Each year, before 2020, millions of children contracted influenza virus.1 From 2020 to 2021, protective measures to prevent the spread of coronavirus disease 2019 (COVID-19), such as mask wearing, social distancing, and frequent hand-washing, likely protected children from other infectiousdiseases, including seasonal influenza.2 However, as COVID-19 preventive measures begin to abate and children return to school and normal activities outside the home, the seasonal influenza will again be a threat to young children nationally.
Children under 18 years of age are twice as likely to develop symptoms as adults over age 65 years, and those under 4 years of age are over 3 times as likely.1 Young children, especially those under 5 years old, are at the highest risk for severe illness and death from influenza.1,3 Children are also key drivers of transmission, on average spreading influenza to multiple age groups and for longer periods than adults.4
Influenza vaccination is still the best method of preventing influenza and its associated complications. Influenza vaccine should be given to children starting at age 6 months, and 2 doses of influenza vaccine, administered 28 days apart, should be given to a child under age 9 years if they have not previously received 2 doses during an influenza season. Previous studies have shown the importance of both doses, especially in vaccine-naïve children. For example, in vaccine-naïve children aged 2 years or younger, vaccine effectiveness is cut in half with only 1 dose.5
Unfortunately, ∼2 in 5 children went unvaccinated during the 2019–2020 influenza season,6 with even lower rates for adolescents. Among those who are vaccinated, only about half who need a second dose receive it, leaving them without full protection.5 The timing of vaccination is also important. For optimal protection, children should be fully vaccinated by the start of increased influenza activity, which is usually in October.7 Even with low vaccination rates, nearly 24 000 hospitalizations of children aged 17 years and under and hundreds of deaths were averted during the 2019–2020 influenza season.8 The price of low vaccination coverage is high. Although it is fortunately rare, each year children die of influenza; the vast majority (80%) have not been fully vaccinated.9
A time-proven method to improve immunization rates is reminder-and-recall interventions, which have been particularly effective in helping busy parents to remember to bring their children in for the influenza vaccine.10 In this issue of Pediatrics, Lerner et al11 examine influenza vaccine reminders using a medical record patient. In this intention-to-treat randomized clinical trial of 22 046 children aged 6 months to <18 years in 53 primary care practices, portal reminders did not significantly increase vaccination rates of the first dose of the influenza vaccine, but they did have a substantial impact on improving rates of second doses of influenza vaccine for children aged <3 years who needed 2 doses. Completion rates for the second dose of the influenza were 55.0% for the reminder group and 44.1% for the no-reminder group. For caregivers who have already demonstrated intent to vaccinate their children, the portal reminders may have served as a cue-to-action, prompting them to return to their child’s health care provider for the second dose of the influenza vaccine. However, the limited impact on first doses suggest that reminders may be less effective in motivating families who have not already decided to vaccinate. Conversations addressing vaccine hesitation in caregivers still are necessary to overcome barriers to influenza.12
This study also assessed the importance of message framing in influenza vaccination reminders. The investigators compared loss-framed (the risks of not receiving the vaccine) versus gain-framed reminders (benefits of receiving the vaccine). There was no significant difference in vaccination rates among the portal message recipients who received the loss-framed versus gain-framed reminders versus the no-reminder control group (56.9%). This reaffirms a previous meta-analysis of loss- versus gain-framed vaccination messages that revealed no significant differences in vaccination rates by message type.13 Precommitment messages asking the family to commit in advance to vaccinate their child for the influenza vaccine that season also were not effective, likely because of only 6.9% of families opening the e-mail. According to the Elaboration Likelihood Model framework, which outlines how people process information, these static messages could be engaging along the peripheral route, with recipients relying on heuristics or mental shortcuts to process the message quickly. To effect change, messages may need to be provided in a way or through a modality in which caregivers process them through the central route that encourages them to have more in-depth consideration of the information that leads to lasting change.14,15
Patient portal use is increasing, even more dramatically in the last year with COVID-19 with the uptake of telehealth,16 and exploring ways to use this technology most effectively is important. As more caregivers and patients begin to use this technology, portal reminders could have a larger impact of improving immunization rates. In this study, only 27.0% of patients or caregivers in the first influenza vaccine reminder groups opened any of the 3 messages they received. If more patients or caregivers or patients actually read the reminder messages, it is possible that influenza rates could have improved even more. It has been found that portal use by patients can be increased with encouragement from providers, and the absence of encouragement has been shown to be a barrier to use. Reading portal messages also requires the caregiver to log into the portal to view messages, creating a barrier in ease of use and access. Sociodemographic characteristics have also been shown to be predictive of portal use.17 Efforts must be made to ensure that there are equitable efforts to increase patient portal use and accessibility, as well as to ensure that messages are available in the family’s preferred language.
Overall, this study demonstrated the ability of portal messages to increase influenza vaccination in children for those in need of a second dose. Strengths include the large sample size that allows a truer estimate of the impact of portal reminder message in real-life practice. Ways to optimize this intervention may include ensuring that portal messages are sent in the patient’s preferred language and that providers and other pediatric clinical staff are active in encouraging its use. Portal messages should be used alongside strong provider recommendations and other reminder recall methods, such as text messages or phone calls, to address other barriers to first-dose influenza vaccination. Moreover, for families that are hesitant about vaccination, the decision to obtain the influenza vaccine may still need to be a conversation.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-048413.
POTENTIAL CONFLICT OF INTEREST: Dr Stockwell has received grants from the National Institutes of Health and Centers for Disease Control and Prevention; and Drs Wynn and Stephens have indicated they have no financial relationships relevant to this article to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.