Public Health and Economic Consequences of Vaccine Hesitancy for Measles in the United States

Modeling Reemergence of Vaccine-Eliminated Infectious Diseases Under Declining Vaccination in the US

Importance

Widespread childhood vaccination has eliminated many infectious diseases in the US. However, vaccination rates are declining, and there are ongoing policy debates to reduce the childhood vaccine schedule, which may risk reemergence of previously eliminated infectious diseases.

Objective

To estimate the number of cases and complications in the US under scenarios of declining childhood vaccination for measles, rubella, poliomyelitis, and diphtheria.

Design, Setting, and Participants

A simulation model was used to assess the importation and dynamic spread of vaccine-preventable infectious diseases across 50 US states and the District of Columbia. The model was parameterized with data on area-specific estimates for demography, population immunity, and infectious disease importation risk. The model evaluated scenarios with different vaccination rates over a 25-year period. Inputs for current childhood vaccination rates were based on 2004-2023 data.

Main Outcomes and Measures

The primary outcomes were estimated cases of measles, rubella, poliomyelitis, and diphtheria in the US. The secondary outcomes were estimated rates of infection-related complications (postmeasles neurological sequelae, congenital rubella syndrome, paralytic poliomyelitis, hospitalization, and death) and the probability and timing for an infection to reestablish endemicity.

Results

At current state-level vaccination rates, the simulation model predicts measles may reestablish endemicity (83% of simulations; mean time of 20.9 years) with an estimated 851 300 cases (95% uncertainty interval [UI], 381 300 to 1.3 million cases) over 25 years. Under a scenario with a 10% decline in measles-mumps-rubella (MMR) vaccination, the model estimates 11.1 million (95% UI, 10.1-12.1 million) cases of measles over 25 years, whereas the model estimates only 5800 cases (95% UI, 3100-19 400 cases) with a 5% increase in MMR vaccination. Other vaccine-preventable diseases are unlikely to reestablish endemicity under current levels of vaccination. If routine childhood vaccination declined by 50%, the model predicts 51.2 million (95% UI, 49.7-52.5 million) cases of measles over a 25-year period, 9.9 million (95% UI, 6.4-13.0 million) cases of rubella, 4.3 million cases (95% UI, 4 cases to 21.5 million cases) of poliomyelitis, and 197 cases (95% UI, 1-1000 cases) of diphtheria. Under this scenario, the model predicts 51 200 cases (95% UI, 49 600-52 600 cases) with postmeasles neurological sequelae, 10 700 cases (95% UI, 6700-14 600 cases) of congenital rubella syndrome, 5400 cases (95% UI, 0-26 300 cases) of paralytic poliomyelitis, 10.3 million hospitalizations (95% UI, 9.9-10.5 million hospitalizations), and 159 200 deaths (95% UI, 151 200-164 700 deaths). In this scenario, measles became endemic at 4.9 years (95% UI, 4.3-5.6 years) and rubella became endemic at 18.1 years (95% UI, 17.0-19.6 years), whereas poliovirus returned to endemic levels in about half of simulations (56%) at an estimated 19.6 years (95% UI, 14.0-24.7 years). There was large variation across the US population.

Conclusions and Relevance

Based on estimates from this modeling study, declining childhood vaccination rates will increase the frequency and size of outbreaks of previously eliminated vaccine-preventable infections, eventually leading to their return to endemic levels. The timing and critical threshold for returning to endemicity will differ substantially by disease, with measles likely to be the first to return to endemic levels and may occur even under current vaccination levels without improved vaccine coverage and public health response. These findings support the need to continue routine childhood vaccination at high coverage to prevent resurgence of vaccine-preventable infectious diseases in the US.

Global, regional, and national trends of measles burden and its vaccination coverage among children under five years old: an updated systematic analysis from the Global Burden of Disease study 2021

OBJECTIVES

This study examines trends in measles burden and measles-containing vaccine (MCV) coverage among children under five years old, with a focus on the impact of the COVID-19 pandemic.

METHODS

We analyzed measles incidence, mortality, and DALYs in children under five years old using GBD 2021 data and MCV coverage in 204 countries from the Global Health Data Exchange (GHDx). Trends from 1990 to 2021 were assessed through estimated annual percentage change (EAPC) at global, regional, and national levels.

RESULTS

In 2021, measles caused 4.1 million cases, 48.1 thousand deaths, and 4.2 million disability-adjusted life years (DALYs) among children under five years old globally. From 1990 to 2021, incidence, mortality, and DALYs declined by over 90%, but low Socio-demographic Index (SDI) regions continued to bear the highest burden. During the COVID-19 pandemic (2019-2021), the global measles burden declined overall, but mortality (estimated annual percentage change, EAPC = 155.55, 95% CI: 53.89 to 324.38) and DALY rates (EAPC = 146.94, 95% CI: 46.25 to 316.94) in East Asia increased. The pandemic also disrupted vaccination, with MCV1 coverage declining (EAPC = -2.08, 95% CI: -3.30 to -0.85), reversing previous trends in 68 countries (33.33%) for MCV1 and 50 countries (24.51%) for MCV2.

CONCLUSIONS

Global measles incidence has declined over the past 30 years, but regional disparities persist. The COVID-19 pandemic disrupted vaccination efforts, raising the risk of outbreaks among children. Enhanced efforts are critical to achieving measles elimination.

Socioeconomic Differences in Vaccination Coverage After a Mandatory Vaccination Law, 1855-1900

Importance

Mandatory vaccination is a major tool to combat increasing vaccine hesitancy. In principle, a vaccination law, ie, a mandatory vaccination law without exemptions, applies equally to everyone, but its effects across different socioeconomic groups (SEGs) remain unknown.

Objective

To examine the association of a vaccination law with vaccination coverage in different SEGs during 1855 to 1900.

Design, Setting, and Participants

This population-based cohort study monitored 45 years (1855-1900) of Finland's first vaccination campaign against smallpox to estimate the association of the 1883 vaccination law with vaccination coverage in infants (age <1 year) across different SEGs. Data were analyzed from October 2023 to January 2024.

Exposure

A mandatory smallpox vaccination law for all children.

Main Outcomes and Measures

Vaccination status was determined from vaccination records and defined as receiving 1 dose of the smallpox vaccine. The primary outcome was the annual vaccination coverage in different SEGs and its change before vs after the vaccination law.

Results

A total of 40 008 children aged less than 1 year were included. The high SEG had high vaccination coverage, at a mean (SD) of 90% (49 percentage points), and the law was associated with halting its declining trend. For the middle SEG, the law was associated with a 26-percentage point increase in coverage, to a mean (SD) of 83% (50 percentage points). For the low SEG, the law had no association with vaccination coverage, which always remained below 35% (mean [SD]: prelaw, 26% [22 percentage points]; postlaw, 32% [23 percentage points]).

Conclusions and Relevance

In this cohort study, a historic vaccination law was not associated with increased vaccination in the SEG with the lowest vaccination coverage, emphasizing the need for additional interventions to increase vaccine uptake in low-coverage communities.

Pediatric Vaccine Hesitancy in the United States-The Growing Problem and Strategies for Management Including Motivational Interviewing

Vaccine hesitancy is a significant global issue and is recognized by the World Health Organization (WHO) as one of the most pressing threats to public health. Defined as the delay in acceptance or refusal of vaccines despite their availability, vaccine hesitancy undermines decades of progress in preventing vaccine-preventable diseases. The issue is complex, influenced by misinformation, distrust in healthcare systems, cultural beliefs, and access barriers. These challenges require innovative and empathetic solutions to increase vaccine acceptance. Addressing this growing epidemic requires a multifaceted approach, which involves broader strategies and policymaking and in addition, effective communication tools for clinicians. Motivational Interviewing (MI), a patient-centered communication technique, offers an effective strategy to address pediatric vaccine hesitancy by fostering trust, understanding, and informed decision-making. This review aims to explore the problem of pediatric vaccine hesitancy in the United States, examine its underlying factors, and highlight evidence-based strategies, including Motivational Interviewing, to address this growing concern in clinical and public health settings. It offers practical guidance for healthcare providers and pediatricians to tackle this growing problem effectively and emphasizes the need for a combined effort of communication, community outreach, education, and systemic policy to overcome vaccine hesitancy.

Vaccination Hesitancy and Its Impact on Immunization Coverage in Pediatrics: A Systematic Review

One significant global health issue that is present in more than 190 nations globally is routine vaccination reluctance. This study aimed to synthesize the current evidence on vaccination hesitancy and its impact on immunization coverage in pediatrics. We searched for relevant studies across four databases (Scopus, Web of Science, PubMed/EMBASE, and Cumulated Index in Nursing and Allied Health Literature). Prespecified inclusion and exclusion criteria were used to extract relevant studies while excluding irrelevant ones. We found 4,085 studies on four different databases in which 23 satisfied the inclusion and exclusion criteria. These 23 relevant studies involving 29,131 parents, guardians, and caregivers from over 30 countries met the inclusion criteria and quality assessment. Studies were assessed for risk bias using the Newcastle-Ottawa scale. Vaccination hesitancy is caused by several factors, such as cultural customs, economic reforms, perceived rumors, myths, misconceptions, physicians and other healthcare professionals, and perceived risks and problems of vaccines. These results highlight the importance of addressing demand-side factors related to socioeconomic determinants and supply-side issues such as improving health literacy, combating misinformation, ensuring clarity in communication, and promoting a consistent, evidence-based message. More observations and research should be conducted regularly to develop strategies for encouraging youngsters to receive immunizations in large quantities.

Promoters and Barriers of Vaccine Hesitancy

This systematic review explores the psychological antecedents of Vaccine Hesitancy, a significant determinant of vaccination behavior. Following PRISMA guidelines, an extensive search was conducted starting from 1673 papers and resulting in 48 publications from various databases. The review identifies psychological factors, specifically cognitive, personality, experiential, and social factors contributing to hesitancy. Cognitive factors include health literacy, conspiracy beliefs, trust, and perceived risk. Personality traits such as extraversion, openness, and psychological capital impact hesitancy, while psychopathy increases it. Personal experiences, like perceived stress and racial discrimination, indirectly affect hesitancy. Social factors, including social relationships and norms, play a significant role in reducing hesitancy. Tailored interventions addressing these factors can enhance vaccine acceptance.

[Evaluation of the scenario of hesitancy in vaccines against seasonal influenza among public school teachers in Teresina, Piauí State, Brazil, in COVID-19 times]

The objectives of this study were to evaluate the frequency of vaccine hesitancy against seasonal influenza and to analyze the associated factors among teachers in the municipal school system of Teresina, Piauí State, Brazil. An online questionnaire was applied, adapted from the Health Belief Model, and 449 teachers were included. Of the public interviewed, most live in the capital Teresina, (373, 83.26%), are women (360, 80.54%), aged between 23 and 50 years (306, 81.38%), born in the state of Piauí (382, 86.82%), brown (289, 64.65%), married (254, 56.70%) and with a lato sensu graduate degree (327, 72.99%). In total, 33.18% were considered hesitant, and hesitancy was defined as teachers who were not vaccinated against influenza in 2020. The variables associated with hesitancy in this group were: not being vaccinated against influenza in 2019, the flu vaccine is not convenient, there are many risks associated with it, and concern about reactions to the flu vaccine, the new coronavirus pandemic changed the relationship with the act of vaccinating and greater adherence to the vaccine after hearing information about its benefits in the media. However, in the regression analysis, only the variables "not being vaccinated against influenza in 2019" and "the change in behavior after the pandemic" were significant. Vaccines continue to be the main method of prevention and control of a series of diseases related to influenza viruses, requiring greater adherence by teachers, a priority population that is in constant contact with students from different backgrounds, representing an important source of virus dissemination.

Characteristics Associated With Measles, Mumps, and Rubella Coverage and Exemptions After a School Immunization Law Change in Washington, 2019-2020

BACKGROUND

We aimed to better understand the impact of statewide legislation removing personal belief exemptions (PBEs) for the measles, mumps, and rubella (MMR) school immunization requirement and factors associated with resulting health-seeking behaviors.

METHODS

We used chi-squared tests and logistic regression models to determine individual- and school-level characteristics associated with holding a MMR PBE and with post-law MMR immunization status among students linked to the Washington State Immunization Information System.

RESULTS

Of students with a MMR PBE pre-law change, 43.0% completed the MMR vaccine series and 40.4% sought another exemption type. Religious exemptions made up most new MMR exemptions signed (71.8%), followed by medical exemptions (18.5%), and religious membership exemptions (9.7%). Students were more likely to complete the vaccine series post-law change if they attended a school with a low school-level MMR exemption rate, a public school, or held a lower number of school-required immunization exemptions.

CONCLUSIONS

This study confirms previous concerns that parents might replace their PBE with another exemption type; however, nearly half the students in the cohort completed the MMR vaccine series. Our findings suggest that targeted immunization policies can increase MMR coverage 1-year post-law change but must account for a replacement effect when exemption categories are eliminated.

Case Series of Vaccine Hesitancy Encountered at the Pediatric Emergency Department

Vaccine hesitancy (VH) is a significant concern, although its specific characteristics remain unclear. Moreover, strategies to shift vaccine-hesitant parents' attitudes toward immunization are not yet well-defined. Pediatric emergency department (ED) physicians frequently encounter patients who are inadequately vaccinated due to parental VH; however, it is challenging to allocate sufficient time during ED visits to provide comprehensive vaccination education. Our institution operates a dedicated outpatient clinic that provides vaccine education for parents with vaccine hesitancy identified in the pediatric ED. The aim of this study was to identify the characteristics of vaccine-hesitant individuals presenting to a pediatric ED in Japan and to assess the effectiveness of our vaccination education clinic. We found 78 vaccine hesitancy cases in the patients who visited the pediatric ED. Among them, 31 (40%) visited our vaccination education clinic. The majority (29/31, 94%) of parents who attended our vaccination education clinic replied that they gained a positive view of vaccination. The pediatric ED is a useful location to identify VH patients and parents. Vaccination education by pediatric infectious diseases specialists may be useful in changing parental attitudes towards immunization.

Predictors on parent's attitudes toward the measles-rubella (MR) vaccine in Jordan: An education program

BACKGROUND

Vaccine hesitancy is considered 1 of the top 10 threats to global health. This study aims to assess the impact of an education program on parents' attitudes toward the measles-rubella vaccine.

METHODS

A study was conducted with 250 parents using a randomized controlled trial design. The intervention group (125 parents) received training, education programs, and video, while the control group (125 parents) only received video. The Parent Attitudes about Childhood Vaccines (PACV) scale, including its behavior, safety and efficacy, and trust subscales, was used for pre-post assessment. This allowed for comparison between the groups and measurement of score differences. The PACV scale (range 0-42) identified vaccine hesitancy, with a score below 21 indicating "non-hesitant" and 21 or higher indicating "hesitant."

RESULTS

The intervention group had a significant decrease in PACV scores after the program (17.54 ± 4.7, P = .001), mainly in behavior, safety, efficacy, and trust (6.4 ± 3.6, 9.8 ± 4.7, 3.9 ± 2; P = .001, .011, .002). The control group showed no changes (23.6 ± 3.5; P = .402). Postintervention PACV score differences were significant (t = 11.562, P = .001).

DISCUSSION

Findings indicate that the education program had a positive effect on changing vaccine hesitancy.

CONCLUSIONS

The education programs promoted vaccine acceptance among parents.

Low Rates of Immunity among Medical Students and Residents in the Era of the Resurgence of Measles

Measles is a highly contagious viral disease spread through respiratory droplets. The number of reported cases increased worldwide in 2023, particularly in the European Region. Italy reported 213 cases in the first quarter of 2024, with most of them in unvaccinated adults aged 15-64. Maintaining high vaccination coverage is essential to prevent outbreaks, especially in healthcare settings where measles transmission is a significant risk. In our study, we collected serological and demographic information from all Italian and foreign medical students and residents (850) who underwent a pre-training assessment at the Tor Vergata Occupational Medicine Service, Rome, between 3 April 2023 and 31 January 2024. Of the 850 students and residents analyzed, we found only 546 (64.2%) with a protective level of IgG antibodies against measles, with a median IgG level of 2.00 AI. A significant proportion of students and residents were serologically non-immune, raising concerns about the potential risk of hospital transmission. To manage this risk, it is important to assess serological levels, vaccinate those with inadequate levels, and promote vaccination in the general population.

Vaccine Hesitancy in Taiwan: Temporal, Multilayer Network Study of Echo Chambers Shaped by Influential Users

BACKGROUND

Vaccine hesitancy is a growing global health threat that is increasingly studied through the monitoring and analysis of social media platforms. One understudied area is the impact of echo chambers and influential users on disseminating vaccine information in social networks. Assessing the temporal development of echo chambers and the influence of key users on their growth provides valuable insights into effective communication strategies to prevent increases in vaccine hesitancy. This also aligns with the World Health Organization's (WHO) infodemiology research agenda, which aims to propose new methods for social listening.

OBJECTIVE

Using data from a Taiwanese forum, this study aims to examine how engagement patterns of influential users, both within and across different COVID-19 stances, contribute to the formation of echo chambers over time.

METHODS

Data for this study come from a Taiwanese forum called PTT. All vaccine-related posts on the "Gossiping" subforum were scraped from January 2021 to December 2022 using the keyword "vaccine." A multilayer network model was constructed to assess the existence of echo chambers. Each layer represents either provaccination, vaccine hesitant, or antivaccination posts based on specific criteria. Layer-level metrics, such as average diversity and Spearman rank correlations, were used to measure chambering. To understand the behavior of influential users-or key nodes-in the network, the activity of high-diversity and hardliner nodes was analyzed.

RESULTS

Overall, the provaccination and antivaccination layers are strongly polarized. This trend is temporal and becomes more apparent after November 2021. Diverse nodes primarily participate in discussions related to provaccination topics, both receiving comments and contributing to them. Interactions with the antivaccination layer are comparatively minimal, likely due to its smaller size, suggesting that the forum is a "healthy community." Overall, diverse nodes exhibit cross-cutting engagement. By contrast, hardliners in the vaccine hesitant and antivaccination layers are more active in commenting within their own communities. This trend is temporal, showing an increase during the Omicron outbreak. Hardliner activity potentially reinforces their stances over time. Thus, there are opposing forces of chambering and cross-cutting.

CONCLUSIONS

Efforts should be made to moderate hardliner and influential nodes in the antivaccination layer and to support provaccination users engaged in cross-cutting exchanges. There are several limitations to this study. One is the bias of the platform used, and another is the lack of a comprehensive definition of "influence." To address these issues, comparative studies across different platforms can be conducted, and various metrics of influence should be explored. Additionally, examining the impact of influential users on network structure and chambering through network simulations and regression analysis provides more robust insights. The study also lacks an explanation for the reasons behind chambering trends. Conducting content analysis can help to understand the nature of engagement and inform interventions to address echo chambers. These approaches align with and further the WHO infodemic research agenda.

Vaccine Science Diplomacy and "The Phenomenon of Man"

The central tenets of international scientific collaborations leading to the development, testing, and the equitable distribution vaccines to combat poliomyelitis, smallpox, COVID-19, and other devasting infections, first accelerated in the mid-twentieth century. The genesis of vaccine science diplomacy also coincides with the publication of Le Phénomène Humain (The Phenomenon of Man) shortly after the death of its author, the French Jesuit priest and scientist, Dr. Teilhard de Jardin. Several tenets of Teilhard's posthumous essay, including our collective consciousness, and the "conjugated faces" of science and religion, are relevant to a modern vaccine diplomacy framework, even if Teilhard may not have specifically addressed vaccines in his writings. This could also include the potential for arriving at an "omega point" through international scientific collaboration and joint vaccine development, while simultaneously avoiding the destructive forces of anti-vaccine or anti-science activism. Collaborations between the Vatican, Catholic research universities and institutions; and leaders of the Catholic-majority nations in Africa, Asia, and Latin America in an integrated framework might accelerate these activities as they apply to both pandemic threats and neglected diseases of poverty.

Guarding the gatekeepers: a comprehensive approach to control nosocomial measles

PURPOSE

Despite substantial vaccination progress, persistent measles outbreaks challenge global elimination efforts, particularly within healthcare settings. In this paper, we critically review the factors contributing to measles outbreak and effective control measures for nosocomial transmission of measles.

METHODS

We systematically searched electronic databases for articles up to 17th May, 2023. This was performed by two independent reviewers, with any disagreements resolved by a third reviewer. We also searched governmental and international health agencies for relevant studies.

RESULTS

Forty relevant articles were systematically reviewed, revealing key factors fuelling measles outbreak in healthcare settings, including high transmissibility capability; high intensity exposure; delayed care; failure to use protective equipment and implement control measures; vaccine failure; unclear immunisation history and lack of registries; and lacking recommendation on healthcare workers' (HCWs) measles vaccination. To combat these challenges, successful control strategies were identified which include early notification of outbreak and contact tracing; triaging all cases and setting up dedicated isolation unit; strengthening protective equipment use and physical measures; improving case detection; determining immunity status of HCWs; establishing policy for measles vaccination for HCWs; management of exposed personnel; and developing a pre-incident response plan.

CONCLUSION

A coordinated and comprehensive approach is essential to promptly identify and manage measles cases within healthcare settings, necessitating multifactorial strategies tailored to individual settings. These findings provide a valuable foundation for refining strategies to achieve and maintain measles elimination status in healthcare environments.

Effectiveness and safety of a mumps containing vaccine in preventing laboratory-confirmed mumps cases from 2002 to 2017: A meta-analysis

Emerging evidence has figured that serum conversion rate of mumps is a crucial link of mumps disease. Nevertheless, a rising number of mumps outbreaks caused our attention and studies examining the serum conversion cases were conducted in small samples previously; this meta-analysis was conducted to assess the immunogenicity and safety of a mumps containing vaccine (MuCV) before 2019. We identified a total of 17 studies from the year of 2002-2017. In the case-control studies, the vaccine effectiveness (VE) of MuCV in preventing laboratory-confirmed mumps was 68% (odds risk: 0.32; 95% confidence interval [CI], 0.14-0.70) while in the cohort studies and randomised control trials, 58% (relative risk [RR]: 0.42; 95% CI, 0.26-0.69). Similar intervals of effectiveness rates were found during non-outbreak periods compared with outbreak periods (VE: 66%; RR: 0.34; 95% CI, 0.18-0.68 versus VE: 49%; RR: 0.51; 95% CI, 0.21-1.27). In addition, the MuCV group with two and three doses did not show enhanced laboratory-confirmed mumps than one dose (VE: 58%; RR: 0.42; 95% CI, 0.20-0.88 versus VE: 65%, RR: 0.35; 95% CI, 0.20-0.61) for the reason of the overlap of 95% CI. MuCV had comparable effectiveness comparing non-outbreak and outbreak period, one dose, and two or three doses. MuCV displayed acceptable adverse event profiles.

Hearing Loss after COVID-19 and Non-COVID-19 Vaccination: A Systematic Review

(1) Background: Vaccine safety is an important topic with public health implications on a global scale. The purpose of this study was to systematically review available literature assessing sensorineural hearing loss (SNHL) incidence and severity following both coronavirus disease 2019 (COVID-19) and non-COVID-19 vaccinations, as well as prognosis and outcomes. (2) Methods: This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Relevant publications evaluating post-vaccination SNHL were selected from PubMed and Embase, searching from inception to July 2023. (3) Results: From 11 observational studies, the incidence of post-vaccination SNHL was low for both COVID-19 and non-COVID-19 vaccines, ranging from 0.6 to 60.77 per 100,000 person-years, comparable to all-cause SNHL. (4) Conclusions: The incidence rates of SNHL following COVID-19 and non-COVID-19 vaccinations remained reassuringly low. Most patients experienced improved hearing function in the weeks to months following vaccination. This study underscores the importance and safety of vaccinations and encourages ongoing surveillance and detailed reporting of hearing loss cases post-vaccination.

Impact of household decision makers' hesitancy to vaccinate children against COVID-19 on other household members: A family-based study in Taizhou, China

BACKGROUND

Vaccination is the most effective means of preventing outbreaks of infectious diseases, and family ;decision makers play an important role in decision-making regarding family matters and may influence other family members to take an active role in vaccinating children against COVID-19.

PURPOSE

This study examined the influence of family decision makers on the hesitation of other family members to vaccinate their children against COVID-19.

METHODS

A population-based, self-administered online questionnaire was administered in Taizhou, China, from September 1, 2021, to September 15, 2021. The questionnaire included demographic information, knowledge, attitudes, and perceptions about the COVID-19 vaccine as well as hesitation regarding the use of the COVID-19 vaccination in children. In total, 490 respondents were included in this study. Logistic regression was used to assess the factors associated with vaccine hesitancy.

RESULTS

In total, 490 respondents from 190 households were interviewed. Of the 190 family decision makers, 43.7% (83/190) were hesitant to vaccinate their children against COVID-19. When family decision makers were hesitant to vaccinate children against COVID-19, 65.1% (82/126) of the other family members expressed similar hesitancy regarding vaccination. When family decision makers were not hesitant to vaccinate children, only 21.3% (37/174) of other family members were hesitant to do so. In the regression analysis, family decision makers' hesitation to vaccinate their children was associated with other family members' hesitation (OR=6.264, 95% CI:3.132-12.526). In addition, decision makers' perceptions of the safety of the vaccine (OR=0.422, 95% CI:0.215-0.826) and hesitation to vaccinate themselves (OR=8.967, 95% CI:4.745-16.948) influenced their hesitation to vaccinate their children.

CONCLUSION

The present study found that family decision makers' hesitation to vaccinate children against COVID-19 influenced other family members' hesitation to vaccinate children. In addition, family decision makers' perceptions of the safety of the vaccine and their hesitation to vaccinate themselves influenced other family members' hesitation to vaccinate their children.

Routine immunization experience and practices during the COVID-19 pandemic of caregivers attending a tertiary hospital in Cape Town

Introduction

Immunizations are successful, cost-effective interventions for the control of infectious diseases and preventing mortality. Lockdown restrictions during the COVID-19 pandemic had adverse effects on child-health including access to immunizations. Our study aimed to document immunization status, describe caregiver experiences around accessing immunizations during the COVID-19 pandemic and identify any significant factors associated with immunization status.

Methods

Caregivers, with children between the ages of 10 to 33 months, attending Tygerberg Hospital Paediatric Department were invited to complete an anonymous survey from 15th September-15th December 2022. Data was captured using a REDCap questionnaire and analysed using Stata Version 17.

Results

171 caregivers completed the survey. Immunizations were up to date in 81%. Most (155, 88%) agreed it was important to immunize their child. A third of caregivers (55) felt it was unsafe to attend the clinic and 37% (62) agreed it was difficult to attend. Caregivers receiving a social grant (p = 0.023) or who felt safe attending clinic (p = 0.053) were more likely to be up to date with immunizations. Three-quarters (128, 78%) were aware of recommendations to continue immunization. These caregivers were more likely to think it was important to immunize on time (p = 0.003) and to receive family encouragement (p = 0.001). Caregivers were more likely to attend clinic if they felt it was important to vaccinate on time (p < 0.001) or felt safe attending clinic (p = 0.036).

Conclusion

Immunization rates were higher than expected but below global targets. Although caregivers feel immunizations are important, unknowns still instilled fear of attending clinics. Social factors such as family support and social grants improve vaccine seeking behaviour.

Using machine learning to identify COVID-19 vaccine-hesitancy predictors in the USA

Introduction

Vaccine hesitancy is complex, multicausative phenomenon that undermines public health efforts to contain the spread of infectious diseases. Improving our understanding of the drivers of vaccine hesitancy might improve our capacity to address it.

Methods

We used the results of the May 2021 Assistant Secretary for Planning and Evaluation's survey on COVID-19 vaccine hesitancy, which estimated the proportion of adults for every US county that felt either hesitant or unsure and strongly hesitant towards taking the COVID-19 vaccine when it becomes available. We developed a prediction model to identify the most important predictors of vaccine hesitancy. The potential predictors included demographic characteristics, the Centers for Disease Control and Prevention's Social Vulnerability Index and the Republican Party's voting share in the 2020 presidential election as a proxy of political affiliation, all at the county level.

Results

We found that the main drivers of vaccine hesitancy are income level, marital status, poverty, income, schooling, race/ethnicity, age, health insurance status and political affiliation. While the drivers are shared by both levels of hesitancy, the order changes. Particularly, political affiliation is a more important predictor for strong hesitancy than for hesitancy or unsure.

Conclusions

These results deepen our understanding of the phenomenon and could help design more targeted interventions to reduce hesitancy in specific subgroups of the population.

Prevalence, predictors and reasons for COVID-19 vaccine hesitancy: Results of a global online survey

Vaccine hesitancy has the potential to cripple efforts to end the COVID-19 pandemic. Policy makers need to be informed about the scale, nature and drivers of this problem, both domestically and globally, so that effective interventions can be designed. To this end, we conducted a statistical analysis of data from the CANDOUR survey (n = 15,536), which was carried out in 13 countries representing approximately half of the global population. Both pooled and country-level ordered regression models were estimated to identify predictors of vaccine hesitancy and reasons for not getting vaccinated. We found high levels of hesitancy, particularly in high-income countries. Factors driving moderate hesitancy differed from those driving extreme hesitancy. A lack of trust in health care providers was consistently the underlying driver of more extreme hesitancy. Predictors of moderate hesitancy varied across countries, though being younger and female was typically associated with greater hesitancy. While political ideology played a role in vaccine hesitancy in some countries, this effect was often moderated by income level, particularly in the US. Overall, the results suggest that different interventions such as mass-media campaigns and monetary incentives may be needed to target the moderately versus extremely hesitant. The lack of trust in health care professionals that drives extreme hesitancy may reflect deep societal mistrust in science and institutions and be challenging to overcome.

Psychological and Social Aspects of Vaccination Hesitancy-Implications for Travel Medicine in the Aftermath of the COVID-19 Crisis: A Narrative Review

Vaccines are an important tool of preventive medicine. Although organized vaccination programs have saved large populations from serious infectious diseases, there is a considerable part of the population who oppose vaccinations. In particular, anti-vaccination perceptions, among travelers to countries with endemic diseases, are a major public health concern. Although hesitancy towards vaccinations is not a novel phenomenon, it came back to the forefront during the fight against the COVID-19 pandemic. This review explores the etiology of anti-vaccination beliefs among travelers and draws conclusions about their impact on public health and society in general. For this purpose, a purposeful search for data on the causative factors of vaccine hesitancy and their impact on people's health was conducted. A descriptive analysis of the findings and conclusions regarding possible implications in health policy and clinical practice are presented. A fear of side effects, lack of credence in the necessity of vaccines, and mistrust of medical authorities are important causative factors. Their interplay shapes hesitancy towards vaccines. However, anti-vaccination beliefs can also be an aspect of a more general unconventional stance of life. Health care professionals and organizations must be ready to tackle vaccine hesitancy by making the necessary interventions. Correcting misconceptions about vaccinations is a prerequisite for ensuring personal and public health, especially in the context of a pandemic or epidemic. Moreover, ensuring the efficacy and safety of vaccines, especially in cases of modern technology applications, is a fundamental factor in addressing people's concerns about vaccines. For this purpose, medical authorities and organizations must provide accurate and clear information on vaccines so as to eliminate misinformation. Furthermore, clinicians should cultivate their communication skills in order to convey the appropriate messages to prospective recipients of vaccinations.

Exploring data trends and providers' insights on measles immunization uptake in south-west Nigeria

Introduction

measles outbreak remains a recurring episode and continues to be responsible for millions of deaths globally every year. This study examines measles immunization coverage and uncovers barriers and enablers to effective provision and uptake of measles immunization services from the supply end and provider´s perspective in a developing nation´s context.

Methods

the study employed a mixed-method approach to explore trends and patterns of measles immunization uptake in Ekiti State-a state in the southwestern region of Nigeria-utilizing DHIS 2014 - 2019 data of 789,518 under 1-year children and complemented the quantitative study with key informant interviews from appointed Immunization Officers in the state. Using deductive methods, we thematically analyzed the interview data using NVivo version 12 while STATA 16 was used to analyze the quantitative data.

Results

the annualized measles immunization coverage ranged between 49% and 86% from 2014 to 2019, which is below the WHO set threshold for measles infection prevention. Caregiver, geographical, human, and infrastructural factors were elicited as barriers, while potential enablers include increased public engagement and enhanced media involvement.

Conclusion

while programmatic efforts are being improved nationally to drive up the uptake, this study provides baseline information for benchmarking the subsequent level of efforts and recommends improved collaboration across contextually similar states to promote program efficiency. The results can inform policy and program development, execution and direct future research on measles immunization to address uptake challenges at both local and central administration levels, especially in the aspect of surveillance and monitoring.

Parents' COVID-19, HPV, and Monkeypox vaccination intention: A multilevel structural equation model of risk, benefit, barrier, and efficacy perceptions and individual characteristics

OBJECTIVE

This study seeks to comparatively examine parents' intention to vaccinate their children for three infectious diseases, including COVID-19, HPV, and monkeypox.

METHODS

Utilizing a mixed-design survey and multilevel structural equation models, we investigated if perception of the diseases and vaccines explained the variance in parents' vaccine-specific decision-making and population difference in vaccination intention.

RESULTS

Compared with the COVID-19 vaccine, parents were more willing to get an HPV vaccine for their children due to greater perceived benefit and lower perceived barrier. Concerns about vaccine safety and lower disease risk perception were associated with lower intention to get a monkeypox vaccine. Parents of color, less educated, and lower-income parents were less willing to get vaccines for their children due to low benefit perception and high perceived barriers.

CONCLUSION

Parents were motivated by different social and psychological factors when deciding whether to get a COVID-19, HPV, and monkeypox vaccine for their children.

PRACTICE IMPLICATIONS

Vaccine promotion should be tailored to the characteristics of the target population and the vaccines. Underprivileged communities may be better approached with information about vaccine benefit and barriers, and vaccines for unfamiliar diseases may be better communicated with disease risk information.

Vaccine hesitancy promotes emergence of new SARS-CoV-2 variants

The successive emergence of SARS-CoV-2 mutations has led to an unprecedented increase in COVID-19 incidence worldwide. Currently, vaccination is considered to be the best available solution to control the ongoing COVID-19 pandemic. However, public opposition to vaccination persists in many countries, which can lead to increased COVID-19 caseloads and hence greater opportunities for vaccine-evasive mutant strains to arise. To determine the extent that public opinion regarding vaccination can induce or hamper the emergence of new variants, we develop a model that couples a compartmental disease transmission framework featuring two strains of SARS-CoV-2 with game theoretical dynamics on whether or not to vaccinate. We combine semi-stochastic and deterministic simulations to explore the effect of mutation probability, perceived cost of receiving vaccines, and perceived risks of infection on the emergence and spread of mutant SARS-CoV-2 strains. We find that decreasing the perceived costs of being vaccinated and increasing the perceived risks of infection (that is, decreasing vaccine hesitation) will decrease the possibility of vaccine-resistant mutant strains becoming established by about fourfold for intermediate mutation rates. Conversely, we find increasing vaccine hesitation to cause both higher probability of mutant strains emerging and more wild-type cases after the mutant strain has appeared. We also find that once a new variant has emerged, perceived risk of being infected by the original variant plays a much larger role than perceptions of the new variant in determining future outbreak characteristics. Furthermore, we find that rapid vaccination under non-pharmaceutical interventions is a highly effective strategy for preventing new variant emergence, due to interaction effects between non-pharmaceutical interventions and public support for vaccination. Our findings indicate that policies that combine combating vaccine-related misinformation with non-pharmaceutical interventions (such as reducing social contact) will be the most effective for avoiding the establishment of harmful new variants.

State Policy Removing the Personal Belief Exemption for Measles, Mumps, and Rubella (MMR) School Immunization Requirement, Washington State, 2014-2022

Objectives. To assess the impact of Washington State's 2019 Engrossed House Bill (EHB) 1638-which removed measles, mumps, and rubella (MMR) personal belief exemptions-on MMR vaccine series completion and exemption rates in K-12 students. Methods. We used interrupted time-series analyses to examine changes in MMR vaccine series completion rates before and after EHB 1638 was passed and the χ2 test for differences in exemption rates. Results. EHB 1638 implementation was associated with a 5.4% relative increase in kindergarten MMR vaccine series completion rates (95% confidence interval = 3.8%, 7.1%; P ≤ .001), and results were similar with Oregon as a control state (no change observed in Oregon; P = .68). MMR exemptions overall decreased 41% (from 3.1% in 2018-2019 to 1.8% in 2019-2020; P ≤ .001), and religious exemptions increased 367% (from 0.3% to 1.4%; P ≤ .001). Conclusions. EHB 1638 was associated with an increase in MMR vaccine series completion rates and a decrease in any MMR exemption. However, effects were partially offset by an increase in religious exemption rates. Public Health Implications. Removal of personal belief exemptions for the MMR immunization requirement only may be an effective approach to increase MMR vaccine coverage rates statewide and among underimmunized communities. (Am J Public Health. 2023;113(7):795-804. https://doi.org/10.2105/AJPH.2023.307285).

Psychological Distance, Construal Level, and Parental Vaccine Hesitancy for COVID-19, HPV, and Monkey Pox Vaccines

Building on the construal-level theory and the multi-dimensional model of behavioral barriers, this study examined whether psychological distance and construal level explain the association between behavioral intention and behavioral barriers that may lead to parental vaccine hesitancy. Results of multilevel structural equation models show that low vaccination intention, far distance perception, and abstract construal of vaccines led to more global concerns, such as vaccine safety and relevance. Such effects emerged when people considered specific vaccines, such as coronavirus disease 2019 (COVID-19), human papillomavirus (HPV), and monkeypox vaccines, and when they considered multiple vaccines in general.

The Role of Perceived Risk in the Relationship Between Disgust Sensitivity and COVID-19 Vaccine Hesitancy

Background

Despite widespread availability of COVID vaccines and evidence of their efficacy, vaccine hesitancy remains prevalent. Several studies have examined the relationship between disgust sensitivity and vaccine hesitancy. Although results from studies using data collected prior to the COVID pandemic indicate that higher disgust sensitivity is related to greater vaccine hesitancy, results from studies using data collected during the COVID pandemic are equivocal. The present study examined whether perceived risk of contracting COVID moderated the relationship between disgust sensitivity and vaccine hesitancy.

Methods

Participants (n = 152) completed self-report measures of disgust sensitivity, perceived risk of contracting COVID, and COVID vaccine hesitancy (defined as both vaccine confidence and vaccine complacency).

Results

Perceived risk of contracting COVID significantly moderated the relationship between disgust sensitivity and vaccine complacency, with the association strengthened at low levels of perceived risk. Perceived risk of contracting COVID also marginally moderated the relationship between disgust sensitivity and vaccine confidence, with the association strengthened at low and average levels of perceived risk.

Conclusions

Results suggest that individuals with elevated disgust sensitivity who also report low levels of perceived risk of contracting COVID are more likely to express vaccine hesitancy. Implications of these findings are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-023-10391-8.

Why Parents Say No to Having Their Children Vaccinated against Measles: A Systematic Review of the Social Determinants of Parental Perceptions on MMR Vaccine Hesitancy

Ongoing outbreaks of measles threaten its elimination status in the United States. Its resurgence points to lower parental vaccine confidence and local pockets of unvaccinated and undervaccinated individuals. The geographic clustering of hesitancy to MMR indicates the presence of social drivers that shape parental perceptions and decisions on immunization. Through a qualitative systematic review of published literature (n = 115 articles; 7 databases), we determined major themes regarding parental reasons for MMR vaccine hesitancy, social context of MMR vaccine hesitancy, and trustworthy vaccine information sources. Fear of autism was the most cited reason for MMR hesitancy. The social drivers of vaccine hesitancy included primary care/healthcare, education, economy, and government/policy factors. Social factors, such as income and education, exerted a bidirectional influence, which facilitated or hindered vaccine compliance depending on how the social determinant was experienced. Fear of autism was the most cited reason for MMR hesitancy. Vaccine hesitancy to MMR and other childhood vaccines clustered in middle- to high-income areas among mothers with a college-level education or higher who preferred internet/social media narratives over physician-based vaccine information. They had low parental trust, low perceived disease susceptibility, and were skeptical of vaccine safety and benefits. Combating MMR vaccine misinformation and hesitancy requires intersectoral and multifaceted approaches at various socioecological levels to address the social drivers of vaccine behavior.

Proposing a New Conceptual Syndemic Framework for COVID-19 Vaccine Hesitancy: A Narrative Review

BACKGROUND

Discussions regarding syndemics have dominated research in recent years. Vaccine hesitancy has also been propelled to the forefront. In this narrative review, we aim to frame a novel syndemic framework to understand the interaction between vaccine hesitancy, COVID-19, and negative health outcomes.

METHODS

A non-systematic electronic search was conducted in PubMed and Google Scholar. Search criteria were limited to articles published between November 2019 and June 2022. Articles related to the COVID-19 syndemic and vaccine hesitancy were included.

RESULTS

Our review revealed that the adherence to COVID-19 regulations-although they were effective in preventing COVID-19 transmission, cases, and deaths-created a dynamically unstable 'vicious cycle' between undesirable health, economic, and social outcomes. The "accumulation" of complex stressors decreased individuals' cognitive flexibility and hindered them from making decisions and getting vaccinated. Furthermore, it increased individuals' risk of acquiring COVID-19, losing their employment, increasing poverty, and decreasing healthcare utilization. We illustrated how the amalgamation of sociodemographic and contextual factors associated with COVID-19 might impact people's vaccine decisions, making them more hesitant toward COVID-19 vaccination. Failing to receive vaccinations increases the chances of COVID-19 transmission, hospitalization, and other negative health outcomes.

CONCLUSIONS

Understanding the interaction between these factors is essential to provide policymakers with inspiration to set appropriate interventions for promoting COVID-19 vaccination acceptance to decrease the overall burden of pandemics.

Trends in vaccination schedules and up-to-date status of children 19-35 months, United States, 2015-2020

OBJECTIVES

To estimate trends in, and factors associated with, vaccination patterns and up-to-date immunization status of U.S. children by 19 to 35 months of age.

METHODS

Data from the 2015 to 2020 National Immunization Surveys were used to assess trends in vaccination patterns, up-to-date status, and zero vaccination status of U.S. children by 19-35 months. Vaccination patterns were categorized as: 1) recommended, 2) alternate, or 3) unknown or unclassifiable. Multivariable analyses were conducted to examine factors associated with each vaccination pattern and up-to-date status for all recommended vaccines.

RESULTS

From 2015 to 2020, the proportion of U.S. children completing the recommended schedule increased from 62.5% to 69.4%, alternative schedule decreased from 21.6% to 16.2%, and unknown or unclassifiable schedules decreased from 15.9% to 14.3%. In addition, being not up-to-date decreased from 39.7% to 35.6%. There was no change in the percentage of children receiving zero vaccinations from 2015 to 2020 (0.9% to 0.9%). Respondents with lower household income or who were uninsured were more likely to follow an alternate or unknown/unclassifiable schedule, or not be up-to-date with vaccines.

CONCLUSION

Following any schedule other than the recommended schedule was associated with not being up-to-date on immunizations. Increased efforts to catch up on recommended vaccines is important for protecting children's health. Further efforts should be made to improve timely adherence to recommended vaccination schedules, particularly among populations with the largest disparities in coverage through a tailored approach to increase confidence in and access to vaccines.

The Effects of Offering Freedom to Comply by Pediatricians and Nurses, Using the But-You-Are-Free (BYAF) Technique, on Vaccination Compliance on 185 Parents of Newborn Babies Conducted in Outpatient Clinics in Poland Between January 2022 and July 2022

BACKGROUND This study aimed to evaluate, in outpatient clinics in Poland between January 2022 and July 2022, the effectiveness of the But-You-Are-Free (BYAF) social influence technique by healthcare professionals during interaction with 185 parents deciding about vaccinating (eg, Hexacima, Prevenor 13, Synflorix, Rotateq, Act Hib, Boostrix, Pentaxim, DTP, Imovax, Priorix, MMR, Tetracim, Adacel, Euvax B, Fuvax, FSME, Varilix, Nimenrix, Bexero vaccines) their babies. MATERIAL AND METHODS During an interaction with pediatricians or nurses, the parents were encouraged to vaccinate their babies. In experimental condition (111 interactions), the BYAF technique was employed, and the phrase "But you are free" was added at the end of the conversation. In the control condition (74 interactions), it was not employed. RESULTS In the experimental condition, 71 (64%) participants declared intention to vaccinate their children. In the control condition, it 61 (84%) participants declared intention to vaccinate (the difference in percentages was significant: P=0.006). The number of parents who actually vaccinated their babies in the experimental condition was 92 (83%) and in the control condition it was 70 (95%; P=0.018). CONCLUSIONS The findings showed that participants who were exposed to the BYAF technique declared lower intentions to vaccinate their babies, and vaccinated them less often than those in the control condition. This result critically highlights that this technique should not be employed in the medical settings of pediatric vaccination.

A cross-sectional analysis of the predictors of COVID-19 vaccine uptake and vaccine hesitancy in Iraq

BACKGROUND

Vaccine hesitancy poses a significant risk to global recovery from COVID-19. To date however, there is little research exploring the psychological factors associated with vaccine acceptability and hesitancy in Iraq.

AIM

To explore attitudes towards COVID-19 vaccination in Iraq. To establish the predictors of vaccine uptake and vaccine hesitancy in an Iraqi population.

METHODS

Using a cross-sectional design, 7,778 participants completed an online questionnaire exploring their vaccination status, likelihood of infection, perceived severity infection, benefits of vaccine, barriers to vaccine, anticipated regret, subjective norms, and trust in government.

FINDINGS

Vaccination rates increased with age and were greater in males, those who were married, divorced or widowed, those with children and those with underlying conditions. Vaccine hesitancy was widespread with 61.40% of unvaccinated individuals reported an unwillingness to receive a COVID-19 vaccine. In unvaccinated groups, vaccine hesitancy was associated with lower trust in the government, more negative social norms, greater perceived barriers to vaccination and reduced perceived benefits.

CONCLUSIONS

There is significant COVID-19 vaccine hesitancy in Iraq. Public health institutions should be aware of the influence of demographic factors, as well as personal beliefs and social norms, on individuals' decisions to vaccinate. Public health messaging should therefore aim to be tailored to address the concerns of citizens.

Stages of HPV Vaccine Hesitancy Among Guardians of Female Secondary School Students in China

PURPOSE

Female secondary school students are the primary recommended population for human papillomavirus (HPV) vaccines. However, vaccine hesitancy may affect uptake. In this study, we assessed the vaccine hesitancy levels among the guardians of female secondary school students in China.

METHODS

We developed a questionnaire and conducted cross-sectional surveys among guardians of secondary school girls aged 12-19 years in mainland China based on the Increasing Vaccination Model and the Precaution Adoption Process Model.

RESULTS

We collected 3,225 valid samples. Among the participating guardians, 53.9% were vaccine hesitant, although only 0.9% had refused HPV vaccines. Some individual characteristics of guardians (e.g. sex, education/income level) were associated with understanding HPV vaccines. Better knowledge of HPV vaccines and communication with reliable sources of information were associated with vaccine nonhesitancy. Practical barriers such as vaccine shortage and busy schedules prevented nonhesitant guardians from vaccinating their children.

DISCUSSION

A substantial proportion of the guardians surveyed were HPV vaccine hesitant. Promoting HPV knowledge and communication with reliable sources (e.g. clinical doctors) could help fight against vaccine hesitancy.

Attitudes, hesitancy, concerns, and inconsistencies regarding vaccines reported by parents of preschool children

OBJECTIVE

This study aimed to assess attitudes, concerns, information and knowledge about vaccines among parents of preschool children attending kindergartens in a city in the interior of São Paulo, Brazil, using a self-administered questionnaire.

METHODS

Cross-sectional, questionnaire-based study of knowledge and attitudes regarding vaccination among parents of children aged up to 72 months from public and private schools, between 2018 and 2019.

RESULTS

Among the 2,528 questionnaires, 1,261 were answered and grouped by respondents' educational level. According to information, 96.6% of the children were up to date with vaccines. The prevalence of vaccine hesitancy was 5.0%. The lower the educational level, the lower was the income, the larger the number of household members, and the greater the lack of knowledge about vaccines. The higher the educational level, the lower was the vaccine hesitancy, and the greater the dissatisfaction with the information received.

CONCLUSIONS

Generally, parents consider vaccines to be important for preventing diseases and to be safe, with their benefits outweighing the risks. Positive comments were accompanied by doubts, concerns, hesitancy, and inconsistencies. The level of educational attainment makes a difference in the access to information, medical care provided by pediatricians, and the feeling of obligation to vaccinate. Parents have vaccinated and still intend to vaccinate their children, but ensuring adequate levels of vaccination coverage will be a post-pandemic challenge.

The influence of social class and institutional relationships on the experiences of vaccine-hesitant mothers: a qualitative study

BACKGROUND

Vaccine hesitancy is a growing problem in the United States. However, our understanding of the mechanisms by which socioeconomic status (SES) shapes the experience of vaccine hesitancy and decision-making is incomplete.

AIM

The aim of this study was to understand how social class influences the experiences and perspectives of vaccine-hesitant mothers.

METHODS

We conducted semistructured interviews with middle- and working-class vaccine-hesitant mothers. Participants were identified through neighborhood parenthood groups in the Philadelphia area, as well as in-person and online groups whose members express concerns about vaccines. Interviews were audio recorded and inductively analyzed.

RESULTS

Interviews were conducted with 37 vaccine-hesitant mothers, who described their vaccine decision-making through the lens of interactions with three institutional stakeholders: 1) pediatric clinicians; 2) school administrators; and 3) emergency room staff. In discussing these interactions, middle- and working-class mothers invoked distinct levels of authority in relation to these institutions. Specifically, working-class mothers expressed concerns that medical or school professionals could act as reporters for state intervention, including Child Protective Services, while middle-class mothers did not. These interactions highlighted the ways middle- and working-class mothers in our study felt differently empowered and constrained in their vaccine choices, and ultimately influenced their perceptions of available actions.

CONCLUSIONS

Our findings indicate that experiences of vaccine hesitancy may be influenced by mothers' social class via their relationships to institutional authorities. These findings have implications for how clinicians communicate with parents from different social backgrounds to best build trust and facilitate vaccine uptake.

Waning of maternal antibody against measles virus in Shufu, China

BACKGROUND

As measles vaccination coverage has increased, measles infection has shifted to the population of infants. We conducted a follow-up seroepidemiological study among mothers and their infants to evaluate measles seroprevalence and the persistence of maternal measles antibody in Shufu, Kashgar from 2018 to 2020.

METHODS

Maternal venous blood and cord blood was obtained among mothers and their infants at 0, 3, 5, 8, 9, and 12 months of age. An enzyme-linked immunosorbent assay was used for quantitative measurement of measles antibodies. We analyzed the correlation between maternal and neonatal measles antibodies, and antibodies persistence after infants were born.

RESULTS

The overall neonatal maternal ratio was 2.38 (95%CI: 2.05-2.71). The measles antibodies for mothers and newborns were 438.93 IU/mL (95%CI: 409.47-470.51 IU/mL) and 440.10 IU/mL (95%CI: 410.82-471.48 IU/mL), respectively. Neonatal measles antibodies were dropping after birth and then beginning to increase starting at 8 months of age.

CONCLUSIONS

Infant measles antibody levels progressively declined after birth regardless of maternal measles antibody levels. Efforts should be carried out to eliminate measles.

An Examination of US COVID-19 Vaccine Distribution in New Jersey, Pennsylvania, and New York

COVID-19 quickly spread across the United States (US) while communications and policies at all government levels suffered from inconsistency, misinformation, and lack of coordination. In order to explain the discrepancy between availability and population uptake, a case study was conducted analyzing vaccine rollout plans, social media, and Health Officer/Other Key Informant interviews in New Jersey, New York, and Pennsylvania. Key research questions included, "What were the barriers and facilitators of early COVID vaccine distribution?" and "What mechanisms in the community emerged to alleviate strains in early vaccination?" Findings from this study revealed that pre-existing emergency preparedness infrastructures and plans developed since the 9/11 tragedy were seemingly abandoned. This caused health departments at all levels of government to make impromptu, non-uniform decisions leading to confusion, vaccine hesitancy, and ultimately low uptake. The results indicate that future vaccine rollout best practices must include evidence-based decision-making, coordinated communications, and outreach to high-priority and vulnerable communities.

Trends, barriers and enablers to measles immunisation coverage in Saskatchewan, Canada: A mixed methods study

Many social, cultural, and systemic challenges affect the uptake of measles immunisation services. Prior studies have looked at the caregivers' perspectives, but little is known about the perspectives of the health care providers on the barriers of measles immunisation services in Canada. This study examined measles immunisation coverage trends across the regional health authorities in Saskatchewan and explored the barriers and enablers to measles immunisation coverage from providers' perspectives. The study adopted an explanatory sequential mixed method. We utilized the entire population of 16,582 children under two years of age available in the Saskatchewan Immunisation Management System (SIMS) registry for 2002 and 2013 in aggregate format and interviewed 18 key informants in pre-determined two-stages in 2016 and 2017. The quantitative analysis was done with Joinpoint regression modelling, while the qualitative interview data was analyzed using hybrid inductive and deductive thematic approaches. There was a 16.89%-point increase in measles immunisation coverage in the province from 56.32% to 73.21% between 2002 and 2013. There was also a persistently higher coverage among the affluent (66.95% - 82.37%) than the most deprived individuals (45.79% - 62.60%) in the study period. The annual rate of coverage change was marginally higher among the most deprived (16.81%; and average annual percentage change (AAPC) 2.0, 95% CI 1.7-2.2) than among the affluent group (15.42% and AAPC 3.0; 95% CI 2.0-4.0). While access-related issues, caregivers' fears, hesitancy, anti-vaccination challenges, and resource limitations were barriers to immunisation, improving community engagement, service delivery flexibility, targeted social responses and increasing media role were found useful to address the uptake of measles and other vaccine-preventable diseases immunisation. There is low coverage and inequity in measles immunisation uptake in Saskatchewan from social and institutional barriers. Even though there is evidence of disparity reduction among the different groups, the barriers to increasing measles immunisation coverage have implications for the health of the socio-economically deprived groups, the healthcare system and other vaccination programs. There is a need to improve policy framework for community engagement, targeted programs, and public health discourse.

Prevention, diagnosis and treatment of cervical cancer: A systematic review of the impact of COVID-19 on patient care

Worldwide, the COVID-19 pandemic disrupted healthcare services, including cervical cancer management, and an increased burden for this condition is expected. This systematic review synthetizes the available evidence on the impact of the pandemic on prevention, diagnosis and treatment of cervical cancer. Searches were performed on PubMed, Embase, and Scopus for relevant studies on these topics with the purpose of comparing service access and care delivery before and during COVID-19 pandemic. Due to the methodological heterogeneity among the studies, findings were narratively discussed. Of the 715 screened titles and abstracts, 33 articles were included, corresponding to 42 reports that covered the outcomes of interest: vaccination against human papillomavirus (HPV) (6 reports), cancer screening (19), diagnosis (8), and treatment (8). Seven studies observed reductions in HPV vaccination uptake and coverage during COVID-19. Reports on cervical screening and cancer diagnosis activities showed a substantial impact of the pandemic on access to screening services and diagnostic procedures. All but one study that investigated cervical cancer treatment reported changes in the number of women with cervical lesions who received treatments, as well as treatment delay and interruption. With a major impact during the first wave in 2020, COVID-19 and restriction measures resulted in a substantial disruption in cervical cancer prevention and management, with declines in screening and delays in treatment. Taken together, findings from this systematic review calls for urgent policy interventions for recovering cervical cancer prevention and care.

Trends in Vaccine Refusal and Acceptance Using Electronic Health Records from a Large Pediatric Hospital Network, 2013-2020: Strategies for Change

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’s Hospital of Philadelphia’s 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 [2.30−2.40, p < 0.001]), in patients with increased age 11−17 years (aOR [CI]: 3.85 [3.79−3.91], p < 0.001), and those eligible for the VFC program (aOR [CI]: 1.10 [1.08−1.11]. 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.

Worldwide Evolution of Vaccinable and Nonvaccinable Viral Skin Infections: Google Trends Analysis

BACKGROUND

Most common viral skin infections are not reportable conditions. Studying the population dynamics of these viral epidemics using traditional field methods is costly and time-consuming, especially over wide geographical areas.

OBJECTIVE

This study aimed to explore the evolution, seasonality, and distribution of vaccinable and nonvaccinable viral skin infections through an analysis of Google Trends.

METHODS

Worldwide search trends from January 2004 through May 2021 for viral skin infections were extracted from Google Trends, quantified, and analyzed.

RESULTS

Time series decomposition showed that the total search term volume for warts; zoster; roseola; measles; hand, foot, and mouth disease (HFMD); varicella; and rubella increased worldwide over the study period, whereas the interest for Pityriasis rosea and herpes simplex decreased. Internet searches for HFMD, varicella, and measles exhibited the highest seasonal patterns. The interest for measles and rubella was more pronounced in African countries, whereas the interest for HFMD and roseola was more pronounced in East Asia.

CONCLUSIONS

Harnessing data generated by web searches may increase the efficacy of traditional surveillance systems and strengthens the suspicion that the incidence of some vaccinable viral skin infections such as varicella, measles, and rubella may be globally increasing, whereas the incidence of common nonvaccinable skin infections remains stable.

COVID's collateral damage: likelihood of measles resurgence in the United States

BACKGROUND

Lockdowns imposed throughout the US to control the COVID-19 pandemic led to a decline in all routine immunizations rates, including the MMR (measles, mumps, rubella) vaccine. It is feared that post-lockdown, these reduced MMR rates will lead to a resurgence of measles.

METHODS

To measure the potential impact of reduced MMR vaccination rates on measles outbreak, this research examines several counterfactual scenarios in pre-COVID-19 and post-COVID-19 era. An agent-based modeling framework is used to simulate the spread of measles on a synthetic yet realistic social network of Virginia. The change in vulnerability of various communities to measles due to reduced MMR rate is analyzed.

RESULTS

Results show that a decrease in vaccination rate [Formula: see text] has a highly non-linear effect on the number of measles cases and this effect grows exponentially beyond a threshold [Formula: see text]. At low vaccination rates, faster isolation of cases and higher compliance to home-isolation are not enough to control the outbreak. The overall impact on urban and rural counties is proportional to their population size but the younger children, African Americans and American Indians are disproportionately infected and hence are more vulnerable to the reduction in the vaccination rate.

CONCLUSIONS

At low vaccination rates, broader interventions are needed to control the outbreak. Identifying the cause of the decline in vaccination rates (e.g., low income) can help design targeted interventions which can dampen the disproportional impact on more vulnerable populations and reduce disparities in health. Per capita burden of the potential measles resurgence is equivalent in the rural and the urban communities and hence proportionally equitable public health resources should be allocated to rural regions.

Sustainable Development Goals and childhood measles vaccination in Ekiti State, Nigeria: Results from spatial and interrupted time series analyses

Measles remains an important cause of childhood mortality in many resource-limited countries. With Sustainable Development Goals (SDG), there has been increasing emphasis on measles vaccination as a key strategy to remarkably improve child survival. While progress has been made towards measles vaccination coverage due to SDG in some settings, there has been no prior study evaluating its impact in Nigeria. To assess the effectiveness of SDG policy implementation on measles vaccination coverage, we examined the changes in first dose of measles vaccination coverage rates among children aged 9-15 months following the implementation of SDG, and changes in spatial patterns of measles vaccination from 2014 to 2019 in Ekiti State, Southwest Nigeria. Using state and local government area-level District Health Information data from January 2014 to December 2019, we conducted interrupted time series (ITS) and spatiotemporal analyses. The ITS evaluated the immediate and continuous effects of SDG policy implementation on the monthly childhood measles vaccination coverage by comparing longitudinal changes in rates between pre-intervention period (January 2014-December 2015) and during-intervention period (January 2016-December 2019). The low and high coverage clusters across the years were detected with spatial cluster analysis. The average state-level measles vaccination coverage rates from 2014 to 2019 was 70.67%. In 2019, coverage rate was 49%-a 35.53% decline from 76% in 2014 and a state-level gap of 46%. The geographical distribution of measles vaccination varied considerably across the local government areas from 2014 to 2019. There was an initial acceleration of vaccination rates (β^ = 24.07, p-value = 0.012), but a significant decrease in coverage rates after implementation of SDG policy in Ekiti State (β^ = -1.08, p-value < 0.001). No local government area had accelerated monthly coverage rates following SDG-implementation. Evidence suggests immediate acceleration in coverage rates which could not be sustained during SDG-era and calls for a rethink measles immunization coverage strategy in the state and other resource-limited jurisdictions to ensure vaccination scale-up.

Economic Considerations in COVID-19 Vaccine Hesitancy and Refusal: A Survey of the Literature

The COVID-19 global pandemic has triggered one of the greatest economic shocks in a century. Effective COVID-19 vaccines have been developed, but a proportion of people either are hesitant or refuse to be vaccinated, facilitated by a global misinformation campaign. If 'herd immunity' cannot be achieved, there is potential not only for ongoing surges in infection, but also for development of new strains of the virus that could evade vaccines and precipitate further health and economic crises. We review the economics of vaccination and of vaccine hesitancy and refusal, and their potential effects on the recovery from the COVID-19 pandemic.

The Lean Six Sigma Define, Measure, Analyze, Implement, Control (LSS DMAIC) Framework: An Innovative Strategy for Quality Improvement of Pharmacist Vaccine Recommendations in Community Pharmacy

Community pharmacies represent a highly accessible and convenient setting for vaccination. However, setting-specific barriers exist which contribute to suboptimal vaccination rates, particularly for pneumococcal vaccinations. One proven quality improvement framework growing in use within healthcare settings is Lean Six Sigma (LSS). This paper describes the application of the LSS framework in select locations of a national pharmacy chain. The implementation of a training program for improved recommendation techniques to promote higher rates of pneumococcal vaccinations in high-risk adult populations is also addressed. A mixed-methods approach including pre/post quasi-experimental design and in-depth key informant interviews was used.

Effect of COVID-19 Pandemic on Influenza Vaccination Intention: A Meta-Analysis and Systematic Review

Poorer outcomes have been reported with COVID-19 and influenza coinfections. As the COVID-19 pandemic rages on, protection against influenza by vaccination is becoming increasingly important. This study examines how COVID-19 has influenced influenza vaccination intentions from a global perspective. A literature search was conducted on Embase, PubMed, and CNKI from 1 January 2019 to 31 December 2021 for articles reporting rates of influenza vaccination pre-COVID-19 (19/20 season), and intention and/or uptake of influenza vaccination post-COVID-19 (20/21 season). The changes in vaccination intention and reasons for changes were reported. Subgroup analyses were performed by region, gender, age, and occupation. Newcastle Ottawa Scale was used for quality assessment of the articles. Twenty-seven studies with 39,193 participants were included. Among 22 studies reporting intention to vaccinate in 20/21, there was increased intention to vaccinate (RR 1.50, 95% CI 1.32−1.69, p < 0.001) regardless of age, gender, and occupation. The remaining five studies reporting vaccination intention and uptake in 20/21 showed a similar increase (RR 1.68, 95%CI 1.20−2.36). Important determinants include historical vaccine acceptance, and perception of influenza severity and vaccine safety. The COVID-19 pandemic has increased intention to vaccinate against influenza internationally. The pandemic could be a window of opportunity to promote influenza vaccination and decrease vaccine hesitancy.

Therapist disclosure to combat COVID-19 vaccine hesitancy: a narrative review

With the onset of the COVID-19 pandemic in 2019–2020 and the rapid development of vaccines to prevent this disease came a rise in interest around vaccine hesitancy. Naturally, methods of combatting vaccine hesitancy and increasing vaccination rates are of paramount importance. One such method is building upon the trust and openness of one’s relationship with their healthcare provider. Specifically, this paper examines how psychotherapist self-disclosure could facilitate effective health behaviors in patients, focusing on vaccines. Traditionally, mental health therapists have been encouraged to avoid self-disclosure of personal information due to the possibility of unbalancing or damaging the therapeutic relationship. However, research from medicine and other disciplines suggests that personal recommendation, self-disclosure of vaccination status, and expert encouragement may be effective methods of addressing vaccine hesitancy. In addition, recommendations for therapists in discussing vaccination and in working with vaccine-hesitant patients are provided.

The Clinical and Economic Impact of Measles-Mumps-Rubella Vaccinations to Prevent Measles Importations From US Pediatric Travelers Returning From Abroad

BACKGROUND

Pediatric international travelers account for nearly half of measles importations in the United States. Over one third of pediatric international travelers depart the United States without the recommended measles-mumps-rubella (MMR) vaccinations: 2 doses for travelers ≥12 months and 1 dose for travelers 6 to <12 months.

METHODS

We developed a model to compare 2 strategies among a simulated cohort of international travelers (6 months to <6 years): (1) No pretravel health encounter (PHE): travelers depart with baseline MMR vaccination status; (2) PHE: MMR-eligible travelers are offered vaccination. All pediatric travelers experience a destination-specific risk of measles exposure (mean, 30 exposures/million travelers). If exposed to measles, travelers' age and MMR vaccination status determine the risk of infection (range, 3%-90%). We included costs of medical care, contact tracing, and lost wages from the societal perspective. We varied inputs in sensitivity analyses. Model outcomes included projected measles cases, costs, and incremental cost-effectiveness ratios ($/quality-adjusted life year [QALY], cost-effectiveness threshold ≤$100 000/QALY).

RESULTS

Compared with no PHE, PHE would avert 57 measles cases at $9.2 million/QALY among infant travelers and 7 measles cases at $15.0 million/QALY among preschool-aged travelers. Clinical benefits of PHE would be greatest for infants but cost-effective only for travelers to destinations with higher risk for measles exposure (ie, ≥160 exposures/million travelers) or if more US-acquired cases resulted from an infected traveler, such as in communities with limited MMR coverage.

CONCLUSIONS

Pretravel MMR vaccination provides the greatest clinical benefit for infant travelers and can be cost-effective before travel to destinations with high risk for measles exposure or from communities with low MMR vaccination coverage.