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1.  Physicians’ Human Papillomavirus Vaccine Recommendations, 2009 and 2011 
Background
Physician recommendation is a key predictor of human papillomavirus (HPV) vaccine uptake. Understanding factors associated with recommendation is important for efforts to increase current suboptimal vaccine uptake.
Purpose
This study aimed to examine physician recommendations to vaccinate female patients aged 11–26 years, in 2009 and 2011, at 3 and 5 years postvaccine licensure, respectively. A second aim was to identify trends in factors associated with vaccine recommendation for ages 11 and 12 years.
Methods
Nationally representative samples of physicians practicing family medicine, pediatrics, and obstetrics and gynecology were randomly selected from the American Medical Association Physician Masterfile (n=1538 in 2009, n=1541 in 2011). A mailed survey asked physicians about patient and clinical practice characteristics; immunization support; and frequency of HPV vaccine recommendation (“always” = >75% of the time vs other). Analyses were conducted in 2012.
Results
Completed surveys were received from 1013 eligible physicians (68% response rate) in 2009 and 928 (63%) in 2011. The proportion of physicians who reported “always” recommending HPV vaccine increased significantly from 2009 to 2011 for patients aged 11 or 12 years (35% vs 40%, respectively; p=0.03), but not for patients aged 13–17 years (53% vs 55%; p= 0.28) or 18–26 years (50% vs 52%; p=0.52). Physician specialty, age, and perceived issues/barriers to vaccination were associated with vaccine recommendation for patients aged 11 or 12 in both years.
Conclusions
Results suggest a modest increase in recommendations for HPV vaccination of girls aged 11 or 12 years over a 2-year period; however, recommendations remain suboptimal for all age groups despite national recommendations for universal immunization.
doi:10.1016/j.amepre.2013.07.009
PMCID: PMC3895928  PMID: 24355675
2.  Epidemiology of vaccine hesitancy in the United States 
Human Vaccines & Immunotherapeutics  2013;9(12):2643-2648.
Vaccines are among the most effective public health interventions against infectious diseases. However, there is evidence in the United States for parents either delaying or refusing recommended childhood vaccination. Exemptions to school immunization laws and use of alternative schedule from those recommended by the Advisory Committee on Immunization Practices and the American Academy of Pediatrics cannot only increase the risk of children contracting vaccine-preventable diseases but also increases the risk of infecting others who are either too young to be vaccinated, cannot be vaccinated for medical reasons or did not develop a sufficient immunological response to the vaccine. Healthcare providers are cited as the most influential source by parents on vaccine decision-making. Vaccine hesitancy needs to be addressed by healthcare providers and the scientific community by listening to the parental concerns and discussing risks associated with either delaying or refusing vaccines.
doi:10.4161/hv.27243
PMCID: PMC4162046  PMID: 24247148
vaccines; vaccine hesitancy; immunizations; exemptions; parent beliefs; attitudes
3.  Missed Clinical Opportunities: Provider Recommendations for HPV Vaccination for 11-12 Year Old Girls is Limited 
Vaccine  2011;29(47):8634-8641.
Objective
The purpose of this study was to determine the prevalence of physician recommendation of human papillomavirus (HPV) vaccination in early (ages 11-12), middle (13-17), and late adolescent/young adult (18-26) female patients by physician specialty, and to identify factors associated with recommendation in early adolescents.
Methods
A 38-item survey was conducted April 2009 through August 2009 among a nationally representative random sample of 1,538 Family Physicians, Pediatricians, and Obstetricians and Gynecologists obtained from the American Medical Association Physician Masterfile. A multivariable model was used to assess factors associated with frequency of physician recommendation of HPV vaccination (“always”=76-100% of the time vs. other=0-75%) within the past 12 months.
Results
Completed surveys were received from 1,013 physicians, including 500 Family Physicians, 287 Pediatricians, and 226 Obstetricians and Gynecologists (response rate = 67.8%). Across the specialties, 34.6% of physicians reported they “always” recommend the HPV vaccine to early adolescents, 52.7% to middle adolescents, and 50.2% to late adolescents/young adults. The likelihood of “always” recommending the HPV vaccine was highest among Pediatricians for all age groups (P < .001). Physician specialty, age, ethnicity, reported barriers, and Vaccines for Children provider status were significantly associated with “always” recommending HPV vaccination for early adolescents.
Conclusions
Findings suggest missed clinical opportunities for HPV vaccination, and perceived barriers to vaccination may drive decisions about recommendation. Results suggest the need for age and specialty targeted practice and policy level interventions to increase HPV vaccination among US females.
doi:10.1016/j.vaccine.2011.09.006
PMCID: PMC3200426  PMID: 21924315
human papillomavirus; HPV vaccine; cancer vaccine; cervix cancer; physician
4.  Parents' Source of Vaccine Information and Impact on Vaccine Attitudes, Beliefs, and Nonmedical Exemptions 
In recent years, use of the Internet to obtain vaccine information has increased. Historical data are necessary to evaluate current vaccine information seeking trends in context. Between 2002 and 2003, surveys were mailed to 1,630 parents of fully vaccinated children and 815 parents of children with at least one vaccine exemption; 56.1% responded. Respondents were asked about their vaccine information sources, perceptions of these sources accuracy, and their beliefs about vaccination. Parents who did not view their child's healthcare provider as a reliable vaccine information source were more likely to obtain vaccine information using the Internet. Parents who were younger, more highly educated, and opposed to school immunization requirements were more likely than their counterparts to use the Internet for vaccine information. Compared to parents who did not use the Internet for vaccine information, those who sought vaccine information on the Internet were more likely to have lower perceptions of vaccine safety (adjusted odds ratio (aOR), 1.66; 95% CI, 1.18–2.35), vaccine effectiveness (aOR, 1.83; 95% CI, 1.32–2.53), and disease susceptibility (aOR, 2.08; 95% CI, 1.49–2.90) and were more likely to have a child with a nonmedical exemption (aOR 3.53, 95% CI, 2.61–4.76). These findings provide context to interpret recent vaccine information seeking research.
doi:10.1155/2012/932741
PMCID: PMC3469070  PMID: 23082253
6.  The Association Between Intentional Delay of Vaccine Administration and Timely Childhood Vaccination Coverage 
Public Health Reports  2010;125(4):534-541.
SYNOPSIS
Objectives
We evaluated the association between intentional delay of vaccine administration and timely vaccination coverage.
Methods
We used data from 2,921 parents of 19- to 35-month-old children that included parents' reports of intentional delay of vaccine administration. Timely vaccination was defined as administration with ≥4 doses of diphtheria, tetanus, and pertussis; ≥3 doses of polio vaccine; ≥1 dose of measles, mumps, and rubella vaccine; ≥3 doses of Haemophilus influenzae type b vaccine; ≥3 doses of hepatitis B vaccine; and ≥1 dose of varicella vaccine by 19 months of age, as reported by vaccination providers.
Results
In all, 21.8% of parents reported intentionally delaying vaccinations for their children. Among parents who intentionally delayed, 44.8% did so because of concerns about vaccine safety or efficacy and 36.1% delayed because of an ill child. Children whose parents intentionally delayed were significantly less likely to receive all vaccines by 19 months of age than children whose parents did not delay (35.4% vs. 60.1%, p<0.05). Parents who intentionally delayed were significantly more likely to have heard or read unfavorable information about vaccines than parents who did not intentionally delay (87.6% vs. 71.9%, p<0.05). Compared with parents who intentionally delayed only because their child was ill, parents who intentionally delayed only because of vaccine safety or efficacy concerns were significantly more likely to seek additional information about their decision from the Internet (11.4% vs. 1.1%, p<0.05), and significantly less likely to seek information from a doctor (73.9% vs. 93.9%, p<0.05).
Conclusions
Intentionally delayed vaccine doses are not uncommon. Children whose parents delay vaccinations may be at increased risk of not receiving all recommended vaccine doses by 19 months of age and are more vulnerable to vaccine-preventable diseases. Providers should consider strategies such as educational materials that address parents' vaccine safety and efficacy concerns to encourage timely vaccination.
PMCID: PMC2882604  PMID: 20597453
7.  Importance of background rates of disease in assessment of vaccine safety during mass immunisation with pandemic H1N1 influenza vaccines 
Lancet  2009;374(9707):2115-2122.
Because of the advent of a new influenza A H1N1 strain, many countries have begun mass immunisation programmes. Awareness of the background rates of possible adverse events will be a crucial part of assessment of possible vaccine safety concerns and will help to separate legitimate safety concerns from events that are temporally associated with but not caused by vaccination. We identified background rates of selected medical events for several countries. Rates of disease events varied by age, sex, method of ascertainment, and geography. Highly visible health conditions, such as Guillain-Barré syndrome, spontaneous abortion, or even death, will occur in coincident temporal association with novel influenza vaccination. On the basis of the reviewed data, if a cohort of 10 million individuals was vaccinated in the UK, 21·5 cases of Guillain-Barré syndrome and 5·75 cases of sudden death would be expected to occur within 6 weeks of vaccination as coincident background cases. In female vaccinees in the USA, 86·3 cases of optic neuritis per 10 million population would be expected within 6 weeks of vaccination. 397 per 1 million vaccinated pregnant women would be predicted to have a spontaneous abortion within 1 day of vaccination.
doi:10.1016/S0140-6736(09)61877-8
PMCID: PMC2861912  PMID: 19880172
8.  Acceptance of a Vaccine Against Novel Influenza A (H1N1) Virus Among Health Care Workers in Two Major Cities in Mexico 
Archives of medical research  2009;40(8):705-711.
Background and Aims
Further cases of novel influenza A (H1N1) outbreak are expected in the coming months. Vaccination has been proven to be essential to control a pandemic of influenza; therefore, considerable efforts and resources have been devoted to develop a vaccine against the influenza A (H1N1) virus. With the current availability of the vaccine, it will be important to immunize as many people as possible. However, previous data with seasonal influenza vaccines have shown that there are multiple barriers related to perceptions and attitudes of the population that influence vaccine use. The aim of the study was to evaluate the acceptance of a newly developed vaccine against pandemic (H1N1) 2009 influenza A among healthcare workers (HCW) in Mexico.
Methods
We conducted a cross-sectional study among HCW in three hospitals in the two largest cities in Mexico—Mexico City and Guadalajara—between June and September 2009.
Results
A total of 1097 HCW participated in the survey. Overall, 80% (n = 880) intended to accept the H1N1 pandemic vaccine and 71.6% (n = 786) reported they would recommend the vaccine to their patients. Doctors were more likely to accept and recommend the vaccine than nurses. HCWs who intend to be immunized will be more likely to do so if they know that the vaccine is safe and effective.
Conclusions
Knowledge of the willingness to accept the vaccine can be used to plan strategies that will effectively respond to the needs of the population studied, reducing the health and economic impact of novel influenza A (H1N1) virus.
doi:10.1016/j.arcmed.2010.01.004
PMCID: PMC2854164  PMID: 20304260
Vaccine acceptance; Influenza A (H1N1) virus; Health care workers
9.  Individual freedoms versus collective responsibility: immunization decision-making in the face of occasionally competing values 
Modern public health strives for maximizing benefits for the highest number of people while protecting individual rights. Restrictions on individual rights are justified for two reasons-for the benefit of the individual or the benefit of the community.
In extreme situations there may be a need to protect the health of an individual and particularly a child; even by overriding individual/parental autonomy. However, The American Academy of Pediatrics recently concluded that "Continued (vaccine) refusal after adequate discussion should be respected unless the child is put at significant risk of serious harm (as, for example, might be the case during an epidemic). Only then should state agencies be involved to override parental discretion on the basis of medical neglect".
Many countries have compulsory immunization requirements. These laws curtail individual autonomy in order to protect the community from infectious diseases because unvaccinated individuals pose risk to the community – including vaccinated individuals (since vaccines are not 100% efficacious), children too young to be vaccinated, and persons who have medical vaccine contraindications. There are situations where there can be a real or perceived divergence between individual and community benefits of vaccination. This divergence may occasionally be based upon current scientific evidence and may exemplify the need for overriding individual autonomy. A divergence between individual and community benefits may also exist when there are ideological beliefs incongruent with vaccination or individuals are unaware of or do not accept available scientific evidence.
When the state curtails individual freedoms for the collective good, it should address several issues including the magnitude of the individual and community risk, the strength of the individual's conviction, wider and long-term consequences of restricting individual autonomy, effective risk communication, best available scientific evidence, and transparency of the decision making process.
doi:10.1186/1742-7622-3-13
PMCID: PMC1592474  PMID: 17005041
10.  Support for immunization registries among parents of vaccinated and unvaccinated school-aged children: a case control study 
BMC Public Health  2006;6:236.
Background
Immunizations have reduced childhood vaccine preventable disease incidence by 98–100%. Continued vaccine preventable disease control depends on high immunization coverage. Immunization registries help ensure high coverage by recording childhood immunizations administered, generating reminders when immunizations are due, calculating immunization coverage and identifying pockets needing immunization services, and improving vaccine safety by reducing over-immunization and providing data for post-licensure vaccine safety studies. Despite substantial resources directed towards registry development in the U.S., only 48% of children were enrolled in a registry in 2004. Parental attitudes likely impact child participation. Consequently, the purpose of this study was to assess the attitudes of parents of vaccinated and unvaccinated school-aged children regarding: support for immunization registries; laws authorizing registries and mandating provider reporting; opt-in versus opt-out registry participation; and financial worth and responsibility of registry development and implementation.
Methods
A case control study of parents of 815 children exempt from school vaccination requirements and 1630 fully vaccinated children was conducted. Children were recruited from 112 elementary schools in Colorado, Massachusetts, Missouri, and Washington. Surveys administered to the parents, asked about views on registries and perceived utility and safety of vaccines. Parental views were summarized and logistic regression models compared differences between parents of exempt and vaccinated children.
Results
Surveys were completed by 56.1% of respondents. Fewer than 10% of parents were aware of immunization registries in their communities. Among parents aware of registries, exempt children were more likely to be enrolled (65.0%) than vaccinated children (26.5%) (p value = 0.01). A substantial proportion of parents of exempt children support immunization registries, particularly if registries offer choice for participation. Few parents of vaccinated (6.8%) and exempt children (6.7%) were aware of laws authorizing immunization registries. Support for laws authorizing registries and requiring health care providers to report to registries was more common among parents of vaccinated than exempt children. Most parents believed that the government, vaccine companies or insurance companies should pay for registries.
Conclusion
Parental support for registries was relatively high. Parental support for immunization registries may increase with greater parental awareness of the risks of vaccine preventable diseases and utility of vaccination.
doi:10.1186/1471-2458-6-236
PMCID: PMC1592086  PMID: 16995946

Results 1-10 (10)