ABSTRACT
Background Vaccine hesitancy is complex, ranging from safety concerns to decisions built atop disinformation and medical mistrust. Though distrust towards healthcare providers has been described in those with adverse childhood experiences (ACEs), studies have not assessed for links between caregiver ACEs and pediatric vaccine refusal. We sought to determine the association between caregiver ACEs and caregiver decisions to immunize their child with influenza and COVID-19 vaccines. Method This was a cross-sectional study of caregivers of patients >6 months at one pediatric primary care center. Caregivers completed a 19-question survey to determine ACE score, influenza vaccine acceptance and beliefs (adapted from a CDC-validated survey), and intention to accept the COVID-19 vaccine for their children. Demographic characteristics, social risk factors (e.g. housing and food insecurity), social work notes or medical legal partnership referrals within 3 days of a clinic visit, and vaccination data of the children present with each caregiver were extracted from the electronic medical record. Statistical analyses included chi-square tests for categorical variables and t-tests for age. The chi-square test was used to determine the association between caregiver ACEs (high versus low) and demographic, social risk factors and vaccination acceptance, and the two-sample t-test was used to test for differences in child age. Results A total of 234 caregivers participated, representing 276 patients (mean age of 5.9 years, 52% male). Of participating caregivers, 24% (n = 56) had high ACEs (score ≥ 4) and 38% (n = 88) accepted influenza vaccination for their child in 2021. Of those with high ACEs, 51% accepted influenza vaccination for their child compared to 34% with low ACEs (p = 0.03). Those with high ACEs also had more positive attitudes toward influenza vaccine safety and efficacy (p=0.01). Intention to vaccinate children with COVID-19 vaccine also varied by caregiver ACE score (high ACEs: 40%;low ACEs: 24%;p=0.03). Insurance type, a positive social risk screen, and social work consult were not associated with ACEs (Table 1). Conclusion Influenza vaccination rates and intention to vaccinate children with the COVID-19 vaccine differed between caregivers with high and low ACEs – those with more ACEs were more likely to vaccinate. Further studies assessing the role of caregiver ACEs on vaccine decision-making is warranted.
ABSTRACT
Background Influenza vaccine hesitancy rates are increasing in the United States, even as influenza infection accounts for significant pediatric morbidity and mortality. Disinformation and controversy surrounding COVID-related public health protections and SARS-CoV-2 vaccine roll-out may have unintended consequences that impact pediatric influenza vaccination. We sought to assess influenza vaccination rates before and during the COVID-19 pandemic in one pediatric primary care center (PPCC), which serves a predominantly Medicaid-insured, minoritized population. Method A cross-sectional study assessed influenza vaccination rates for children aged 6 months to 12 years (~17,000 patients) over influenza seasons (September-March): 1) 2018-19 and 2019-20 (pre-pandemic rates), and 2) 2020-21 and 2021-22 (intra-pandemic rates). Demographic characteristics and social risk questionnaires (e.g. food and housing insecurity, transportation and public benefit issues, etc.) were pulled from PPCC electronic medical record data. Total tetanus vaccinations during each influenza season were used as a comparison for general vaccination rates, as clinic visits varied due to COVID-related shutdowns. Generalized linear regression models with robust standard errors (SEs) evaluated differences in demographics, social factors, and influenza vaccination rates by influenza season by specifying an appropriate distribution and link function for each factor. In a subgroup of patients with clinic visits in 2018-19 and 2020-21, influenza vaccine rates were compared using the McNemar test. Multivariable logistic regression with robust SEs evaluated associations between influenza season, demographic characteristics, reported social risks, and influenza vaccination. Results The percentages of patients receiving influenza vaccinations by influenza season are depicted in Table 1. Pre-pandemic, 42% of patients with a clinic visit were vaccinated (2019-20), and this rate decreased to 30% by 2021-22 during the pandemic. Both influenza and tetanus vaccinations significantly differed across influenza seasons, with lower uptake during the COVID-19 pandemic (p < 0.01, Table 1). Both mean age (5.5, 5.7, 6.0, and 6.2 years for the 2018-19, 2019-20, 2020-21, and 2021-22 influenza seasons, respectively) and positive social risk screens (13%, 22%, 25%, 27% for the 2018-19, 2019-20, 2020-21, and 2021-22 influenza seasons, respectively) significantly increased across influenza seasons (p < 0.01). Of a subset of 1629 patients with clinic visits in both 2018-19 and 2021-22 seasons, 42% received the influenza vaccine in 2018-19, but only 30% have received the vaccine in 2021-22 (McNemar's test, p < 0.01). In a multivariable regression model, the 2020-21 (OR 0.88 [0.82-0.94]) and 2021-22 (OR 0.68 [0.62-0.74]) influenza seasons, age (OR 0.98 [0.97-0.99]), black race (OR 0.58 [0.54-0.62]), and self-pay (OR 0.84 [0.72-0.99]) were associated with influenza vaccine refusal (p < 0.05). Conclusion Influenza vaccination rates within one PPCC decreased over the years of the COVID-19 pandemic and have not rebounded. New interventions to promote influenza and possibly other vaccines are needed to improve evidence-based child health measures.
ABSTRACT
BACKGROUND: We report the clinical, radiological, laboratory, and neuropathological findings in support of the first diagnosis of lethal, small-vessel cerebral vasculitis triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a pediatric patient. PATIENT DESCRIPTION: A previously healthy, eight-year-old Hispanic girl presented with subacute left-sided weakness two weeks after a mild febrile illness. SARS-CoV-2 nasopharyngeal swab was positive. Magnetic resonance imaging revealed an enhancing right frontal lobe lesion with significant vasogenic edema. Two brain biopsies of the lesion showed perivascular and intraluminal lymphohistiocytic inflammatory infiltrate consistent with vasculitis. Despite extensive treatment with immunomodulatory therapies targeting primary angiitis of the central nervous system, she experienced neurological decline and died 93 days after presentation. SARS-CoV-2 testing revealed positive serum IgG and positive cerebrospinal fluid IgM. Comprehensive infectious, rheumatologic, hematologic/oncologic, and genetic evaluation did not identify an alternative etiology. Postmortem brain autopsy remained consistent with vasculitis. CONCLUSION: This is the first pediatric presentation to suggest that SARS-CoV-2 can lead to a fatal, postinfectious, inflammatory small-vessel cerebral vasculitis. Our patient uniquely included supportive cerebrospinal fluid and postmortem tissue analysis. While most children recover from the neurological complications of SARS-CoV-2, we emphasize the potential mortality in a child with no risk factors for severe disease.