AAP eBooks

Immunization Strategies and Practices

By American Academy of Pediatrics

Vaccine delivery is a substantive portion of pediatric practice and addressing vaccine hesitancy is time-consuming. This collection of articles will assist providers by providing vaccine information and policy statements in a single, easily accessible platform.


  1. Page 1
  2. Page 4
    Address correspondence to Allison Kempe, MD, MPH, University of Colorado, Department of Pediatrics, Mail Stop F443, 13199 E Montview Blvd, Suite 300, Aurora, CO 80045. E-mail: allison.kempe@childrenscolorado.org

    OBJECTIVES To assess among US physicians (1) frequency of requests to spread out recommended vaccination schedule for children <2 years, (2) attitudes regarding such requests, and (3) strategies used and perceived effectiveness in response to such requests.

    METHODS An e-mail and mail survey of a nationally representative sample of pediatricians and family physicians from June 2012 through October 2012.

    RESULTS The response rate was 66% (534 of 815). In a typical month, 93% reported some parents of children <2 years requested to spread out vaccines; 21% reported ≥10% of parents made this request. Most respondents thought these parents were putting their children at risk for disease (87%) and that it was more painful for children (84%), but if they agreed to requests, it would build trust with families (82%); further, they believed that if they did not agree, families might leave their practice (80%). Forty percent reported this issue had decreased their job satisfaction. Most agreed to spread out vaccines when requested, either often/always (37%) or sometimes (37%); 2% would often/always, 4% would sometimes, and 12% would rarely dismiss families from their practice if they wanted to spread out the primary series. Physicians reported using a variety of strategies in response to requests but did not think they were effective.

    CONCLUSIONS Virtually all providers encounter requests to spread out vaccines in a typical month and, despite concerns, most are agreeing to do so. Providers are using many strategies in response but think few are effective. Evidence-based interventions to increase timely immunization are needed to guide primary care and public health practice.

  3. Page 18
    Address correspondence to Alison Kent, MBChB, MRCPCH, Paediatric Infectious Diseases Research Group and Vaccine Institute, St George’s, University of London, London, UK. E-mail: alisonkent@doctors.org.uk

    BACKGROUND AND OBJECTIVE Premature infants have a higher risk of invasive pneumococcal disease and are more likely to have lower vaccine responses compared with term infants. Increasingly, immunization schedules are including a reduced, 2-dose, pneumococcal conjugate vaccine priming schedule. Our goal was to assess the immunogenicity of 3 commonly used 13-valent pneumococcal conjugate vaccine (PCV13) priming schedules in premature infants and their response to a 12-month booster dose.

    METHODS Premature infants (<35 weeks’ gestation) were randomized to receive PCV13 at 2 and 4 months (reduced schedule); 2, 3, and 4 months (accelerated schedule); or 2, 4, and 6 months (extended schedule). All infants received a 12-month PCV13 booster. Serotype-specific pneumococcal immunoglobulin G (IgG) for PCV13 serotypes was measured by using enzyme-linked immunosorbent assay 1 month after the primary and booster vaccinations.

    RESULTS A total of 210 infants (median birth gestation, 29+6 weeks; range, 23+2–34+6 weeks) were included. After the primary vaccination, 75% (95% confidence interval [CI], 62–85), 88% (95% CI, 76–95), and 97% (95% CI, 87–99) of participants had protective antibody concentrations for at least one-half the PCV13 serotypes for the reduced, accelerated, and extended schedules, respectively. After the booster vaccination, participants receiving the extended schedule had significantly lower (P < .05) geometric mean concentrations compared with reduced (for 9 of 13 serotypes) and accelerated (for 4 of 13 serotypes) schedules, but nearly all participations, regardless of schedule or serotype, had seroprotective IgG concentrations.

    CONCLUSIONS A reduced priming schedule of PCV13 resulted in higher post-booster IgG concentrations but lower post-primary concentrations. The optimum vaccine schedule for preterm infants will therefore depend on when they are most at risk for invasive pneumococcal disease.

  4. Page 37
    Address correspondence to Nicola P. Klein, MD, PhD, Kaiser Permanente Vaccine Study Center, 1 Kaiser Plaza, 16th Floor, Oakland, CA 94611. E-mail: nicola.klein@kp.org

    BACKGROUND Vaccination against pertussis during pregnancy is recommended to protect newborns, yet there is limited information about the effectiveness of maternal tetanus toxoid, reduced diphtheria toxoid, acellular pertussis (Tdap) vaccine before the first infant dose of diphtheria, tetanus and acellular pertussis (DTaP) vaccine and during the first year of life in infants who have received DTaP.

    METHODS In a retrospective cohort study of infants born at Kaiser Permanente Northern California from 2010 to 2015, we estimated the effectiveness of maternal pertussis vaccination for protecting newborns against pertussis in the first 2 months of life and in the first year of life accounting for each infant DTaP dose.

    RESULTS Among 148 981 newborns, the vaccine effectiveness of maternal Tdap was 91.4% (95% confidence interval [CI], 19.5 to 99.1) during the first 2 months of life and 69.0% (95% CI, 43.6 to 82.9) during the entire first year of life. The vaccine effectiveness was 87.9% (95% CI, 41.4 to 97.5) before infants had any DTaP vaccine doses, 81.4% (95% CI, 42.5 to 94.0) between doses 1 and 2, 6.4% (95% CI, −165.1 to 66.9) between doses 2 and 3, and 65.9% (95% CI, 4.5 to 87.8) after infants had 3 DTaP doses.

    CONCLUSIONS Maternal Tdap vaccination was highly protective against infant pertussis, especially in the first 2 months of life. Even after infant DTaP dosing, there was evidence of additional protection from maternal Tdap vaccination for the first year of life. This study strongly supports the United States’ current recommendation to administer Tdap during each pregnancy.

  5. Page 46
    Address correspondence to Lauri E. Markowitz, MD, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS A-34, Atlanta, GA 30329. E-mail: lem2@cdc.gov

    BACKGROUND Since mid-2006, human papillomavirus (HPV) vaccination has been recommended for females aged 11 to 12 years and through 26 years if not previously vaccinated.

    METHODS HPV DNA prevalence was analyzed in cervicovaginal specimens from females aged 14 to 34 years in NHANES in the prevaccine era (2003–2006) and 4 years of the vaccine era (2009–2012) according to age group. Prevalence of quadrivalent HPV vaccine (4vHPV) types (HPV-6, -11, -16, and -18) and other HPV type categories were compared between eras. Prevalence among sexually active females aged 14 to 24 years was also analyzed according to vaccination history.

    RESULTS Between the prevacccine and vaccine eras, 4vHPV type prevalence declined from 11.5% to 4.3% (adjusted prevalence ratio [aPR]: 0.36 [95% confidence interval (CI): 0.21–0.61]) among females aged 14 to 19 years and from 18.5% to 12.1% (aPR: 0.66 [95% CI: 0.47–0.93]) among females aged 20 to 24 years. There was no decrease in 4vHPV type prevalence in older age groups. Within the vaccine era, among sexually active females aged 14 to 24 years, 4vHPV type prevalence was lower in vaccinated (≥1 dose) compared with unvaccinated females: 2.1% vs 16.9% (aPR: 0.11 [95% CI: 0.05–0.24]). There were no statistically significant changes in other HPV type categories that indicate cross-protection.

    CONCLUSIONS Within 6 years of vaccine introduction, there was a 64% decrease in 4vHPV type prevalence among females aged 14 to 19 years and a 34% decrease among those aged 20 to 24 years. This finding extends previous observations of population impact in the United States and demonstrates the first national evidence of impact among females in their 20s.

  6. Page 61
    Address correspondence to Jacqueline Tate, PhD, Centers for Disease Control and Prevention, 1600 Clifton Rd NE MS-A34, Atlanta, GA 30333. E-mail: jqt8@cdc.gov

    BACKGROUND Recent US studies have identified a small increased risk of intussusception after rotavirus vaccination, mainly after the first dose. We examined trends in intussusception hospitalizations before (2000–2005) and after (2007–2013) rotavirus vaccine introduction to assess whether this observed temporal risk translates into more hospitalized cases at the population level.

    METHODS Intussusception hospitalizations in children <12 months of age were abstracted from the State Inpatient Database maintained by the Healthcare Cost and Utilization Project for 26 states that provided data from 2000 to 2013. Rates were calculated using bridged-race postcensal population estimates. Trends were analyzed by age groups (6–14 weeks, 15–24 weeks, and 25–34 weeks) based on the recommended ages for vaccine administration as well as 8–11 weeks when the majority of first doses are given. Rate ratios were calculated by using Poisson regression.

    RESULTS No consistent change in intussusception hospitalization rates was observed among all children <12 months of age and among children 15 to 24 weeks and 25 to 34 weeks of age. The intussusception hospitalization rate for children aged 8 to 11 weeks was significantly elevated by 46% to 101% (range: 16.7–22.9 per 100 000) in all postvaccine years except 2011 and 2013 compared with the prevaccine baseline (11.7 per 100 000).

    CONCLUSIONS The increase in the intussusception hospitalization rate in children 8 to 11 weeks when the majority of first doses of vaccine are given is consistent with recent US postlicensure studies. Given the magnitude of declines in rotavirus disease compared with this small increase in intussusception, the benefits of rotavirus vaccination outweigh the increase risk of intussusception.

  7. Page 70
    Address correspondence to John D. Lantos, MD, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: jlantos@cmh.edu

    One of the most divisive issues in pediatrics today concerns the proper response by pediatricians to parents who refuse routine childhood immunizations for their children. Many pediatricians refuse to care for such families. Others continue to provide care and continue to try to convince parents that the benefits of immunizations far outweigh the risks. Two of the most powerful arguments in favor of dismissing such parents are as follows: (1) their refusal suggests such lack of trust in the physicians’ recommendations that it undermines the basis for a meaningful physician–patient–parent relationship; and (2) unimmunized children present an unacceptable risk to other children in the physicians’ waiting rooms. This article examines those arguments.

  8. Page 79

    Immunizations have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about addressing parental concerns about vaccination.

  9. Page 95

    Routine childhood immunizations against infectious diseases are an integral part of our public health infrastructure. They provide direct protection to the immunized individual and indirect protection to children and adults unable to be immunized via the effect of community immunity. All 50 states, the District of Columbia, and Puerto Rico have regulations requiring proof of immunization for child care and school attendance as a public health strategy to protect children in these settings and to secondarily serve as a mechanism to promote timely immunization of children by their caregivers. Although all states and the District of Columbia have mechanisms to exempt school attendees from specific immunization requirements for medical reasons, the majority also have a heterogeneous collection of regulations and laws that allow nonmedical exemptions from childhood immunizations otherwise required for child care and school attendance. The American Academy of Pediatrics (AAP) supports regulations and laws requiring certification of immunization to attend child care and school as a sound means of providing a safe environment for attendees and employees of these settings. The AAP also supports medically indicated exemptions to specific immunizations as determined for each individual child. The AAP views nonmedical exemptions to school-required immunizations as inappropriate for individual, public health, and ethical reasons and advocates for their elimination.

  10. Page 101
    Address correspondence to Linda Fu, MD, MS, Goldberg Center for Community Pediatric Health, Children’s National Health System, 111 Michigan Ave, NW, Washington, DC 20010. E-mail: lfu@childrensnational.org

    OBJECTIVE New emphasis on and requirements for demonstrating health care quality have increased the need for evidence-based methods to disseminate practice guidelines. With regard to impact on pediatric immunization coverage, we aimed to compare a financial incentive program (pay-for-performance [P4P]) and a virtual quality improvement technical support (QITS) learning collaborative.

    METHODS This single-blinded (to outcomes assessor), cluster-randomized trial was conducted among unaffiliated pediatric practices across the United States from June 2013 to June 2014. Practices received either the P4P or QITS intervention. All practices received a Vaccinator Toolkit. P4P practices participated in a tiered financial incentives program for immunization coverage improvement. QITS practices participated in a virtual learning collaborative. Primary outcome was percentage of all needed vaccines received (PANVR). We also assessed immunization up-to-date (UTD) status.

    RESULTS Data were analyzed from 3, 147 patient records from 32 practices. Practices in the study arms reported similar QI activities (∼6 to 7 activities). We found no difference in PANVR between P4P and QITS (mean ± SE, 90.7% ± 1.1% vs 86.1% ± 1.3%, P = 0.46). Likewise, there was no difference in odds of being UTD between study arms (adjusted odds ratio 1.02, 95% confidence interval 0.68 to 1.52, P = .93). In within-group analysis, patients in both arms experienced nonsignificant increases in PANVR. Similarly, the change in adjusted odds of UTD over time was modest and nonsignificant for P4P but reached significance in the QITS arm (adjusted odds ratio 1.28, 95% confidence interval 1.02 to 1.60, P = .03).

    CONCLUSIONS Participation in either a financial incentives program or a virtual learning collaborative led to self-reported improvements in immunization practices but minimal change in objectively measured immunization coverage.

  11. Page 111
    Address correspondence to Cameron C. Grant, MBChB, PhD, Department of Paediatrics, Child and Youth Health, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Wellesley St, Auckland 1142, New Zealand. E-mail: cc.grant@auckland.ac.nz

    OBJECTIVES Pregnant women routinely receive information in support of or opposing infant immunization. We aimed to describe immunization information sources of future mothers’ and determine if receiving immunization information is associated with infant immunization timeliness.

    METHODS We analyzed data from a child cohort born 2009–2010 in New Zealand. Pregnant women (N = 6822) at a median gestation of 39 weeks described sources of information encouraging or discouraging infant immunization. Immunizations received by cohort infants were determined through linkage with the National Immunization Register (n = 6682 of 6853 [98%]). Independent associations of immunization information received with immunization timeliness were described by using adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

    RESULTS Immunization information sources were described by 6182 of 6822 (91%) women. Of these, 2416 (39%) received information encouraging immunization, 846 (14%) received discouraging information, and 565 (9%) received both encouraging and discouraging information. Compared with infants of women who received no immunization information (71% immunized on-time), infants of women who received discouraging information only (57% immunized on time, OR = 0.49, 95% CI 0.38–0.64) or encouraging and discouraging information (61% immunized on time, OR = 0.51, 95% CI 0.42–0.63) were at decreased odds of receiving all immunizations on time. Receipt of encouraging information only was not associated with infant immunization timeliness (73% immunized on time, OR = 1.00, 95% CI 0.87–1.15).

    CONCLUSIONS Receipt, during pregnancy, of information against immunization was associated with delayed infant immunization regardless of receipt of information supporting immunization. In contrast, receipt of encouraging information is not associated with infant immunization timeliness.

  12. Page 123
    Address correspondence to Emily K. Brunson, MPH, PhD, Department of Anthropology, Texas State University, 601 University Dr, San Marcos, TX 78666. E-mail: ebrunson@txstate.edu

    BACKGROUND AND OBJECTIVE Parents decide whether their children are vaccinated, but they rarely reach these decisions on their own. Instead parents are influenced by their social networks, broadly defined as the people and sources they go to for information, direction, and advice. This study used social network analysis to formally examine parents’ social networks (people networks and source net-works) related to their vaccination decision-making. In addition to providing descriptions of typical networks of parents who conform to the recommended vaccination schedule (conformers) and those who do not (nonconformers), this study also quantified the effect of network variables on parents’ vaccination choices.

    METHODS This study took place in King County, Washington. Participation was limited to US-born, first-time parents with children aged ≤18 months. Data were collected via an online survey. Logistic regression was used to analyze the resulting data.

    RESULTS One hundred twenty-six conformers and 70 nonconformers completed the survey. Although people networks were reported by 95% of parents in both groups, nonconformers were significantly more likely to report source networks (100% vs 80%, P < .001). Model comparisons of parent, people, and source network characteristics indicated that people network variables were better predictors of parents’ vaccination choices than parents’ own characteristics or the characteristics of their source networks. In fact, the variable most predictive of parents’ vaccination decisions was the percent of parents’ people networks recommending nonconformity.

    CONCLUSIONS These results strongly suggest that social networks, and particularly parents’ people networks, play an important role in parents’ vaccination decision-making.

  13. Page 135
    Address correspondence to Noel T. Brewer, PhD, Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Rosenau Hall CB7440, Chapel Hill, NC 27599. E-mail: ntb@unc.edu

    OBJECTIVE Improving provider recommendations is critical to addressing low human papillomavirus (HPV) vaccination coverage. Thus, we sought to determine the effectiveness of training providers to improve their recommendations using either presumptive “announcements” or participatory “conversations.”

    METHODS In 2015, we conducted a parallel-group randomized clinical trial with 30 pediatric and family medicine clinics in central North Carolina. We randomized clinics to receive no training (control), announcement training, or conversation training. Announcements are brief statements that assume parents are ready to vaccinate, whereas conversations engage parents in open-ended discussions. A physician led the 1-hour, in-clinic training. The North Carolina Immunization Registry provided data on the primary trial outcome: 6-month coverage change in HPV vaccine initiation (≥1 dose) for adolescents aged 11 or 12 years.

    RESULTS The immunization registry attributed 17 173 adolescents aged 11 or 12 to the 29 clinics still open at 6-months posttraining. Six-month increases in HPV vaccination coverage were larger for patients in clinics that received announcement training versus those in control clinics (5.4% difference, 95% confidence interval: 1.1%–9.7%). Stratified analyses showed increases for both girls (4.6% difference) and boys (6.2% difference). Patients in clinics receiving conversation training did not differ from those in control clinics with respect to changes in HPV vaccination coverage. Neither training was effective for changing coverage for other vaccination outcomes or for adolescents aged 13 through 17 (n = 37 796).

    CONCLUSIONS Training providers to use announcements resulted in a clinically meaningful increase in HPV vaccine initiation among young adolescents.

  14. Page 146
    Address correspondence to Henry H. Bernstein, DO, MHCM, FAAP. E-mail: hbernstein@northwell.edu

    With the expansion of the adolescent immunization schedule during the past decade, immunization rates notably vary by vaccine and by state. Addressing barriers to improving adolescent vaccination rates is a priority. Every visit can be viewed as an opportunity to update and complete an adolescent’s immunizations. It is essential to continue to focus and refine the appropriate techniques in approaching the adolescent patient and parent in the office setting. Health care providers must continuously strive to educate their patients and develop skills that can help parents and adolescents overcome vaccine hesitancy. Research on strategies to achieve higher vaccination rates is ongoing, and it is important to increase the knowledge and implementation of these strategies. This clinical report focuses on increasing adherence to the universally recommended vaccines in the annual adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. This will be accomplished by (1) examining strategies that heighten confidence in immunizations and address patient and parental concerns to promote adolescent immunization and (2) exploring how best to approach the adolescent and family to improve immunization rates.

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