Text Message Reminders for Second Dose of Influenza Vaccine: A Randomized Controlled Trial Journal Club – October 28 th, 2015 Brian Skinner, PharmD PGY-1 Pharmacy Practice Resident Pediatrics. 2015;135(1):e83-91

Background Over 31.8 million people were infected with influenza during the season Over 380,000 people died as a result of influenza infection The virus is studded with 2 major proteins – hemagglutinin and neuraminidase Quadrivalent vaccines protect against two strains of influenza A and 2 strains of influenza B Trivalent vaccines protect against two strains of influenza A and 1 strain of influenza B Healthy People 2020 has a goal vaccination rate of 70% MMWR. 2013;62(49): Pediatr Rev. 2014;35(6): Healthy People 2020.

Background Flu Vaccination Coverage, United States, Influenza Season

ACIP Recommendations MMWR. 2012;61(32): MMWR. 2015;64(30):

Text Message Reminders The use of reminder/recall systems are recommended to improve vaccination rates Use of reminder/recall as a single intervention increases vaccination rates by 8% Use of reminder/recall as a part of a multi-modal approach increases vaccination rates by 16% Text messages have been shown to be effective in low-income and minority populations JAMA. 2012;307(16): Am J Prev Med. 2000;18(1 suppl): Am J Public Health. 2012;102(2):e15-e21.

Methods Enrolled families at 4 clinics between August 29, 2012 and March 31, 2013 Inclusion Criteria 6 months old – 8 years old Received first dose of influenza at study site Eligible for 2 doses of influenza vaccine during the season Had cell phone with text capability Exclusion Non-English/non-Spanish speakers Compensation $10

Methods Day 7 Day 21 Day 25 Day 28 Day 42 Randomized to 1:1:1 allocation of written, conventional text, educational text

Study Population

Outcomes Primary Endpoint: Receipt of 2 nd dose by April 30 th, 2013 Secondary Endpoint: Receipt of 2 nd dose by day 42 Analysis Chi-square analysis was utilized to compare differences in proportions Secondary analysis was performed stratifying by receipt of dose 1 before November 15 th versus on or after November 15 th Kaplan-Meier curves compared doses received over time up to April 30 th, 2013

Results

Conclusions Author’s conclusions: Utilization of educational text message reminders for second dose of influenza vaccine increases 2 nd dose vaccination rates greater than conventional text messages and written-only reminders My conclusions: Text message reminders, in general, improve 2 nd dose vaccination rates for influenza Regardless of intervention, receipt of the first vaccine earlier in the flu season is associated with improved 2 nd dose vaccination rates for influenza

Strengths Author’s OpinionMy opinion Hospital EHR is synchronized with city-wide immunization information system There was a high rate of participation and only 2 participants opted out of the text messages during the study Text messages are relatively cheap and can be delivered in real-time as opposed to traditional mail reminders Text messages were offered in multiple languages to accommodate the patient population served at the clinics

Weaknesses Author’s OpinionMy opinion Vaccination records could be incomplete Low percentage of patients utilized interactive text messages (15.7%) Some families did not remember receiving the text messages Statistical analysis did not delineate individual comparisons Patients were primarily minority and publically insured ~95% of families were eligible for the Vaccines for children program Vaccination of some patients occurred too early No education was provided to tell families that waiting 28 days was imperative for the child to develop an adequate immune response

Application to St. Vincent Utilization of educational text messages may enhance the completion of vaccination series A system that is synchronized with our EHR, Athena, and CHIRP would be the most beneficial to avoid unnecessary text messages Efforts should be made to get our patients the first dose of the influenza vaccine prior to November 15 th

References Briss PA, Rodewald LE, Hinman AR, et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services. Am J Prev Med. 2000;18(1 suppl): CDC. Estimated influenza illnesses and hospitalizations averted by influenza vaccination – United States, influenza season. MMWR Morb Mortal Wkly Rep. 2013;62(49): CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP) -- United States, influenza season. MMWR Morb Mortal Wkly Rep. 2012;61(32):613-8 CDC. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices, United States, influenza season. MMWR Morb Mortal Wkly Rep. 2015;64(30): Fox TG, Christenson JC. Influenza and parainfluenza viral infections in children. Pediatr Rev. 2014;35(6):217-27

Flu Vaccination Coverage, United States, Influenza Season. CDC estimates.htm#1. Accessed: October 27, 2015 Immunization and Infectious Diseases. Healthy People topic/immunization-and-infectious-diseases/objectives. Accessed: October 27, 2015 Stockwell MS, Hofstetter AM, DuRivage N, et al. Text message reminders for second dose of influenza vaccine: a randomized controlled trial. Pediatrics. 2015;135(1):e83-91 Stockwell MS, Kharbanda EO, Martinez RA, et al. Effect of a text messaging intervention on influenza vaccination in an urban, low- income pediatric and adolescent population: a randomized controlled trial. JAMA. 2012;307(16): Stockwell MS, Kharbanda EO, Martinez RA, et al. Text4Health: Impact of text message reminder–recalls for pediatric and adolescent immunizations. Am J Public Health. 2012;102(2):e15-e21 References