{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T00:11:21Z","timestamp":1788307881096,"version":"build-2803163510"},"reference-count":39,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2022,10,10]],"date-time":"2022-10-10T00:00:00Z","timestamp":1665360000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Vaccines"],"abstract":"<jats:p>Understanding trends in vaccine refusal is critical to monitor as small declines in vaccination coverage can lead to outbreaks of vaccine-preventable diseases. Using electronic heath record (EHR) data from the Children\u2019s Hospital of Philadelphia\u2019s 31 outpatient primary care sites, we created a cohort of 403,448 children less than age 20 years who received at least one visit from 1 January 2013 through 31 December 2020. The sample represented 1,449,061 annualized patient and 181,131 annualized preventive vaccination visits per year. We characterized trends in vaccine refusal and acceptance using a repeated cross-sectional observational analysis of electronic health records (EHR) data using a single annual merged observation measure for patients seen multiple times for preventive healthcare within a calendar year. Refusals were identified for 212,900 annualized patient-visit year observations, which represented 14.6% of annualized patient-visit year observations and 25.1% of annualized vaccine patient-year observations. The odds of having a refusal marker were significantly increased in patients seen in suburban practices (aOR [CI]: 2.35 [2.30\u20132.40, p &lt; 0.001]), in patients with increased age 11\u201317 years (aOR [CI]: 3.85 [3.79\u20133.91], p &lt; 0.001), and those eligible for the VFC program (aOR [CI]: 1.10 [1.08\u20131.11]. Parental refusal (61.0%) and provider decisions (32.0%) were the most common documented in progress notes for not administering vaccines, whereas contraindications (2.5%) and supply issues (1.8%) were the least common. When offered, vaccine acceptance increased for human papillomavirus, hepatitis B, measles-mumps-rubella-containing and varicella-containing vaccines and decreased for hepatitis A and meningococcal vaccines. Repeated offering of vaccines was central to increasing acceptance, in part due to increased opportunities to address specific concerns.<\/jats:p>","DOI":"10.3390\/vaccines10101688","type":"journal-article","created":{"date-parts":[[2022,10,11]],"date-time":"2022-10-11T06:13:27Z","timestamp":1665468807000},"page":"1688","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Trends in Vaccine Refusal and Acceptance Using Electronic Health Records from a Large Pediatric Hospital Network, 2013\u20132020: Strategies for Change"],"prefix":"10.3390","volume":"10","author":[{"given":"Angela K.","family":"Shen","sequence":"first","affiliation":[{"name":"Vaccine Education Center, Children\u2019s Hospital of Philadelphia, Philadelphia, PA 19104, USA"},{"name":"Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA"},{"name":"Department of Medical Bioethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8290-5588","authenticated-orcid":false,"given":"Robert W.","family":"Grundmeier","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19146, USA"},{"name":"Center for Pediatric Clinical Effectiveness, Children\u2019s Hospital of Philadelphia, Philadelphia, PA 19146, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7262-630X","authenticated-orcid":false,"given":"Jeremey J.","family":"Michel","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19146, USA"},{"name":"Center for Pediatric Clinical Effectiveness, Children\u2019s Hospital of Philadelphia, Philadelphia, PA 19146, USA"},{"name":"ECRI Guidelines Trust, ECRI Plymouth Meeting, Philadelphia, PA 19462, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,10,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"4161","DOI":"10.1016\/j.vaccine.2015.04.036","article-title":"Vaccine hesitancy: Definition, scope and determinants","volume":"33","author":"MacDonald","year":"2015","journal-title":"Vaccine"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Committee NVA (2015). 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