Coronavirus disease 2019 (COVID-19), induced by severe acute respiratory syndrome coronavirus 2, had an unprecedented and widespread impact on nearly all aspects of life for children and their families. As of May 2023, nearly 16 million children have tested positive for COVID-19 since the onset of the pandemic, with children representing ∼20% of the total number of cumulative cases.1 Children with preexisting chronic conditions, younger age, and an underlying immunocompromised state are at a low but increased risk of severe or fatal disease and are at a higher risk of sequelae post-infection, including multisystem inflammatory syndrome in children.2–4 Efforts to reduce the spread of disease and mitigate the impact of COVID-19 are a public health priority with vaccination at the forefront to reduce overall morbidity and mortality.5
In December 2020, the US Food and Drug Administration granted emergency use authorization for the administration of the Pfizer-BioNTech COVID-19 vaccine for children ages 16 and older. In May 2021, approval of the vaccine was amended to include adolescents aged 12 to 15, and in October of that year, the age range for vaccination extended to children aged 5 to 11. Despite the scientific evidence revealing the safety and efficacy of COVID-19 vaccination against the disease for children and adolescents, pediatric vaccine acceptance remains low.5,6 For series completion, US vaccination rates for children aged 5 to 11 and 12 to 17 are 32% and 59%, respectively.7 These percentages underscore the importance of identifying ways to address COVID-19 vaccine acceptance and hesitancy to improve public health measures and encourage vaccination uptake in the pediatric population.5
In this edition of Hospital Pediatrics, Rush and colleagues, in “Pediatric COVID-19 Vaccination in the Inpatient Setting,” highlight a creative strategy to address and improve COVID-19 vaccination rates by targeting hospitalized children. As the article reveals, hospital admissions provide a unique opportunity to identify patients often at higher risk of the disease and its complications, offer education and counseling, and address misinformation.8 National best practice guidelines recommend providers use every health care encounter, including the inpatient setting, as an opportunity to screen for immunization status and vaccinate to eliminate missed opportunities.9,10 Additionally, inpatient vaccination may help reduce health care disparities for patients who experience barriers to outpatient immunizations, such as routine access to their primary care physician, financial constraints, and transportation difficulties.11 The inpatient setting also offers a unique niche for patients with complex medical needs who are frequently hospitalized and at high risk of complications from vaccine-preventable diseases, as well as adolescent patients who are the group most likely to be under-immunized at the time of hospitalization.9,11
The article by Rush et al adds to a growing body of literature focused on making immunization a routine part of medical care for hospitalized children.10–15 Several previous studies have revealed the value of screening vulnerable inpatient pediatric populations for vaccine eligibility and interest.9–12 Foradori et al found that by engaging an interdisciplinary medical team, providing family and provider education, and implementing a vaccine protocol with electronic health record modifications, the influenza immunization rate for admitted patients with status asthmaticus at their institution increased from 13% to 57%.13 Mirza et al similarly improved the administration of the 23-valent pneumococcal polysaccharide vaccine rate in an inpatient pediatric diabetic population from 27% to 42% by partnering with pediatric clinical pharmacists and providing staff education.14 An inpatient vaccination program developed by Bell et al increased the number of fully vaccinated preschool-aged children in an under-immunized urban population from 44% on admission to 70% on discharge and formed an essential outpatient linkage to community pediatricians.10 Together, these inpatient immunization examples reveal ways to promote opportunities for vaccine access and administration in the hospital setting.
In the study by Rush et al, the authors highlight the use of an electronic health record screening questionnaire and alert, as well as participation from multidisciplinary team members, as key strategies to promote inpatient vaccination. With these interventions, they successfully vaccinated 29% of patients interested in the vaccine and 2% of those who initially declined. Notably, 71% of patients who expressed interest in vaccination during the admission ultimately remained unvaccinated at the time of discharge.8 It is likely that a variety of individual and systems-level barriers existed to explain this including uncertainty when it came time to vaccinate, input from other caregivers not initially at bedside at the time of evaluation, timing of vaccine-ordering related to patient discharge, as well as the need for subsequent vaccination doses. Additional insight could be gathered by conducting postdischarge follow-ups for this group of patients to assess the family perspective on barriers and whether vaccination was eventually sought in the outpatient setting.
Although the study by Rush et al revealed a modest number of inpatient COVID-19 vaccines administered, the overall immunization rate remained low.8 This underscores the need to evaluate the opportunity cost for the development of such programs and the time, effort, and resources required to implement these in an already stressed health care environment. Additionally, although reasons for acceptance, uncertainty, or refusal of COVID-19 vaccination were not evaluated, the lower vaccination rate emphasizes the need to understand unique facilitators and barriers for vaccine acceptance both globally and specifically for hospitalized children. The authors of previous studies have found that the perceived lack of confidence in the safety and efficacy of the COVID-19 vaccine and a lack of trust in the government, particularly among marginalized groups, are key factors associated with vaccine hesitancy.5 The hospital setting may then be of particular benefit for vaccines with low uptake and high parental hesitancy because hospital admissions provide patients and families the opportunity to work with an interdisciplinary team of health care professionals and medical specialists with whom they can address concerns, receive counseling, and discuss misconceptions.9,16–18 However, as this study reveals, significant barriers remain that could potentially be better addressed by further investigating and elucidating specific in-hospital challenges. In addition, although previous quality improvement efforts have evaluated effective strategies in communicating the need for inpatient vaccination to providers, studies assessing provider-specific perceptions regarding inpatient vaccination are lacking.11,19 Promoting buy-in from the patient’s primary medical team is essential to establishing a successful inpatient immunization program and understanding provider attitudes, perceived challenges, and effective interventions may therefore allow for increased rates of vaccine screening and administration.15
By implementing a pediatric vaccination program for hospitalized patients, the study by Rush et al reveals how an inpatient infrastructure can rapidly be created in the setting of a global pandemic at a time when health care systems faced insurmountable challenges.8 An important long-term implication of this work will be the application of these initiatives in times of acute need and whether the resources required to implement such programs can be justified in the inpatient setting. Future efforts to identify contributing factors to success and ways to expand workflows effectively from single-site to multicenter institutions will be essential.11,18 Additionally, identifying determinants of vaccine acceptance and hesitancy will be critical to the ongoing development of effective public health strategies and targeted interventions in the inpatient setting and beyond.5
COMPANION PAPER: A companion to this article can be found online at www.hosppeds.org/cgi/doi/10.1542/hpeds.2022-006804.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: Dr Fallon is a shareholder of Merck & Co, Inc; and Drs Ramazani and Sosa have indicated they have no potential conflicts of interest to disclose.