of the current vaccination recommendations for immunosuppressed patients and a lack of customizable vaccine records. Strategies to address these barriers included educating providers about current national vaccination recommendations and implementing a new patient vaccination history intake form. Post-implementation audits revealed 83% compliance, with a 16% increase from baseline. This evidence-based implementation project enhanced best practices by educating providers and implementing an updated patient vaccination history form. Recommendations include the improved compliance with the use of the new form and to assess the effectiveness and usability of a customizable electronic form that interfaces with the clinic's electronic medical records.

Implementing Effective Care in a University Population Based on National Vaccination Recommendations.

Vaccines are among the most cost-effective and successful medical interventions, saving approximately 2.3 million lives annually. Unfortunately, vaccination coverage for adults remains low, leading to unnecessary and costly health consequences. An initial chart review revealed that 95% (N = 20) of students were not up to date with vaccines. In a patient survey, 100% of students (N = 21) did not recall receiving useful vaccine information, but 66.7% reported it would be helpful (≥4 of 5 on the Likert scale). Strategies supporting effective care, an Institute of Medicine quality domain, were used to address these gaps. The aim was to increase effective care in university adult students for vaccines by 30% over 90 days. The quality improvement method of Plan-Do-Study-Act cycles was used to evaluate iterative tests of change. Examining contextual elements, team and patient feedback, aggregate data, and run charts informed tests of change over 4 cycles. Core interventions included enhanced screening, vaccine shared decision-making, provider checklists, and a team engagement plan. Greater than 83% (N = 152) of students were not up to date with vaccines as per national guidelines. Over 8 weeks, the team effectively referred students for 265 of the 274 vaccines they were eligible for-an accuracy rate of 95.3%. The aim score, a mean composite score reflecting all 3 interventions, increased from 49% to 95%. Effective care for vaccine uptake increased by 83.8%-far exceeding the goal. Campus health centers and other primary care settings could benefit from adopting a similar strategy that provides clear benefits to patients and the broader community while decreasing health care costs.

TBE-antibody titer study: Is a booster already necessary after 5 years?

As long as there is only symptomatic treatment against thick-borne encephalitis (TBE) available, vaccination is considered the only prevention against infection.The national vaccination recommendations prescribe a booster vaccination every 5 years after a basic vaccination has been carried out. This study deals with the question if antibodies in sufficient concentration exist or not when the last immunization had been five years ago.The TBE titer was determined in 168 subjects using indirect ELISA and the vaccination history was collected.The results show that 97.3 % of the participants have a sufficient titer 5 years after the last booster vaccination. The time period since the last booster and the type of the vaccine influence the antibody level the most. In conclusion, it was found that by controlling the titer, it is possible to postpone a booster vaccination, if the immunization is still sufficient.

Knowledge, Attitudes, and Practices of European Healthcare Professionals towards Hepatitis A and Hepatitis B Vaccination in at-Risk Adults.

Despite the occurrence of several hepatitis A (hepA) and hepatitis B (hepB) outbreaks in Europe in the last few decades, not all European countries have implemented hepA and hepB vaccinations in their national immunization programs, especially for adults at risk for hepA and/or hepB infection, such as men who have sex with men or patients with chronic liver disease. Currently, little is known on the attitudes of European healthcare professionals (HCPs) towards hepA and hepB vaccinations for at-risk adults. We conducted an online survey among HCPs in Germany, Spain, and the United Kingdom to assess their awareness of and adherence to their national hepA and hepB vaccination guidelines for at-risk adults. Among the 698 HCPs who took the survey, most (91.1%) were familiar with their national vaccination recommendations and always followed them or followed them most of the time when advising or prescribing hepA or hepB vaccines. Major and moderate barriers for recommending or administering such vaccines were the non-disclosure of risk factors by the patient (53.0-57.6%) and the patient's lack of motivation or knowledge about the risk of the disease (50.3-52.9%). These results may help inform strategies to improve and accelerate hepA and hepB vaccination in European at-risk adults.

A dynamic transmission model to calculate vaccination coverage needed to control COVID-19 in Germany

Abstract Background Control of the 2019 coronavirus disease (COVID-19) pandemic in Germany and return to pre-pandemic behaviour can only be achieved through natural or vaccine-induced immunity. Sufficient vaccine capacity promotes interest in the necessary and feasible target vaccination coverage. Methods An age and risk group stratified SEIR transmission model was used to assess the impact of vaccination coverage ranging 65%-95% for 12-59-year-olds and 90%-95% for ≥ 60-year-olds on COVID-19 incidence and intensive care unit (ICU) utilization between 01.07.2021-31.03.2022. Separate implementation of licensed vaccines allows to consider different efficacies, delivery rates and age-specific national vaccination recommendations. The analysis was conducted under different assumptions about contact behaviour during summer, reduction of daily contacts with increasing number of cases, daily vaccination uptake and the dominant variant. Data from the COVIMO study (N = 3004, data collection: 17.05.-09.06.2021) were used to define the population percentage willing to be vaccinated. Results The COVIMO study indicates an achievable vaccination compliance rate of 83.9% among 12-59-year-olds and 94.8% among those ≥ 60-year-olds. Maximum incidence or ICU utilization during observation period decreases from 385 to 61 and 6220 to 2800, respectively, with an increase in vaccination coverage from 65% to 95% of 12-59-year-olds, 90% vaccination rate among ≥ 60-year-olds, compared to pre-pandemic reduced contact behaviour in summer and reduction of contacts as case numbers increase. Conclusions The vaccination campaign should be continued at high intensity until at least 85% of 12-59-year-olds or 90% of ≥ 60-year-olds are fully vaccinated against COVID-19. Based on the population's willingness to be vaccinated, this goal seemed feasible. Key messages • Mathematical modeling was used to determine an evidence-based target vaccination coverage of ≥ 85%. • Expertise in modeling should be further strengthened.

Descriptive study of pneumococcal vaccination in cases of inflammatory disease: Analysis of practices

IntroductionPneumococcal infections are frequent and potentially serious in patients with inflammatory diseases treated with immunosuppressants and/or biotherapies. This patient population considered to be at very high risk of infection is subject to national vaccination recommendations. The main objective of this study was to assess pneumococcal vaccine coverage in a day hospital (internal medicine and vascular disease) in patients treated with immunosuppressants. MethodsAn observational, descriptive, retrospective, and single-center study. We included 150 consecutive patients for 3 months (February to April 2018). We studied pneumococcal vaccination coverage and the time elapsed between the date of vaccination with the 13-valent polysaccharide conjugate vaccine (PCV13) and the start of immunosuppressive therapy. ResultsAmong the 150 patients included in the study, vaccination coverage with PCV13 was 85% (127/150) and decreased to 46.7% (70/150) for the recommended vaccination schedule. Taking into account vaccine efficacy according to the date of initiation of the treatment, only 28.7% (43/150) of the patients in the study were able to benefit from an optimal complete vaccination schedule, i.e. 33.8% (43/127) among patients vaccinated with PCV13. ConclusionDespite official recommendations, vaccination coverage against pneumococcus remains insufficient in patients under immunosuppressants and/or biotherapies. In addition to the continued training of doctors, optimizing computer prescription of vaccines in view of facilitating vaccination tracing and having vaccination carried out at the site of consultation are avenues for improvement to be considered.

Estimates of the Health and Economic Burden of Pneumococcal Infections Attributable to the 15-Valent Pneumococcal Conjugate Vaccine Serotypes in the USA.

IntroductionDespite the availability of vaccines, pneumococcal disease (PD) is associated with high clinical and economic burden, mainly caused by non-vaccine serotypes and certain vaccine-type serotypes. V114 is a 15-valent pneumococcal conjugate vaccine (PCV) that contains two epidemiologically important serotypes, 22F and 33F, in addition to the 13 serotypes in 13-valent PCV (PCV13). This study quantified the epidemiologic and economic burden of PD attributable to V114 serotypes among adults in the USA.MethodsA Markov model was used to estimate the burden of V114 serotypes in a hypothetical, non-vaccinated cohort of US adults ≥ 19 years of age who were tracked from 2019 until death. The model calculated all the invasive pneumococcal disease (IPD) and non-bacteremic pneumococcal pneumonia (NBPP) cases, deaths, and costs. Economic burden was estimated from a healthcare payer perspective (2019 US dollars) and discounted at 3%.ResultsThe model estimated 415,229 and 10.3 million lifetime cases of V114-type IPD and NBPP, respectively. Serotypes 22F and 33F caused approximately 33% of IPD cases and 20% of NBPP cases, while serotype 3 accounted for approximately 36% of IPD cases and 13% of NBPP cases. V114 serotypes caused 472,063 total lifetime deaths. Total discounted lifetime costs attributable to V114 serotypes were $44.8 billion US dollars.ConclusionsIn this hypothetical model of a non-vaccinated cohort of US adults, V114 serotypes were associated with a substantial health and economic burden, the majority of which was attributable to serotypes 3, 22F, and 33F. The addition of V114 to the national vaccination recommendations may help to reduce the epidemiologic and economic burden associated with PD in adults ≥ 19 years of age in the USA by providing increased coverage of these serotypes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-022-00588-x.

Impact of a pharmacist‐led pneumococcal vaccination outreach program in a primary care setting

AbstractIntroductionStreptococcus pneumoniae is a leading cause of bacterial infections and leads to 1.5 million hospitalizations annually. Vaccinations are one of the most important and cost‐effective tools available in healthcare to prevent infectious diseases. However, gaps still exist between what is recommended and actual vaccination rates in the United States.ObjectiveThe primary objective of this study was to assess the impact of a newly implemented pharmacist‐led pneumococcal vaccination outreach program on overall PPSV23 rates in the primary care setting.MethodsThis was a retrospective, quasi‐experimental study conducted following the implementation of a newly developed, pharmacist‐led, vaccination outreach program as part of a novel standard of care practice implemented in two primary care offices. Pharmacists provided direct patient outreach through telephone calls to all patients deemed eligible for PPSV23 that met inclusion criteria. Pharmacists provided counseling on PPSV23 and action steps to receive the vaccine at the office through appointment. The primary outcome of change in vaccination rates was assessed 90 days after patient outreach. Secondary outcomes assessed feasibility, common barriers to vaccination, coadministration with influenza vaccination, and revenue changes.ResultsA total of 762 patients were contacted under the outreach program. Overall PPSV23 vaccination rates significantly increased following the implementation of the pharmacist‐led vaccination outreach program (54.1% vs 60.5%, P < 0.001). Of the 398 patients reached, 38.9% accepted the recommendation for PPSV23 and 66.5% of those patients had confirmed administration. Approximate revenue generation secondary to the program was $5568.85.ConclusionA pharmacist‐led PPSV23 vaccination outreach program significantly increased the rate of PPSV23 vaccination in two primary care offices, leading to improved compliance with national vaccination recommendations and revenue generation.

Are patients with rheumatic diseases on immunosuppressive therapies protected against preventable infections? A cross-sectional cohort study

ObjectiveTo evaluate the prevalence of infections, prevalence of hospitalisation due to infections, the vaccination status and perceived screening of infections prior to the start of biologic disease modifying antirheumatic drugs...

Incorporation of health economic evaluation into immunization policy-making in Canada: Barriers and facilitators

IntroductionDespite the WHO recommendation that economic evidence be considered in national vaccine recommendations, this element of decision-making has been lacking or not done routinely in Canada. This study aimed to investigate barriers and facilitators to using economic evaluations in public health immunization programs decision-making across Canadian jurisdictions. MethodsThis mixed methods study consisted of a cross-sectional survey and semi-structured interviews of national, provincial and territorial public health level key informants, and of members of the national immunization research network in Canada. Barriers were categorized according to accessibility (e.g. access to human resources to conduct the evaluation) and acceptability (e.g. political resistance to using the evaluation). ResultsOf 63 survey participants, 12 were federal, provincial or territorial key informants (response rate 12/31, 39%) and 51 were members from the research network (response rate 51/214, 24%). Eleven stakeholders gave semi-structured interviews. All respondents support increased use of economic evaluation and of it becoming a routine part of immunization policy-making. However, 70% of the survey respondents identified limited resources (human and financial) to perform economic evaluations, and 39% reported lack of expertise to interpret economic evidence. Vaccine effectiveness and the burden of disease were seen as more important than cost-effectiveness by survey respondents and interviewees. Potential facilitators were for economic evaluations to either be conducted at the national level, or through a collaboration between provinces and territories with capacity to address shared needs so that evaluations occurred in a co-ordinated but distributed way. Recommendations:Barriers to incorporation of economic evaluation in immunization policy-making in Canada include lacking human and financial resources to conduct them and understanding of economic evidence. National, provincial and territorial public health actors reported that facilitators to incorporating economic evidence include developing increased capacity to conduct and use economic evaluations and establishing inter-jurisdictional systems to share the work of conducting economic evaluation and/or by national leadership.

Policy support for expanding the adolescent vaccine school mandate in Pennsylvania to include the human papillomavirus (HPV) vaccine

Approximately 27,000 men and women are affected by human papillomavirus (HPV)-related cancer every year. The Advisory Committee for Immunization Practices and the Centers for Disease Control and Prevention (CDC) routinely recommend that adolescents receive HPV, tetanus, diphtheria, and acellular pertussis (tetanus-diphtheria-acellular pertussis [Tdap]) and meningococcal (MCV) vaccines at age 11-12 years. Although the CDC and professional organizations such as the American Academy of Pediatrics make national vaccine recommendations, according to the National Vaccine Information Center, it is the responsibility of "state health departments to make and enforce vaccine mandates for school entry." The Pennsylvania Department of Health has only mandated two of the recommended three vaccinations: Tdap and MCV. As of 2016, 92% of adolescents aged 13-17 years in Pennsylvania received the Tdap vaccine and 92.7% received the MCV. However, only 58% of females and 44.4% of males aged 13-17 years received all three doses of the HPV vaccine. A comparison of HPV vaccine rates in states with school mandates was compared with Pennsylvania rates. Human papillomavirus vaccination rates were found to be significantly higher in the District of Columbia and Rhode Island, which have HPV vaccine school-entry requirements, supporting the need for a statewide HPV mandate in Pennsylvania.

Vaccine hesitancy in Austria : A cross-sectional survey.

Vaccine hesitancy is an emerging phenomenon particularly in industrialized nations. It has led to repeated epidemic outbreaks of otherwise vaccine-preventable, infectious diseases. Compared to other countries very low rates of influenza and measles vaccination rates have been reported in Austria. We performed asingle-center cross-sectional, questionnaire-based survey. A total of 350 adult patients attending our emergency room participated in this survey. We assessed knowledge and attitudes towards vaccination and the associated infectious diseases. Out of 350 participants 40 (11.4 %) declared that they deliberately refused vaccinations. Most common reasons for non-vaccination were fear of adverse effects (35.9 %), doubt of effectiveness of vaccines (35.9 %) and distrust towards the pharmaceutical industry (23.1 %). Of all 350 participants only 148 (42.3 %) thought themselves to be sufficiently informed about national vaccination recommendations as stated in the Austrian National Vaccination Program (ANVP). General practitioners (GP) were the primary source of healthcare-related information for 256 (73.1 %) participants. Furthermore, GPs as well as hospital-based physicians achieved the highest level of trust in this study population. The results of our study underline the necessity of comprehensive informational campaigns on the merits of vaccination. Alack of knowledge about the benefits of vaccination, uncertainty and unfounded fears seem to prevent the achievement of recommended vaccination rates. Family GPs enjoyed the highest levels of trust in our study population. We believe that additional information communicated by GPs could help boost the low vaccination rates. This study underlines the important role of primary care practitioners in informing patients about vaccines and healthcare topics.

Characteristics and practices of National Immunisation Technical Advisory Groups in Europe and potential for collaboration, April 2014.

In many countries, national vaccination recommendations are developed by independent expert committees, so-called national immunisation technical advisory groups (NITAG). Since the evaluation of vaccines is complex and resource-demanding, collaboration between NITAGs that evaluate the same vaccines could be beneficial. We conducted a cross-sectional survey among 30 European countries in February 2014, to explore basic characteristics and current practices of European NITAGs and identify potential modes and barriers for collaboration. Of 28 responding countries, 26 reported to have a NITAG or an equivalent expert group. Of these, 20 apply a systematic approach in the vaccine decision-making process, e.g. by considering criteria such as country-specific disease epidemiology, vaccine efficacy/effectiveness/safety, health economics, programme implementation/logistics or country-specific values/preferences. However, applied frameworks and extent of evidence review differ widely. The use of systematic reviews is required for 15 of 26 NITAGs, while results from transmission modelling and health economic evaluations are routinely considered by 18 and 20 of 26 NITAGs, respectively. Twenty-five countries saw potential for NITAG-collaboration, but most often named structural concerns, e.g. different NITAG structures or countries’ healthcare systems. Our survey gathered information that can serve as an inventory on European NITAGs, allowing further exploration of options and structures for NITAG collaboration.

Überblick und Bewertung der verfügbaren Datenquellen zur Inzidenz impfpräventabler Krankheiten, zum Durchimpfungsgrad und zum Immunstatus in Deutschland

The surveillance of vaccine preventable diseases and vaccination coverage is necessary in order to deliver epidemiological data with respect to national vaccination recommendations and control targets. The data available on the incidence of vaccine preventable diseases, vaccination coverage, and immune status of the population are fragmentary and do not allow the epidemiological situation to be fully assessed. Although the majority of vaccine preventable diseases are under surveillance nationwide (by statutory reporting or sentinel surveillance), data are not available for some diseases. In addition, data on vaccination coverage are not collected centrally. Nationwide data on vaccination coverage are only available for children at school entry. Use of secondary data such as data from health insurance companies or associations of statutory health insurance physicians provides an opportunity to close gaps in knowledge and to improve the surveillance of vaccine preventable diseases.

Historical Comparisons of Morbidity and Mortality for Vaccine-Preventable Diseases in the United States

National vaccine recommendations in the United States target an increasing number of vaccine-preventable diseases for reduction, elimination, or eradication. To compare morbidity and mortality before and after widespread implementation of national vaccine recommendations for 13 vaccine-preventable diseases for which recommendations were in place prior to 2005. For the United States, prevaccine baselines were assessed based on representative historical data from primary sources and were compared to the most recent morbidity (2006) and mortality (2004) data for diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella (including congenital rubella syndrome), invasive Haemophilus influenzae type b (Hib), acute hepatitis B, hepatitis A, varicella, Streptococcus pneumoniae, and smallpox. Number of cases, deaths, and hospitalizations for 13 vaccine-preventable diseases. Estimates of the percent reductions from baseline to recent were made without adjustment for factors that could affect vaccine-preventable disease morbidity, mortality, or reporting. A greater than 92% decline in cases and a 99% or greater decline in deaths due to diseases prevented by vaccines recommended before 1980 were shown for diphtheria, mumps, pertussis, and tetanus. Endemic transmission of poliovirus and measles and rubella viruses has been eliminated in the United States; smallpox has been eradicated worldwide. Declines were 80% or greater for cases and deaths of most vaccine-preventable diseases targeted since 1980 including hepatitis A, acute hepatitis B, Hib, and varicella. Declines in cases and deaths of invasive S pneumoniae were 34% and 25%, respectively. The number of cases of most vaccine-preventable diseases is at an all-time low; hospitalizations and deaths have also shown striking decreases.

Konzept zur Verbesserung der Impfraten in Bayern

The aim of the Bavarian immunisation concept is the effective implementation of national vaccination recommendations taking into account known characteristics in Bavaria and social groups with limited access to vaccinations. Furthermore, it intends to coordinate the various players in the field of vaccine-prevention of disease. Key points of this concept are, among others, improvement of the available data, definition of vaccination aims, implementation of vaccination recall systems during the regular examination on entering primary and secondary school, coordination and enforcement of vaccination campaigns in schools as well as steps for the qualification and motivation of the physicians involved in vaccination. In addition, an independent committee for the coordination of professionals and institutions participating in vaccine prevention in Bavaria was created. This "Bayerische Landesarbeitsgemeinschaft Impfen (LAGI)", which was established at the end of 2006 includes representatives from medical associations and corporations, health insurance companies and public health agencies and is the key for the realisation and further development of this concept.

Varicella Vaccine, Cost-effectiveness Analyses, and Vaccination Policy

HAS VARICELLA VACCINATION BEEN AS COSTeffective as anticipated when it was universally recommended for children 10 years ago? The answer is complicated and illuminates an evolving controversy regarding the role of cost-effectiveness analyses in deliberations over national vaccine recommendations. In 1994, Lieu and colleagues estimated the costeffectiveness of a universal childhood varicella vaccination program. Projecting a national vaccination rate of 97% by the sixth year of the program, they estimated a 94% reduction in varicella incidence, accompanied by an 89% reduction in direct medical costs. Accounting as well for reductions in the quantity of parents’ and other adults’ lost work time attributable to varicella (ie, the “indirect” benefits of vaccination), Lieu et al projected that a varicella vaccination program would save more than $5 for every $1 spent. These projections of reduced varicella disease burden and direct medical costs with varicella vaccination appear prescient, even though they were based on optimistic vaccination rates. In this issue of JAMA, Zhou and colleagues present data from a national group of privately insured individuals in 1994-2002 that indicate reductions of nearly 90% in hospitalization rates for varicella, nearly 60% in ambulatory visit rates, and 74% in costs borne by health care payers— accomplished in an era when slightly more than 80% of US toddlers had been vaccinated against chickenpox. Cost reductions might have been even more substantial if Zhou et al had sufficient data to analyze pharmaceutical expenditures for antiviral agents that Lieu et al considered. Although the study by Zhou et al is based solely on trends among insured individuals, the magnitude of their findings corresponds well to patterns of varicella incidence and mortality collected without regard to payer and to varicellarelated hospitalization trends and associated charges collected on insured and uninsured children and adults. In addition, these data support the strong evidence of herd immunity against varicella in the vaccination era, with adults experiencing the benefits of children’s vaccination, and infants—who are not eligible for vaccination—showing the greatest reductions of all child age groups. Nonetheless, these findings do not conclusively confirm that childhood varicella vaccination is as cost-effective as originally anticipated, for several reasons. First, the cost of the vaccine has increased more than $10 per dose in inflationadjusted terms since 1995 (the current public sector price per dose is $52.25), although an increase of this magnitude was not anticipated to change the cost-effectiveness dramatically. Second, the national varicella vaccine recommendation prompted states to measure and react to varicella as a reportable vaccine-preventable illness. The costs of such monitoring and of responding to outbreaks of varicella (eg, in day care or school settings) may be substantial and were not included in the original analysis by Lieu et al. Third, and perhaps most important, there is great uncertainty about the extent to which parents and other adults experienced reductions in lost work time attributable to varicella. As with other childhood and adolescent vaccines that have recently been recommended (eg, pneumococcal and meningococcal conjugate vaccines), indirect cost savings with varicella vaccine were expected to be larger than savings in direct medical costs. With varicella vaccine, the ratio of indirect cost savings to direct cost savings was expected to be nearly 5:1. Despite the importance of indirect cost quantification to the evaluation of vaccination programs, there are no established mechanisms to measure such effects. Therefore, it is possible that the increasing value of work time over the past decade may have increased savings beyond what Lieu et al anticipated. Conversely, increasing unemployment may have allowed more parents to care for their ill children at home without missing work, effectively reducing savings attributable to the program. Both of these changes may have occurred disproportionately in specific sectors of the economy (eg, wage increases in the software industry and unemployment increases in the manufacturing industry) that may have different likelihoods of having young children in the household. These changes are plausible, but their magnitude remains unknown. Pointing out current limitations in measuring indirect benefits of vaccination programs may seem methodologically nitpicky, but it is more than an academic exercise. The contem-

The 2002 United States varicella vaccine shortage and physician recommendations for vaccination

Background. The US experienced a shortage of varicella vaccine in 2002, leading to the concerns about its impact. Methods. 204 Minnesota and Pennsylvania physicians, most (164) of whom were interviewed in 1999 on the topic of varicella vaccine, responded to a 2003 survey. Results. Although 67% were aware of the 2002 varicella vaccine shortage, 24% experienced it and only 45% were aware of the 2002 temporary change in national vaccination recommendations. In response, more vaccinated until the supply was exhausted (59%) than postponed vaccination as recommended (41%). Most (91%) reported that the shortage did not change their likelihood of recommending vaccine. From 1999 to 2003, the percentage of physicians highly likely to recommend vaccination increased from 73% to 82% for children 12–18 months old ( P < 0.01). In 2003, more physicians believed that it was likely for secondary skin infections to occur following varicella disease and for parents to request vaccination than in 1999 ( P < 0.01). Almost all (93%) physicians in both years believed that serious side effects were unlikely. Conclusions. Over half of physicians were unaware of the change in vaccine recommendations due to the shortage and many did not follow that change, suggesting the need for a different strategy.

Childhood immunization in rural Malawi: time of administration and predictors of non-compliance.

A cohort of 760 newborns was followed prospectively for 2 years to ascertain the time of administration of childhood vaccinations in rural Malawi and to study predictors of non-compliance with national vaccination recommendations. At 1 year of age, 99% of the infants were fully vaccinated against tuberculosis, 91% against polio, 90% against diphtheria, pertussis and tetanus and 64% against measles. At 2 years, the corresponding vaccination coverages were 99%, 93%, 93% and 84%. On average, all vaccinations were given 1-3 months later than recommended. Many of the delayed measles vaccinations were given during a separate vertical campaign, during which 25% of previously unvaccinated 21-23-month-old children were identified and immunized. Non-compliance with vaccination recommendations was associated with living in villages with no access to mobile vaccination teams, birth between April and June and birth at home. In this rural Malawian area, most vaccination services were functioning well. To increase measles vaccination coverage, regular outreach activities should be encouraged.