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Influenza immunization of chronically ill children in pediatric tertiary care hospitals Eve Dubé
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Kossowski , Caroline Quach & Monique Landry
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, Dominique Gagnon , Caroline Huot , Renée Paré , Solange Jacques , Alexandra h
a
Institut national de santé publique du Québec (INSPQ); Québec, Canada
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Centre de recherche du CHU de Québec; Québec, Canada
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Université Laval; Québec, Canada
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Direction de santé publique de la Capitale-Nationale; Québec, Canada
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Direction de santé publique de Montréal; Montréal, Québec, Canada
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Hôpital de Montréal pour enfants; Montréal, Québec, Canada
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Université McGill; Montréal, Québec, Canada
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Ministère de la santé et des Services sociaux; Montréal, Québec, Canada Accepted author version posted online: 31 Oct 2014.Published online: 19 Nov 2014.
To cite this article: Eve Dubé, Dominique Gagnon, Caroline Huot, Renée Paré, Solange Jacques, Alexandra Kossowski, Caroline Quach & Monique Landry (2014) Influenza immunization of chronically ill children in pediatric tertiary care hospitals, Human Vaccines & Immunotherapeutics, 10:10, 2935-2941, DOI: 10.4161/21645515.2014.970498 To link to this article: http://dx.doi.org/10.4161/21645515.2014.970498
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SHORT REPORT Human Vaccines & Immunotherapeutics 10:10, 2935--2941; October 2014; © 2014 Taylor & Francis Group, LLC
Influenza immunization of chronically ill children in pediatric tertiary care hospitals Eve Dub e1,2,3,*, Dominique Gagnon1, Caroline Huot4, Renee Pare5, Solange Jacques4, Alexandra Kossowski5, Caroline Quach6,7, and Monique Landry8 1 Institut national de sante publique du Quebec (INSPQ); Quebec, Canada; 2Centre de recherche du CHU de Quebec; Quebec, Canada; 3Universite Laval; Qu ebec, Canada; Direction de sant e publique de la Capitale-Nationale; Quebec, Canada; 5Direction de sante publique de Montreal; Montreal, Quebec, Canada; 6H^ opital de Montreal pour enfants; Montr eal, Quebec, Canada; 7Universite McGill; Montreal, Quebec, Canada; 8Ministere de la sante et des Services sociaux; Montreal, Quebec, Canada
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Keywords: acceptance, children, immunization, live attenuated influenza vaccine, pediatrics
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Abbreviations: LAIV, live attenuated influenza vaccine; KAB, knowledge, attitudes and behaviors; DSP, Direction de sant e publique, Regional Public Health Directorate; TIV, trivalent inactivated influenza vaccine
Despite a publicly funded immunization program and continuous promotional efforts, vaccine uptake for seasonal influenza in Quebec (Canada) remains under its goal of 80%. Missed opportunities can explain the low influenza vaccine rates among chronically ill children. To address that, demonstration projects using the live attenuated influenza vaccine (LAIV) were implemented in 3 pediatric tertiary care hospitals to evaluate the feasibility and acceptability of implementing influenza immunization of chronically ill children in hospitals’ outpatient clinics. A diary was used to document barriers and enabling factors regarding the implementation, and a questionnaire was distributed to healthcare professionals involved in the project in each hospital. Parent’s knowledge, attitudes and behaviors (KAB) about influenza immunization and acceptability of immunization in outpatient clinics were also measured with a questionnaire. As part of the project, 2,478 children were immunized. Enabling factors included the financial support received from Quebec ministry of Health, the nasal mode of administration of the LAIV and the presence of a leader specifically dedicated to influenza immunization. Barriers to influenza immunization in outpatient clinics included difficulties of hiring extra staff to work in immunization clinics and additional tasks added to regular activities of the clinics. Results from both questionnaires illustrated a high level of acceptability of seasonal influenza immunization in hospitals’ outpatient clinics by parents and healthcare professionals. Influenza immunization in pediatric tertiary care hospital is an effective way to reach chronically ill children and does not involve major feasibility or acceptability issues.
Introduction Annual immunization is an effective measure to prevent severe influenza outcomes. The Canadian National Advisory Committee on Immunization recommends influenza immunization for people at high risk of serious infection as well as for their contacts.1 Individuals aged 2 years with chronic medical conditions (e.g. cardiac and pulmonary disorders, diabetes, immunecompromised conditions, renal disease, asthma, etc.) are targeted by the publicly funded immunization program in Quebec.2 Influenza immunization of chronically ill children is important because they are particularly predisposed to more severe disease and complications.3 However, vaccine uptake in this group is sub-optimal and far from the public health goal of 80% uptake.4 After the 2011-2012 campaign, the influenza vaccine uptake was around 30% for individuals with chronic medical conditions aged between 18 and 59 years.5 There is no data for immunization coverage against influenza among chronically ill children aged 2–17 years. Results of a recent study conducted among a
representative sample of Quebec healthy children aged 2 years have indicated that only one out of 8 children were completely immunized against influenza (2 doses) after the 2011–2012 campaign.6 Studies have indicated that missed opportunities, in which vaccine-eligible individuals are seen for care but not immunized, contribute significantly to low influenza immunization rates among children with chronic medical conditions.7-11 Delivering immunization in clinical settings and reducing administrative barriers to obtaining immunization services within clinics are strategies enhancing access to immunization services. When combined with strategies to promote immunization, these strategies are effective to improve coverage.12-14 Indeed, offering seasonal influenza immunization in hospitals’ outpatient clinics could be a good way to reach chronically ill children. In addition, as of October 2012, the Quebec Committee on Immunization recommended the preferential use of the live attenuated influenza vaccine (LAIV) for non-immunosuppressed children aged 2-17 years.15 Because LAIV is an intranasal vaccine, it could reduce barriers related to patients’ fear of needles or fear of
*Correspondence to: Eve Dube; Email: [email protected] Submitted: 05/13/2014; Revised: 06/20/2014; Accepted: 07/03/2014 http://dx.doi.org/10.4161/21645515.2014.970498
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injection pain.16 In this context, demonstration projects were funded by the Quebec ministry of Health to assess the feasibility and acceptability of offering LAIV to chronically ill children in hospital outpatient clinics where children are coming for their scheduled visits. This paper reports the organizational barriers and facilitators to influenza immunization of chronically ill children in outpatient clinics; parents’ and healthcare professionals’ acceptance of LAIV and their acceptance of influenza immunization at the hospital.
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Results Diaries The modalities of implementation varied slightly, but the vaccine was offered to parents of chronically ill children in all hospitals by regular staff of the outpatient clinic (nurses or doctors) during scheduled visits. Parents who agreed could have their child immunized right after the consultation without having to come back to the clinic. In one hospital, the vaccine was also offered to household contacts (parents and siblings) of chronically ill children. As part of the project, 2,478 children were immunized. In all 3 hospitals, the financial support offered by the Quebec ministry of Health was an important facilitator for the implementation of seasonal influenza immunization. The possibility to have clinics dedicated to immunization was also identified as well as the presence of a physician or nurse responsible for the implementation of the immunization campaign. The implementation was easier in one outpatient clinic where influenza immunization had been offered in the past, because some logistical aspects were already in place (premises, refrigerator for vaccine storage, etc.). Finally, the nasal mode of administration of the LAIV and the tolerability of the vaccine were identified as facilitating influenza immunization in all 3 centers. In 2 hospitals, barriers to influenza immunization in outpatient clinics included the difficulties in hiring extra staff to work during the immunization campaign. In-these 2 hospitals where it was impossible to hire dedicated staff, the fact that influenza immunization was added to the regular activities of the clinic was acknowledged as an important barrier. In one hospital, the fact that it was impossible to immunize household contacts of chronically ill children because TIV was not available was identified as a barrier. Finally, research activities related to the evaluation of the project (in particular, the distribution of questionnaires to patients) were adding to the workload of the staff and were identified as another barrier in 2 hospitals. Questionnaires to parents Overall, 236 questionnaires were completed. The objective of 500 questionnaires was not reached, mostly because questionnaires were not distributed in one center in Montreal. Most participants were mothers (78%) and 2 third (64%) were living in Montreal. The most frequent medical conditions of the children coming to the outpatient clinic were diabetes (25%) or chronic cardiac or pulmonary disorder (20%). The proportion of chronically ill children who were part of the study reflected the expected
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demography: school-aged (6- and 17-years-old) represented 62% of the population (31% were aged between 6- and 11-years-old and 31% were aged between 12- and 17-years-old) and children aged between 2- and 5-years-old represented 26% of the population. More than 9 out of 10 parents believed that seasonal influenza immunization was useful to protect the health of chronically ill individuals, and the majority considered intranasal immunization against seasonal influenza as being safe and effective. More than one-third of parents of an eligible child (35%) reported that their child was immunized the year before the study. At the time of the study, 12% of children were aged less than 2 years-old and thus were not eligible to receive the LAIV and 7% of parents reported that their child had already received the vaccine before completing the questionnaire. Among parents of unimmunized children, 29% of parents said they intended to have their child immunized against seasonal influenza, 27% of parents said they intended not to have their child immunized, and 44% were undecided (Fig. 1). Protection against seasonal influenza and high perceived vulnerability of the child were the main reasons mentioned by parents who intended to have their child immunized (Table 1). Low perceived vulnerability or low perceived severity of the disease were the main reasons mentioned by parents who indicated not having the intention to have their child immunized (Table 1). Almost 60% (n D 135) of children whose parents completed the questionnaire were immunized against seasonal influenza during their scheduled visit in the outpatient clinic. Among these children, 65% (n D 88) received the LAIV and 31% (n D 42) the TIV (unknown vaccine received for 5 children). Seventy-9 children (79) who had not received the vaccine in the year preceding the study received the seasonal influenza vaccine in the outpatient clinic (among these children, 6 were less than 2 yearsold and may have been ineligible for seasonal influenza immunization at that time). The main reason mentioned by parents for choosing the LAIV was that it was “easy, without using needles and without pain.” The main reason for having the child immunized with TIV was a contraindication to receive LAIV. Almost all parents of the 88 children who received the LAIV estimated that it was easy for their child to receive the LAIV (91% very easy, 6% somewhat easy). Moreover, 97% of parents wished that their child receive LAIV again next year (83% fully agree, 14% somewhat agree). Among parents of immunized children, 95% considered that hospital outpatient clinic was the best place to have their child immunized (74% fully agree, 21% somewhat agree), and 96% would want to have their child immunized in the outpatient clinic in the future (Fig. 2). Questionnaire to healthcare professionals Overall, 37 questionnaires were completed by healthcare professionals and managers for a response rate of 49% (37/76). Most respondents were physicians (62%, n D 23) or nurses (27%, n D 10) and were mainly working in outpatient clinics (68%, n D 25). Around one-third of healthcare professionals had been practicing between 10-19 years (30%, n D 11) and 41% (n D 15) had been practicing for 20 years or more.
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Figure 1. Seasonal influenza vaccination in pediatric tertiary care hospitals.
The majority of participants (70%) indicated having received the seasonal influenza vaccine in 2012–2013. Protection of vulnerable patients was the main reason mentioned by those who have received the vaccine while doubt regarding the vaccine effectiveness was the main reason mentioned by those who were not immunized. All respondents indicated that seasonal influenza immunization of chronically ill children was useful (86% strongly agreed, 11% agreed). More than 95% of healthcare professionals and managers estimated that the LAIV was effective (49% strongly agreed, 43% agreed) and safe (59% strongly agreed, 35% agreed). Almost all also considered that the LAIV has been well accepted by parents (81% strongly agreed, 16% agreed) and by healthcare professionals (78% strongly agreed,
22% agreed). When asked to compare the efficacy and safety of vaccines against seasonal influenza, the majority considered LAIV as effective (62%) or more effective (38%) than TIV. LAIV was also considered as safe (74%) or safer (21%) than TIV. Almost all respondents felt their knowledge about LAIV and TIV was sufficient for their practice (one-third strongly agreed with both statements). During the 2012-2013 campaign, the majority of respondents mentioned having recommended seasonal influenza immunization to parents for themselves (49% strongly agreed, 16% agreed) and for their child (54% strongly agreed, 24% agreed). Seventy-3 percent (73%) of respondents reported having administered both LAIV and TIV, 5% reported use of LAIV only while 19%
Table 1. Parents’ main reasons for accepting or refusing influenza vaccine for their child Main reasons for having accepted the influenza vaccines (n D 64)
n
%
Protection against seasonal influenza High perceived susceptibility to influenza (by example: underlying disease) Having received a recommendation (family/friend/healthcare professional) Protection of a relative/at-risk person/pregnancy/children Daycare center attendance Social responsibility/Following recommendations/ General positive attitude about vaccination No answer Main reasons for having refused the influenza vaccines (n D 60) Low perceived susceptibility to influenza or severity of the infection Unnecessary/ No beneficial Doubts regarding vaccine efficacy Against medication and vaccines Fear of shot Othersa No answer
17 15 5 3 2 1 21
27% 23% 8% 5% 3% 2% 33%
9 5 4 2 2 6 32
15% 8% 7% 3% 3% 10% 53%
a
Included reasons as contraindication for vaccination, no daycare attendance, etc.
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indicated not having administered vaccine. Respondents who have used LAIV strongly agreed (86%) or agreed (14%) that it was easy to immunize children with a nasal spray. Almost all professionals perceived that implementing influenza immunization for chronically ill children in pediatric tertiary care hospital was useful and feasible (Table 2). Most respondents also judged that offering influenza immunization in outpatient clinics has been perceived positively by hospital staff and patients. Overall, 78% of respondents judged that the implementation modalities of the demonstration project were appropriate. Respondents were also asked about common questions or concerns raised by parents in regard to LAIV. According to the respondents, most frequent concerns and questions of parents were around vaccine safety (67%), efficacy (62%) or utility (59%). Almost half of professionals mentioned that parents had little or no concerns about LAIV (14% strongly agreed, 30% agreed).
Discussion The recommendation of Quebec Immunization Committee to use LAIV preferentially to TIV for children with chronic medical conditions as well as the low influenza vaccine uptake in this group provided an interesting opportunity to assess the acceptability and feasibility of influenza immunization in hospitals’ outpatient clinics. Findings from the evaluation of the 3 demonstration projects indicate that there were no major
feasibility or acceptability issues to the implementation of seasonal influenza immunization in outpatient clinics. Barriers were mainly linked to increase in workload for staff, especially if no additional staff was hired. Successful conditions for implementation included: financial support, dedicated staff and dedicated clinics as well as the presence of a positive leader or “immunization champion” to support the immunization campaign. These conditions already were been identified in the literature to increase seasonal influenza vaccine uptake of healthcare workers.17 Immunization in pediatric tertiary care hospital has been well accepted by parents and the majority of them expressed high willingness to have their child immunized in the outpatient clinic in the future. Even if the majority of parents considered influenza immunization as being safe and effective, only a small proportion of them did immunize their child during the scheduled visit. Indeed, educational efforts should be done to ensure that parents are adequately informed about the importance of seasonal influenza immunization for chronically ill children and about the availability of LAIV. Promotional and informational material on that topic should be available in outpatient clinics, reaching most parents of chronically ill children. Few barriers to influenza immunization in outpatient clinics have been reported by healthcare professionals involved in the demonstration projects. The majority of healthcare professionals expressed interest in pursuing seasonal influenza immunization in the outpatient clinics in the future. Healthcare professionals’ recommendations have previously been shown to be an
Figure 2. bFour missing answers given for both questions were excluded from the analysis.
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Table 2. Perceptions of the demonstration project for the seasonal influenza vaccination of children with chronic conditions in hospital clinics In your opinion, the seasonal flu vaccination of children with chronic conditions in outpatient clinics Is beneficial Is feasible Was viewed positively by patients Was viewed positively by clinic staff
Strongly agree n (%)
Agree n (%)
Agree somewhat n (%)
Disagreec n (%)
No answer n (%)
33 (89%) 32 (86%) 27 (73%) 23 (62%)
1 (3%) 2 (5%) 6 (16%) 9 (24%)
1 (3%) 1 (3%) 3 (8%) 3 (8%)
0 1 (3%) 0 0
2 (5%) 1(3%) 1(3%) 2 (5%)
c
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Including 3 levels of disagreement (disagree somewhat, disagree, strongly disagree).
important determinant of vaccine uptake in their patients.18-23 It will be important to reiterate to physicians and nurses the importance of recommending influenza immunization to at-risk patients and to inform them about the recommendations regarding LAIV use, as many studies have shown the importance of physicians’ recommendations to increase seasonal influenza immunization uptake among chronically ill children.3,24 Offering the influenza vaccine in pediatric tertiary care hospital also seems to have reached chronically ill children who may have not been immunized otherwise. For instance, 79 of the 143 eligible children who were not immunized the year before the project received the vaccine as part of the demonstration project. Because chronically ill children regularly visit outpatient clinics, offering seasonal influenza immunization in these settings is an effective approach to reduce missed opportunities.25 Results of this evaluation should be interpreted in the light of some limitations. First, as in most questionnaires, responses are subject to self-report biases, including social desirability, which is the tendency of respondents to reply in a manner that will be viewed favorably by others. In our study, this could have led to more positive answers toward influenza vaccination. However, the fact that the questionnaire was anonymous should have reduced socially desirable responses. Second, questionnaires to parents were not distributed in one of the site, which limits the generalizability of the results. In addition, not all parents answered every survey question which could have led to response bias, especially regarding reasons behind the intention to have their child vaccinated against influenza. Finally, response rate for the healthcare professionals’ questionnaire was only 49% and there is a potential for non-participation bias. No information on non-respondents was available. In conclusion, this evaluation demonstrated that influenza immunization in pediatric tertiary care hospital is a feasible and acceptable way to reach and immunize chronically ill children. Although offering seasonal influenza immunization in outpatient clinics inevitably necessitates additional resources and organizational efforts, it is the preferred setting to reduce missed opportunities to immunize chronically ill children.
Material and Methods Setting In Quebec, chronically ill children targeted by the publicly funded immunization program against influenza are those aged
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between 6 months and 17 years of age with the following chronic health conditions: chronic cardiac or pulmonary disorder; chronic condition such as diabetes; inborn error of metabolism; severe obesity (defined as a BMI > 40); hepatic disorder; haematological disorder; cancer; immune deficiency. Influenza vaccination is also indicated and offered free of charge to children and adolescents with conditions treated for long periods with acetylsalicylic acid or with another medical condition that could compromise the elimination of respiratory secretions and increase the risk of aspiration (e.g., a cognitive disorder, spinal cord injury, seizure disorder, etc.). Demonstration projects were implemented in 3 tertiary care hospitals located in the 2 largest cities in the province of Quebec: Montreal (2 hospitals) and Quebec City (one hospital). In each hospital, a physician was responsible for project’s implementation, often in collaboration with nurses. Public health professionals working at the Regional Public Health Directorate (Directions de sante publique, DSP) were also supporting the project by ensuring collaboration between the provincial (Quebec ministry of Health) and local (the hospital) levels. Data collection Three sources of data were used. First, a diary was used to document barriers and facilitators to the implementation of influenza immunization in outpatient clinics. This diary was designed to record information about project implementation in regard to 15 specific topics (such as information about the project given to other healthcare workers, training of staff involved in the project, promotion to patients, logistic aspects – premises, vaccine storage – surveillance of adverse events following immunization, etc.). For each topic, information was recorded on the chosen modes of organization, the person who was responsible for this aspect, the level of implementation (none, partial, complete), the challenges or difficulties encountered as well as facilitators. The diaries were completed by the physicians leading the project in each hospital in collaboration with the public health professionals at the DSP. Information was recorded in diaries between January and April 2013, after the end of the 2012–2013 immunization campaign. To ensure that all important information was recorded, physicians received a blank version before the launch of the immunization campaign. In the second and the third week of the demonstration project, administrative support staff distributed a questionnaire to every parent of chronically ill children upon clinic registration. Parents who agreed to participate could fill the questionnaire
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Figure 3. Data collection procedures.
during the waiting time before consultation. In addition to familial socio-demographic characteristics, the first section of the questionnaire was designed to collect information about: 1) past seasonal influenza immunization of the child; 2) opinions regarding the safety and efficacy of seasonal influenza vaccine; 3) parents’ intention to have their child immunized at the outpatient clinic and 4) main reasons for intending to immunize their child or not. The next section was designed to be completed by the healthcare professional after the consultation and contained questions on the medical conditions of the child, contraindications for seasonal influenza immunization and recommendations given to parents (LAIV, trivalent inactivated influenza vaccine (TIV) or no vaccine). For parents who chose to have their child immunized, the second page of the questionnaire was completed during the waiting time after immunization and contained questions regarding their experience and level of satisfaction regarding the immunization at the outpatient clinic. The final questionnaire contained 9 close-ended questions for all parents (8 additional questions were asked to parents of children who were immunized at the clinic) and 4 questions for healthcare professionals. The goal was to distribute 500 questionnaires to patients (150 in Quebec City and 175 in each hospital in Montreal). After the 2012–2013 immunization campaign, all healthcare professionals and managers involved in the demonstration project
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in each hospital (n D 76) were asked to complete a short questionnaire. The questionnaire contained 20 questions designed to collect information about: 1) knowledge, attitudes and practices regarding seasonal influenza immunization; 2) opinions regarding the demonstration project (barriers and facilitators) and 3) socio-professional characteristics. Figure 3 illustrates the data collection procedures.
Data analysis Diaries were submitted to qualitative content analysis. Findings were summarized and returned for validation to physicians leading the project in each hospital. If needed, corrections were made. Data collected by both questionnaires were analyzed separately. Descriptive statistics were generated for all variables. The exact verbatim of the open-ended questions were submitted to content analysis. Statistical analyses were performed using SAS version 9.3 while content analysis was first done using Microsoft Word processing software and then imported into SAS.
Disclosure of Potential Conflicts of Interest
No potential conflicts of interest were disclosed.
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Acknowledgments
Funding
We would like to thank all professionals who participated in this project.
We would like to thank the Quebec ministry of Health and Social services for the study funding.
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17. Hollmeyer H, Hayden F, Mounts A, Buchholz U. Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza Other Respir Viruses 2013; 7:604-21; PMID:22984794; http://dx.doi.org/10.1111/irv.12002 18. Hollmeyer HG, Hayden F, Poland G, Buchholz U. Influenza vaccination of health care workers in hospitals–a review of studies on attitudes and predictors. Vaccine 2009; 27:3935-44; PMID:19467744; http:// dx.doi.org/10.1016/j.vaccine.2009.03.056 19. Posfay-Barbe KM, Heininger U, Aebi C, Desgrandchamps D, Vaudaux B, Siegrist CA. How do physicians immunize their own children? Differences among pediatricians and nonpediatricians. Pediatrics 2005; 116:e623-33; PMID:16263976; http://dx.doi.org/ 10.1542/peds.2005-0885 20. Katz-Sidlow RJ, Sidlow R. A look at the pediatrician as parent: experiences with the introduction of varicella vaccines. Clin Pediatr (Phila) 2003; 42:635-40; PMID:14552523; http://dx.doi.org/10.1177/ 000992280304200710 21. Zimmerman RK, Bradford BJ, Janosky JE, Mieczkowski TA, DeSensi E, Grufferman S. Barriers to measles and pertussis immunization: the knowledge and attitudes of Pennsylvania primary care physicians. Am J Prev Med 1997; 13:89-97; PMID:9088444 22. Connors CM, Miller NC, Krause VL. Universal hepatitis B vaccination: hospital factors influencing firstdose uptake for neonates in Darwin. Aust N Z J Public Health 1998; 22:143-5; PMID:9599867; http://dx. doi.org/10.1111/j.1467-842X.1998.tb01159.x 23. Clark SJ, Cowan AE, Wortley PM. Influenza vaccination attitudes and practices among US registered nurses. American journal of infection control 2009; 37:551-6; PMID:19556035; http://dx.doi.org/10.1016/j.ajic.2009. 02.012 24. Soyer OU, Hudaverdiyev S, Civelek E, Isik E, Karabulut E, Kocabas C, Sekerel BE. Parental perspectives on influenza vaccination in children with asthma. Pediatr Pulmonol 2011; 46:139-44; PMID:20812246; http:// dx.doi.org/10.1002/ppul.21332 25. Bhat-Schelbert K, Lin CJ, Matambanadzo A, Hannibal K, Nowalk MP, Zimmerman RK. Barriers to and facilitators of child influenza vaccine - Perspectives from parents, teens, marketing and healthcare professionals. Vaccine 2012; 30:2448-52; PMID:22300721; http:// dx.doi.org/10.1016/j.vaccine.2012.01.049
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Human Vaccines & Immunotherapeutics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/khvi20
Influenza immunization of chronically ill children in pediatric tertiary care hospitals Eve Dubé
abc e
a
fg
Kossowski , Caroline Quach & Monique Landry
Click for updates
d
e
d
, Dominique Gagnon , Caroline Huot , Renée Paré , Solange Jacques , Alexandra h
a
Institut national de santé publique du Québec (INSPQ); Québec, Canada
b
Centre de recherche du CHU de Québec; Québec, Canada
c
Université Laval; Québec, Canada
d
Direction de santé publique de la Capitale-Nationale; Québec, Canada
e
Direction de santé publique de Montréal; Montréal, Québec, Canada
f
Hôpital de Montréal pour enfants; Montréal, Québec, Canada
g
Université McGill; Montréal, Québec, Canada
h
Ministère de la santé et des Services sociaux; Montréal, Québec, Canada Accepted author version posted online: 31 Oct 2014.Published online: 19 Nov 2014.
To cite this article: Eve Dubé, Dominique Gagnon, Caroline Huot, Renée Paré, Solange Jacques, Alexandra Kossowski, Caroline Quach & Monique Landry (2014) Influenza immunization of chronically ill children in pediatric tertiary care hospitals, Human Vaccines & Immunotherapeutics, 10:10, 2935-2941, DOI: 10.4161/21645515.2014.970498 To link to this article: http://dx.doi.org/10.4161/21645515.2014.970498
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SHORT REPORT Human Vaccines & Immunotherapeutics 10:10, 2935--2941; October 2014; © 2014 Taylor & Francis Group, LLC
Influenza immunization of chronically ill children in pediatric tertiary care hospitals Eve Dub e1,2,3,*, Dominique Gagnon1, Caroline Huot4, Renee Pare5, Solange Jacques4, Alexandra Kossowski5, Caroline Quach6,7, and Monique Landry8 1 Institut national de sante publique du Quebec (INSPQ); Quebec, Canada; 2Centre de recherche du CHU de Quebec; Quebec, Canada; 3Universite Laval; Qu ebec, Canada; Direction de sant e publique de la Capitale-Nationale; Quebec, Canada; 5Direction de sante publique de Montreal; Montreal, Quebec, Canada; 6H^ opital de Montreal pour enfants; Montr eal, Quebec, Canada; 7Universite McGill; Montreal, Quebec, Canada; 8Ministere de la sante et des Services sociaux; Montreal, Quebec, Canada
4
Keywords: acceptance, children, immunization, live attenuated influenza vaccine, pediatrics
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Abbreviations: LAIV, live attenuated influenza vaccine; KAB, knowledge, attitudes and behaviors; DSP, Direction de sant e publique, Regional Public Health Directorate; TIV, trivalent inactivated influenza vaccine
Despite a publicly funded immunization program and continuous promotional efforts, vaccine uptake for seasonal influenza in Quebec (Canada) remains under its goal of 80%. Missed opportunities can explain the low influenza vaccine rates among chronically ill children. To address that, demonstration projects using the live attenuated influenza vaccine (LAIV) were implemented in 3 pediatric tertiary care hospitals to evaluate the feasibility and acceptability of implementing influenza immunization of chronically ill children in hospitals’ outpatient clinics. A diary was used to document barriers and enabling factors regarding the implementation, and a questionnaire was distributed to healthcare professionals involved in the project in each hospital. Parent’s knowledge, attitudes and behaviors (KAB) about influenza immunization and acceptability of immunization in outpatient clinics were also measured with a questionnaire. As part of the project, 2,478 children were immunized. Enabling factors included the financial support received from Quebec ministry of Health, the nasal mode of administration of the LAIV and the presence of a leader specifically dedicated to influenza immunization. Barriers to influenza immunization in outpatient clinics included difficulties of hiring extra staff to work in immunization clinics and additional tasks added to regular activities of the clinics. Results from both questionnaires illustrated a high level of acceptability of seasonal influenza immunization in hospitals’ outpatient clinics by parents and healthcare professionals. Influenza immunization in pediatric tertiary care hospital is an effective way to reach chronically ill children and does not involve major feasibility or acceptability issues.
Introduction Annual immunization is an effective measure to prevent severe influenza outcomes. The Canadian National Advisory Committee on Immunization recommends influenza immunization for people at high risk of serious infection as well as for their contacts.1 Individuals aged 2 years with chronic medical conditions (e.g. cardiac and pulmonary disorders, diabetes, immunecompromised conditions, renal disease, asthma, etc.) are targeted by the publicly funded immunization program in Quebec.2 Influenza immunization of chronically ill children is important because they are particularly predisposed to more severe disease and complications.3 However, vaccine uptake in this group is sub-optimal and far from the public health goal of 80% uptake.4 After the 2011-2012 campaign, the influenza vaccine uptake was around 30% for individuals with chronic medical conditions aged between 18 and 59 years.5 There is no data for immunization coverage against influenza among chronically ill children aged 2–17 years. Results of a recent study conducted among a
representative sample of Quebec healthy children aged 2 years have indicated that only one out of 8 children were completely immunized against influenza (2 doses) after the 2011–2012 campaign.6 Studies have indicated that missed opportunities, in which vaccine-eligible individuals are seen for care but not immunized, contribute significantly to low influenza immunization rates among children with chronic medical conditions.7-11 Delivering immunization in clinical settings and reducing administrative barriers to obtaining immunization services within clinics are strategies enhancing access to immunization services. When combined with strategies to promote immunization, these strategies are effective to improve coverage.12-14 Indeed, offering seasonal influenza immunization in hospitals’ outpatient clinics could be a good way to reach chronically ill children. In addition, as of October 2012, the Quebec Committee on Immunization recommended the preferential use of the live attenuated influenza vaccine (LAIV) for non-immunosuppressed children aged 2-17 years.15 Because LAIV is an intranasal vaccine, it could reduce barriers related to patients’ fear of needles or fear of
*Correspondence to: Eve Dube; Email: [email protected] Submitted: 05/13/2014; Revised: 06/20/2014; Accepted: 07/03/2014 http://dx.doi.org/10.4161/21645515.2014.970498
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injection pain.16 In this context, demonstration projects were funded by the Quebec ministry of Health to assess the feasibility and acceptability of offering LAIV to chronically ill children in hospital outpatient clinics where children are coming for their scheduled visits. This paper reports the organizational barriers and facilitators to influenza immunization of chronically ill children in outpatient clinics; parents’ and healthcare professionals’ acceptance of LAIV and their acceptance of influenza immunization at the hospital.
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Results Diaries The modalities of implementation varied slightly, but the vaccine was offered to parents of chronically ill children in all hospitals by regular staff of the outpatient clinic (nurses or doctors) during scheduled visits. Parents who agreed could have their child immunized right after the consultation without having to come back to the clinic. In one hospital, the vaccine was also offered to household contacts (parents and siblings) of chronically ill children. As part of the project, 2,478 children were immunized. In all 3 hospitals, the financial support offered by the Quebec ministry of Health was an important facilitator for the implementation of seasonal influenza immunization. The possibility to have clinics dedicated to immunization was also identified as well as the presence of a physician or nurse responsible for the implementation of the immunization campaign. The implementation was easier in one outpatient clinic where influenza immunization had been offered in the past, because some logistical aspects were already in place (premises, refrigerator for vaccine storage, etc.). Finally, the nasal mode of administration of the LAIV and the tolerability of the vaccine were identified as facilitating influenza immunization in all 3 centers. In 2 hospitals, barriers to influenza immunization in outpatient clinics included the difficulties in hiring extra staff to work during the immunization campaign. In-these 2 hospitals where it was impossible to hire dedicated staff, the fact that influenza immunization was added to the regular activities of the clinic was acknowledged as an important barrier. In one hospital, the fact that it was impossible to immunize household contacts of chronically ill children because TIV was not available was identified as a barrier. Finally, research activities related to the evaluation of the project (in particular, the distribution of questionnaires to patients) were adding to the workload of the staff and were identified as another barrier in 2 hospitals. Questionnaires to parents Overall, 236 questionnaires were completed. The objective of 500 questionnaires was not reached, mostly because questionnaires were not distributed in one center in Montreal. Most participants were mothers (78%) and 2 third (64%) were living in Montreal. The most frequent medical conditions of the children coming to the outpatient clinic were diabetes (25%) or chronic cardiac or pulmonary disorder (20%). The proportion of chronically ill children who were part of the study reflected the expected
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demography: school-aged (6- and 17-years-old) represented 62% of the population (31% were aged between 6- and 11-years-old and 31% were aged between 12- and 17-years-old) and children aged between 2- and 5-years-old represented 26% of the population. More than 9 out of 10 parents believed that seasonal influenza immunization was useful to protect the health of chronically ill individuals, and the majority considered intranasal immunization against seasonal influenza as being safe and effective. More than one-third of parents of an eligible child (35%) reported that their child was immunized the year before the study. At the time of the study, 12% of children were aged less than 2 years-old and thus were not eligible to receive the LAIV and 7% of parents reported that their child had already received the vaccine before completing the questionnaire. Among parents of unimmunized children, 29% of parents said they intended to have their child immunized against seasonal influenza, 27% of parents said they intended not to have their child immunized, and 44% were undecided (Fig. 1). Protection against seasonal influenza and high perceived vulnerability of the child were the main reasons mentioned by parents who intended to have their child immunized (Table 1). Low perceived vulnerability or low perceived severity of the disease were the main reasons mentioned by parents who indicated not having the intention to have their child immunized (Table 1). Almost 60% (n D 135) of children whose parents completed the questionnaire were immunized against seasonal influenza during their scheduled visit in the outpatient clinic. Among these children, 65% (n D 88) received the LAIV and 31% (n D 42) the TIV (unknown vaccine received for 5 children). Seventy-9 children (79) who had not received the vaccine in the year preceding the study received the seasonal influenza vaccine in the outpatient clinic (among these children, 6 were less than 2 yearsold and may have been ineligible for seasonal influenza immunization at that time). The main reason mentioned by parents for choosing the LAIV was that it was “easy, without using needles and without pain.” The main reason for having the child immunized with TIV was a contraindication to receive LAIV. Almost all parents of the 88 children who received the LAIV estimated that it was easy for their child to receive the LAIV (91% very easy, 6% somewhat easy). Moreover, 97% of parents wished that their child receive LAIV again next year (83% fully agree, 14% somewhat agree). Among parents of immunized children, 95% considered that hospital outpatient clinic was the best place to have their child immunized (74% fully agree, 21% somewhat agree), and 96% would want to have their child immunized in the outpatient clinic in the future (Fig. 2). Questionnaire to healthcare professionals Overall, 37 questionnaires were completed by healthcare professionals and managers for a response rate of 49% (37/76). Most respondents were physicians (62%, n D 23) or nurses (27%, n D 10) and were mainly working in outpatient clinics (68%, n D 25). Around one-third of healthcare professionals had been practicing between 10-19 years (30%, n D 11) and 41% (n D 15) had been practicing for 20 years or more.
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Figure 1. Seasonal influenza vaccination in pediatric tertiary care hospitals.
The majority of participants (70%) indicated having received the seasonal influenza vaccine in 2012–2013. Protection of vulnerable patients was the main reason mentioned by those who have received the vaccine while doubt regarding the vaccine effectiveness was the main reason mentioned by those who were not immunized. All respondents indicated that seasonal influenza immunization of chronically ill children was useful (86% strongly agreed, 11% agreed). More than 95% of healthcare professionals and managers estimated that the LAIV was effective (49% strongly agreed, 43% agreed) and safe (59% strongly agreed, 35% agreed). Almost all also considered that the LAIV has been well accepted by parents (81% strongly agreed, 16% agreed) and by healthcare professionals (78% strongly agreed,
22% agreed). When asked to compare the efficacy and safety of vaccines against seasonal influenza, the majority considered LAIV as effective (62%) or more effective (38%) than TIV. LAIV was also considered as safe (74%) or safer (21%) than TIV. Almost all respondents felt their knowledge about LAIV and TIV was sufficient for their practice (one-third strongly agreed with both statements). During the 2012-2013 campaign, the majority of respondents mentioned having recommended seasonal influenza immunization to parents for themselves (49% strongly agreed, 16% agreed) and for their child (54% strongly agreed, 24% agreed). Seventy-3 percent (73%) of respondents reported having administered both LAIV and TIV, 5% reported use of LAIV only while 19%
Table 1. Parents’ main reasons for accepting or refusing influenza vaccine for their child Main reasons for having accepted the influenza vaccines (n D 64)
n
%
Protection against seasonal influenza High perceived susceptibility to influenza (by example: underlying disease) Having received a recommendation (family/friend/healthcare professional) Protection of a relative/at-risk person/pregnancy/children Daycare center attendance Social responsibility/Following recommendations/ General positive attitude about vaccination No answer Main reasons for having refused the influenza vaccines (n D 60) Low perceived susceptibility to influenza or severity of the infection Unnecessary/ No beneficial Doubts regarding vaccine efficacy Against medication and vaccines Fear of shot Othersa No answer
17 15 5 3 2 1 21
27% 23% 8% 5% 3% 2% 33%
9 5 4 2 2 6 32
15% 8% 7% 3% 3% 10% 53%
a
Included reasons as contraindication for vaccination, no daycare attendance, etc.
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indicated not having administered vaccine. Respondents who have used LAIV strongly agreed (86%) or agreed (14%) that it was easy to immunize children with a nasal spray. Almost all professionals perceived that implementing influenza immunization for chronically ill children in pediatric tertiary care hospital was useful and feasible (Table 2). Most respondents also judged that offering influenza immunization in outpatient clinics has been perceived positively by hospital staff and patients. Overall, 78% of respondents judged that the implementation modalities of the demonstration project were appropriate. Respondents were also asked about common questions or concerns raised by parents in regard to LAIV. According to the respondents, most frequent concerns and questions of parents were around vaccine safety (67%), efficacy (62%) or utility (59%). Almost half of professionals mentioned that parents had little or no concerns about LAIV (14% strongly agreed, 30% agreed).
Discussion The recommendation of Quebec Immunization Committee to use LAIV preferentially to TIV for children with chronic medical conditions as well as the low influenza vaccine uptake in this group provided an interesting opportunity to assess the acceptability and feasibility of influenza immunization in hospitals’ outpatient clinics. Findings from the evaluation of the 3 demonstration projects indicate that there were no major
feasibility or acceptability issues to the implementation of seasonal influenza immunization in outpatient clinics. Barriers were mainly linked to increase in workload for staff, especially if no additional staff was hired. Successful conditions for implementation included: financial support, dedicated staff and dedicated clinics as well as the presence of a positive leader or “immunization champion” to support the immunization campaign. These conditions already were been identified in the literature to increase seasonal influenza vaccine uptake of healthcare workers.17 Immunization in pediatric tertiary care hospital has been well accepted by parents and the majority of them expressed high willingness to have their child immunized in the outpatient clinic in the future. Even if the majority of parents considered influenza immunization as being safe and effective, only a small proportion of them did immunize their child during the scheduled visit. Indeed, educational efforts should be done to ensure that parents are adequately informed about the importance of seasonal influenza immunization for chronically ill children and about the availability of LAIV. Promotional and informational material on that topic should be available in outpatient clinics, reaching most parents of chronically ill children. Few barriers to influenza immunization in outpatient clinics have been reported by healthcare professionals involved in the demonstration projects. The majority of healthcare professionals expressed interest in pursuing seasonal influenza immunization in the outpatient clinics in the future. Healthcare professionals’ recommendations have previously been shown to be an
Figure 2. bFour missing answers given for both questions were excluded from the analysis.
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Table 2. Perceptions of the demonstration project for the seasonal influenza vaccination of children with chronic conditions in hospital clinics In your opinion, the seasonal flu vaccination of children with chronic conditions in outpatient clinics Is beneficial Is feasible Was viewed positively by patients Was viewed positively by clinic staff
Strongly agree n (%)
Agree n (%)
Agree somewhat n (%)
Disagreec n (%)
No answer n (%)
33 (89%) 32 (86%) 27 (73%) 23 (62%)
1 (3%) 2 (5%) 6 (16%) 9 (24%)
1 (3%) 1 (3%) 3 (8%) 3 (8%)
0 1 (3%) 0 0
2 (5%) 1(3%) 1(3%) 2 (5%)
c
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Including 3 levels of disagreement (disagree somewhat, disagree, strongly disagree).
important determinant of vaccine uptake in their patients.18-23 It will be important to reiterate to physicians and nurses the importance of recommending influenza immunization to at-risk patients and to inform them about the recommendations regarding LAIV use, as many studies have shown the importance of physicians’ recommendations to increase seasonal influenza immunization uptake among chronically ill children.3,24 Offering the influenza vaccine in pediatric tertiary care hospital also seems to have reached chronically ill children who may have not been immunized otherwise. For instance, 79 of the 143 eligible children who were not immunized the year before the project received the vaccine as part of the demonstration project. Because chronically ill children regularly visit outpatient clinics, offering seasonal influenza immunization in these settings is an effective approach to reduce missed opportunities.25 Results of this evaluation should be interpreted in the light of some limitations. First, as in most questionnaires, responses are subject to self-report biases, including social desirability, which is the tendency of respondents to reply in a manner that will be viewed favorably by others. In our study, this could have led to more positive answers toward influenza vaccination. However, the fact that the questionnaire was anonymous should have reduced socially desirable responses. Second, questionnaires to parents were not distributed in one of the site, which limits the generalizability of the results. In addition, not all parents answered every survey question which could have led to response bias, especially regarding reasons behind the intention to have their child vaccinated against influenza. Finally, response rate for the healthcare professionals’ questionnaire was only 49% and there is a potential for non-participation bias. No information on non-respondents was available. In conclusion, this evaluation demonstrated that influenza immunization in pediatric tertiary care hospital is a feasible and acceptable way to reach and immunize chronically ill children. Although offering seasonal influenza immunization in outpatient clinics inevitably necessitates additional resources and organizational efforts, it is the preferred setting to reduce missed opportunities to immunize chronically ill children.
Material and Methods Setting In Quebec, chronically ill children targeted by the publicly funded immunization program against influenza are those aged
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between 6 months and 17 years of age with the following chronic health conditions: chronic cardiac or pulmonary disorder; chronic condition such as diabetes; inborn error of metabolism; severe obesity (defined as a BMI > 40); hepatic disorder; haematological disorder; cancer; immune deficiency. Influenza vaccination is also indicated and offered free of charge to children and adolescents with conditions treated for long periods with acetylsalicylic acid or with another medical condition that could compromise the elimination of respiratory secretions and increase the risk of aspiration (e.g., a cognitive disorder, spinal cord injury, seizure disorder, etc.). Demonstration projects were implemented in 3 tertiary care hospitals located in the 2 largest cities in the province of Quebec: Montreal (2 hospitals) and Quebec City (one hospital). In each hospital, a physician was responsible for project’s implementation, often in collaboration with nurses. Public health professionals working at the Regional Public Health Directorate (Directions de sante publique, DSP) were also supporting the project by ensuring collaboration between the provincial (Quebec ministry of Health) and local (the hospital) levels. Data collection Three sources of data were used. First, a diary was used to document barriers and facilitators to the implementation of influenza immunization in outpatient clinics. This diary was designed to record information about project implementation in regard to 15 specific topics (such as information about the project given to other healthcare workers, training of staff involved in the project, promotion to patients, logistic aspects – premises, vaccine storage – surveillance of adverse events following immunization, etc.). For each topic, information was recorded on the chosen modes of organization, the person who was responsible for this aspect, the level of implementation (none, partial, complete), the challenges or difficulties encountered as well as facilitators. The diaries were completed by the physicians leading the project in each hospital in collaboration with the public health professionals at the DSP. Information was recorded in diaries between January and April 2013, after the end of the 2012–2013 immunization campaign. To ensure that all important information was recorded, physicians received a blank version before the launch of the immunization campaign. In the second and the third week of the demonstration project, administrative support staff distributed a questionnaire to every parent of chronically ill children upon clinic registration. Parents who agreed to participate could fill the questionnaire
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Figure 3. Data collection procedures.
during the waiting time before consultation. In addition to familial socio-demographic characteristics, the first section of the questionnaire was designed to collect information about: 1) past seasonal influenza immunization of the child; 2) opinions regarding the safety and efficacy of seasonal influenza vaccine; 3) parents’ intention to have their child immunized at the outpatient clinic and 4) main reasons for intending to immunize their child or not. The next section was designed to be completed by the healthcare professional after the consultation and contained questions on the medical conditions of the child, contraindications for seasonal influenza immunization and recommendations given to parents (LAIV, trivalent inactivated influenza vaccine (TIV) or no vaccine). For parents who chose to have their child immunized, the second page of the questionnaire was completed during the waiting time after immunization and contained questions regarding their experience and level of satisfaction regarding the immunization at the outpatient clinic. The final questionnaire contained 9 close-ended questions for all parents (8 additional questions were asked to parents of children who were immunized at the clinic) and 4 questions for healthcare professionals. The goal was to distribute 500 questionnaires to patients (150 in Quebec City and 175 in each hospital in Montreal). After the 2012–2013 immunization campaign, all healthcare professionals and managers involved in the demonstration project
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in each hospital (n D 76) were asked to complete a short questionnaire. The questionnaire contained 20 questions designed to collect information about: 1) knowledge, attitudes and practices regarding seasonal influenza immunization; 2) opinions regarding the demonstration project (barriers and facilitators) and 3) socio-professional characteristics. Figure 3 illustrates the data collection procedures.
Data analysis Diaries were submitted to qualitative content analysis. Findings were summarized and returned for validation to physicians leading the project in each hospital. If needed, corrections were made. Data collected by both questionnaires were analyzed separately. Descriptive statistics were generated for all variables. The exact verbatim of the open-ended questions were submitted to content analysis. Statistical analyses were performed using SAS version 9.3 while content analysis was first done using Microsoft Word processing software and then imported into SAS.
Disclosure of Potential Conflicts of Interest
No potential conflicts of interest were disclosed.
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Acknowledgments
Funding
We would like to thank all professionals who participated in this project.
We would like to thank the Quebec ministry of Health and Social services for the study funding.
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