Efforts to monitor Global progress on individual and community demand for immunization: Development of definitions and indicators for the Global Vaccine Action Plan Strategic Objective 2

How to increase and maintain high immunization coverage: Vaccination Demand Resilience (VDR) framework

BACKGROUND

Resilience in vaccination demand is ever more critical as the COVID-19 pandemic has increased our understanding of the importance of vaccines on health and well-being. Yet timid demand for COVID-19 vaccines where available and reduced uptake of routine immunizations globally further raise the urgent need to build vaccination resilience. We demonstrate the complexity of vaccination demand and resilience in a framework where relevant dimensions are intertwined, fluid, and contextual.

METHODS

We developed the Vaccination Demand Resilience (VDR) framework based on a literature review on vaccination demand and expert consultation. The matrix framework builds on three main axes: 1) vaccination attitudes and beliefs; 2) vaccination seeking behavior; and 3) vaccination status. The matrix generated eight quadrants, which can help explain people's levels of vaccination demand and resilience. We selected four scenarios as examples to demonstrate different interventions that could move people across quadrants and build vaccination resilience.

RESULTS

Incongruence between individuals' attitudes and beliefs, vaccination behavior, and vaccination status can arise. For example, an individual can be vaccinated due to mandates but reject vaccination benefits and otherwise avoid seeking vaccination. Such incongruence could be altered by interventions to build resilience in vaccination demand. These interventions include information, education and communication to change individuals' vaccination attitudes and beliefs, incentive programs and reminder-recalls to facilitate vaccination seeking, or by strengthening healthcare provider communications to reduce missed opportunities.

CONCLUSIONS

Vaccination decision-making is complex. Individuals can be vaccinated without necessarily accepting the benefits of vaccination or seeking vaccination, threatening resilience in vaccination demand. The VDR framework can provide a useful lens for program managers and policy makers considering interventions and policies to improve vaccination resilience. This would help build and sustain confidence and demand for vaccinations, and help to continue to prevent disease, disability, and death from vaccine-preventable diseases.

Evaluation of online videos to engage viewers and support decision-making for COVID-19 vaccination: how narratives and race/ethnicity enhance viewer experiences

Background

Vaccine hesitancy has hampered the control of COVID-19 and other vaccine-preventable diseases.

Methods

We conducted a national internet-based, quasi-experimental study to evaluate COVID-19 vaccine informational videos. Participants received an informational animated video paired with the randomized assignment of (1) a credible source (differing race/ethnicity) and (2) sequencing of a personal narrative before or after the video addressing their primary vaccine concern. We examined viewing time and asked video evaluation questions to those who viewed the full video.

Results

Among 14,235 participants, 2,422 (17.0%) viewed the full video. Those who viewed a personal story first (concern video second) were 10 times more likely to view the full video (p < 0.01). Respondent-provider race/ethnicity congruence was associated with increased odds of viewing the full video (aOR: 1.89, p < 0.01). Most viewers rated the informational video(s) to be helpful, easy to understand, trustworthy, and likely to impact others' vaccine decisions, with differences by demographics and also vaccine intentions and concerns.

Conclusion

Using peer-delivered, personal narrative, and/or racially congruent credible sources to introduce and deliver vaccine safety information may improve the openness of vaccine message recipients to messages and engagement.

Towards a More Critical Public Health Understanding of Vaccine Hesitancy: Key Insights from a Decade of Research

Vaccine hesitancy has gained renewed attention as an important public health concern worldwide. Against this backdrop, over the last decade, we have conducted various qualitative, social science studies with the broad shared aim of better understanding this complex phenomenon. This has included various Cochrane systematic reviews of qualitative research globally, systematic reviews of qualitative research in Africa, and primary research studies in South Africa. These studies have also explored vaccine hesitancy for various vaccines, including routine childhood vaccination, HPV vaccination and other routine vaccinations for adolescents, and, most recently, COVID-19 vaccination. In this reflective and critical commentary piece we reflect on seven key overarching insights we feel we have gained about this complex phenomenon from the varying studies we have conducted over the past decade. These insights comprise the following: (1) the relationship between vaccine knowledge and hesitancy is complex and may operate in multiple directions; (2) vaccine hesitancy is driven by multiple socio-political forces; (3) vaccine hesitancy may be many things, rather than a single phenomenon; (4) vaccine hesitancy may be an ongoing 'process', rather than a fixed 'stance'; (5) vaccine hesitancy may sometimes be about a 'striving', rather than a 'resisting'; (6) 'distrust' as a driver of vaccine hesitancy needs to be better contextualized and disaggregated; and (7) the 'demand-side' versus 'supply/access-side' distinction of the drivers of suboptimal vaccination may be misleading and unhelpful. In unpacking these insights, we problematize some of the common assumptions within the vaccine hesitancy literature and flag topics that we think could benefit from further scrutiny and debate. Our hope is that this can provide a platform for further engagement on these issues and ultimately contribute towards fostering a more critical public health understanding of vaccine hesitancy.

Measuring National Immunization System Performance: A Systematic Assessment of Available Resources

BACKGROUND

Vaccination coverage is widely used to assess immunization performance but, on its own, provides insufficient information to drive improvements. Assessing the performance of underlying components of immunization systems is less clear, with several monitoring and evaluation (M&E) resources available for use in different operational settings and for different purposes. We studied these resources to understand how immunization system performance is measured.

METHODS

We reviewed peer-reviewed and gray literature published since 2000 to identify M&E resources that include national-level indicators measuring the performance of immunization systems or their components (governance, financing, regulation, information systems, vaccine logistics, workforce, service delivery, and demand generation). We summarize indicators by the system components or outcomes measured and describe findings narratively.

RESULTS

We identified 20 resources to monitor immunization program objectives and guide national strategic decision-making, encompassing 631 distinct indicators. Indicators for immunization program outcomes comprised the majority (124/631 [19.7%]), largely vaccination coverage (110/124 [88.7%]). Almost all resources (19/20 [95%]) included indicators for vaccine logistics (83/631 [13.2%]), and those for regulation (19/631 [3.0%]) and demand generation (28/631 [4.4%]) were least common. There was heterogeneity in how information systems (92/563 [14.6%]) and workforce (47/631 [7.4%]) were assessed across resources. Indicators for vaccination coverage in adults, data use in decision-making, equity and diversity, effectiveness of safety surveillance, and availability of a public health workforce were notably lacking.

CONCLUSIONS

Between the resources identified in this review, we identified considerable variability and gaps in indicators assessing the performance of some immunization system components. Given the multitude of indicators, policymakers may be better served by tailoring evaluation resources to their specific context to gain useful insight into health system performance and improve data use in decision-making for immunization programs.

So Many Choices, How Do I Choose? Considerations for Selecting Digital Health Interventions to Support Immunization Confidence and Demand

Childhood vaccines are a safe, effective, and essential component of any comprehensive public health system. Successful and complete child immunization requires sensitivity and responsiveness to community needs and concerns while reducing barriers to access and providing respectful quality services. Community demand for immunization is influenced by multiple complex factors, involving attitudes, trust, and the dynamic relationship between caregivers and health workers. Digital health interventions have the potential to help reduce barriers and enhance opportunities for immunization access, uptake, and demand in low- and middle-income countries. But with limited evidence and many interventions to choose from, how do decision makers identify promising and appropriate tools? Early evidence and experiences with digital health interventions for immunization demand are presented in this viewpoint to help stakeholders make decisions, guide investment, coordinate efforts, as well as design and implement digital health interventions to support vaccine confidence and demand.

Unbalanced global vaccine product trade pattern: A network perspective

Mass vaccination is the most cost-effective intervention in response to public health events. Thus, equitable access to vaccine products is essential to ensure global human health. Based on the global vaccine product trade data from 2000 to 2018 and employing social network analysis, this paper explores the unbalanced pattern of global vaccine product trade and assesses the sensitivity interdependence between countries. Overall, the analysis shows that global vaccine product trade links have long been highly concentrated within developed countries in Europe and America. Nevertheless, with the rise of global and regional hub countries, the global vaccine product trade network has begun to evolve from a unipolar structure with the U.S. as the sole core to a multipolar structure with the U.S. and Western European countries as the core. Meanwhile, emerging countries, represented by China and India, are increasingly participating in the global vaccine product trade network and are beginning to play an important role. The formation of this multipolar pattern has provided countries in the Global South with more options for cooperation in the vaccine product trade and reduces the sensitivity interdependence of network periphery countries on core countries, which consequently reduces the global supply risk of vaccine products.

A structural equation modelling approach to understanding the determinants of childhood vaccination in Nigeria, Uganda and Guinea

Vaccines have contributed to reductions in morbidity and mortality from preventable diseases globally, but low demand for vaccination threatens to reverse these gains. Explorations of the determinants of vaccination uptake may rely on proxy variables to describe complex phenomena and construct models without reference to underlying theories of vaccine demand. This study aimed to use the results of a formative qualitative study (described elsewhere) to construct and test a model to explain the determinants of vaccination uptake. Using the results of a survey among more than 3,000 primary caregivers of young children in Nigeria, Uganda and Guinea, factor analysis produced six explanatory factors. We then estimated the effects of each of these factors on uptake of immunization using a structural equation model. The results showed that the probability that a child is fully vaccinated increases if a caregiver has support from others to vaccinate them (B = 0.33, β = 0.21, p<0.001) and if caregivers had poor experiences with the healthcare system (B = 0.09, β = 0.09, p = 0.007). Conversely, the probability of full vaccination decreases if the caregiver's husband exerts control over her decision-making ability (B = -0.29, β = -0.20, p<0.001), or if the caregiver perceives vaccines to be of low importance (B = -0.37, β = -0.27, p<0.001). Belief in religious protection (B = -0.07, β = -0.05, p = 0.118) and a belief that vaccines are harmful (B = -0.12, β = -0.04, p = 0.320) did not have an observed effect on vaccination status. This research suggests that interventions may benefit from that including entire families and communities in their design.

Building and sustaining public and political commitment to the value of vaccination: Recommendations for the Immunization Agenda 2030 (Strategic Priority Area 2)

Vaccines have contributed to substantial improvements in health and social development outcomes for millions in recent decades. However, equitable access to immunization remains a critical challenge that has stalled progress toward improving several health indicators around the world. The COVID-19 pandemic has also negatively impacted routine immunization services around the world further threatening universal access to the benefits of lifesaving vaccines. To overcome these challenges, the Immunization Agenda 2030 (IA2030) focuses on increasing both commitment and demand for vaccines. There are three broad barriers that will need to be addressed in order to achieve national and subnational immunization targets: (1) shifting leadership priorities and resource constraints, (2) visibility of disease burden, and (3) social and behavioral drivers. IA2030 proposes a set of interventions to address these barriers. First, efforts to ensure government engagement on immunization financing, regulatory, and legislative frameworks. Next, those in subnational leadership positions and local community members need to be further engaged to ensure local commitment and demand. Governance structures and health agencies must accept responsibility and be held accountable for delivering inclusive, quality, and accessible services and for achieving national targets. Further, the availability of quality immunization services and commitment to adequate financing and resourcing must go hand-in-hand with public health programs to increase access to and demand for vaccination. Last, strengthening trust in immunization systems and improving individual and program resilience can help mitigate the risk of vaccine confidence crises. These interventions together can help ensure a world where everyone, everywhere has access to and uses vaccines for lifesaving vaccination.

Applying a social-ecological model to understand factors impacting demand for childhood vaccinations in Nigeria, Uganda, and Guinea

Vaccines have reduced child mortality across the world, but low levels of demand for vaccination threatens to undermine progress. Existing frameworks to understand demand tend to prioritise primary caregivers' decision-making processes. We aimed to build a wider understanding of vaccine demand by applying an adapted socio-ecological model to analyse 158 interviews with primary caregivers and fathers of young children, and community influencers in Nigeria, Uganda, and Guinea. We found that several factors come together to inform a primary caregiver's demand for vaccination, including their familial and social relationships, their interactions with government and healthcare institutions, and the wider social and cultural norms in their communities. The study suggests that interventions targeted at families and communities instead of individuals could be effective. The results could be used to ensure that vaccine demand frameworks used by researchers and intervention designers are comprehensive and consider a wider range of influences on the primary caregiver.

Impact of vaccine pause due to Thrombosis with thrombocytopenia syndrome (TTS) following vaccination with the Ad26.COV2.S vaccine manufactured by Janssen/Johnson & Johnson on vaccine hesitancy and acceptance among the unvaccinated population

BACKGROUND

In response to reports of thrombosis with thrombocytopenia syndrome (TTS) post-vaccination, the Johnson & Johnson (J&J) vaccine was paused and then restarted in April 2021. Our objective was to assess whether this pause adversely impacted vaccine confidence.

METHODS

Two large internet-based surveys were conducted in the US among adults to measure knowledge, attitudes and perceptions of the J&J vaccine pause and rates of vaccine hesitancy among unvaccinated persons before, during and after the pause.

RESULTS

Among 66% of respondents aware of the pause, 44% identified blood clots as the reason for the pause without prompting. The impact of the pause on vaccine behavior among unvaccinated persons and perception of the vaccine safety system was mixed and modified by trust in the public health authorities. Those who were less willing to get vaccinated because of the pause were less inclined for all vaccines, not only the J&J product. Moreover, a notable proportion (22.1%) of the small number of persons (n = 30) vaccinated with the J&J vaccine after the pause reported not receiving information about the risk of TTS. The proportion of unvaccinated persons who were hesitant was increasing before and during the pause and then leveled off after the pause.

CONCLUSIONS

The J&J vaccine pause is unlikely to be a major barrier to vaccine uptake. Public attitudes about vaccines may be more resilient than appreciated, especially when safety issues are investigated with transparent communication. This paper has important implications for messaging and program administration with future vaccine-specific adverse events. Efforts may be warranted to ensure all persons being offered the J&J vaccine are made aware of the risk of TTS.

Factors affecting recommended childhood vaccine demand

Reaching a high vaccination coverage level is of vital essence when preventing epidemic diseases. For mandatory vaccines, the demand can be forecasted using some demographics such as birth rates or populations between certain ages. However, it has been difficult to forecast non-mandatory vaccine demands because of vaccine hesitation, alongside other factors such as social norms, literacy rate, or healthcare infrastructure. Consequently, the purpose of this study is to explore the predominant factors that affect the non-mandatory vaccine demand, focusing on the recommended childhood vaccines, which are usually excluded from national immunization programs. For this study, fifty-nine factors were determined and categorized as system-oriented and human-oriented factors. After a focus group study conducted with ten experts, seven system-oriented and eight human-oriented factors were determined. To reveal the cause and effect relationship between factors, one of the multi-criteria decision-making methods called Fuzzy-DEMATEL was implemented. The results of the analysis showed that “Immunization-related beliefs”, “Media/social media contents/messaging”, and “Social, cultural, religious norms” have a strong influence on non-mandatory childhood vaccine demand. Furthermore, whereas “Availability and access to health care facilities” and “Political/ financial support to health systems” are identified as cause group factors, “Quality of vaccine and service delivery management” is considered an effect group factor. Lastly, a guide was generated for decision-makers to help their forecasting process of non-mandatory vaccine demands to avoid vaccine waste or shortage.

Taking stock of global immunisation coverage progress: the gains, the losses and the journey ahead

Despite the enormous benefits of vaccination, global immunisation coverage progress has stalled and remains suboptimal in many countries. In this commentary, we review the recently published update of the World Health Organization and United Nations Children's Fund Estimates of National Immunization Coverage. We highlight trends in which, despite substantial gains made in improving immunisation coverage at the global level, there remain numerous challenges with reaching and sustaining optimal coverage. We contextualise the trends by exploring plausible supply- and demand-side root causes. Based on these, we stress the need for targeted, context-appropriate strategies for reaching and maintaining optimal immunisation coverage.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis

BACKGROUND

Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.

OBJECTIVES

- Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.

SELECTION CRITERIA

We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.

MAIN RESULTS

We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.

AUTHORS' CONCLUSIONS

Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

Vaccine Hesitancy: Drivers and How the Allergy Community Can Help

Vaccine hesitancy-defined by the World Health Organization (WHO) as a "delay in acceptance or refusal of vaccines despite availability of vaccination services"-is not a recent phenomenon. Historical records indicate that vaccine hesitancy existed by the 18th century in Europe and even resulted in violent riots. The drivers of vaccine hesitancy have evolved over the last 200 years but not, perhaps, as much as one might expect. More problematic are the means by which concerns over vaccine hesitancy are communicated by a new landscape of digital communication, generating what has been described as an "infodemic" in which an overabundance of information-both factual and misinformation-contributes to hesitancy. In this review, we discuss the background and current drivers of vaccine hesitancy and the evidence base for strategies to combat this. We highlight the important role the allergy/immunology community could have in working to mitigate vaccine hesitancy, particularly with respect to the current coronavirus disease 2019 (COVID-19) pandemic.

The World of Immunization: Achievements, Challenges, and Strategic Vision for the Next Decade

Immunization is among the most cost-effective public health interventions available and is estimated to have averted at least 37 million deaths between 2000 and 2019. Since the establishment of the Expanded Programme on Immunization in 1974, global vaccination coverage increased and the coverage gap between rich and poor countries decreased. Creation of Gavi, the Vaccine Alliance, in 2000 allowed the poorest countries in the world to benefit from new, life-saving vaccines and expand the breadth of protection against an increasing number of vaccine-preventable diseases. Despite this progress, inequities in access to and uptake of vaccines persist. Opportunities to realize the full potential of vaccines are within reach but require focused, tailored and committed action by Governments and immunization stakeholders. The Immunization Agenda 2030 provides a framework for action during the next decade to attain a world where everyone, everywhere, at every age fully benefits from vaccines for good health and well-being.

The influence of linkages, feedback mechanisms, and caregiver mobility on immunization follow-up visits in Lideta sub-city of Addis Ababa, Ethiopia: a qualitative study

Background

Losing children to follow-up is one of the major barriers identified in Ethiopia’s immunization programme. In many urban slum areas like Lideta sub-city, Addis Ababa, several demand- and supply-side factors affect the follow-up visits for routine immunization services, so this study aimed to explore the influence of linkages, a feedback mechanism, and caregiver mobility on immunization follow-up visits.

Methods

The study team employed a qualitative method and conducted 30 in-depth interviews with caregivers, 26 interviews with key informants, and five focus group discussions with health officials and decision-makers. A deductive content and thematic analysis was carried out by importing the transcripts into OpenCodes, applying the a priori codes, and identifying new codes and themes.

Results

The linkages among health facilities included those from hospitals to health centres, from hospitals to hospitals, and from health centres to health centres within and outside the sub-city. Using these linkages, most vaccinators transfer caregivers without providing multi-dose vial (MDV) vaccines, mainly bacille Calmette–Guérin (BCG) and measles-containing vaccines (MCV), “to minimize wastage” and thus successfully reduce vaccine wastage rates; yet most caregivers wasted their time, energy, and money travelling from one health facility to another. Despite some efforts to transfer caregivers using “transferal slips” and informal phone calls to vaccinators’ friends, unfortunately, there was no formally established system for obtaining feedback about the arrival of caregivers and continuation of the follow-up visits. Overall, the transfer process lacked uniformity, used various approaches, and was not systematic.

Conclusions

Transferal of caregivers for the sake of minimizing wastage of MDV vaccines without checking the vaccination schedules of the receiving health facilities, using various informal types of tools and approaches, along with a poor follow-up and feedback system, were major identified challenges which cost caregivers extra money, energy, and time in getting timely immunization services. Therefore, the Federal Ministry of Health should strengthen the linkages among facilities, ensure the establishment of formal communications by developing guidelines and standardized tools – transferal slips and approaches – and initiate a fast feedback provision system using SMS text messages.

Royal society of Canada COVID-19 report: Enhancing COVID-19 vaccine acceptance in Canada

COVID-19 vaccine acceptance exists on a continuum from a minority who strongly oppose vaccination, to the “moveable middle” heterogeneous group with varying uncertainty levels about acceptance or hesitancy, to the majority who state willingness to be vaccinated. Intention for vaccine acceptance varies over time. COVID-19 vaccination decisions are influenced by many factors including knowledge, attitudes, and beliefs; social networks; communication environment; COVID-19 community rate; cultural and religious influences; ease of access; and the organization of health and community services and policies.

Reflecting vaccine acceptance complexity, the Royal Society of Canada Working Group on COVID-19 Vaccine Acceptance developed a framework with four major factor domains that influence vaccine acceptance (people, communities, health care workers; immunization knowledge; health care and public health systems including federal/provincial/territorial/indigenous factors)—each influencing the others and all influenced by education, infection control, extent of collaborations, and communications about COVID-19 immunization. The Working Group then developed 37 interrelated recommendations to support COVID vaccine acceptance nested under four categories of responsibility: 1. People and Communities, 2. Health Care Workers, 3. Health Care System and Local Public Health Units, and 4. Federal/Provincial/Territorial/Indigenous. To optimize outcomes, all must be engaged to ensure co-development and broad ownership.

A global agenda for older adult immunization in the COVID-19 era: A roadmap for action

Given our global interconnectedness, the COVID-19 pandemic highlights the urgency of building a global system that can support both routine and pandemic/epidemic adult immunization. As such, a framework to recommend vaccines and build robust platforms to deliver them to protect the rapidly expanding demographic of older adults is needed. Adult immunization as a strategy has the broad potential to preserve and improve medical, social, and economic outcomes, including maintaining functional ability that benefits older adults, their families, communities, and countries. While we will soon have multiple vaccines against COVID-19, we must recognize that we already have a variety of vaccines against other pathogens that can keep adults healthier. They can prevent simultaneous co-infection with COVID-19, and may favorably impact- the outcome of a COVID-19 illness. Further, administering a vaccine against COVID-19 requires planning now to determine delivery strategies impacting how older adults will be immunized in a timely manner. A group of international experts with various backgrounds from health and aging disciplines met to discuss the evidence case for adult immunization and crucial knowledge gaps that must be filled in order to implement effective policies and programs for older adult immunization. This group, coming together as the International Council on Adult Immunization (ICAI), outlined a high-level roadmap to catalyze action, provide policy guidance, and envision a global adult immunization platform that can be adapted by countries to fit their local contexts. Further meetings centered around the value of adult immunization, particularly in the context of COVID-19. There was agreement that programs to deliver existing influenza, pneumococcal, herpes zoster vaccines, and future COVID-19 vaccines to over a billion older adults who are at substantially higher risk of death and disability due to vaccine-preventable diseases are more urgent than ever before. Here we present a proposed framework for delivering routine and pandemic vaccines. We call upon the global community and governments to prioritize action for integrating robust adult immunization programs into the public health agenda.

Ebola vaccine? Family first! Evidence from using a brief measure on Ebola vaccine demand in a national household survey during the outbreak in Sierra Leone

BACKGROUND

Vaccination against Ebolavirus is an emerging public health tool during Ebola Virus Disease outbreaks. We examined demand issues related to deployment of Ebolavirus vaccine during the 2014-2015 outbreak in Sierra Leone.

METHODS

A cluster survey was administered to a population-based sample in December 2014 (N = 3540), before any Ebola vaccine was available to the general public in Sierra Leone. Ebola vaccine demand was captured in this survey by three Likert-scale items that were used to develop a composite score and dichotomized into a binary outcome to define high demand. A multilevel logistic regression model was fitted to assess the associations between perceptions of who should be first to receive an Ebola vaccine and the expression of high demand for an Ebola vaccine.

RESULTS

The largest proportion of respondents reported that health workers (35.1%) or their own families (29.5%) should receive the vaccine first if it became available, rather than politicians (13.8%), vaccination teams (9.8%), or people in high risk areas (8.2%). High demand for an Ebola vaccine was expressed by 74.2% of respondents nationally. The odds of expressing high demand were 13 times greater among those who said they or their families should be the first to take the vaccine compared to those who said politicians should be the first recipients (adjusted odds ratio [aOR] 13.0 [95% confidence interval [CI] 7.8-21.6]). The ultra-brief measure of the Ebola vaccine demand demonstrated acceptable scale reliability (Cronbach's α = 0.79) and construct validity (single-factor loadings > 0.50).

CONCLUSION

Perceptions of who should be the first to get the vaccine was associated with high demand for Ebola vaccine around the peak of the outbreak in Sierra Leone. Using an ultra-brief measure of Ebola vaccine demand is a feasible solution in outbreak settings and can help inform development of future rapid assessment tools.

Trust in vaccines and medicines in Uganda

Trust underlies numerous decisions in health care, affecting vaccine uptake as well as care seeking rates, treatment adherence, and health outcomes. Although trust in the doctor-patient relationship has garnered much attention, trust in health care commodities such as vaccines and medicines has rarely been examined. We report findings from a cross-sectional survey to assess trust in vaccines vis-à-vis their trust in conventional medicines and traditional medicines in Uganda. Trust in vaccines, conventional and traditional medicines were assessed by adapting the vaccine hesitancy scale developed by the SAGE Working Group on Vaccine Hesitancy. Reported trust in vaccines and conventional medicines was much higher than trust in traditional medicines. Significant associations were observed between trust in vaccines and trust in conventional medicines. Of the trust components explored, respondents were most concerned about access to and safety of vaccines and medicines. Further, respondents' previous health care experiences, primary source of health information, and trust in providers' skills were significantly associated with reported trust in vaccines and medicines. Although strong levels of trust in vaccines and conventional medicines were observed overall, the findings identify areas where policies and communication efforts can focus to strengthen trust.

Collective construction of bundle for immunobiological agents conservation best practices

OBJECTIVE

to construct collectively with nursing professionals bundle for best practices of cold chain maintenance of immunobiological agents conservation at the local level.

METHOD

a qualitative research of convergent care type. Bundle construction was guided by the Evidence-Based Practice criterion. Data collection was carried out from October to December 2016, through five workshops, with the participation of 21 professionals from 7 vaccination rooms of a municipality of Minas Gerais State. The framework developed by Morse and Field was adopted for data analysis.

RESULTS

through bundle, care is taken regarding refrigeration equipment temperature monitoring, contingency plan performance, recyclable ice coil setting and chamber use as refrigeration equipment.

FINAL CONSIDERATIONS

the chosen interventions began to guide the practice and promote a care based on safety and quality.

Factors that influence parents' and informal caregivers' acceptance of routine childhood vaccination: a qualitative evidence synthesis

This is a protocol for a Cochrane Review (Qualitative). The objectives are as follows:

Identify, appraise and synthesise qualitative studies exploring: parents’ and informal caregivers’ views, experiences, or decision‐making regarding routine childhood vaccination; or the factors influencing acceptance of routine childhood vaccination arising from parents’ and informal caregivers’ accounts. Develop a conceptual understanding of what and how different factors influence parental acceptance of routine childhood vaccination. Explore how the findings of this review can enhance our understanding of the related intervention reviews (Saeterdal 2014 ; Oyo‐Ita 2016 ; Jacobson 2018 ; Kaufman 2018 ).

Vaccine acceptance: Science, policy, and practice in a 'post-fact' world

Suboptimal vaccination uptake may be associated with outbreaks of vaccine-preventable diseases in many parts of the world. Researchers and practitioners working on improving vaccine acceptance and uptake gathered together for the fifth annual meeting on vaccine acceptance, organized by the Fondation Mérieux at its conference centre in Veyrier-du-Lac, France, to share their experiences in building, improving and sustaining vaccine confidence and uptake. The importance and value of truly listening to people and seeking to understand the perspectives of vaccine hesitant people was emphasized throughout the meeting. The benefits of social marketing, which can be used to influence behavior that benefit individuals and communities for the greater social good, and its integration into strategies aimed at improving vaccine acceptance and uptake, were discussed. Healthcare professionals (HCPs) need tools and training to help them engage effectively in vaccination acceptance conversations with parents and other patients. Two potential tools, motivational interviewing (MI) and AIMS (Announce, Inquire, Mirror, Secure), were presented. Examples of MI approaches that have successfully improved vaccination acceptance and uptake included a project in Canada aimed at parents just after the birth of their baby. The role of mandates to increase vaccination uptake in the short-term was discussed, but to achieve sustainable vaccination uptake this must be complemented with other strategies. These annual meetings have led to the creation of an informal community of practice that facilitates cross-pollination between the various disciplines and different settings of those involved in this area of research and implementation. It was agreed that we must continue our efforts to promote vaccine acceptance and thus increase vaccination uptake, by fostering more effective vaccination communication, monitoring of the media conversation on vaccination, designing and rigorously evaluating targeted interventions, and surveillance of vaccine acceptance and uptake with pertinent, reliable measures.

Six dimensions of research trial acceptability: how much, what, when, in what circumstances, to whom and why?

Ethics guidelines emphasise that research should be acceptable to the people invited to take part. However, acceptability is subjective and dependent on context, complicating its assessment and use as an ethical standard. This paper examines the concept of acceptability in relation to parents' perspectives on a paediatric vaccine trial in Malawi. We examined decisions on participation and experiences of the trial through interviews with parents in 41 households invited to enrol their children and participant observation of trial processes. Fieldwork took place in Chikwawa, Southern Malawi from February-October 2016. Parents were not neatly split between those who saw the trial as acceptable and those who did not; instead there were mixed and changing feelings among parents who enrolled their children, and among those who withdrew or did not take part. Some parents agreed to participate but had concerns about the trial, while others expressed satisfaction with the trial but still did not take part. These experiences indicate substantial variation in the nature of acceptance. We describe these variations in relation to six dimensions of acceptability: how acceptable the trial is, what aspects are acceptable, changes over time, circumstances affecting acceptability, variations between people, and reasons for participation or non-participation. The findings illustrate the difficulty of determining whether a trial is sufficiently acceptable to potential participants. We suggest that clarifying definitions of acceptability and examining how acceptability varies in degree, between trial components, over time, and between people and contexts may help researchers generate more nuanced descriptions of acceptability that support responsive and ethical trial design.

Parents' preferences for interventions to improve childhood immunization uptake in northern Nigeria

BACKGROUND

Routine childhood immunization coverage has been low in northern Nigeria. While local authorities and international partners have been working hard to improve coverage, population preferences for interventions have not been documented. This study aimed to understand parents' preferences and identify possible interventions to improve uptake of childhood immunization.

METHODS

Preferences for immunization interventions were elicited using a best-worst scaling (BWS) instrument among parents with children under five. We explored the value of six program attributes (each varying across three levels) identified through a literature review and engagement with local stakeholders. In each of 18 hypothetical programs identified through a main effect orthogonal design, respondents selected the best and worst attributes that may facilitate vaccination of children. Assuming sequential best-worst responses, we used conditional logit to estimate preferences. We employed latent class analysis (LCA) to categorize and examine respondents' preferences across interventions.

RESULTS

97 men and 101 women in 198 households were surveyed. The most preferred level for each attribute included door-to-door vaccinations, free food supplements, bundling with nutritional support programs, involvement of religious leaders, information dissemination through media campaigns, and strengthening of health services by the government. Three types of preferences were recognized in the LCA. The value-driven group (14%) characterized by youngest age, predominantly female, and lower education perceived bundled services with food and nutritional programs as the most important feature of an intervention. Convenience and information seekers (28%) characterized by oldest age and the lowest employment preferred door-to-door vaccinations and media campaigns. The remaining complacent group (58%), characterized by highest education and highest employment, did not show strong preferences to any intervention compared to the other two groups.

CONCLUSIONS

Routine immunization programs should consider joining forces with food and nutritional programs to improve vaccination uptake. Incorporating door-to-door visits and media campaigns to target older and unemployed populations may increase childhood immunization uptake in northern Nigeria.

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

Vaccine hesitancy around the globe: Analysis of three years of WHO/UNICEF Joint Reporting Form data-2015-2017

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WHO vaccine hesitancy definition understood; >90% countries report hesitancy.

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Long list of reasons, varied by country income level; WHO region, changed overtime.

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Most cited: risk-benefit (scientific evidence) equaled <25% of reasons cited.

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Reasons cited based on assessments in only 1/3 of countries; need to increase this.

In order to gather a global picture of vaccine hesitancy and whether/how it is changing, an analysis was undertaken to review three years of data available as of June 2017 from the WHO/UNICEF Joint Report Form (JRF) to determine the reported rate of vaccine hesitancy across the globe, the cited reasons for hesitancy, if these varied by country income level and/or by WHO region and whether these reasons were based upon an assessment. The reported reasons were classified using the Strategic Advisory Group of Experts (SAGE) on Immunization matrix of hesitancy determinants (www.who.int/immunization/sage/meetings/2014/october/SAGE_working_group_revised_report_vaccine_hesitancy.pdf). Hesitancy was common, reported by >90% of countries. The list of cited reasons was long and covered 22 of 23 WHO determinants matrix categories. Even the most frequently cited category, risk- benefit (scientific evidence e.g. vaccine safety concerns), accounted for less than one quarter of all reasons cited. The reasons varied by country income level, by WHO region and over time and within a country. Thus based upon this JRF data, across the globe countries appear to understand the SAGE vaccine hesitancy definition and use it to report reasons for hesitancy. However, the rigour of the cited reasons could be improved as only just over 1/3 of countries reported that their reasons were assessment based, the rest were opinion based. With respect to any assessment in the previous five years, upper middle income countries were the least likely to have done an assessment. These analyses provided some of the evidence for the 2017 Assessment Report of the Global Vaccine Action Plan recommendation that each country develop a strategy to increase acceptance and demand for vaccination, which should include ongoing community engagement and trust-building, active hesitancy prevention, regular national assessment of vaccine concerns, and crisis response planning (www.who.int/immunization/sage/meetings/2017/october/1_GVAP_Assessment_report_web_version.pdf).