Provider Attitudes Regarding Varicella Vaccine Objective To determine which factors influence Vaccines for Children (VFC) providers’ decision not to use varicella vaccine The objective of this study was to determine which factors influence a clinic’s decision to not offer free varicella vaccine for children. Public Health Seattle & King County

Provider Attitudes Regarding Varicella Vaccine Vaccine available free of charge to providers in Washington State through the VFC program since May 1995 Only 54% (153/285) of King County clinics participating in the VFC program offered the varicella vaccine to their patients in 2001 Despite the availability of free vaccine, only approximately 50% of clinics participating in the VFC program offer the varicella vaccine to their patients. Public Health Seattle & King County

Varicella Vaccine Coverage Rates for 19-35 Month-Old Children, in King County by Year Public Health Seattle & King County

Provider Attitudes Regarding Varicella Vaccine Methods Standardized surveys mailed to VFC clinics that did not use varicella vaccine Surveys were addressed to the designated contact person on the VFC contract Surveys followed by a phone call with an opportunity for a telephone interview In May of 2001 standardized surveys were mailed to clinics that participated in the VFC program, but did not offer varicella vaccine at the time of the survey. The surveys were mailed to the contact person listed on the VFC contract. The contact person was most often a nurse or medical assistant who handled vaccine ordering and storage for the clinic. Each mailed survey was followed by a reminder phone call with an opportunity for the respondent to complete an oral interview. Public Health Seattle & King County

Influenced Providers’ Decision to Not Order Varicella Vaccine Clinics were asked to indicate which factors influenced their decision to not order the varicella vaccine. The most frequently mentioned reason for not ordering varicella vaccine was clinics did not have an adequate freezer (70%). The second most frequently mentioned reason was that parents do not request the vaccine (33.0%). 18% of clinics stated that they felt that the vaccine was a low priority compared to other required childhood vaccines. 14% indicated that they had some concern about the possibility of waning immunity and 14% expressed concern about the vaccines efficacy. The total is greater than 100% as it was possible of the respondent to choose more than one answer. Public Health Seattle & King County

Most Influential Reasons For Not Using VFC Varicella Vaccine % Respondents 67% 33% Reason Inadequate freezer Lack of parental interest Public Health Seattle & King County

Reasons for Not Using Varicella Vaccine Of Clinics Indicating That Having an Inadequate Freezer Most Influenced Their Usage Decision (n=78) 18% also considered the vaccine to be a low priority 14% were also concerned about waning immunity in adulthood 12% were also unsure of overall efficacy of the vaccine Of Clinics That Stated Lack of Parental Interest Influenced Their Usage Decision (n=37) 35% considered the vaccine to be a low priority 24% prefer patients become immune through natural infection 19% consider varicella to be a mild illness Initial analysis of the survey indicated that inadequate refrigeration and parents not requesting the vaccine were the most influential reasons for not offering the vaccine. However, further analysis showed that those sites responding that inadequate refrigeration and lack of parent demand were most influential were more likely to consider the vaccine to be a low priority and/or question the efficacy of the vaccine. Of those clinics that indicated that having an inadequate freezer influenced their ordering decision, 18% stated that they consider the vaccine to be a low priority. 14% were concerned about waning immunity in adulthood, and 12% were unsure about the overall efficacy of the vaccine. Public Health Seattle & King County

Effects of Partial Uptake of Varicella Vaccine 63% of providers agreed that if varicella vaccine coverage rates reached a certain point (e.g. 50% coverage) then it would make sense to immunize all children due to the perceived negative effects of partial vaccine uptake on varicella incidence and natural immunity 10% disagreed 27% did not know Initial analysis of the survey indicated that inadequate refrigeration and parents not requesting the vaccine were the most influential reasons for not offering the vaccine. However, further analysis showed that those sites responding that inadequate refrigeration and lack of parent demand were most influential were more likely to consider the vaccine to be a low priority and/or question the efficacy of the vaccine. Of those clinics that indicated that having an inadequate freezer influenced their ordering decision, 18% stated that they consider the vaccine to be a low priority. 14% were concerned about waning immunity in adulthood, and 12% were unsure about the overall efficacy of the vaccine. Public Health Seattle & King County

Discussion Varicella vaccine has unique storage requirements VFC providers may have misconceptions about freezer and storage requirements Clinics may not want to invest in a new refrigeration system for one vaccine Beliefs about vaccine efficacy and priority among some providers may result in some parents not being offered the varicella vaccine As more children become immunized against varicella, infections in the community will decrease. Unimmunized children will be less likely to encounter naturally occurring varicella and consequently will remain susceptible to infection later in life, with an associated increase in complications. Public Health Seattle & King County

Summary Our results suggest that the majority of providers would use the varicella vaccine if they had an adequate freezer The majority of providers would consider using varicella vaccine if the vaccine coverage rate was high enough to achieve herd immunity To prevent varicella among older children and adults, health care providers who do not routinely offer varicella vaccine to young children should be sure those children who have not been immunized or had varicella infection by age 13 receive the vaccine. Public Health Seattle & King County

Conclusions VFC provider attitudes may result in sub-optimal use of varicella vaccine in King County, WA VFC providers may require additional education about varicella vaccine storage requirements Recent reports depicting the benefits of varicella vaccine including herd immunity should be reviewed by VFC providers Providers who do not normally offer varicella vaccine should be sure that children who have not been immunized or had varicella infection by age 13 receive the vaccine Public Health Seattle & King County

Limitations Responses of survey participants may not be representative of all providers in the practice Subgroups too small for multivariate analysis Unable to analyze by provider type (family practice vs. pediatricians vs. nurse practitioners) To prevent varicella among older children and adults, health care providers who do not routinely offer varicella vaccine to young children should be sure those children who have not been immunized or had varicella infection by age 13 receive the vaccine. Public Health Seattle & King County