Improving Flu Vaccine Uptake: Is Texting the Answer?

The day before Rosie Baxter turned 4 years old, she sat in the garden of her home in Sydney, Australia, having a tea party with her twin sister Ellie. Both little girls had been inside with the flu for several days, and mom Kerry-Anne thought it was time for a bit of fresh air. Rosie made an effort to join in the party and smile, but her eyes started to close. "I was watching her," said Kerry-Anne, "and I knew something wasn't right."

At the local emergency department, the physician sprinted back to Kerry-Anne with the X-ray: Rosie's lungs were completely consolidated. Despite oxygen and supportive measures, the medical team began losing the battle.

"They told us to say goodbye," said Kerry-Anne. "We held her while they gave her something and intubated her."

Rosie did live, but only just. A sputum culture identified the virus: she was battling H1N1/09 influenza.

"If I'd known that flu could kill, it would have been a no-brainer. Of course I would have vaccinated her," Kerry-Anne said.

Children in the Crosshairs

During the 2018-2019 flu season, the hospitalization rate was 72/100,000 for children under 5 years of age and 20/100,000 for those 5 years and older. Worldwide there are 870,000 influenza-related hospitalizations a year in children under 5 years.

With flu vaccine uptake for children in the United States at only around 45%, young children are in the crosshairs. Perhaps surprisingly, flu vaccination in children with chronic lung diseases is no better than in the general population, and the hospitalization rate for flu is five times higher than in children without lung conditions.

"Vaccine uptake in children with asthma is only 30% to 40% [in Australia]," said Nusrat Homaira, MBBS, MPH, PhD, a senior lecturer in pediatrics at the University of New South Wales, Sidney, Australia, "despite being a developed country where the vaccine is recommended and free."

She searched for a simple way to combat the poor uptake of flu vaccine among children with chronic lung diseases. The vaccine is offered during flu season to children attending clinic visits at Sydney Children's Hospitals, but no reminders are sent to children who don't have clinic visits at that time.

Communicating in the Digital Era

Homaira's study was presented as a poster in late August at OPTIONS X, the conference of the International Society for Influenza and Other Respiratory Virus Diseases. Forty-six children were randomly divided into two groups, with parents and carers in the intervention group receiving automated text-message reminders twice monthly during the 2018 flu season.

Vaccine uptake in the text-message group was 91% versus 61% in the no-text group — a 30% absolute increase (approximately 50% relative increase). Though the pilot study was not powered to show a significant difference, Homaira was still impressed. "We were expecting some increase, but this was huge. It was very pleasing to see that," she said.

She is now working with colleagues at the Sydney Children's Hospitals Network to implement text-message reminders for all children with chronic conditions. The approach is feasible for low- to middle-income countries, too, Homaira said. "This could potentially be replicated anywhere. It was very cheap. Sending text messages twice a month for 5 months costs only $800 AUD." In contrast, hospitalization for flu in children with lung disease costs almost $20,000 AUD per episode, said Homaira.

Example of a Text-Message Reminder for Flu Vaccination

XX's (child's name) doctor at Sydney Children's Hospital recommends that XX receives the flu shot every year. The flu shot can protect your child's health by reducing the risk of serious complications from flu. Remember it's time for XX to take this year's flu shot. Please take XX to your doctor to have a flu shot as soon as possible. Please ignore this message if XX has already received the flu shot this year.

The inspiration for this pilot study was the work of US-based Melissa Stockwell, MD, MPH, founding director of the Center for Children's Digital Health Research at Columbia University, New York City. In 2012, Stockwell's team published the first large-scale study of text-message reminders for flu vaccine. Since then, her group has conducted 12 studies using text-based technology for flu-vaccine reminders, vaccine side effect monitoring, and epidemiological surveys.

Stockwell was not surprised that the Sydney study in a specialized lung-disease setting worked. "It's a nice study that shows it's potentially effective; the next step would be to try to do it in a larger population." Stockwell said it would "definitely" work in the United States.

The strength of text messaging, Stockwell said, is its scalability and efficient information delivery. "[Families] want information but don't have time to talk to somebody. [With texts], they can choose the action and act on it right away."

On the other hand, Stockwell warns healthcare professionals to think through the consequences of an avalanche of text reminders going out at the same time. Her first study involved 9213 children registered at four New York City community-based clinics during the 2010-2011 season. By March 31, 2011, in total 1653 kids had headed to the clinics for a flu shot.

"It's important to think of who's downstream of your texting and to tailor it to your institutional needs. Maybe you don't want to text 1000 people at the same time," she said. In her study, reminders were staggered, and the text campaign significantly increased uptake of flu vaccine.

Texts need to be under 160 characters long, Stockwell said, which forces communication to be short and sweet. Elaborate educational messages may not be needed. Her study of New York City adolescents found that a simple call to action worked better than educational statements for texts sent early in the flu season. Any texts containing educational material should be tailored using audience research, she said.

Other Strategies

Other research on flu-vaccine messaging at OPTIONS X included a mixed-methods study from the University of Wisconsin designed to illuminate flu-vaccine barriers and motivators. To the researchers' surprise, altruism was a significant motivator for parents to have their children get the flu shot. Lead author Maureen Goss, MPH, said, "I wasn't really expecting to see the importance of preventing transmission to other people. That was really interesting."

William Fisher, PhD, a distinguished professor emeritus in the department of psychology at Western University, London, Ontario, Canada, uniquely turned the mirror towards physicians themselves. In Fisher's Pediatric Influenza Vaccination Optimization Trial (PIVOT), which was sponsored by Seqirus and was also presented at OPTIONS X, half the physicians in the study went through behavioral training that taught them to buffer parental reluctance to vaccinate by verbally probing any concerns. PIVOT found that physicians who undertook this training achieved more flu vaccine uptake in their pediatric patients than physicians without behavioral training.

"The days of continuing medical education as a biological info dump should be over. We have to integrate the [actions] a physician must take in integrating a flu vaccine into practice with simple behavioral steps that are going to produce better vaccine uptake," said Fisher. The approach should also work for parents of children with chronic lung disease, he said.

For some physicians, text messaging is a no-brainer to get families into the clinic for those crucial conversations. Cedric "Jamie" Rutland, MD, an assistant clinical professor at the University of California Riverside and medical spokesperson for the American Lung Association, doesn't need convincing that text reminders work for flu vaccination. "Everyone I see has an acute or chronic lung condition. I tell them the flu vaccine is coming, your life is at risk, you really need to get it. All my patients have my cell phone number. I will text hundreds of them during the flu season."

The Baxter family is now first in line for the flu vaccine each season. Rosie's brush with death has "absolutely changed my life," said Kerry-Anne. "It's taken me out of the bubble of happy families that don't think it could happen. This is real. It could happen to anyone," she said.

Helen Leask, PhD, CPF, is a freelance science journalist and certified facilitator. She was a 2017-2018 fellow in global journalism at the Munk School of Global Affairs, University of Toronto, Ontario, Canada. Her journalistic beats are oncology and human factors in medicine.

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