General practitioners and vaccination of children presenting with a benign infection

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General practitioners and vaccination of children presenting with a benign infection

M. Le Marechal, L. Fressard, Jocelyn Raude, P. Verger, C. Pulcini

To cite this version:

M. Le Marechal, L. Fressard, Jocelyn Raude, P. Verger, C. Pulcini. General practitioners and vaccination of children presenting with a benign infection. Médecine et Maladies Infectieuses, Elsevier Masson, 2018, 48 (1), pp.44-52. �10.1016/j.medmal.2017.09.018�. �hal-01789197�

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Médecineetmaladiesinfectieuses48(2018)44–52

Originalarticle

General practitioners and vaccination of children presenting with a benign infection

Médecins généralistes et vaccination des enfants présentant une infection fébrile non compliquée

M. Le Maréchal

^a,∗

, L. Fressard

^b,c,d

, J. Raude

^e,f

, P. Verger

^b,c,d,g

, C. Pulcini

^a,g,h

aUniversitédeLorraine,EA4360APEMAC,54000Nancy,France

bAix-Marseilleuniversité,UMRS912,IRD,13000Marseille,France

cObservatoirerégionaldelasantéProvence-Alpes-Côted’Azur(ORSPACA),13000Marseille,France

dInserm,UMRS912,«SciencesÉconomiques&SocialesdelaSantéetTraitementdel’InformationMédicale»(SESSTIM),13000Marseille,France

eEHESP-Rennes,Sorbonne-Paris-Cité,35043Rennes,France

fAix-Marseilleuniversité,EPV-UMRD190«ÉmergencedesPathologiesVirales»,13000Marseille,France

gInserm,F-CRIN,I-Reivac(Innovativeclinicalresearchnetworkinvaccinology),75654Paris,France

hServicedemaladiesinfectieusesettropicales,CHRUdeNancy,54000Nancy,France Received16December2016;accepted28September2017

Availableonline4November2017

Abstract

Purpose.–Toassesstheself-reportedvaccinationbehaviorofgeneralpractitioners(GPs)whenaskedwhethertheywould recommendthe vaccinationofachildpresentingwithafebrileuncomplicatedcommoncold.

Methods.–Weperformedacross-sectionalsurveyin2014onanationalsampleofGPs.GPswererandomlyassignedtooneofeightclinical vignettes,alldescribingachildpresentingwithanuncomplicatedfebrilecommoncold,butdifferingbyage(4or11months),temperature(38^◦C or39^◦C),andthemother’semotionalstate(calmorworried).GPswereaskedwhethertheywouldrecommendimmediatevaccinationofthe childwithahexavalentvaccine(diphtheria,tetanus,pertussis,poliomyelitis,Haemophilusinﬂuenzaetypeb,andhepatitisB),orpostponeit.We investigatedtherelationbetweentheGPs’recommendationtovaccinate,theclinicalvignette’svariables,andtheGPs’perceptions,attitudes,and practicestowardvaccinationinamultivariatemodel.

Results.–Amongthe1582participatingGPs,6%recommendedimmediatevaccination.Thisbehaviorwasmorefrequentwithatemperatureof 38^◦Cratherthan39^◦C(10%vs.3%,P<0.001).GPswhofeltcomfortablegivingexplanationsaboutvaccinesafetyweremorelikelytorecommend immediatevaccinationofthefebrilechild(P=0.045),butnoneoftheotherGPs’characteristicswereassociatedwiththeirvaccinationbehavior.

Conclusions.–AlmostallGPspostponedthehexavalentvaccinationofthefebrilechildpresentingwithanuncomplicatedviraldisease;fever beingthemajorfactoraffectingtheirdecision.Moreresearchisneededonvaccinationresponsesinsickchildren,aswellasclearerguidelines.

Keywords: Fever;Generalpractitioner;Immunization;Vaccination Résumé

Objectifs.–Évaluerlecomportementdesmédecinsgénéralistes(MG)faceàuneéventuellevaccinationd’unenfantavecunerhinopharyngite fébrilenoncompliquée.

Méthodes. –Étude transversale sur un échantillon national deMG (2014). Chaque MGa rec¸u une vignette clinique parmi huit, toutes décrivantun enfantavecunerhinopharyngitefébrilenoncompliquée.Les vignettesdifféraientsurl’âge(quatreou11mois),latempérature (38^◦C ou 39^◦C) etlecomportement delamère(calmeou inquiète).Nous avonsdemandéaux MGs’ils recommanderaientlavaccination

∗Correspondingauthor.FacultédemédecinedeNancy,EA-4360APEMAC,9,avenuedelaForêt-de-Haye,54505Vandœuvre-Lès-Nancy,France.

E-mailaddress:marionlemarechal@gmail.com(M.LeMaréchal).

https://doi.org/10.1016/j.medmal.2017.09.018

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M.LeMaréchaletal./Médecineetmaladiesinfectieuses48(2018)44–52 45 decetenfantlejourmêmeaveclevaccinhexavalent(diphtérie,tétanos,poliomyélite,Haemophilusinﬂuenzaedetypeb,hépatiteB,coqueluche) ous’ilslareporteraient.Avecunmodèlemultivarié,nousavonsanalysélarelationentrelarecommandationduMGdevaccinerounonetses perceptions,attitudesetpratiquesconcernantlavaccination.Résultats

Parmiles1582participants,6%ontrecommandélavaccinationdel’enfantlejourmême.Cettedécisionétaitplusfréquentequandlatempérature étaitde38^◦Cplutôtque39^◦C(10%contre3%,p<0,001).LesMGquisesentaientàl’aisepourdonnerdesexplicationsconcernantlasécurité desvaccinsétaientplusenclinsàvaccinerl’enfantlejourmême(p=0,045).

Conclusions.–PresquetouslesMGrepousseraientlavaccinationd’unenfantprésentantunerhinopharyngitefébrilenoncompliquée;l’intensité delatempératureétantleprincipalfacteurinfluenc¸antleurdécision.Davantagederecherchessontnécessairesconcernantlaréponsevaccinale chezl’enfantmalade,ainsiquedesrecommandationsplusclaires.

Motsclés:Fièvre;Immunisation;Médecingénéraliste;Vaccination

1. Introduction

Childrenpresentingwithfeverfrequentlyconsulttheirgen- eralpractitioner(GP).Theyaccountforapproximately20–39%

ofpediatricconsultations[1,2],andanestimated67%ofone- year-oldchildrenpresentmorethan60daysofrespiratoryillness duringtheirfirstyearoflife,especiallyiftheyaregoingtoday carecenter[3,4].Itisthencommonpracticeforprimarycare physicianstomanagechildrenwhoneedtobevaccinated,but present with afebrile or afebrile benign infection. Available guidelinesprovideconflictingandsometimesunclearadviceon howtodealwithsuchasituation.Forinstance,theAmerican recommendation of the Advisory Committee on Immuniza- tion Practices states that “vaccination should not be delayed because of the presence of mild respiratory tract illness, or other acuteillness with or without fever” [5]; in the United Kingdom, the Green book states that “minor illnesses with- outfever orsystemic upsetare notvalidreasonstopostpone immunization. If an individual is acutely unwell, immuniza- tionmaybepostponeduntiltheyhavefullyrecovered”[6];in FrancetheVaccinationGuidestatesthat“Contrarytopopular opinion, minor infectious diseases, [...], are not contraindi- cations tovaccination”[7],butfever is notmentioned inthe recommendations.

Howdophysiciansdealwiththeserecommendationsindaily practice?Tothebestofourknowledgenostudyhaseverassessed thepracticesofGPsregardingthevaccinationofchildrenpre- sentingwithafebrilebenigninfection.

Tobetterunderstandthevaccinationpractices,perceptions, andattitudesofGPsinFrance,weperformedacross-sectional surveywithinalargerepresentativesampleofFrenchGPs.We focusedonthefollowingobjectives:toassesstheself-reported vaccinationbehavior of physicians when asked whether they wouldrecommendthevaccinationofachildpresentingwitha febrileuncomplicatedcommoncoldandtoidentifythefactors associatedwithGPs’responses.

2. Materialandmethods 2.1. Literatureandwebsitesearch

Recommendations from all countries, available online in French or English language were searched to look for

recommendations/guidelines on the vaccination of patients presenting with a benign infection, with or without fever.

2.2. Sample

Thisworktookadvantageof arecurrentseriesof national surveys onarepresentativesample ofGPs inprivatepractice designed to study their attitudes, perceptions, and practices relatedtovariousmedicaltopics.Themethodusedtosetupthe survey hasbeen described elsewhereindetail [8].Enrolment tookplacebetweenDecember2013andMarch2014.Partici- pantswereselectedbyrandomsamplingfromtheMinistryof HealthexhaustivedatabaseofhealthcareprofessionalsinFrance (RPPS,Healthcare workersshared repertoire). Sampling was stratifiedbygender,age(terciles:<50years,[50–57]years,>57 years),potentiallocalaccessibilitytoGPsofthemunicipality ofpractice(threecategoriesbasedonthevariationaround the nationalaverage:<−19.3%,[−19.3to+17.7]%,or>+17.7%, andthephysicians’workload(numberofproceduresduringthe year2012:<3,067,[3,067–6,028],>6,028).GPswithanexclu- sivepracticeofalternativemedicine(acupuncture,homeopathy, naturopathicmedicine,etc.),or with<5.2visitsperweekin 2012wereexcluded.GPswhoagreedtoparticipateintheover- archingsurvey committedthemselves toansweringthe entire seriesofsurveys:onesurveyeverysixmonthsfortwoandahalf years,totalingsixsurveys.Tolimitanyselectionbiasthatmight haveresultedfromspecificopinions/attitudes,thetopicsofeach surveywereonlymentionedtoGPsaftertheywereaskedtopar- ticipate.Ofthe5,151randomlyselectedGPsfortheoverarching survey,695couldnotbecontactedand732werenoteligible.Of 3,724eligibleGPs,1,712agreedtoparticipate(46.0%)(Fig.1).

GPswhorefusedtoparticipateweremoreoftenmen(P<0.001), older(P<0.001),andhadmoreconsultationsin2012(P<0.05).

Theyreportedtwomainraisonsforrefusingparticipation:lack oftime(55%)andlackofinterestinparticipatinginasurvey (31%).

Thefirstofthesefivecross-sectionalsurveyswasdedicated tovaccinationandwasbasedonatelephoneorweb-basedques- tionnaire.

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Fig.1.FlowchartofthegeneralpractitionersincludedinthenationalFrenchsample.GPs:generalpractitioners;N:numberofGPs.

Diagrammedesmédecinsgénéralistesinclusdansl’échantillonfran¸caisnational.

2.3. Questionnaire(availablefromtheauthorsupon request)

Thequestionnairewasdesignedbasedonaliteraturereview andmeetingswithexpertsinthefieldofvaccination.Information collectedfocusedon:

• generalattitudestowardvaccination;

• vaccinationpracticesofGPsforthemselvesandtheirfamily;

• vaccinationrecommendationsofGPstotheirpatients;

• clinical vignette on fever before vaccination (content explainedbelow);

• beliefsaboutthepotentialrisksofcertainvaccines;

• beliefsaboutactionsthatmightencouragevaccination.

Thequestionnairewastestedforclarityandlength,andwas validatedinapilotstudywith50GPs.

Professional investigators conducted the interviews with computer-assistedtelephoneinterview(CATI)software.

2.4. Clinicalvignette

Aclinicalvignettewiththreevariables(eachsubject toan alternative possibility shown in between brackets) was pre-

sented toGPs describing the following situation:“A mother comestoyoursurgerywithher(4or11)month-oldchildfora hexavalentvaccine(diphtheria,tetanus,pertussis,poliomyelitis, Haemophilusinfluenzaetypeb,andhepatitisB);thechildhas been feverishfortwo days(38or 39^◦C)andpresentwithan uncomplicatedcommoncold;themedicalexaminationisnor- mal;themothertellsyouthatthechild’sbehavioristhesameas usual.Themotheris(worriedornotworried)aboutwhetherher feverishchildwillbeabletocopewiththevaccine.GPswere askedthefollowingquestion:“Themotherhasbroughtthevac- cine;doyourecommendperformingthevaccinationshotright away,ordoyoupostponetheshotuntiltemperaturereturnsto normal?”.

GPswererandomlyallocatedtooneofeight(2×2×2)clin- icalscenarios,differingbyageofthechild(4-or11-month-old), temperature (38 or 39^◦C), and the mother’s emotional state (calmorworried).

2.5. Statisticalanalysis

The dependent variablewas“GP’srecommendation tothe mothertohaveherchildvaccinatedthatday”(yes/no).

Weassessedthreepotentialexplanatoryvariablesrelatedto the clinicalvignette: thechild’sageandtemperature,andthe

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M.LeMaréchaletal./Médecineetmaladiesinfectieuses48(2018)44–52 47

mother’s emotionalstate. Wealso assessedGPs’ characteristics,includingtheirperceptions,attitudes,andpracticestoward vaccination:

• GPs’ perceptions (two variables): their perceived need for traininginvaccination;theirperceptionofbeingmoreorless comfortablegivingexplanationstopatientsaboutthesafety ofvaccines;

• GPs’attitude (onevariable):their opinionconcerning vaccination in general in their daily practice (more or less favorable);

• GPs’ practices (three variables): participation in any con- tinuing medical education over the past12 months on the topicofinfectiousdiseasesand/orvaccination;consultation oftheFrenchvaccinationguide;andfinallywhethertheyhad beenconfrontedwithaserioushealthissue,i.e.onewhich ledtohospitalization,disability,etc.,potentiallylinkedtoa vaccinationinoneoftheirpatients.

Forthedescriptiveanalysis,datawereweightedtomatchthe samplemorecloselytothenationalFrenchGPpopulationfor age,gender,2012workload,andpotentiallocalaccessibilityto GPsofthemunicipalityofpractice.Wethenperformedbivari- ateanalysesbetweenthedependentvariableandtheexplanatory variablesusingthechi-squaredtestorFisher’sexacttest.Finally, we performed a multivariate analysis using a log-binomial regression adjusted on the four stratification variables (GP’s age,gender,2012 workload,andpotentiallocalaccessibility) [9],onGPs’typeofpractice(soloorgrouppractice),andonthe occasionalpracticeofalternativemedicine(yes/no).Thethree variablesoftheclinicalvignette,andallthevariablesofinter- estwithaP<0.1inthebivariateanalyseswereenteredintothe

modelasexplanatoryvariables.Allanalyseswerebasedontwo- sidedPvalues,withstatisticalsignificancedefinedbyP<0.05.

AnalyseswereperformedusingtheRsoftware(version3.0.3) andthe“survey”package.

3. Results

3.1. Literatureandwebsitesearch

Recommendations addressing the practice to adopt when apatient(children/adults)presentswitha(febrile orafebrile) benigninfectionaresummarizedinTable1.Resultsaredivided intofourcategories:

• countriesrecommendingvaccinationirrespectiveofthetem- perature(UnitedStates,Switzerland,andCanada)[5,10,11];

• countriesdefiningatemperaturecut-offtodecidewhetheror nottovaccinatethechild(38^◦CinIrelandandNewZealand, 38.5^◦CinAustralia)[12–14];

• countrieswithsomewhatunclearrecommendations(United Kingdom,France)[6,7];

• countrieswithnorecommendationfound.

3.2. Cross-sectionalnationwidesurvey

Ofthe1,712GPswhoagreedtoparticipateintheoverarch- ingsurvey,1,582GPs(92%)answeredthefirstcross-sectional surveyonvaccination(Fig.1).Theircharacteristicsdidnotdif- fersignificantlyfromtheGPswhoagreedtoparticipateinthe overarchingsurvey,butdidnotactuallyanswerthevaccination survey(130GPs).

Table1

Recommendationsforthevaccinationofa(febrileorafebrile)child/adultpresentingwithabenigninfectioninvariouscountries[5–7,10–14].

Recommandationspourlavaccinationd’unenfant/adulteprésentantuneinfectionnoncompliquée(fébrileounon)dansdifférentspays[5–7,10–14].

Recommendedbehavior Country/institution Quotation Vaccination,irrespective

oftemperature

Switzerland,United States,Canada

UnitedSates:“Vaccinationshouldnotbedelayedbecauseofthepresenceofmildrespiratorytract illness,orotheracuteillnesswithorwithoutfever.”

Switzerland:“Nocontraindication:discreetacutedisease,withorwithoutfever.”

Canada:“Acuteillness(withorwithoutfever).Ingeneral,peoplewithminorormoderateacute illnessmayreceivevaccines.Thereisnoincreaseinriskofadverseeventsfollowingimmunization andnointerferencewithresponsetovaccine.”

Temperaturethresholdto decidewhetherto vaccinate

Ireland,NewZealand, Australia

Cut-off:

Ireland,NewZealand=38^◦C Australia=38.5^◦C

Somewhatunclear recommendations

UnitedKingdom,ECDC, France,Denmark

UnitedKingdom:“Minorillnesseswithoutfeverorsystemicupsetarenotvalidreasonstopostpone immunization.Ifanindividualisacutelyunwell,immunizationmaybepostponeduntiltheyhave fullyrecovered.”

France:“Contrarytopopularopinion,minorinfectiousdiseases,[...],arenotcontraindicationsto vaccination”,butfeverisnotmentionedintherecommendations.

Denmark:“Childrenwhoareill,suchasrunningafever,arenotnormallyvaccinated.Nevertheless, childrenwhohaveamildcoldcanbevaccinated.”

ECDC:“Babiesandchildrenwithminorcoughsandcolds,orthoseonantibiotics,canbeimmunized safelyandeffectively.However,ifyourchildhasahightemperature,theimmunizationshouldbeput offuntilyourchildisbetter.”

Norecommendation Belgium,Luxembourg, TheNetherlands,Sweden ECDC:EuropeanCentreforDiseasePreventionandControl.

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Theweighteddescriptiveanalysisrevealedthat6.3%ofGPs reportedthattheywouldrecommendtheimmediatevaccination ofthefebrilechildpresentingwithanuncomplicatedcommon cold. Characteristicsof GPs aredescribed inTable 2.Asthe resultsofweightedandnon-weighteddescriptiveanalyseswere similar,onlyunweightedanalysesarepresentedinthebivariate andmultivariateanalyses.

Among GPs’ characteristics, the two only variables that were significant in bivariate analysis and were added to the multivariatemodel(Table3)were:feelingcomfortablegiving explanationstopatientsaboutthesafetyofvaccines,andcon- sultingtheFrenchvaccinationguide.Themultivariateanalysis showedthattheintensityoffeverwastheonlyfactorfromthe vignettethatsignificantlyinfluencedthevaccinationbehaviorof GPs(10%recommendedthevaccinationwhenthetemperature was38^◦Cvs.Threepercentwhenthetemperature was39^◦C [P<0.001]); thechild’sagedid notinfluencethe vaccination recommendation, andneither did the mother’s behavior. GPs whofeltcomfortablegivingexplanationsaboutvaccinesafety weremorelikelytorecommendimmediatevaccinationofthe febrilechild(P=0.045).NoneoftheotherGPs’characteristics wereassociatedwiththeirvaccinationbehavior(Table4).

4. Discussion

AlmostallFrenchGPs(94%)recommendedpostponingthe vaccinationofafebrilechildpresentingwithanuncomplicated common cold. A hightemperature was the only factor from thevignettefoundtobeindependentlyassociatedwithpostpon- ingvaccination.GPswhofeltcomfortablegivingexplanations aboutvaccinesafetywerealsomorelikelytoimmediatelyvac- cinatethefeverishchildpresentingwithabenigninfection.No otherGPs’characteristicsweresignificantlyassociatedwiththis vaccinationbehavior.

Inthecontextofnationalunclearanddifficult-to-accessrec- ommendations(theFrenchvaccinationguideisnotwell-known byGPsasitisnotpartoftheofficialannualvaccinationsched- uleeditedbytheMinistry ofHealth,andisquitehardtofind ontheInternet),almostallFrenchGPschosetopostponethe hexavalent vaccination of a febrile child presenting with an uncomplicatedcommon cold. Theyprobably thoughtthatthe risksofimmediatevaccinationoutweighedtherisksofpostpon- ingthevaccination.

AsthehepatitisBvaccineisincludedinthehexavalentvac- cine,thismighthavecontributedtothisbehavior.HepatitisB vaccine isquitecontroversialinFrance[15],butthevignette specifiedthatthemothercametothesurgerywiththevaccine, implyingthat shewas infavor ofher childbeingvaccinated.

ThevastmajorityofGPsincludedinthisstudywerealsonot opposedtothisvaccine(63%ofthemalwaysoroftenrecom- mendedhepatitisBvaccinationtoteenagers,95%ofthemwere themselvesvaccinatedagainsthepatitisB,and84%hadsome oralltheirchildrenvaccinatedagainsthepatitisB).

Ourliteratureandwebsitesearchhighlightedthatavailable internationalrecommendations areconflicting andsometimes unclearonthistopic,probablybecauseofapoorlevel ofevi- dence.Onlythe Americanguidelines, issuedbytheAdvisory

Committee on Immunization Practices (ACIP), provide ref- erences to support the recommendation to vaccinate a child presentingwithanacuteillnesswithorwithoutfever[5,16–18].

However,thecitedstudiesonlydealwithmeaslesvaccination, andtheirscientificqualityisinsufficienttoconcludeonthecon- sequencesofvaccinatingafebrilechild.TheworkofLindegren et al.determined the proportion of valid contraindication for measlesvaccinationduringameaslesoutbreakintwodifferent emergencydepartments.Theynoticedthatchildrenpresenting with current fever or ahistory of fever were less vaccinated (22%)thanchildrenvisitinghospitalforanotherreason(48%;

P<0.05).However,no follow-upwas performedfor children vaccinatedduringthefebrileepisode.

Onthebasisofliteraturedataandcommonpreconceptionsin themedicalfield,themainpotentialperceivedrisksofimmediate vaccinationare:

• thesimultaneityofthevaccineadministrationandthecom- moncoldcouldmakeitdifficulttodeterminethecauseofthe feveraftervaccination[6];

• lowervaccineeffectivenessduringacommoncoldispossible butnotdemonstrated[19];

• GPsand/orparentsmightwanttoavoidworseningthechild’s condition in the short-term caused by the vaccination (for exampletheintensityofthefevermightleadtomorefebrile seizures);

• GPs might fear that parents may overestimate the vaccination’s sideeffect (the fever)and thereforemight be less inclinedtovaccinatetheirchildinthe future,andalsoGPs couldthink thatif theyagree tothe parents’wish topost- ponevaccination,it willallowfor agreaterdegreeoftrust betweenthem[20].Thelasttwohypothesesarenotsupported byanyavailableliterature,butareconsistentwiththeresult indicatingthatGPswhofeltcomfortableprovidingexplana- tionsabout vaccinesafetyweremorelikely torecommend theimmediatevaccinationofthefebrilechildasthisimplies feelingconfidenttoreassureparentsandpromotevaccination.

Ontheotherhand,whatarethepotentialrisksofpostponing vaccination?Thereisevidenceshowingthatpostponingvacci- nationinchildhoodmayleadtomissedopportunities,notjustfor theindividual.Itmayalsoweakencollectiveprotectionagainst preventable infectiousdiseases andit isarisk factorfor out- breaks(suchasthemeaslesoutbreakinEuropein2008–2011) [21].Ithasbeenestimatedthatachildwhoexperienceatleast onemissedvaccinationopportunityis3.1times lesslikelyto becompletelyimmunizedthanachildwhonevermissedavac- cination opportunity[22].Lowsocioeconomicstatus [23,24], parents’negligence[25],orvaccinehesitancy[25,26]areknown riskfactorsforpostponingvaccination.However,todatelittleis knownabouttheroleofminorillnesses,andespeciallyaboutthe influenceoffeverinthesemissedopportunities[24].Postponing avaccinationshotinafeverishchildmightleadtoitneverbeing administeredoradministeredwithalongdelay[21].

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M.LeMaréchaletal./Médecineetmaladiesinfectieuses48(2018)44–52 49 Table2

Descriptiveanalysisofthestudypopulation(Frenchnationwidesurveyofgeneralpractitioners,weighteddata,n=1582).

Analysesdescriptivesdelapopulationd’étude(enquêtenationaleauprèsdemédecinsgénéralistesfran¸cais,donnéespondérées,n=1582).

Surveyparticipants

n=1,582 Frequency(%) Stratiﬁcationvariables

Gender

Male 1076 68.0

Female 506 32.0

Age(years)

<50 538 34.0

[50–58] 556 35.1

>58 488 30.9

PotentiallocalaccessibilitytoGPsofthemunicipalityofpractice^a

<−19.3% 406 25.7

[−19.3to+17.7]% 797 50.3

>+17.7% 379 24.0

2012workload(numberofprocedures)

<3,067 350 22.1

[3,067–6,028] 813 51.4

>6,028 419 26.5

Professionalcharacteristics Typeofpractice(11NA)

Grouppractice 909 57.9

Solopractice 662 42.1

Occasionalpracticeofalternativemedicine^b(9NA)

Yes 243 15.4

No 1330 84.6

Clinicalvignette(17NA)

Recommendedtogivethevaccination 98 6.3

Whenthechildwas38^◦C 75/781 9.6

Whenthechildwas39^◦C 22/784 2.8

Whenthechildwas4monthsold 51/762 6.7

Whenthechildwas11monthsold 47/803 5.9

Whenthemotherwascalm 56/778 7.2

Whenthemotherwasworried 42/787 5.3

AttitudesofGPs

Opiniononvaccinationingeneral(7NA)

Veryfavorable 1268 80.5

Otheropinion 307 19.5

PerceptionsofGPs

Needfortraininginvaccination(10NA)

Yes 337 21.4

No 1235 78.6

Feelcomfortablegivingexplanationsaboutthesafetyofvaccines(12NA)

Yes 1286 81.9

No 284 18.1

PracticesofGPs

Attendancetoanycontinuingmedicaleducationcourses(22NA)^c

Yes 683 43.8

No 877 56.2

Consultedthevaccinationguide(8NA)

Yes 1203 76.4

No 371 23.6

Hasbeenconfrontedwithaserioushealthissuepotentiallylinkedtoavaccinationinoneofhis/herpatients(8NA)

Yes 254 16.2

No 1320 83.8

GP:generalpractitioner;NA:notavailable,includesthefollowinganswersinthequestionnaire:“Doesn’tknow”,“Doesn’tanswer”,oranswersnotavailable.

PercentagesdonotincludetheNAvalues.Ofthe1582GPswhoansweredthequestionnaire,86hadatleastonemissingvalue,whichtotals1496completecases.

a Variationaroundthenationalaverage.

b Alternativemedicine:homeopathyand/oracupuncture.

c Continuousmedicaleducationcoursesoninfectiousdiseasesandvaccinationinthepreviousyear.

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Table3

Generalpractitioners’(GPs)attitudes,perceptions,andpractices^atowardvaccinationassociatedwiththerecommendationtovaccinatethefebrilechildpresenting withanuncomplicatedcommoncold(FrenchnationwidesurveyofGPs,unweighteddata,bivariateanalysis,N=1565).

Attitudes,perceptionsetpratiquesdesmédecinsgénéralistesconcernantlavaccinationassociéesàlarecommandationdevaccinerunenfantprésentantune rhinopharyngitefébrilenoncompliquée(enquêtenationaleauprèsdemédecinsgénéralistesfran¸cais,donnéesnonpondérées,régressionmultivariéelog-binomiale, N=1565).

Vaccination^b Pvalue

n/N(%) AttitudesofGPs

Opiniononvaccinationingeneral

Veryfavorable 86/1263(6.8) 0.125

Otheropinion 13/296(4.4)

PerceptionsofGPs

Needfortraininginvaccination

Yes 15/336(4.5) 0.129

No 82/1219(6.7)

Feelcomfortablegivingexplanationsaboutthesafetyofvaccines

Yes 89/1271(7.0) 0.031^*

No 10/283(3.5)

PracticesofGPs

Attendancetoanycontinuingmedicaleducationcourses^c

Yes 51/690(7.4) 0.107

No 46/854(5.4)

Consultedthevaccinationguide

Yes 86/1195(7.2) 0.013^*

No 13/363(3.6)

Hasbeenconfrontedwithaserioushealthissuepotentiallylinkedtoavaccinationinoneofhis/herpatients

Yes 17/248(6.9) 0.725

No 82/1310(6.3)

GP:generalpractitioner;n:numberofGPswhogavethatanswerandvaccinatedthechild;N:numberofGPswhogavethatanswer.Thisnumberdoesnotcorrespond totheresultsofTable2becausethe17NAvaluesoftheclinicalvignette’sanswers(recommendedornotthevaccinationofthechild)arenotconsideredhere.

* P<0.1addedtothemultivariateregressionmodel.

aThefourstratificationvariablesandthetwoprofessionalcharacteristicvariableswerenotstudiedinthebivariateanalysisastheywerenecessarilyenteredinto themultivariatemodelasadjustmentvariables.

b GP’srecommendationtothemothertohaveherchildvaccinatedonthatday.

cContinuousmedicaleducationcoursesoninfectiousdiseasesandvaccinationinthepreviousyear.

4.1. Strengthsandlimitationsofthestudy

Thisworkisoriginalandisbasedonalargesampleselected inthe exhaustive list of French GPs; ourstudy population is therefore very representative. Thisworkalso has limitations.

Participantsmaydifferfromnon-participantseventhoughthe sample wasrepresentative ofthe French nationalGP popula- tionintermsofgender,age,and2012workload.Nevertheless, weighingthedatadidnotaffectourresults,suggestingthatthe selection biaswasnegligibleinour study.Moreover,46% of eligibleGPsagreedtoparticipateinthesurvey.Thisisahigh responseratecomparedwithothersurveys,consideringthatGPs committedthemselvesfor twoandahalf years(fivedifferent surveys) [27].Furthermore, therecommendation to vaccinate wasnotbasedonrealpractices.Itwasbasedonself-reported behavior,butclinicalvignetteshavebeenshowntobeareliable waytoassessclinicalpractice[28–31].Then,thespecificities oftheFrenchvaccinationsystemmightlimitthegeneralizabil- ityofourresults.WealsodidnotexploreifthesurveyedGPs postponingvaccinationwouldhavescheduledanappointment forcatch-upvaccination,whichwouldhavetoldusifitwasa permanentmissedopportunityoronlyaone-timedelayvaccina- tion.Finally,thecross-sectionalnatureofthestudydidnotallow foranycausalinferences.Despitetheselimitations,thedecision

topostponethevaccinationofafebrilechildpresentingwithan uncomplicatedcommoncoldwassofrequentinourstudythat itisunlikelyforthisconclusiontobebiased.

5. Conclusion

Inthissurveyconductedamongalargerepresentativesam- pleofFrenchGPs,weobservedaveryhighprevalence(94%)of postponedhexavalentvaccinationduetoafebrileminorillness.

Moreresearchisneededtoconfirmandunderstandthesefind- ings,andtoassesstherelativerisksofimmediateandpostponed vaccinationinthiscommonclinicalsituation.Clearerandmore consistentguidelineswouldcertainlybeofhelp.

Ethicalapproval

TheNational AuthorityforStatisticalinformation(Conseil nationaldel’InformationStatistique)approvedthepanel.

Roleofthefundingsource

MLM was awarded the 2014grant from the “Vaccination andPrevention”groupoftheFrenchInfectiousDiseasesSociety (FrenchacronymSPILF).

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M.LeMaréchaletal./Médecineetmaladiesinfectieuses48(2018)44–52 51 Table4

Factorsassociatedwiththerecommendationtovaccinatethefebrilechildpresentingwithanuncomplicatedcommoncold(FrenchnationwidesurveyofGPs, unweighteddata,multivariatelog-binomialregression,N=1565).

Facteursassociésàlarecommandationdevaccinerunenfantfébrileprésentantunerhinopharyngitenoncompliquée(enquêtenationaleauprèsdemédecins généralistesfran¸cais,donnéesnonpondérées,régressionmultivariéelog-binomiale,N=1565).

Multivariateanalysis^a

Pvalue RR[95%CI]

Stratiﬁcationvariables Gender

Male 0.252 1.29[0.84–1.98]

Female Reference

Age(years)

<50 Reference

[50–58] 0.734 1.08[0.70–1.66]

>58 0.574 0.86[0.51–1.45]

PotentiallocalaccessibilitytoGPsofthemunicipalityofpractice^b

<−19.3 Reference

[−19.3to+17.7]% 0.092 1.55[0.93–2.57]

>+17.7% 0.121 1.58[0.89–2.81]

2012workload(numberofprocedures)

<3,067 Reference

[3,067–6,028] 0.104 1.65[0.90–3.04]

>6,028 0.629 1.19[0.60–2.36]

Professionalcharacteristics Typeofpractice

Grouppractice 0.117 1.41[0.92–2.17]

Solopractice Reference

Occasionalpracticeofalternativemedicine^c

Yes 0.137 0.56[0.26–1.20]

No Reference

Clinicalvignetteanswer Fever

38^◦C <0.001^* 3.24[2.05–5.13]

39^◦C Reference

Age(months)

4 0.505 1.14[0.78–1.65]

11 Reference

Mother

Calm 0.157 1.32[0.90–1.92]

Worried Reference

PerceptionsofGPs

Feelingcomfortablegivingexplanationsaboutthesafetyofvaccines

Yes 0.045^* 1.99[1.01–3.90]

No Reference

PracticesofGPs

Consultedthevaccinationguide

Yes 0.052 1.75[1.00–3.09]

No Reference

CI:confidenceinterval;GP:generalpractitioner.

* Pvalue<0.05consideredstatisticallysignificant.

a ModellingoftheGP’srecommendationtothemothertohaveherchildvaccinatedonthatday.

b Variationaroundthenationalaverage.

c Alternativemedicine:forexample,homeopathyand/oracupuncture.

PVwasawardedagrantfromtheFrenchInstituteforPublic HealthResearch(FrenchacronymIReSP).

ThestudywasfundedbytheDirectorateforResearch,Stud- ies, Assessmentand Statistics of Ministry of Health (French acronymDREES), the French Ministry of SocialAffairs and Health,theNationalInstituteforpreventionandhealtheduca- tion(FrenchacronymINPES),theNationalInstituteforHealth andMedicalResearch(FrenchacronymInserm),andtheIReSP.

The DRESS and INPES, funding agencies of the study, playedasupportingroleinthestudydesignandresultanalysis;

the ORS PACA-UMR-SESSTIM ensured scientific coordina- tionofthestudy.

Contributors

MLManalyzedandinterpretedthedata,draftedthearticle, andapprovedthefinalversiontobesubmitted.

LFanalyzedandinterpretedthedata,revisedthearticlefor importantintellectualcontent,andapprovedthefinalversionto besubmitted.