Association between social vulnerability and influenza and tetanus-diphtheria-acellular pertussis vaccination in pregnant and postpartum individuals

Influenza vaccination hesitancy and related factors among pregnant and breastfeeding women: A cross-sectional study

Achieving safe influenza vaccination coverage among pregnant and breastfeeding women is a global health goal due to the potential risks of serious influenza for both mother and child. However, vaccine hesitancy remains a significant barrier to vaccination uptake. Since anxiety represents a determinant in vaccine decision-making, this study aimed to assess influenza vaccination hesitancy and anxiety levels in this population and to explore the association between women's characteristics, their reluctance, and anxiety levels. A multicentre, cross-sectional study was conducted between February and June 2022 using structured phone interviews to assess: (1) socio-demographics and clinical history; (2) anti-flu vaccination status, previous anti-flu vaccination, and Sars-CoV-2 infection history; (3) insights into influenza vaccination during pregnancy; (4) attitudes toward anti-flu vaccination, using the Vaccination Attitudes Examination (VAX) Scale; (5) anxiety levels, measured by the Self-Rating Anxiety Scale (SAS). Among the 387 participants, 22.8% were already vaccinated or expressed willingness to be vaccinated against influenza, and 54% had an anxiety disorder. While anxiety was not significantly associated with vaccine hesitancy, ongoing pregnancy emerged as an independent predictor of anxiety. Higher educational levels, ongoing pregnancy, already being vaccinated or willingness to get vaccinated, and being employed were associated with reduced vaccine hesitancy, while prior SARS-CoV-2 infection with increased hesitancy. Fear of unpredictable events and lack of healthcare professionals' recommendations emerged as reasons for vaccine reluctance. Given the low coverage rates, these findings highlight the need for health services to enhance vaccination efforts and provide clear recommendations to counter misinformation and ensure accurate vaccine safety information.

Social Vulnerability Index and Health Outcomes in the United States: A Systematic Review

The Centers for Disease Control and Prevention created the Social Vulnerability Index (SVI) for the purpose of allocating resources in times of emergency based on social determinants of health (SDOH). The purpose of this systematic review was to evaluate how the SVI tool has been applied in health care literature focused on health in the United States (US). A systematic literature review was conducted in 7 research databases with an 11-year time frame reflecting the launch of SVI, with the last search completed on September 29, 2022. Studies were included that involved humans, health, SVI, and conducted in the US. Articles were excluded if the SVI was used in COVID-19, disaster, pandemic, environment, or hazards. A total of 47 articles were included in the systematic review. The majority of studies analyzed individual/population health outcomes in clinical, surgical, mortality, or health promotion areas. The majority of studies showed a relationship between neighborhood-level SDOH and health outcomes. Study authors reported strengths, limitations, and recommendations of the SVI tool. A potential limitation of the study was the exclusion of studies that used the SVI related to disaster. The SVI represents a powerful tool to assess neighborhood-level SDOH and examine upstream drivers health outcomes with direct implications for research, policy, and practice.

Attitudes and Experiences Regarding Communication About Maternal Vaccination: Qualitative Findings from Non-Hispanic Black Pregnant People

Comprehensive prenatal care incorporates recommended vaccines to help protect the mother, the pregnancy, and the infant from adverse health outcomes and severe illness from vaccine preventable diseases (VPDs). However, vaccinations during pregnancy remain underutilized, often influenced by concerns about vaccine safety and low perception of disease risk. Self-reported vaccine hesitancy among pregnant people in the United States has significantly increased in the last few years, and influenza and Tdap (tetanus, diphtheria, and pertussis) vaccination rates have declined. Furthermore, the number of vaccines routinely recommended during pregnancy has expanded. Communication strategies tailored to pregnant people may help build vaccine confidence among pregnant people and their health care providers. While characteristics and perceptions associated with hesitancy to vaccinate during pregnancy are documented in existing literature, more information is needed on promising communication practices preferred by subgroups of pregnant persons, particularly Black pregnant people who have higher rates of illness from VPDs and greater risk of pregnancy-related complications. This article summarizes literature on the current landscape of prenatal vaccination, discusses qualitative findings from focus groups with non-Hispanic Black pregnant people, and describes promising practices for communicating with this group about vaccination. Promising practices include specifying the benefits of vaccination for both the pregnant person and the infant, outlining potential risks, and emphasizing the overall importance of vaccination during pregnancy, while also acknowledging that many non-Hispanic Black pregnant people may have health concerns they perceive as superseding vaccination.

The Impact of Social Vulnerability on Substance Use Detection Practices in Pregnancy

This study aimed to synthesize current literature regarding the impact of social vulnerability on pregnancy-related substance use detection in the United States and highlight disparities in substance use detection practices. Clinicaltrials.gov, Google Scholar, PubMed (includes MEDLINE), and Cochrane Library databases were searched using the following Medical Subject Headings (MeSH): (["pregnancy" or "prenatal"] AND ["substance use screening" or "urine toxicology testing" or "toxicology testing" or "urine drug screening" or "CRAFFT" or "4P's" or "4P's Plus" or "NIDA Quick Screen" or "DAST-10" or "SURP-P" or "WIDUS"], AND ("bias" or "disparities" or "social vulnerability"]). The search included systematic reviews, prospective and retrospective studies, randomized controlled trials, case studies, and qualitative and quantitative research from January 2014 through November 2023. Selected literature was limited to studies published in English, which included a study population of either pregnant individuals or pregnancy health care providers in the United States, and that were focused on inequities in pregnancy substance use detection. Using Covidence, three authors screened abstracts, and two screened full articles for inclusion. The included studies were evaluated for quality of evidence using the mixed methods appraisal tool. The search yielded 4,188 manuscripts; 37 were eligible for full review. A total of 18 manuscripts were included based on the relevancy of the topic. The most common social vulnerability domain identified was minority status (17/18), followed by socioeconomic status (11/18), household characteristics (8/18), and housing type (1/18). Social vulnerability plays a role in substance use detection among pregnant individuals. Most notably, race and ethnicity, age, and public insurance lead to increased rates of detection, though most individual factors need to be studied in greater depth. This study was registered with PROSPERO (PROSPERO ID CRD42022352598), the International Prospective Register of Systematic Reviews. KEY POINTS: · Socially vulnerable pregnant individuals are more likely to receive substance use screening or urine toxicology testing.. · Race, ethnicity, age, and insurance influence substance use detection disparities.. · More research is needed to understand how other characteristics influence disparities in substance use detection..

Social Vulnerability May Underlie Racial Disparities in Peripartum Cardiomyopathy Outcomes

Objective

Black patients have disproportionately more cases of peripartum cardiomyopathy (PPCM) and more severe disease. To better understand these disparities, we examined the geographic distribution of patients with PPCM by race and evaluated associations between race and social vulnerability. We hypothesized that Black patients with PPCM are more likely than White patients to live in socially vulnerable communities.

Study Design

A retrospective cohort study of patients with PPCM defined by the National Institutes of Health, National Heart, Lung, and Blood Institute was conducted at a single center from January 2000 to November 2017. The US census tract for each patient was identified, and social vulnerability was assessed using the Centers for Disease Control and Prevention Social Vulnerability Index (SVI). Higher SVI values represent a more vulnerable community. SVI and select subcomponents were compared by self-reported race.

Results

Among 90 patients with PPCM (47 White, 43 Black), the ejection fraction at diagnosis was similar between groups, although Black patients were more likely to have an ejection fraction of ≤40% at 6 to 12 months postpartum. Black race was associated with living in areas of greater social vulnerability; mean SVI was significantly higher among Black individuals than among White individuals (.56 versus .33, P=.0003). Black patients lived in areas with more people living in poverty, higher unemployment, and more single-parent households.

Conclusion

Black patients with PPCM were more likely to have persistent left ventricular dysfunction and live in areas of greater social vulnerability. Strategies to achieve equitable social determinants of health are needed to improve health outcomes in Black patients with PPCM.

Exploring the role of the social vulnerability index in understanding COVID-19 immunization rates

Communities that are historically marginalized and minoritized were disproportionately impacted by the COVID-19 pandemic due to long-standing social inequities. It was found that those who experience social vulnerabilities faced a heightened burden of COVID-19 morbidities and mortalities and concerningly lower rates of COVID-19 vaccination. The CDC's Social Vulnerability Index (CDC-SVI) is a pivotal tool for planning responses to health crises such as the COVID-19 pandemic. This study explores the associations between CDC-SVI and its corresponding themes with COVID-19 vaccine uptake in Nevada counties. Additionally, the study discusses the utility of the CDC-SVI in the context of equitable vaccine uptake in a pandemic setting. We examined the linear association between the 2020 CDC-SVI (including the composite score and the four themes) and COVID-19 vaccine uptake (including initial and complete vaccinations) for the seventeen Nevada counties. These associations were further examined for spatial-varied effects. Each CDC-SVI theme was negatively correlated with initial and complete COVID-19 vaccine uptake (crude) except for minority status, which was positively correlated. However, all correlations were found to be weak. Excessive vaccination rates among some counties are not explained by the CDC-SVI. Overall, these findings suggest the CDC-SVI themes are a better predictor of COVID-19 vaccine uptake than the composite SVI score at the county level. Our findings are consistent with similar studies. The CDC-SVI is a useful measure for public health preparedness, but with limitations. Further understanding is needed of which measures of social vulnerability impact health outcomes.

A Retrospective Review of Social Deprivation Index and Maternal Outcomes with Placenta Accreta Spectrum from a Single Referral Center

OBJECTIVE

Little is known about how community characteristics influence placenta accreta spectrum (PAS) outcomes. Our objective was to evaluate whether adverse maternal outcomes among pregnant people (gravidae) with PAS delivering at a single referral center differ by community-level measures of social deprivation.

STUDY DESIGN

We conducted a retrospective cohort study of singleton gravidae with histopathology confirmed PAS delivering from January 2011 to June 2021 at a referral center. Data abstraction collected relevant patient information, including resident zip code, which was linked to Social Deprivation Index (SDI) score (a measure of area-level social deprivation). SDI scores were divided into quartiles for analysis. Primary outcome was a composite of maternal adverse outcomes. Bivariate analyses and multivariable logistic regression were performed.

RESULTS

Among our cohort (n = 264), those in the lowest (least deprived) SDI quartile were older, had lower body mass index, and were more likely to identify as non-Hispanic white. Composite maternal adverse outcome occurred in 81 (30.7%), and did not differ significantly by SDI quartile. Intraoperative transfusion of ≥4 red blood cell units occurred more often among those living in deprived areas (31.2% in the highest [most deprived] vs. 22.7% in the lowest [least deprived] SDI quartile, p = 0.04). No other outcomes differed by SDI quartile. In multivariable logistic regression, a quartile increase in SDI was associated with 32% increased odds of transfusion of ≥4 red blood cell units (adjusted odds ratio: 1.32, 95% confidence interval: 1.01-1.75).

CONCLUSION

Within a cohort of gravidae with PAS delivered at a single referral center, we found that those living in more socially deprived communities were more likely to receive transfusion of ≥4 red blood cell units, but other maternal adverse outcomes did not differ. Our findings highlight the importance of considering how characteristics of the surrounding community can impact PAS outcomes and may assist with risk stratification and resource deployment.

KEY POINTS

· Little is known about how community characteristics influence PAS outcomes.. · In a referral center, transfusion was more common in gravidae living in socially deprived areas.. · Future research should consider how community characteristics can impact PAS outcomes..

Association between community-level political affiliation and peripartum vaccination

BACKGROUND

Political affiliation has been associated with vaccine uptake, but whether this association holds in pregnancy, when individuals are recommended to receive multiple vaccinations, remains to be studied.

OBJECTIVE

This study aimed to examine the association between community-level political affiliation and vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19 in pregnant and postpartum individuals.

STUDY DESIGN

A survey was conducted about tetanus, diphtheria, and pertussis and influenza vaccinations in early 2021, with a follow-up survey of COVID-19 vaccination among the same individuals at a tertiary care academic medical center in the Midwest. Geocoded residential addresses were linked at the census tract to the Environmental Systems Research Institute 2021 Market Potential Index, which ranks a community in comparison to the US national average. The exposure for this analysis was community-level political affiliation, defined by the Market Potential Index as very conservative, somewhat conservative, centrist, somewhat liberal, and very liberal (reference). The outcomes were self-reported vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19 in the peripartum period. Modified Poisson regression was used and adjusted for age, employment, trimester at assessment, and medical comorbidities.

RESULTS

Of 438 assessed individuals, 37% lived in a community characterized by very liberal political affiliation, 11% as somewhat liberal, 18% as centrist, 12% as somewhat conservative, and 21% as very conservative. Overall, 72% and 58% of individuals reported receiving tetanus, diphtheria, and pertussis and influenza vaccinations, respectively. Of the 279 individuals who responded to the follow-up survey, 53% reported receiving COVID-19 vaccination. Individuals living in a community characterized by very conservative political affiliation were less likely to report vaccinations for tetanus, diphtheria, and pertussis (64% vs 72%; adjusted risk ratio, 0.83; 95% confidence interval, 0.69-0.99); influenza (49% vs 58%; adjusted risk ratio, 0.79; 95% confidence interval, 0.62-1.00); and COVID-19 (35% vs 53%; adjusted risk ratio, 0.65; 95% confidence interval, 0.44-0.96) than those in a community characterized by very liberal political affiliation. Individuals living in a community characterized by centrist political affiliation were less likely to report vaccinations for tetanus, diphtheria, and pertussis (63% vs 72%; adjusted risk ratio, 0.82; 95% confidence interval, 0.68-0.99) and influenza (44% vs 58%; adjusted risk ratio, 0.70; 95% confidence interval, 0.54-0.92) than those in a community characterized by very liberal political affiliation.

CONCLUSION

Compared with pregnant and postpartum individuals living in communities characterized by very liberal political beliefs, those living in communities characterized by very conservative political beliefs were less likely to report vaccinations for tetanus, diphtheria, and pertussis; influenza; and COVID-19, and those in communities characterized by centrist political beliefs were less likely to report vaccinations for tetanus, diphtheria, and pertussis and influenza. Increasing vaccine uptake in the peripartum period may need to consider engaging an individual's broader sociopolitical milieu.

Protecting pregnant people & infants against influenza: A landscape review of influenza vaccine hesitancy during pregnancy and strategies for vaccine promotion

Before COVID-19, influenza vaccines were the most widely recommended vaccine during pregnancy worldwide. In response to immunization during pregnancy, maternal antibodies offer protection against potentially life-threatening disease in both pregnant people and their infants up to six months of age. Despite this, influenza vaccine hesitancy is common, with few countries reporting immunization rates in pregnant people above 50%. In this review, we highlight individual, institutional, and social factors associated with influenza vaccine hesitancy during pregnancy. In addition, we present an overview of the evidence evaluating interventions to address influenza vaccine hesitancy during pregnancy. While some studies have indicated promising results, no single intervention has consistently effectively increased influenza vaccine uptake during pregnancy. Using a social-ecological model of health framework, future strategies addressing multiple levels of vaccine hesitancy will be needed to realize the potential health benefits of prenatal immunization programs.

Association between social vulnerability and COVID-19 vaccination hesitancy and vaccination in pregnant and postpartum individuals

OBJECTIVE

To evaluate the association of community-level social vulnerability with COVID-19 vaccine hesitancy and vaccination among pregnant and postpartum individuals.

METHODS

Prospective cohort study assessing COVID-19 vaccine hesitancy among pregnant and postpartum individuals. We performed a baseline survey on COVID-19 vaccine hesitancy from 03/22/21 to 04/02/21, and a follow-up survey on COVD-19 vaccination status 3- to 6-months later. The primary exposure was the Centers for Disease Control and Prevention SVI (Social Vulnerability Index), measured in quartiles. Higher SVI quartiles indicated greater community-level social vulnerability with the lowest quartile (quartile 1) as the referent group. The primary outcome was COVID-19 vaccine hesitancy on the baseline survey (uncertainty or refusal of the vaccine), and the secondary outcome was self-report of not being vaccinated (unvaccinated) for COVID-19 on the follow-up survey.

RESULTS

Of 456 assessed individuals, 46% reported COVID-19 vaccine hesitancy on the baseline survey; and of 290 individuals (290/456, 64%) who completed the follow-up survey, 48% (140/290) were unvaccinated. The frequency of baseline vaccine hesitancy ranged from 25% in quartile 1 (low SVI) to 68% in quartile 4 (high SVI), and being unvaccinated at follow-up ranged from 29% in quartile 1 to 77% in quartile 4. As social vulnerability increased, the risk of COVID-19 vaccine hesitancy at baseline increased (quartile 2 aRR (adjusted relative risk): 1.46; 95% CI:0.98 to 2.19; quartile 3 aRR: 1.86; 95% CI:1.28 to 2.71; and quartile 4 aRR: 2.24; 95% CI:1.56 to 3.21), as did the risk of being unvaccinated at follow-up (quartile 2 aRR: 1.00; 95% CI:0.66 to 1.51; quartile 3 aRR: 1.68; 95% CI:1.17 to 2.41; and quartile 4 aRR: 1.82; 95% CI:1.30 to 2.56).

CONCLUSIONS

Pregnant and postpartum individuals living in an area with higher community-level social vulnerability were more likely to report COVID-19 vaccine hesitancy and subsequently to be unvaccinated at follow-up.