key: cord-0692752-fqy5bg8r
authors: Hofstetter, Annika M.; Rao, Suchitra; Jhaveri, Ravi
title: Beyond Influenza Vaccination: Expanding Infrastructure for Hospital-Based Pediatric COVID-19 Vaccine Delivery
date: 2022-01-29
journal: Clin Ther
DOI: 10.1016/j.clinthera.2022.01.013
sha: 95b849e6946abbd994e82d32a1450849e8dacce5
doc_id: 692752
cord_uid: fqy5bg8r

Controlling the spread of COVID-19 will rely on increasing vaccination rates in an equitable manner. The main reasons for under-vaccination are varied among different segments of the population and include vaccine hesitancy and lack of access. While vaccine hesitancy is a complicated problem that requires long-term solutions, enhancing access can be achieved through evidenced-based delivery strategies that augment traditional approaches. Hospital-based COVID-19 vaccination programs hold particular promise for reaching populations with decreased vaccine access and those at higher risk for adverse outcomes from COVID-19 infection. Hospitals have the necessary equipment and storage capabilities to maintain cold chain requirements, a common challenge in the primary care setting, and can serve as a central distribution point for delivering vaccines to patients in diverse hospital locations, including inpatient units, emergency departments, urgent care centers, perioperative areas, and subspecialty clinics. They also have the capacity for mass vaccination programs and other targeted outreach efforts. Hospital-based vaccination programs can leverage existing infrastructure such as electronic health record tools that have been successful approaches for influenza and other routine vaccinations. With the possibility of COVID-19 becoming endemic, much like seasonal influenza, these programs will require flexibility as well as planning for long-term sustainability. The goal of this review is to highlight existing vaccine delivery to children in hospital-based settings, including key advantages and important challenges, and outline how these systems could be expanded to include COVID-19 vaccine delivery.

The COVID-19 pandemic continues to be the greatest public health crisis in modern history. At the time of writing, there have been more than 330 million cases and over 5.5 million deaths globally, including over 65 million cases and almost 850,000 deaths in the US alone (1) .

In the US, where over 209 million people are fully vaccinated (2) , the pandemic has almost entirely shifted to a pandemic amongst the unvaccinated. Regions of the country with lower vaccination rates have suffered from record numbers of cases, hospitalizations, and deaths that have strained health care infrastructure to such extremes that rationing of care is necessary. The reasons for under-vaccination are varied among different segments of the population and include vaccine hesitancy and lack of access, particularly in medically underserved areas. While vaccine hesitancy is a complicated problem that requires long-term solutions, lack of access is one issue for which solutions already exist and are steeped in past experience and success. The goal of this review is to highlight existing vaccine delivery to children in hospital-based settings, with a specific focus on seasonal influenza vaccination, and discuss how these systems could be expanded to include delivery of COVID-19 vaccines.

Each of our institutions has established a highly successful program to promote influenza vaccination of patients being seen in a variety of inpatient and outpatient settings (3) (4) (5) . We highlight 5 key elements (Table 1 ) critical to implementing these programs and provide examples from our institutions to illustrate these points.

Because the steps to successful influenza vaccination involve many different disciplines across an institution, engagement of and cooperation between individuals representing these disciplines is critical. Our institutions have each convened a team of champions consisting of nurses, advanced practice providers, resident and attending physicians, pharmacists, clinical informaticists, data analysts, and communications specialists. The teams have worked collaboratively towards the shared goal of capturing influenza vaccination opportunities at all healthcare visits. In our experience, support from hospital leadership to promote messaging and provide resources when needed is also critical for program success. 3. Analytic Tools: Accurate and timely data are essential for tracking influenza vaccine screening, ordering, and administration metrics during the season and for evaluating program growth and optimization between seasons. At our institutions, this information is used to show real-time progress for the current season and a comparison to prior seasons. Prospective audit and feedback is provided regularly by influenza vaccine champions, nursing managers, and providers to the inpatient and outpatient teams (e.g., through weekly email reports, monthly staff presentations).

Efforts to teach and share accurate vaccine-related information is imperative for facilitating evidence-based vaccine decision-making. Prior to each influenza season, our programs incorporate education/re-education of nurses, providers, and staff to highlight the impact of seasonal influenza on patients and the role that each team member plays in promoting vaccination. We have used varied approaches including in-person and virtual presentations, newsletters, online resources, and required training modules. Scripting is integrated into the EHR's best practice advisories to promote the use of evidence-based vaccine communication (e.g., offering a strong, presumptive recommendation). Patient and provider education materials highlighting the benefits of influenza vaccination and addressing common questions are provided through web-based materials, handouts and via patient portal messages within the EHR. The examples above describe the experience of inpatient vaccination at several children's hospitals, but the lessons learned from these programs apply to other patient populations.

Vaccination in a hospital setting provides a myriad of advantages, including increased access for populations without a primary medical home, those who face challenges with taking time off work or transportation constraints, and targeted delivery to populations with comorbidities that increase their risk of severe outcomes from infection. Hospital-based health systems can serve as a central distribution point for vaccines, have the necessary equipment and storage capabilities to maintain cold chain requirements, and have the capacity for mass vaccination events. They also can leverage infrastructure that has been established for other vaccine programs such as electronic health record-embedded tools for vaccine screening, ordering, and tracking. Another advantage is the potential for the entire care team, across roles and disciplines, to provide a strong, consistent vaccine message to patients and families. In the hospital, there may be time for prolonged or multiple conversations with a more "captive audience," with the potential for families to be more open to vaccination as perceptions of their child's risk change (6) .

In 2010, nearly 2 million children under 15 years of age (excluding newborns) were hospitalized in the US (7), and the majority of these children have underlying chronic disease (8) with an increased risk of influenza-related complications (9) . Further, many hospitalized children lack a medical home or usual source of care (10) , which may contribute to under-immunization as well as risk for adverse outcomes in general (11) .

An estimated 37-63% of hospitalized children are eligible for influenza vaccination at the time of admission (3, 12, 13) . Of these, only 25-50% are vaccinated before hospital discharge (3, 13, 14) . The high proportion of missed opportunities is concerning, especially since influenza vaccination during hospitalization is recommended by the Advisory Committee of Immunization Practices (9) and serves as an important quality measure (15). Reasons for under-vaccination in the hospital setting have been recently explored. Although many families express interest in receiving vaccines in this setting, evidence suggests that multi-level barriers contribute to missed opportunities (6, 12-14, 16, 17) . These include difficulty ascertaining accurate vaccine records, perceptions about vaccinating during acute illness, provider apprehension about assuming the task of providing vaccinations, considered to be the responsibility of the primary care provider (12) , lack of skills to effectively communicate with hesitant families about vaccines, and billing considerations.

The Emergency Department (ED) is considered a safety net for many children and adults without a medical home and can help overcome many of the aforementioned barriers to accessing vaccines experienced by low-income families (18) . Survey data indicate that families have demonstrated willingness to receive vaccines in the ED setting (18) . Several studies have demonstrated that dedicated programs offering influenza vaccine to families in the ED increased overall vaccination rates (18) (19) (20) and that they are cost-effective (21, 22) .

A study of children hospitalized due to influenza infection indicated that subspecialty clinics represented the visit type with the highest proportion of missed opportunities for vaccination, particularly for children with a high-risk medical condition (23) . Vaccine reminderrecall is an effective strategy relevant to ambulatory settings that has been implemented using various modalities (e.g., letter, telephone, text message, email, EHR-based messages) (24) (25) (26) (27) .

Several studies have evaluated clinic process changes through QI initiatives, such as pre-visit planning, vaccine clinics, immunization champions, and designated vaccine nurses (28, 29) .

Multi-component interventions have been shown to have a more substantial increase in vaccination rates compared with single-component interventions (25, 30) .

In the US, approximately six million children under 18 years of age receive general anesthesia each year and, of those children, more than a million are likely to receive general anesthesia around a vaccine-appropriate age (31) . Administering a vaccine under general anesthesia provides the advantages of patient comfort, convenience, and leveraging existing workflows and processes without sacrificing immunogenicity (32), (33) . For these reasons, the American Academy of Pediatrics states that there are no contraindications to peri-operative vaccine administration (34) .

Vaccinating family members is an effective cocooning strategy to protect patients who are at high-risk for disease, ineligible for vaccination, or who may mount an insufficient immune response to vaccination (35) . These programs are often supported by philanthropic funds to circumvent the need for patient registration and billing. Similar initiatives could be established at adult hospitals and nursing homes to allow for family members to receive seasonal influenza and COVID-19 vaccines during inpatient and outpatient encounters.

As COVID-19 vaccines have become available for children, there has been an operational desire for hospital-based health systems to leverage the current influenza vaccination infrastructure to vaccinate eligible patients. However, inherent differences between COVID-19 mRNA and seasonal influenza vaccines have posed additional challenges that complicate implementation efforts: the need for extreme cold storage requirements for COVID-19 mRNA vaccines (Pfizer/BioNTech in particular), the need for a second dose of vaccine for all patients, limited vaccine supply from the state requiring strategic use of every last dose in multidose vials, and additional reporting/accounting requirements to public health agencies.

Controlling the spread of COVID-19 will rely on increasing vaccination rates in an equitable manner, which will require us to develop strategies that augment traditional approaches. Hospital-based COVID-19 vaccination programs allow for broader reach to those with decreased vaccine access and provide an opportunity to target other vulnerable populations at higher risk for adverse outcomes from COVID-19 infection. These efforts can extend across hospital-based settings, including inpatient units, emergency departments, urgent care centers, perioperative areas, subspecialty clinics, mass vaccination clinics, and targeted outreach/mobile clinics. Hospital-based vaccination programs can leverage existing infrastructure, including EHR tools established for influenza and other routine vaccinations. However, additional challenges specific to COVID-19 vaccination include maintaining cold chain requirements, considerations for access to second and booster doses, and navigating state-managed supply. With the possibility of COVID-19 becoming endemic, much like seasonal influenza, these programs will require flexibility (i.e., as new recommendations emerge) and planning for long-term sustainability. Further study into the most effective implementation strategies to increase influenza, COVID-19, and routine vaccine uptake and the impact of hospital-based delivery methods is crucial. 

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