727465
research-article2017
CPJXXX10.1177/0009922817727465Clinical PediatricsCordrey et al
Article
Pediatric Resident Education and Preparedness Regarding Vaccine-Preventable Diseases
Clinical Pediatrics 1–8 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/0009922817727465 DOI: 10.1177/0009922817727465 journals.sagepub.com/home/cpj
Kyla Cordrey, BA1, Laura McLaughlin, BA1, Prithwijit Das, MSEd1, and Ruth Milanaik, DO1
Abstract This study assessed pediatric residents’ reported knowledge of and self-confidence in identifying/treating 8 vaccinepreventable diseases. Pediatric residents nationwide (n = 385) reported (1) if they had previously diagnosed measles, mumps, rubella, diphtheria, tetanus, pertussis, varicella, and/or polio; (2) their comfort level in treating these diseases; (3) the likelihood of identifying symptoms; and (4) 16 disease-related statements as true/false. More than 25% of residents were not comfortable treating 5 of the 8 diseases. More than 25% reported themselves as unlikely/extremely unlikely to identify symptoms of 3 of these diseases. Third- or fourth-year residents did not feel more confident in identifying disease symptoms than first-year residents, except for pertussis (P ≤ .01). True/false statement accuracy ranged from 56.8% correct (polio) to 94.6% correct (pertussis). Most residents (73.3%) were “extremely concerned” regarding parental vaccine refusal, and 96.0% felt that they would benefit from receiving more information. Increased emphasis on this subject in residency education is essential for the management of potential disease outbreaks. Keywords vaccine-preventable disease, pediatric resident, medical education, immunization, herd immunity
Introduction Since their inception, nationwide vaccination programs have significantly reduced the incidence of vaccine-preventable diseases across the United States.1 These diseases were a major cause of morbidity and mortality among children during the prevaccine era. For example, more than 200 000 cases of diphtheria, resulting in 15 000 deaths were reported each year at the height of the epidemic.2,3 Additionally, polio outbreaks crippled more than 35 000 people annually and were the leading cause of permanent disability in children.4,5 With the advent of routine childhood immunization, the devastating impacts of these and other diseases have been greatly diminished.6 Fewer than 5 cases of diphtheria were reported in the past decade, and polio has been completely eliminated in the United States since 1979.2,5 The incidence of a number of other vaccinepreventable diseases has been reduced by at least 98%.1 These triumphs have led the Centers for Disease Control and Prevention (CDC) to recognize vaccines as one of the top public health achievements of the 20th century.7,8 Vaccination efforts in the United States have been so successful in reducing the prevalence of vaccine-preventable diseases that some among the general public have
come to seemingly underestimate their seriousness.9-13 Although the majority of children nationwide are vaccinated, the number of nonmedical exemptions has increased in recent years.14-16 Parental refusal of vaccines is often justified by concerns regarding vaccine safety, beliefs that vaccines are unnecessary, or arguments that their children are too young to be inoculated.17,18 As fewer individuals become vaccinated, the likelihood that an unimmunized and susceptible individual will come into contact with a carrier of a disease-causing agent increases.19 This herd immunity is vital to the safety of vulnerable populations, including pregnant women and elderly individuals as well as those who are too young to be vaccinated, have medical contraindications to immunization, or are unable to produce immune 1
Steven and Alexandra Cohen Children’s Medical Center of New York, Lake Success, NY, USA Corresponding Author: Ruth Milanaik, Division of Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children’s Medical Center of New York, 1983 Marcus Avenue, Suite 130, Lake Success, NY 11042, USA. Email: [email protected]
2 responses to vaccines.20-25 Declines in immunization coverage are also concerning because diseases may become more virulent when more of the population is vaccinated.26,27 Negative outcomes for measles, chickenpox, and rubella are 4.5, 2.2, and 5.8 times worse, respectively, when compared with outcomes in a prevaccine era.26 If there were to be a reemergence of these diseases, it is likely that the morbidity and mortality resulting from subsequent outbreaks would increase.28 The disappearance of a number of vaccine-preventable diseases has shifted the epidemiological landscape, such that much of the medical community has minimal to no first-hand experience with these diseases.12 Consequently, there may be diminished emphasis on clinical identification and treatment of vaccine-preventable diseases in current medical education and clinical curricula. However, as vaccination rates decline, the medical community may witness an increased incidence and prevalence of these diseases. Infants and young children are especially vulnerable; therefore, pediatricians must be equipped to quickly identify and treat these diseases in order to minimize child morbidity and mortality. It is currently unknown whether pediatric residents feel confident in their ability to recognize, diagnose, and treat vaccine-preventable diseases. This study is the first to assess pediatric resident knowledge and self-reported confidence regarding this concerning health issue.
Methods An anonymous, online questionnaire was developed on SurveyMonkey and piloted to a small group of pediatric residents. After the pilot study, improvements were made to the questionnaire before being distributed to the coordinators of 204 pediatric residency programs nationwide. The residency coordinators were asked to forward information about the questionnaire along with the Web link to their residents. Participants were eligible to complete the questionnaire if they were 18 years or older and were currently enrolled in a pediatric residency program in the United States. The anonymous questionnaire consisted of 3 parts. The first section inquired about each resident’s general, unidentifiable demographic information, medical school, the location (state) of their residency program, their current year of residency training, and their intended specialty. The second portion of the questionnaire asked the participants if they had ever previously diagnosed any of the following diseases: measles, mumps, rubella, diphtheria, tetanus, pertussis, varicella, and polio. The questionnaire prompted residents to report how comfortable they felt treating the 8 vaccine-preventable diseases on a 5-point Likert scale ranging from “not at all comfortable” to “extremely comfortable.” Residents also indicated their
Clinical Pediatrics 00(0) self-perceived likelihood of identifying the symptoms of the 8 listed diseases on a 5-point Likert scale ranging from “extremely unlikely” to “extremely likely.” The final portion of the questionnaire asked residents to identify whether 16 statements about the 8 assessed vaccine-preventable diseases were true or false. The statements were extracted from information available to the public on the CDC website about each disease and included information about disease risk factors, symptoms, and progression.29 Two statements were allocated for each disease. Residents then indicated on a 5-point Likert scale how concerned they were regarding parental refusal of vaccination for children. Finally, the questionnaire asked if the respondents felt that they would benefit from more information regarding vaccine-preventable diseases. On completion of the questionnaire, participants were provided with the answers to the true/false statements and a fact sheet that contained information on the clinical presentations of the 8 vaccine-preventable diseases and how to report an incidence. This study protocol was approved by the institutional review board of the Feinstein Institute for Medical Research.
Statistical Analyses Average values for the Likert scale responses were calculated using coded values ranging from 1 to 5. The percentages correct for the 2 true/false statements were averaged for each of the 8 diseases. Three different binary variables were created for postgraduate year (PGY-2, PGY-3, and PGY-4). Each dummy variable had either a “yes” (1) or “no” (0) value depending on year of residency (eg, a PGY-2 resident would have a 1 for the PGY-2 variable and a 0 for the other 2 dummy variables). PGY-1 residents had all 3 dummy variables set to 0. Multivariate linear regressions were used to compare the likelihood of recognizing disease symptoms and level of comfort in treating vaccine-preventable diseases between pediatric residents of different years, using PGY-1 residents as a baseline.
Results A total of 452 physicians completed the questionnaire, 386 of whom were medical residents. Because of changes made to the questionnaire following the pilot study, responses obtained from the pilot study were excluded from the analysis. Only residents of years 1 through 4 were included in the analysis (n = 385). Respondents represented residency programs in 29 states and 115 medical schools. The majority of pediatric residents who participated were white and female (Table 1).
3
Cordrey et al Table 1. Pediatric Resident Sample Characteristics. Sample Characteristics (n = 385) Age (years): mean = 28.6 (SD = 2.28) Gender Male Female Race White Black or African American Asian Other Not answered Ethnicity Hispanic/Latino Not Hispanic/Latino Not answered Residency year PGY-1 PGY-2 PGY-3 PGY-4
Percentage (n)
27.3 (105) 72.7 (280) 70.1 (270) 5.5 (21) 15.8 (61) 7.0 (27) 1.6 (6) 5.7 (22) 92.5 (356) 1.8 (7) 32.7 (126) 34.6 (133) 30.1 (116) 2.6 (10)
In all, 80.2% (309/385) indicated pediatric primary care as their intended specialty, and 85.7% (330/385) were completing their residency program at a children’s hospital. When asked if they had previously diagnosed any of the 8 vaccine-preventable diseases, 8.1% (31/385) of pediatric residents reported having diagnosed measles, 9.1% mumps (35/385), 1.0% (8/385) rubella, 1.8% (7/385) diphtheria, 5.7% (22/385) tetanus, 43.9% (169/385) pertussis, 39.5% (152/385) varicella, and 0.8% (3/385) polio. Residents were then asked how comfortable they would feel treating each of the 8 vaccine-preventable diseases (Table 2) and how likely it was that they would be able to recognize their symptoms (Table 3). Table 4 contains the results from linear regression analysis using 3 dummy variables (PGY-2, PGY-3, and PGY-4) examining the effect of residency year on pediatric residents’ level of comfort in treating each of the 8 diseases as well as their self-reported likelihood of identifying disease symptoms. Higher comfort level scores for more advanced residents were noted for 4 of the 8 diseases (measles, mumps, pertussis, and varicella). PGY-2, PGY-3, and PGY-4 residents felt more comfortable than PGY-1 residents in treating pertussis and varicella (P < .02). PGY-3 and PGY-4 residents expressed greater levels of comfort in treating mumps than PGY-1 residents (PGY-3: β = 0.43, P = .01; PGY4: β = 0.99, P = .02). However, PGY-3 residents, but not PGY-4 residents, felt more comfortable treating measles than PGY-1 residents (PGY-3: β = 0.41; P = .01).
The level of comfort in treating the other 4 diseases (rubella, diphtheria, tetanus, and polio) did not differ significantly between residency years. Although residency year did affect confidence in ability to treat half of the 8 vaccine-preventable diseases, there was no significant effect of residency year on selfreported likelihood of identifying disease symptoms, with the exception of pertussis. In this exception, PGY-3 and PGY-4 residents felt more confident than PGY-1 residents in their ability to identify pertussis symptoms (PGY-3: β = 0.3, P < .01; PGY-4: β = 0.51, P = .01). In the last part of the questionnaire, pediatric residents indicated if 16 different statements on the 8 vaccine-preventable diseases were true or false. The statements and percentage of true/false responses are listed in Table 5. Most of the residents (73.3%) were “extremely concerned” regarding parental refusal to vaccinate their children, 20.1% were “moderately concerned,” 5.0% were “somewhat concerned,” 1.7% were “slightly concerned,” and none were “not at all concerned.” Nearly all the residents (96.0%) felt that they would benefit from receiving more information regarding vaccinepreventable diseases.
Discussion Vaccines have been deemed one of the greatest successes of public health policy.30 However, previous literature suggests that, in recent years, limited familiarity and minimal direct experience with vaccine-preventable diseases may have resulted in a lessened appreciation of their risks and severity.18-21,26 Opposition to and delay of routine childhood immunizations has been steadily mounting.31,32 Antivaccine campaigns have attempted to reduce confidence in vaccines by questioning the utility, efficacy, and safety of inoculation.33 The retracted 1998 publication in The Lancet of an article by Wakefield et al34 asserted a causal link between the measlesmumps-rubella (MMR) vaccine and autism, a link that was subsequently disproven and widely rejected after further studies found no association.35,36 In spite of the retraction, concerns surrounding immunization have increased, and more and more parents are refusing or delaying vaccination of their children.9,17,31,32,37,38 The consequences of vaccine refusal and delay have already been noted. Geographic clusters of reduced vaccination coverage have increased the risk of resurgence of vaccine-preventable diseases.39 Research has attributed recent outbreaks of measles and pertussis in the United States to rising rates of intentional undervaccination.21-23,40 Reduced vaccine coverage has also led to localized disruptions of herd immunity.24,25 In 2010, a pertussis
4
Clinical Pediatrics 00(0)
Table 2. Pediatric Residents’ Level of Comfort Treating Each of the 8 Vaccine-Preventable Diseases. Disease Measles Mumps Rubella Diphtheria Tetanus Pertussis Varicella Polio
Not at All Comfortable
Slightly Comfortable
Somewhat Comfortable
Moderately Comfortable
Extremely Comfortable
Averagea
28.4% 27.7% 32.0% 36.2% 23.9% 6.6% 4.6% 49.7%
27.7% 25.1% 29.0% 27.6% 26.2% 15.9% 13.9% 25.5%
24.1% 27.4% 23.8% 24.9% 26.2% 18.5% 31.0% 18.2%
17.2% 18.2% 12.9% 10.0% 17.3% 33.4% 32.3% 5.6%
2.6% 1.7% 2.3% 1.3% 6.3% 25.5% 18.2% 1.0%
1.38 3.59 1.24 1.13 1.56 2.55 2.46 0.83
a Average score is computed from the following scale: 1, Not at all comfortable; 2, Slightly comfortable; 3, Somewhat comfortable; 4, Moderately comfortable; 5, Extremely comfortable.
Table 3. Pediatric Residents’ Likelihood of Identifying Each of the 8 Vaccine-Preventable Diseases. Disease Measles Mumps Rubella Diphtheria Tetanus Pertussis Varicella Polio
Extremely Unlikely
Unlikely
Neutral
Likely
Extremely Likely
Averagea
1.1% 0.3% 1.7% 3.4% 0.6% 0.0% 0.0% 6.1%
11.5% 9.2% 26.7% 25.8% 9.0% 2.0% 1.1% 37.7%
23.3% 20.4% 37.9% 30.1% 18.6% 3.6% 5.0% 28.5%
55.6% 58.9% 31.5% 34.8% 57.6% 53.1% 54.5% 23.2%
8.4% 11.2% 2.2% 5.9% 14.1% 41.3% 39.4% 4.5%
3.59 3.72 3.06 3.14 3.76 4.34 4.32 2.82
a
Average score is computed from the following scale: 1, Extremely unlikely; 2, Unlikely; 3, Neutral; 4, Likely; 5, Extremely likely.
epidemic of more than 9000 cases occurred in California.41 The majority of these cases (89%) affected infants who were too young to be fully vaccinated.42 In 2014, 667 cases of measles were reported across 27 states, the greatest number of cases since its elimination from the United States in 2000. The majority of infected individuals during this outbreak were unvaccinated.43 Because decreased rates of immunization are correlated with higher rates of disease outbreaks, pediatricians must be sufficiently knowledgeable about these diseases to prevent further transmission.44 Our study found that significant proportions of pediatricians-in-training who participated in this study reported themselves not likely to identify the symptoms of a number of the vaccinepreventable diseases—namely, diphtheria, polio, and rubella. More than one-third and one-quarter of these pediatric residents were not likely to identify symptoms of measles and mumps, respectively. Pediatric residents in this study also felt uncomfortable in treating several of the tested vaccine-preventable diseases. Nearly half of the participants were “not at all comfortable” treating polio, whereas approximately one-third were “not at all comfortable” treating diphtheria or rubella. Significant percentages of these pediatric
residents were either “slightly comfortable” or “not at all comfortable” treating measles, mumps, and tetanus. Conversely, participants felt most comfortable treating pertussis and varicella. Another important finding of this study was that overall, pediatric residents in this study were unable to correctly identify important statements about vaccinepreventable diseases as true or false. Accuracy in responses to questions about vaccine-preventable diseases varied. Participants were most accurate in responding to questions about pertussis, rubella, and mumps. In comparison, these residents were least successful in responding to questions regarding tetanus, polio, and varicella. Although the difficulty of the questions was not standardized, each statement contained information that is essential for pediatricians to know. Therefore, any significant percentage of residents unable to correctly identify true statements is alarming. Our study found that more-advanced residents who participated in the survey felt no more likely to be able to identify symptoms of these vaccine-preventable diseases than less-advanced ones, with the exception of pertussis. In many pediatric residency programs, pediatric residents
5
Cordrey et al Table 4. The Effect of Residency Year on Self-Reported Level of Comfort in Treating Disease and Likelihood of Identifying Disease Symptoms.a Level of Comfort in Treating Disease
Likelihood of Identifying Disease Symptoms
Disease
Residency Year
n
Effect Size
P
Effect Size
P
Measles
PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4
126 133 116 10 126 133 116 10 126 133 116 10 126 133 116 10 126 133 116 10 126 133 116 10 126 133 116 10 126 133 116 10
— 0.22 0.41 0.71 — 0.28 0.43 0.99 — 0.30 0.25 0.38 — 0.13 0.11 0.26 — 0.22 0.30 0.34 — 0.81 1.16 1.41 — 0.34 0.50 1.13 — 0.21 0.20 0.61
— .17 .01b .11 — .07 .01b .02b — .05 .11 .38 — .37 .45 .53 — .20 .08 .47 —
research-article2017
CPJXXX10.1177/0009922817727465Clinical PediatricsCordrey et al
Article
Pediatric Resident Education and Preparedness Regarding Vaccine-Preventable Diseases
Clinical Pediatrics 1–8 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/0009922817727465 DOI: 10.1177/0009922817727465 journals.sagepub.com/home/cpj
Kyla Cordrey, BA1, Laura McLaughlin, BA1, Prithwijit Das, MSEd1, and Ruth Milanaik, DO1
Abstract This study assessed pediatric residents’ reported knowledge of and self-confidence in identifying/treating 8 vaccinepreventable diseases. Pediatric residents nationwide (n = 385) reported (1) if they had previously diagnosed measles, mumps, rubella, diphtheria, tetanus, pertussis, varicella, and/or polio; (2) their comfort level in treating these diseases; (3) the likelihood of identifying symptoms; and (4) 16 disease-related statements as true/false. More than 25% of residents were not comfortable treating 5 of the 8 diseases. More than 25% reported themselves as unlikely/extremely unlikely to identify symptoms of 3 of these diseases. Third- or fourth-year residents did not feel more confident in identifying disease symptoms than first-year residents, except for pertussis (P ≤ .01). True/false statement accuracy ranged from 56.8% correct (polio) to 94.6% correct (pertussis). Most residents (73.3%) were “extremely concerned” regarding parental vaccine refusal, and 96.0% felt that they would benefit from receiving more information. Increased emphasis on this subject in residency education is essential for the management of potential disease outbreaks. Keywords vaccine-preventable disease, pediatric resident, medical education, immunization, herd immunity
Introduction Since their inception, nationwide vaccination programs have significantly reduced the incidence of vaccine-preventable diseases across the United States.1 These diseases were a major cause of morbidity and mortality among children during the prevaccine era. For example, more than 200 000 cases of diphtheria, resulting in 15 000 deaths were reported each year at the height of the epidemic.2,3 Additionally, polio outbreaks crippled more than 35 000 people annually and were the leading cause of permanent disability in children.4,5 With the advent of routine childhood immunization, the devastating impacts of these and other diseases have been greatly diminished.6 Fewer than 5 cases of diphtheria were reported in the past decade, and polio has been completely eliminated in the United States since 1979.2,5 The incidence of a number of other vaccinepreventable diseases has been reduced by at least 98%.1 These triumphs have led the Centers for Disease Control and Prevention (CDC) to recognize vaccines as one of the top public health achievements of the 20th century.7,8 Vaccination efforts in the United States have been so successful in reducing the prevalence of vaccine-preventable diseases that some among the general public have
come to seemingly underestimate their seriousness.9-13 Although the majority of children nationwide are vaccinated, the number of nonmedical exemptions has increased in recent years.14-16 Parental refusal of vaccines is often justified by concerns regarding vaccine safety, beliefs that vaccines are unnecessary, or arguments that their children are too young to be inoculated.17,18 As fewer individuals become vaccinated, the likelihood that an unimmunized and susceptible individual will come into contact with a carrier of a disease-causing agent increases.19 This herd immunity is vital to the safety of vulnerable populations, including pregnant women and elderly individuals as well as those who are too young to be vaccinated, have medical contraindications to immunization, or are unable to produce immune 1
Steven and Alexandra Cohen Children’s Medical Center of New York, Lake Success, NY, USA Corresponding Author: Ruth Milanaik, Division of Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children’s Medical Center of New York, 1983 Marcus Avenue, Suite 130, Lake Success, NY 11042, USA. Email: [email protected]
2 responses to vaccines.20-25 Declines in immunization coverage are also concerning because diseases may become more virulent when more of the population is vaccinated.26,27 Negative outcomes for measles, chickenpox, and rubella are 4.5, 2.2, and 5.8 times worse, respectively, when compared with outcomes in a prevaccine era.26 If there were to be a reemergence of these diseases, it is likely that the morbidity and mortality resulting from subsequent outbreaks would increase.28 The disappearance of a number of vaccine-preventable diseases has shifted the epidemiological landscape, such that much of the medical community has minimal to no first-hand experience with these diseases.12 Consequently, there may be diminished emphasis on clinical identification and treatment of vaccine-preventable diseases in current medical education and clinical curricula. However, as vaccination rates decline, the medical community may witness an increased incidence and prevalence of these diseases. Infants and young children are especially vulnerable; therefore, pediatricians must be equipped to quickly identify and treat these diseases in order to minimize child morbidity and mortality. It is currently unknown whether pediatric residents feel confident in their ability to recognize, diagnose, and treat vaccine-preventable diseases. This study is the first to assess pediatric resident knowledge and self-reported confidence regarding this concerning health issue.
Methods An anonymous, online questionnaire was developed on SurveyMonkey and piloted to a small group of pediatric residents. After the pilot study, improvements were made to the questionnaire before being distributed to the coordinators of 204 pediatric residency programs nationwide. The residency coordinators were asked to forward information about the questionnaire along with the Web link to their residents. Participants were eligible to complete the questionnaire if they were 18 years or older and were currently enrolled in a pediatric residency program in the United States. The anonymous questionnaire consisted of 3 parts. The first section inquired about each resident’s general, unidentifiable demographic information, medical school, the location (state) of their residency program, their current year of residency training, and their intended specialty. The second portion of the questionnaire asked the participants if they had ever previously diagnosed any of the following diseases: measles, mumps, rubella, diphtheria, tetanus, pertussis, varicella, and polio. The questionnaire prompted residents to report how comfortable they felt treating the 8 vaccine-preventable diseases on a 5-point Likert scale ranging from “not at all comfortable” to “extremely comfortable.” Residents also indicated their
Clinical Pediatrics 00(0) self-perceived likelihood of identifying the symptoms of the 8 listed diseases on a 5-point Likert scale ranging from “extremely unlikely” to “extremely likely.” The final portion of the questionnaire asked residents to identify whether 16 statements about the 8 assessed vaccine-preventable diseases were true or false. The statements were extracted from information available to the public on the CDC website about each disease and included information about disease risk factors, symptoms, and progression.29 Two statements were allocated for each disease. Residents then indicated on a 5-point Likert scale how concerned they were regarding parental refusal of vaccination for children. Finally, the questionnaire asked if the respondents felt that they would benefit from more information regarding vaccine-preventable diseases. On completion of the questionnaire, participants were provided with the answers to the true/false statements and a fact sheet that contained information on the clinical presentations of the 8 vaccine-preventable diseases and how to report an incidence. This study protocol was approved by the institutional review board of the Feinstein Institute for Medical Research.
Statistical Analyses Average values for the Likert scale responses were calculated using coded values ranging from 1 to 5. The percentages correct for the 2 true/false statements were averaged for each of the 8 diseases. Three different binary variables were created for postgraduate year (PGY-2, PGY-3, and PGY-4). Each dummy variable had either a “yes” (1) or “no” (0) value depending on year of residency (eg, a PGY-2 resident would have a 1 for the PGY-2 variable and a 0 for the other 2 dummy variables). PGY-1 residents had all 3 dummy variables set to 0. Multivariate linear regressions were used to compare the likelihood of recognizing disease symptoms and level of comfort in treating vaccine-preventable diseases between pediatric residents of different years, using PGY-1 residents as a baseline.
Results A total of 452 physicians completed the questionnaire, 386 of whom were medical residents. Because of changes made to the questionnaire following the pilot study, responses obtained from the pilot study were excluded from the analysis. Only residents of years 1 through 4 were included in the analysis (n = 385). Respondents represented residency programs in 29 states and 115 medical schools. The majority of pediatric residents who participated were white and female (Table 1).
3
Cordrey et al Table 1. Pediatric Resident Sample Characteristics. Sample Characteristics (n = 385) Age (years): mean = 28.6 (SD = 2.28) Gender Male Female Race White Black or African American Asian Other Not answered Ethnicity Hispanic/Latino Not Hispanic/Latino Not answered Residency year PGY-1 PGY-2 PGY-3 PGY-4
Percentage (n)
27.3 (105) 72.7 (280) 70.1 (270) 5.5 (21) 15.8 (61) 7.0 (27) 1.6 (6) 5.7 (22) 92.5 (356) 1.8 (7) 32.7 (126) 34.6 (133) 30.1 (116) 2.6 (10)
In all, 80.2% (309/385) indicated pediatric primary care as their intended specialty, and 85.7% (330/385) were completing their residency program at a children’s hospital. When asked if they had previously diagnosed any of the 8 vaccine-preventable diseases, 8.1% (31/385) of pediatric residents reported having diagnosed measles, 9.1% mumps (35/385), 1.0% (8/385) rubella, 1.8% (7/385) diphtheria, 5.7% (22/385) tetanus, 43.9% (169/385) pertussis, 39.5% (152/385) varicella, and 0.8% (3/385) polio. Residents were then asked how comfortable they would feel treating each of the 8 vaccine-preventable diseases (Table 2) and how likely it was that they would be able to recognize their symptoms (Table 3). Table 4 contains the results from linear regression analysis using 3 dummy variables (PGY-2, PGY-3, and PGY-4) examining the effect of residency year on pediatric residents’ level of comfort in treating each of the 8 diseases as well as their self-reported likelihood of identifying disease symptoms. Higher comfort level scores for more advanced residents were noted for 4 of the 8 diseases (measles, mumps, pertussis, and varicella). PGY-2, PGY-3, and PGY-4 residents felt more comfortable than PGY-1 residents in treating pertussis and varicella (P < .02). PGY-3 and PGY-4 residents expressed greater levels of comfort in treating mumps than PGY-1 residents (PGY-3: β = 0.43, P = .01; PGY4: β = 0.99, P = .02). However, PGY-3 residents, but not PGY-4 residents, felt more comfortable treating measles than PGY-1 residents (PGY-3: β = 0.41; P = .01).
The level of comfort in treating the other 4 diseases (rubella, diphtheria, tetanus, and polio) did not differ significantly between residency years. Although residency year did affect confidence in ability to treat half of the 8 vaccine-preventable diseases, there was no significant effect of residency year on selfreported likelihood of identifying disease symptoms, with the exception of pertussis. In this exception, PGY-3 and PGY-4 residents felt more confident than PGY-1 residents in their ability to identify pertussis symptoms (PGY-3: β = 0.3, P < .01; PGY-4: β = 0.51, P = .01). In the last part of the questionnaire, pediatric residents indicated if 16 different statements on the 8 vaccine-preventable diseases were true or false. The statements and percentage of true/false responses are listed in Table 5. Most of the residents (73.3%) were “extremely concerned” regarding parental refusal to vaccinate their children, 20.1% were “moderately concerned,” 5.0% were “somewhat concerned,” 1.7% were “slightly concerned,” and none were “not at all concerned.” Nearly all the residents (96.0%) felt that they would benefit from receiving more information regarding vaccinepreventable diseases.
Discussion Vaccines have been deemed one of the greatest successes of public health policy.30 However, previous literature suggests that, in recent years, limited familiarity and minimal direct experience with vaccine-preventable diseases may have resulted in a lessened appreciation of their risks and severity.18-21,26 Opposition to and delay of routine childhood immunizations has been steadily mounting.31,32 Antivaccine campaigns have attempted to reduce confidence in vaccines by questioning the utility, efficacy, and safety of inoculation.33 The retracted 1998 publication in The Lancet of an article by Wakefield et al34 asserted a causal link between the measlesmumps-rubella (MMR) vaccine and autism, a link that was subsequently disproven and widely rejected after further studies found no association.35,36 In spite of the retraction, concerns surrounding immunization have increased, and more and more parents are refusing or delaying vaccination of their children.9,17,31,32,37,38 The consequences of vaccine refusal and delay have already been noted. Geographic clusters of reduced vaccination coverage have increased the risk of resurgence of vaccine-preventable diseases.39 Research has attributed recent outbreaks of measles and pertussis in the United States to rising rates of intentional undervaccination.21-23,40 Reduced vaccine coverage has also led to localized disruptions of herd immunity.24,25 In 2010, a pertussis
4
Clinical Pediatrics 00(0)
Table 2. Pediatric Residents’ Level of Comfort Treating Each of the 8 Vaccine-Preventable Diseases. Disease Measles Mumps Rubella Diphtheria Tetanus Pertussis Varicella Polio
Not at All Comfortable
Slightly Comfortable
Somewhat Comfortable
Moderately Comfortable
Extremely Comfortable
Averagea
28.4% 27.7% 32.0% 36.2% 23.9% 6.6% 4.6% 49.7%
27.7% 25.1% 29.0% 27.6% 26.2% 15.9% 13.9% 25.5%
24.1% 27.4% 23.8% 24.9% 26.2% 18.5% 31.0% 18.2%
17.2% 18.2% 12.9% 10.0% 17.3% 33.4% 32.3% 5.6%
2.6% 1.7% 2.3% 1.3% 6.3% 25.5% 18.2% 1.0%
1.38 3.59 1.24 1.13 1.56 2.55 2.46 0.83
a Average score is computed from the following scale: 1, Not at all comfortable; 2, Slightly comfortable; 3, Somewhat comfortable; 4, Moderately comfortable; 5, Extremely comfortable.
Table 3. Pediatric Residents’ Likelihood of Identifying Each of the 8 Vaccine-Preventable Diseases. Disease Measles Mumps Rubella Diphtheria Tetanus Pertussis Varicella Polio
Extremely Unlikely
Unlikely
Neutral
Likely
Extremely Likely
Averagea
1.1% 0.3% 1.7% 3.4% 0.6% 0.0% 0.0% 6.1%
11.5% 9.2% 26.7% 25.8% 9.0% 2.0% 1.1% 37.7%
23.3% 20.4% 37.9% 30.1% 18.6% 3.6% 5.0% 28.5%
55.6% 58.9% 31.5% 34.8% 57.6% 53.1% 54.5% 23.2%
8.4% 11.2% 2.2% 5.9% 14.1% 41.3% 39.4% 4.5%
3.59 3.72 3.06 3.14 3.76 4.34 4.32 2.82
a
Average score is computed from the following scale: 1, Extremely unlikely; 2, Unlikely; 3, Neutral; 4, Likely; 5, Extremely likely.
epidemic of more than 9000 cases occurred in California.41 The majority of these cases (89%) affected infants who were too young to be fully vaccinated.42 In 2014, 667 cases of measles were reported across 27 states, the greatest number of cases since its elimination from the United States in 2000. The majority of infected individuals during this outbreak were unvaccinated.43 Because decreased rates of immunization are correlated with higher rates of disease outbreaks, pediatricians must be sufficiently knowledgeable about these diseases to prevent further transmission.44 Our study found that significant proportions of pediatricians-in-training who participated in this study reported themselves not likely to identify the symptoms of a number of the vaccinepreventable diseases—namely, diphtheria, polio, and rubella. More than one-third and one-quarter of these pediatric residents were not likely to identify symptoms of measles and mumps, respectively. Pediatric residents in this study also felt uncomfortable in treating several of the tested vaccine-preventable diseases. Nearly half of the participants were “not at all comfortable” treating polio, whereas approximately one-third were “not at all comfortable” treating diphtheria or rubella. Significant percentages of these pediatric
residents were either “slightly comfortable” or “not at all comfortable” treating measles, mumps, and tetanus. Conversely, participants felt most comfortable treating pertussis and varicella. Another important finding of this study was that overall, pediatric residents in this study were unable to correctly identify important statements about vaccinepreventable diseases as true or false. Accuracy in responses to questions about vaccine-preventable diseases varied. Participants were most accurate in responding to questions about pertussis, rubella, and mumps. In comparison, these residents were least successful in responding to questions regarding tetanus, polio, and varicella. Although the difficulty of the questions was not standardized, each statement contained information that is essential for pediatricians to know. Therefore, any significant percentage of residents unable to correctly identify true statements is alarming. Our study found that more-advanced residents who participated in the survey felt no more likely to be able to identify symptoms of these vaccine-preventable diseases than less-advanced ones, with the exception of pertussis. In many pediatric residency programs, pediatric residents
5
Cordrey et al Table 4. The Effect of Residency Year on Self-Reported Level of Comfort in Treating Disease and Likelihood of Identifying Disease Symptoms.a Level of Comfort in Treating Disease
Likelihood of Identifying Disease Symptoms
Disease
Residency Year
n
Effect Size
P
Effect Size
P
Measles
PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4 PGY-1 PGY-2 PGY-3 PGY-4
126 133 116 10 126 133 116 10 126 133 116 10 126 133 116 10 126 133 116 10 126 133 116 10 126 133 116 10 126 133 116 10
— 0.22 0.41 0.71 — 0.28 0.43 0.99 — 0.30 0.25 0.38 — 0.13 0.11 0.26 — 0.22 0.30 0.34 — 0.81 1.16 1.41 — 0.34 0.50 1.13 — 0.21 0.20 0.61
— .17 .01b .11 — .07 .01b .02b — .05 .11 .38 — .37 .45 .53 — .20 .08 .47 —
