While scanning journals for the PAAD, I came across an entire issue of the Pediatric Clinics of North America on vaccine hesitancy (Volume 70, issue 2). As discussed in a previous PAAD (Jan 3, 2023: Influenza vaccination in the perioperative period: A teachable moment https://ronlitman.substack.com/p/influenza-vaccination-in-the-perioperative the perioperative period is an untapped health care opportunity to vaccinate children for influenza.1 As a former, “lapsed” pediatrician, I’ve always been astonished by parental vaccine hesitancy. As a pediatric house officer, I routinely saw meningitis (H. flu, S. pneumonia, N. meningitis) and its sequelae at least once a week until, quite magically, meningitis (and epiglottitis) just about disappeared with the introduction of vaccines. As an elementary school student, I remember lining up at the nurse’s office with my entire class for oral polio (sugar cube) vaccines. There were no consent forms, opt-outs, etc. It was considered a miracle and it was. Could we as anesthesiologists do something about this? After all, almost 5 million American children undergo surgery yearly. Could we take advantage of an otherwise missed health care opportunity? Rao et al.1 showed that the answer is YES! I asked Drs. Kim Strupp and Tyler Morrisey of Children's Hospital Colorado who spearheaded and co-authored the Rao study to assist in today’s PAAD. My goal today is to get you all thinking about this NOW so that you can put into place a flu vaccination program in your own institutions before next year’s flu vaccination period begins (summer-early fall). You may want to ask Dr. Strupp (kim.strupp@childrenscolorado.org) and/or Dr. Morrissey (tyler.morrissey@childrenscolorado.org) for assistance. Additionally, Kim and Tyler are working on a new study that you may want to join. Myron Yaster MD
Original article
Stephens AB, Hofstetter AM, Stockwell MS. Influenza Vaccine Hesitancy: Scope, Influencing Factors, and Strategic Interventions. Pediatr Clin North Am. 2023 Apr;70(2):227-241. doi: 10.1016/j.pcl.2022.11.003. PMID: 36841592
“The primary prevention and control of the influenza virus is through vaccination and the seasonal influenza vaccination program is one of the most commonly utilized immunization programs in the United States. The influenza vaccine is safe and effective, prevents influenza-related complications, and it is particularly important in children as vaccination among children has been shown to reduce influenza illness in older adults.”2 And yet, pediatric influenza vaccination rates in the United States hover around 50% and are far below the 70% target rate set by the U.S. Department of Health and Human Services (Washington, D.C.).3, 4 Indeed, the actual vaccination rate may be as low as 35%4, particularly in the Black community.4 The need to increase pediatric influenza vaccination rates is critically important in order to control flu epidemics. Indeed, preventing influenza virus infection in children can have both direct and indirect benefits to themselves and others. But how?
“What is not measured, cannot be improved”. Lord Kelvin or Peter Drucker
To better understand parental and patient vaccination hesitancy, the Vaccine Hesitancy Scale (VHS), was developed and validated by the World Health Organization’s Strategic Advisory Group of Experts on Immunization.5-8 It has been modified to assess hesitancy to the influenza vaccine.8 Using these scales in future studies is crucial to better understand flu vaccine hesitancy and how the perioperative period may affect parental and patient decisions concerning flu vaccines. For example, are flu vaccine-hesitant parents also hesitant about other childhood vaccines? Kempe et al.9 found that the answer is YES. This has important implications for all of us. If hesitant parents agree to have their child vaccinated during anesthesia AND they haven’t vaccinated their child for other routine childhood vaccinations, could and should we offer them this option perioperatively? The American Academy of Pediatrics has previously stated that there are no contraindications to perioperative vaccination - an exception being for the MMR vaccine, because of a risk of interaction between the live vaccine and transfusions10. Measuring parental responses to proposed vaccination before future studies are planned is therefore critical.
Finally, in discussing flu vaccination with parents and adolescent patients, it is important to understand the most common reasons that drive the decision process in vaccine hesitancy and refusal. Stephans et al.4 point out that “the perceived benefits must outweigh the risks”. Compared to other vaccines, “parents are less likely to think that flu vaccines are important and protective against influenza”. They have good reasons to think this. Flu vaccines vary in their effectiveness from year to year and many parents believe that they or their children actually “caught the flu” after being vaccinated.4 Further, family social processes may affect the decision. If the parents aren’t or won’t be vaccinated for the flu, it's unlikely they will vaccinate their children. Thus, if we offer flu vaccines to children in the perioperative period, should we also offer it to their parents?
We’ve raised more questions than answers in today’s PAAD. If you are interested in joining our quest to use the perioperative period as a health care opportunity to improve flu vaccination rates, contact Kim or Tyler. If you have other thoughts send them to Myron who will post in the Friday Reader Response.
References
1. Rao S, Morrissey T, Ziniel SI, Mandler T, Yaster M, Strupp KM. Influenza Vaccination in Perioperative Settings: A Teachable Moment. Anesthesiology. Dec 1 2022;137(6):745-747. doi:10.1097/aln.0000000000004341
2. Gates DM, Cohen SA, Orr K, Caffrey AR. Pediatric influenza vaccination rates lower than previous estimates in the United States. Vaccine. Oct 19 2022;40(44):6337-6343. doi:10.1016/j.vaccine.2022.09.053
3. U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Healthy People 2030. https://health.gov/healthypeople
4. Stephens AB, Hofstetter AM, Stockwell MS. Influenza Vaccine Hesitancy: Scope, Influencing Factors, and Strategic Interventions. Pediatric clinics of North America. Apr 2023;70(2):227-241. doi:10.1016/j.pcl.2022.11.003
5. MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. Aug 14 2015;33(34):4161-4. doi:10.1016/j.vaccine.2015.04.036
6. Opel DJ, Mangione-Smith R, Taylor JA, et al. Development of a survey to identify vaccine-hesitant parents: the parent attitudes about childhood vaccines survey. Hum Vaccin. Apr 2011;7(4):419-25. doi:10.4161/hv.7.4.14120
7. Opel DJ, Taylor JA, Zhou C, Catz S, Myaing M, Mangione-Smith R. The relationship between parent attitudes about childhood vaccines survey scores and future child immunization status: a validation study. JAMA pediatrics. Nov 2013;167(11):1065-71. doi:10.1001/jamapediatrics.2013.2483
8. Helmkamp LJ, Szilagyi PG, Zimet G, et al. A validated modification of the vaccine hesitancy scale for childhood, influenza and HPV vaccines. Vaccine. 2021/03/26/ 2021;39(13):1831-1839. doi:https://doi.org/10.1016/j.vaccine.2021.02.039
9. Kempe A, Saville AW, Albertin C, et al. Parental Hesitancy About Routine Childhood and Influenza Vaccinations: A National Survey. Pediatrics. Jul 2020;146(1)doi:10.1542/peds.2019-3852
10. Lin C, Vazquez-Colon C, Geng-Ramos G, Challa C: Implications of anesthesia and vaccination. Paediatr Anaesth 2021; 31:531–8. https://doi.org/10.1111/pan.14148