Defining hard-to-reach populations for vaccination

Analyzing Subnational Immunization Coverage to Catch up and Reach the Unreached in Seven High-Priority Countries in the Eastern Mediterranean Region, 2019-2021

Yearly national immunization coverage reporting does not measure performance at the subnational level throughout the year and conceals inequalities within countries. We analyzed subnational immunization coverage from seven high-priority countries in our region. We analyzed subnational, monthly immunization data from seven high-priority countries. Five were Gavi eligible (i.e., Afghanistan, Pakistan, Somalia, Syria, and Yemen); these are countries that according to their low income are eligible for support from the Global Alliance on Vaccine and Immunization, while Iraq and Jordan were included because of a recent decrease in immunization coverage and contribution to the regional number of under and unimmunized children. DTP3 coverage, which is considered as the main indicator for the routine immunization coverage as the essential component of the immunization program performance, varied monthly in 2019-2021 before reaching pre-pandemic coverage in the last two months of 2021. Somalia and Yemen had a net gain in DTP3 coverage at the end of 2021, as improvement in 2021 exceeded the regression in 2020. In Pakistan and Iraq, DTP3 improvement in 2021 equaled the 2020 regression. In Afghanistan, Syria and Jordan, the regression in DTP3 coverage continued in 2020 and 2021. The number of districts with at least 6000 zero-dose children improved moderately in Afghanistan and substantially in Somalia throughout the follow-up period. In Pakistan, the geographical distribution differed between 2020 and 2021.Of the three countries with the highest number of zero-dose children, DTP1 coverage reached 109% in Q4 of 2020 after a sharp drop to 69% in Q2 of 2020. However, in Pakistan, the number of zero-dose children decreased to 1/10 of its burden in Q4 of 2021. In Afghanistan, the number of zero-dose children more than a doubled. Among the even countries, adaptation of immunization service to the pandemic varied, depending on the agility of the health system and the performance of the components of the expanded program on immunization. We recommended monitoring administrative monthly immunization coverage data at the subnational level to detect low-performing districts, plan catchup, identify bottlenecks towards reaching unvaccinated children and customize strategies to improve the coverage in districts with zero-dose children throughout the year and monitor progress.

Perceived barriers of migrants and refugees to vaccinate their children against Measles and polio: a study in Iran

BACKGROUND

This study examined the perceived barriers of migrants and refugees to vaccinating their children against measles and polio in Iran.

METHODS

First, an instrument was developed and validated through several steps. Next, 1,067 parents who had not vaccinated their children against polio and measles or had delayed receiving any dose of these two vaccines until the age of 15 were selected from 16 provinces and completed the instrument. Finally, the data were analyzed.

RESULTS

The results of the explanatory factor analysis showed that the perceived barriers affecting vaccination against polio and measles vaccines were categorized into five factors: low knowledge, negative attitude, communication challenges, lack of participation in vaccination programs, and problems related to migration and refugees. Additionally, the results indicated a significant difference in the mean score of perceived barriers based on participants' level of education, economic status, and nationality.

CONCLUSION

The identified barriers may provide a perspective for developing effective efforts in this area. Interventions should focus on parents with low education and poor economic status.

Evaluation of the COVID-19 Vaccination Campaign ¡Ándale! ¿Qué Esperas? in Latinx Communities in California, June 2021-May 2022

OBJECTIVES

The 12-month vaccination campaign ¡Ándale! ¿Qué Esperas? was launched to increase COVID-19 vaccination rates in Latinx populations in California by expanding community outreach. The objectives of this evaluation were to (1) determine predictors of vaccination rates and (2) identify barriers to vaccination and potential solutions.

METHODS

Five community partners in California serving Latinx populations with high social vulnerability participated in the ¡Ándale! ¿Qué Esperas? campaign. Community health workers were hired to deliver outreach (virtual, one-on-one, group based, and information dissemination), vaccinations, and supportive services. We collected data on outreach strategy used (method and location), number of vaccinations provided and reasons for delay, and number of times that supportive services were provided. We used regression models to assess significant predictors of vaccinations and supportive services.

RESULTS

Community health workers (N = 146) hired from June 1, 2021, through May 31, 2022, performed outreach engagements (n = 6297) and supportive services (n = 313 796), resulting in 130 413 vaccinations and 28 660 vaccine appointments. The number of vaccinations administered was significantly higher at events in which supportive services were provided versus not provided (coefficient = 34.02; 95% CI, 3.34-64.68; P = .03). The odds ratio of supportive services was 3.67 (95% CI, 1.76-7.55) during virtual outreach and 2.95 (95% CI, 2.37-3.69) during one-on-one outreach (P < .001 for both) as compared with information dissemination encounters. Vaccination concerns were reported among 55.0% of vaccinated survey respondents (67.7%, vaccine confidence; 51.7%, access).

CONCLUSIONS

Supportive services facilitate vaccinations, ease transportation and time barriers, and instill confidence among working-class racial and ethnic minority populations.

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.

Defining the Zero Dose Child: A Comparative Analysis of Two Approaches and Their Impact on Assessing the Zero Dose Burden and Vulnerability Profiles across 82 Low- and Middle-Income Countries

While there is a coordinated effort around reaching zero dose children and closing existing equity gaps in immunization delivery, it is important that there is agreement and clarity around how 'zero dose status' is defined and what is gained and lost by using different indicators for zero dose status. There are two popular approaches used in research, program design, and advocacy to define zero dose status: one uses a single vaccine to serve as a proxy for zero dose status, while another uses a subset of vaccines to identify children who have missed all routine vaccines. We provide a global analysis utilizing the most recent publicly available DHS and MICS data from 2010 to 2020 to compare the number, proportion, and profile of children aged 12 to 23 months who are 'penta-zero dose' (have not received the pentavalent vaccine), 'truly' zero dose (have not received any dose of BCG, polio, pentavalent, or measles vaccines), and 'misclassified' zero dose children (those who are penta-zero dose but have received at least one other vaccine). Our analysis includes 194,829 observations from 82 low- and middle-income countries. Globally, 14.2% of children are penta-zero dose and 7.5% are truly zero dose, suggesting that 46.5% of penta-zero dose children have had at least one contact with the immunization system. While there are similarities in the profile of children that are penta-zero dose and truly zero dose, there are key differences between the proportion of key characteristics among truly zero dose and misclassified zero dose children, including access to maternal and child health services. By understanding the extent of the connection zero dose children may have with the health and immunization system and contrasting it with how much the use of a more feasible definition of zero dose may underestimate the level of vulnerability in the zero dose population, we provide insights that can help immunization programs design strategies that better target the most disadvantaged populations. If the vulnerability profiles of the truly zero dose children are qualitatively different from that of the penta-zero dose children, then failing to distinguish the truly zero dose populations, and how to optimally reach them, may lead to the development of misguided or inefficient strategies for vaccinating the most disadvantaged population of children.

Inclusion of intersectionality in studies of immunization uptake in Canada: A scoping review

INTRODUCTION

Intersectionality refers to the interconnectedness of various social locations creating unique experiences for individuals and groups, in the context of systems of privilege and oppression. As part of immunization coverage research, intersectionality allows healthcare professionals and policymakers to become aware of the constellation of characteristics contributing to low vaccine uptake. The objective of this study was to examine the application of intersectionality theory or concepts, and the appropriate use of sex and gender terminology, in Canadian immunization coverage research.

MATERIALS AND METHODS

The eligibility criteria for this scoping review included English or French language studies on immunization coverage among Canadians of all ages. Six research databases were searched without date restrictions. We searched provincial and federal websites, as well as the Proquest Dissertations and Theses Global database for grey literature.

RESULTS

Of 4725 studies identified in the search, 78 were included in the review. Of these, 20 studies included intersectionality concepts, specifically intersections of individual-level characteristics influencing vaccine uptake. However, no studies explicitly used an intersectionality framework to guide their research. Of the 19 studies that mentioned "gender", 18 had misused this term, conflating it with "sex".

CONCLUSIONS

Based on our findings, there is an evident lack of intersectionality framework utilization in immunization coverage research in Canada, as well as misuse of the terms "gender" and "sex". Rather than only focusing on discrete characteristics, research should explore the interaction between numerous characteristics to better understand the barriers to immunization uptake in Canada.

Assessing Potential Exemplars in Reducing Zero-Dose Children: A Novel Approach for Identifying Positive Outliers in Decreasing National Levels and Geographic Inequalities in Unvaccinated Children

Background: Understanding past successes in reaching unvaccinated or “zero-dose” children can help inform strategies for improving childhood immunization in other settings. Drawing from positive outlier methods, we developed a novel approach for identifying potential exemplars in reducing zero-dose children. Methods: Focusing on 2000–2019, we assessed changes in the percentage of under-one children with no doses of the diphtheria–tetanus–pertussis vaccine (no-DTP) across two geographic dimensions in 56 low- or lower-middle-income countries: (1) national levels; (2) subnational gaps, as defined as the difference between the 5th and 95th percentiles of no-DTP prevalence across second administrative units. Countries with the largest reductions for both metrics were considered positive outliers or potential ‘exemplars’, demonstrating exception progress in reducing national no-DTP prevalence and subnational inequalities. Last, so-called “neighborhood analyses” were conducted for the Gavi Learning Hub countries (Nigeria, Mali, Uganda, and Bangladesh), comparing them with countries that had similar no-DTP measures in 2000 but different trajectories through 2019. Results: From 2000 to 2019, the Democratic Republic of the Congo, Ethiopia, and India had the largest absolute decreases for the two no-DTP dimensions—national prevalence and subnational gaps—while Bangladesh and Burundi registered the largest relative reductions for each no-DTP metric. Neighborhood analyses highlighted possible opportunities for cross-country learning among Gavi Learning Hub countries and potential exemplars in reducing zero-dose children. Conclusions: Identifying where exceptional progress has occurred is the first step toward better understanding how such gains could be achieved elsewhere. Further examination of how countries have successfully reduced levels of zero-dose children—especially across variable contexts and different drivers of inequality—could support faster, sustainable advances toward greater vaccination equity worldwide.

The Use of Adaptive Sampling to Reach Disadvantaged Populations for Immunization Programs and Assessments: A Systematic Review

Vaccines prevent 4-5 million deaths every year, but inequities in vaccine coverage persist among key disadvantaged subpopulations. Under-immunized subpopulations (e.g., migrants, slum residents) may be consistently missed with conventional methods for estimating immunization coverage and assessing vaccination barriers. Adaptive sampling, such as respondent-driven sampling, may offer useful strategies for identifying and collecting data from these subpopulations that are often "hidden" or hard-to-reach. However, use of these adaptive sampling approaches in the field of global immunization has not been systematically documented. We searched PubMed, Scopus, and Embase databases to identify eligible studies published through November 2020 that used an adaptive sampling method to collect immunization-related data. From the eligible studies, we extracted relevant data on their objectives, setting and target population, and sampling methods. We categorized sampling methods and assessed their frequencies. Twenty-three studies met the inclusion criteria out of the 3069 articles screened for eligibility. Peer-driven sampling was the most frequently used adaptive sampling method (57%), followed by geospatial sampling (30%), venue-based sampling (17%), ethnographic mapping (9%), and compact segment sampling (9%). Sixty-one percent of studies were conducted in upper-middle-income or high-income countries. Data on immunization uptake were collected in 65% of studies, and data on knowledge and attitudes about immunizations were collected in 57% of studies. We found limited use of adaptive sampling methods in measuring immunization coverage and understanding determinants of vaccination uptake. The current under-utilization of adaptive sampling approaches leaves much room for improvement in how immunization programs calibrate their strategies to reach "hidden" subpopulations.

Is the intention to vaccinate enough? Systematic variation in the value of timely vaccinations and preferences for monetary vs non-monetary incentives among pregnant women in southern Tanzania

Background

Globally, approximately 19.7 million children remain under-vaccinated; many more receive delayed vaccinations. Sustained progress towards global vaccination targets requires overcoming, or compensating for, incrementally greater barriers to vaccinating hard-to-reach and hard-to-vaccinate children. We prospectively assessed pregnant women's valuations of routine childhood vaccinations and preferences for alternative incentives to inform interventions aiming to increase vaccination coverage and timeliness in southern Tanzania.

Methods

Between August and December 2017, 406 women in their last trimester of pregnancy were enrolled from health facilities and communities in the Mtwara region of Tanzania and asked contingent valuation questions about their willingness to vaccinate their child if they were (a) given an incentive, or (b) facing a cost for each vaccination. Interval censored regressions assessed correlates of women's willingness to pay (WTP) for timely vaccinations. Participants were asked to rank monetary and non-monetary incentive options for the timely vaccination of their children.

Findings

All women expected to get their children vaccinated according to the recommended schedule, even without incentives. Nearly all women (393; 96.8 %) were willing to pay for vaccinations. The average WTP was Tanzania Shilling (Tsh) 3,066 (95 % confidence interval Tsh 2,523-3,610; 1 USD ∼ Tsh 2,200) for each vaccination. Women's valuations of timely vaccinations varied significantly with vaccine-related knowledge and attitudes, economic status, and rural vs urban residence. Women tended to prefer non-monetary over monetary incentives for the timely vaccination of their children.

Interpretation

Women placed a high value on timely childhood vaccinations, suggesting that unexpected system-level barriers rather than individual-level demand factors are likely to be the primary drivers of missed vaccinations. Systematic variation in the value of vaccinations across women reflects variation in perceived benefits and opportunity costs. In this setting, nonmonetary incentives and other interventions to increase demand and compensate for system-level barriers hold significant potential for improving vaccination coverage and timeliness.

ClinicalTrialsgov Protocol

NCT03252288.

The shortfalls of vulnerability indexes for public health decision-making in the face of emergent crises: the case of COVID-19 vaccine uptake in Virginia

Equitable and effective vaccine uptake is a key issue in addressing COVID-19. To achieve this, we must comprehensively characterize the context-specific socio-behavioral and structural determinants of vaccine uptake. However, to quickly focus public health interventions, state agencies and planners often rely on already existing indexes of "vulnerability." Many such "vulnerability indexes" exist and become benchmarks for targeting interventions in wide ranging scenarios, but they vary considerably in the factors and themes that they cover. Some are even uncritical of the use of the word "vulnerable," which should take on different meanings in different contexts. The objective of this study is to compare four vulnerability indexes produced by private, federal, and state institutions to assess the application of these measures to the needs of the COVID-19 pandemic and other emergent crises. We focus on federal, state, and private industries' vulnerability indexes for the Commonwealth of Virginia. Qualitative comparison is done by considering each index's methodologies to see how and why they defined and measured "vulnerability." We also quantitatively compare them using percent agreement and illustrate the overlaps in localities identified as among the most vulnerable on a choropleth map. Finally, we provide a short case study that explores vaccine uptake in the six localities that were identified by at least three indexes as most vulnerable, and six localities with very low vaccine coverage that were identified by two or fewer indexes as highly vulnerable. By comparing the methodologies and index (dis)agreements, we discuss the appropriateness of using pre-existing vulnerability indexes as a public health decision-making tool for emergent crises, using COVID-19 vaccine uptake as a case study. The inconsistencies reflected by these indexes show both the need for context-specific and time-sensitive data collection in public health and policy response, and a critical critique of measured "vulnerability."

Factors Associated with Zero-Dose Childhood Vaccination Status in a Remote Fishing Community in Cameroon: A Cross-Sectional Analytical Study

Background: Cameroon's suboptimal access to childhood vaccinations poses a significant challenge to achieving the Immunization Agenda 2030 goal-ranking among the top 15 countries with a high proportion of zero-dose (unvaccinated) children worldwide. There are clusters of zero-dose children in pockets of communities that traditionally miss essential healthcare services, including vaccination. The Manoka Health District (MHD) is home to such settlements with consistently low vaccination coverages (DPT-HepB-Hib-1: 19.8% in 2021) and frequent outbreaks of vaccine-preventable diseases (VPD). Therefore, the absence of literature on zero-dose children in this context was a clarion call to characterize zero-dose children in fragile settings to inform policy and intervention design. Methodology: This cross-sectional analytical study involved 278 children, 0-24 months of age, selected from a 2020 door-to-door survey conducted in the two most populous health areas in an archipelago rural district, MHD (Cap-Cameroon and Toube). We used R Statistical Software (v4.1.2; R Core Team 2021) to run a multivariable logistic regression to determine zero-dose associated factors. Results: The survey revealed a zero-dose proportion of 91.7% (255) in MHD. Children who were delivered in health facilities were less likely to be zero-dose than those born at home (AOR: 0.07, 95% CI: 0.02-0.30, p = 0.0003). Compared to children born of Christian mothers, children born to minority non-Christian mothers had higher odds of being zero-dose (AOR: 6.55, 95% CI: 1.04-41.25, p = 0.0453). Children born to fathers who are immigrants were more likely to be zero-dose children than Cameroonians (AOR: 2.60, 95% CI = 0.65-10.35, p = 0.0016). Younger children were likely to be unvaccinated compared to older peers (AOR: 0.90, 95% CI: 0.82-1.00, p = 0.0401). Conclusions: In the spirit of "leaving no child behind," the study highlights the need to develop context-specific approaches that consider minority religious groups, immigrants, and younger children, including newborns, often missed during vaccination campaigns and outreaches.

COVID-19 Vaccination Coverage Among People Experiencing Homelessness in a Highly Vaccinated Midwest County-Dane County, Wisconsin, 2021

People experiencing homelessness (PEH) are at increased risk for coronavirus disease 2019 (COVID-19) infection. This study assessed COVID-19 vaccination coverage among vaccine-eligible PEH (5 years and older) stratified by demographic characteristics. PEH were less likely to complete a primary vaccination series than the Dane County population (32.0%; 95% confidence interval [CI], 30.3%–33.8% vs 82.4%; 95% CI, 82.3%–82.5%) and were less likely to have received a booster when eligible (30.8%; 95% CI, 27.8%–33.9% vs 67.2%; 95% CI, 67.1%–67.4%). Vaccination rates were lowest among young PEH and PEH of color.

COVID-19 Vaccine Acceptance and Its Determinants among Migrants in Germany-Results of a Cross-Sectional Study

Vaccinations are a core element of infection control. Migrants have been reported to have low vaccination rates for many infectious diseases, including COVID-19. Still, determinants of migrants' uptake of COVID-19 vaccinations are not sufficiently clear. The present study addresses this gap and examines the respective influence of three potential determinants: barriers to access, attitude towards vaccinations in general, and towards COVID-19 vaccines. The study uses a cross-sectional online survey among migrants in Germany. The questionnaire assessed the aforementioned determinants using standardized tools. Information on 204 individuals was available. The vaccination rate in the sample was 80%. Vaccinated as compared to unvaccinated respondents reported more often the absence of financial barriers (71% (95%CI: 64-73%) vs. 45% (95%CI: 28-63%)), short waiting times (51% (95%CI: 43-59%) vs. 22% (95%CI: 5-38%)), and the presence of a vaccination center close-by (91.5% (95%CI: 87-96%) vs. 69.7% (95%CI: 54-85%)). Concerning COVID-19 vaccine acceptance, the majority of respondents (68%) agreed that the vaccine is important. Unvaccinated respondents more often feared side effects, were convinced that the vaccine is not safe, and assumed that COVID-19 is not dangerous. Correspondingly, acceptance of vaccinations in general was higher among vaccinated respondents. In line with findings from previous studies, our survey found that all three determinants seem to influence migrants' vaccination status while their overall vaccination rate was comparable to the general population. Hence, migration background per se does not sufficiently explain vaccine acceptance and further research is needed to identify subgroups of migrants that should be specifically addressed to increase their vaccination rate.

Association between childhood immunisation coverage and proximity to health facilities in rural settings: a cross-sectional analysis of Service Provision Assessment 2013-2014 facility data and Demographic and Health Survey 2015-2016 individual data in Malawi

OBJECTIVES

Despite significant progress in childhood vaccination coverage globally, substantial inequality remains. Remote rural populations are recognised as a priority group for immunisation service equity. We aimed to link facility and individual data to examine the relationship between distance to services and immunisation coverage empirically, specifically using a rural population.

DESIGN AND SETTING

Retrospective cross-sectional analysis of facility data from the 2013-2014 Malawi Service Provision Assessment and individual data from the 2015-2016 Malawi Demographic and Health Survey, linking children to facilities within a 5 km radius. We examined associations between proximity to health facilities and vaccination receipt via bivariate comparisons and logistic regression models.

PARTICIPANTS

2740 children aged 12-23 months living in rural areas.

OUTCOME MEASURES

Immunisation coverage for the six vaccines included in the Malawi Expanded Programme on Immunization schedule for children under 1 year at time of study, as well as two composite vaccination indicators (receipt of basic vaccines and receipt of all recommended vaccines), zero-dose pentavalent coverage, and pentavalent dropout.

FINDINGS

72% (706/977) of facilities offered childhood vaccination services. Among children in rural areas, 61% were proximal to (within 5 km of) a vaccine-providing facility. Proximity to a vaccine-providing health facility was associated with increased likelihood of having received the rotavirus vaccine (93% vs 88%, p=0.004) and measles vaccine (93% vs 89%, p=0.01) in bivariate tests. In adjusted comparisons, how close a child was to a health facility remained meaningfully associated with how likely they were to have received rotavirus vaccine (adjusted OR (AOR) 1.63, 95% CI 1.13 to 2.33) and measles vaccine (AOR 1.62, 95% CI 1.11 to 2.37).

CONCLUSION

Proximity to health facilities was significantly associated with likelihood of receipt for some, but not all, vaccines. Our findings reiterate the vulnerability of children residing far from static vaccination services; efforts that specifically target remote rural populations living far from health facilities are warranted to ensure equitable vaccination coverage.

Mapping the Swiss Vaccine Supply Chain

Objectives

The design of the supply chain determines how effectively any vaccination campaign can be operated. This case study of Switzerland's vaccine supply chain compares its design with public health objectives. It maps the vaccine supply chain in Switzerland as it was set up to handle the first shipments of Covid-19 vaccine in 2021 to enable a more holistic view of supply and demand flows. Recommendations are made to improve emergency logistics of vaccines in the future.

Methods

Twenty-six semi-structured interviews with international and Swiss stake-holders were coded and analyzed to arrive at a description of planning and distribution processes. The vaccine supply chain network structure was mapped, linking upstream and downstream flows of material and information. The visualization of nodes and flows was combined with spatial information, including population data. The results are summarized in narrative form to support decision-makers across disciplines.

Results

Despite adequate vaccine supply, abundant local endowments and high investment in infrastructure, the 2021 design of Switzerland's vaccine supply chain reduced the potential reach of target populations. The segmentation of catchment populations, collaboration between administrative units and better use of information on geolocation and material flows could have improved the speed and reach of vaccinations during the emergency response phase. Three recommendations are made for supply chain structures to support higher vaccination rates in the future.

Conclusions

The visualization identifies design alternatives which could have improved vaccination rates under the prevailing conditions. A supply chain map provides public health officials with a shared view of the vaccine supply chain in order to better match supply with demand. The case study contributes to developed country studies. In order to improve public health outcomes in Switzerland, investments to secure supply, strong national endowments, and excellent infrastructure must be combined with optimized supply chain design.

Parental vaccine hesitancy and concerns regarding the COVID-19 virus

PURPOSE

This study assessed parental vaccine hesitancy in a metropolitan area of the United States. The study aimed to determine what characteristics and contributing factors influenced parental vaccine hesitancy and concerns regarding COVID-19.

DESIGN AND METHODS

An online survey was used to recruit 93 parents to answer demographic and vaccine hesitancy information. Vaccine hesitancy was measured using the Parent Attitudes about Childhood Vaccines survey. The study was conducted between June 2020 and September 2020 during the COVID-19 pandemic.

RESULTS

The rate of vaccine hesitancy was 15%. One hundred percent of vaccine hesitant parents were mothers, at least 30 years of age, married, and had completed at least some college. When characteristics of vaccine hesitant parents were compared to non-hesitant parents, the hesitant parents reported having more children, with 93% reporting two or more children compared to only 74% of non-hesitant parents (p = 0.046). Fifty percent of hesitant parents reported no concerns regarding COVID-19 compared to only 20% of non-hesitant parents (p = 0.006), and significantly less hesitant parents reported willingness to have their children receive a safe, effective COVID-19 vaccine if it were available compared to non-hesitant parents (p < 0.001).

CONCLUSIONS

Our findings indicate that older mothers with two or more children are more likely to be vaccine hesitant and this hesitancy extends to the current COVID-19 pandemic.

PRACTICE IMPLICATIONS

Healthcare providers can use the results of this study to identify parents at risk for vaccine hesitancy and initiate individualized education to promote on-time childhood vaccination.

Efficacy information influences intention to take COVID-19 vaccine

OBJECTIVES

A successful response to the COVID-19 pandemic requires achieving high levels of vaccine uptake. We tested whether directly contrasting the high efficacy of COVID-19 vaccines with the lower efficacy of the annual flu vaccine would increase intentions to take a COVID-19 vaccine.

DESIGN

A pre-registered online study of 481 participants compared four information conditions: (1) no information; (2) COVID-19 Vaccine Information Only; and COVID-19 Vaccine Information combined with flu vaccine information suggesting either (3) 60% efficacy or (4) 40% efficacy; we measured COVID-19 and flu vaccine intentions along with several other vaccine-related variables.

METHODS

The Prolific platform was used to recruit 481 UK participants (64% female; aged between 18 and 85 years) who had been pre-screened to have intermediate levels of vaccine hesitancy. After reading a short text (~200 words) about COVID-19 vaccines, participants were asked about their vaccination intentions.

RESULTS

Providing information about the safety and efficacy of the new COVID-19 vaccines resulted in vaccination intentions that were, on average, 0.39 standard deviations (SDs) higher than those in the no information condition; providing the same COVID vaccine efficacy information in the context of information about flu vaccine efficacy resulted in a further significant increase in vaccination intentions that were 0.68 SD higher than those in the no information condition. This positive contrast effect for the COVID-19 vaccine was not associated with reduced flu vaccine intentions.

CONCLUSIONS

Vaccination intentions can be strengthened through a simple messaging intervention that utilizes context effects to increase perceived response efficacy.

Economic-Related Inequalities in Zero-Dose Children: A Study of Non-Receipt of Diphtheria-Tetanus-Pertussis Immunization Using Household Health Survey Data from 89 Low- and Middle-Income Countries

Despite advances in scaling up new vaccines in low- and middle-income countries, the global number of unvaccinated children has remained high over the past decade. We used 2000–2019 household survey data from 154 surveys representing 89 low- and middle-income countries to assess within-country, economic-related inequality in the prevalence of one-year-old children with zero doses of diphtheria–tetanus–pertussis (DTP) vaccine. Zero-dose DTP prevalence data were disaggregated by household wealth quintile. Difference, ratio, slope index of inequality, concentration index, and excess change measures were calculated to assess the latest situation and change over time, by country income grouping for 17 countries with high zero-dose DTP numbers and prevalence. Across 89 countries, the median prevalence of zero-dose DTP was 7.6%. Within-country inequalities mostly favored the richest quintile, with 19 of 89 countries reporting a rich–poor gap of ≥20.0 percentage points. Low-income countries had higher inequality than lower–middle-income countries and upper–middle-income countries (difference between the median prevalence in the poorest and richest quintiles: 14.4, 8.9, and 2.7 percentage points, respectively). Zero-dose DTP prevalence among the poorest households of low-income countries declined between 2000 and 2009 and between 2010 and 2019, yet economic-related inequality remained high in many countries. Widespread economic-related inequalities in zero-dose DTP prevalence are particularly pronounced in low-income countries and have remained high over the previous decade.

COVID-19 Testing and Vaccine Acceptability Among Homeless-Experienced Adults: Qualitative Data from Two Samples

BACKGROUND

Homeless-experienced populations are at increased risk of exposure to SARS-CoV-2 due to their living environments and face an increased risk of severe COVID-19 disease due to underlying health conditions. Little is known about COVID-19 testing and vaccination acceptability among homeless-experienced populations.

OBJECTIVE

To understand the facilitators and barriers to COVID-19 testing and vaccine acceptability among homeless-experienced adults.

DESIGN

We conducted in-depth interviews with participants from July to October 2020. We purposively recruited participants from (1) a longitudinal cohort of homeless-experienced older adults in Oakland, CA (n=37) and (2) a convenience sample of people (n=57) during a mobile outreach COVID-19 testing event in San Francisco.

PARTICIPANTS

Adults with current or past experience of homelessness.

APPROACH

We asked participants about their experiences with and attitudes towards COVID-19 testing and their perceptions of COVID-19 vaccinations. We used participant observation techniques to document the interactions between testing teams and those approached for testing. We audio-recorded, transcribed, and content analyzed all interviews and identified major themes and subthemes.

KEY RESULTS

Participants found incentivized COVID-19 testing administered in unsheltered settings and supported by community health outreach workers (CHOWs) to be acceptable. The majority of participants expressed a positive inclination toward vaccine acceptability, citing a desire to return to routine life and civic responsibility. Those who expressed hesitancy cited a desire to see trial data, concerns that vaccines included infectious materials, and mistrust of the government.

CONCLUSIONS

Participants expressed positive evaluations of the incentivized, mobile COVID-19 testing supported by CHOWs in unsheltered settings. The majority of participants expressed a positive inclination toward vaccination. Vaccine hesitancy concerns must be addressed when designing vaccine delivery strategies that overcome access challenges. Based on the successful implementation of COVID-19 testing, we recommend mobile delivery of vaccines using trusted CHOWs to address concerns and facilitate wider access to and uptake of the COVID vaccine.

Views and experiences of maternal healthcare providers regarding influenza vaccine during pregnancy globally: A systematic review and qualitative evidence synthesis

BACKGROUND

The World Health Organization (WHO) recommends that pregnant women receive influenza vaccination; however, uptake of the vaccine remains low. Maternity health care professionals (MHCPs) play an important role in motivating pregnant women to receive the influenza vaccine. However, factors such as MHCPs' views and knowledge about the vaccine, and time constraints due to workload may influence MHCPs' practices and opinions about women receiving the influenza vaccine during pregnancy. To date, the qualitative evidence exploring MHCPs' views and experiences around influenza vaccine uptake in pregnant women has not been synthesised.

AIM

To systematically review and thematically synthesise qualitative evidence that explores the views and experiences of MHCPs involved in the provision of the maternal influenza vaccine worldwide.

METHODS

Five databases (MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science) were searched, supplemented with searches of included paper reference lists and grey literature. Study selection was conducted by up to three researchers applying pre-specified inclusion/exclusion criteria. Quality assessment was undertaken, data were extracted, coded and synthesised to develop descriptive and analytical themes.

RESULTS

Eight studies involving 277 participants were included. Seventeen descriptive themes were interpreted, embedded within six analytical themes. MHCPs perceived that maternal influenza vaccination delivery can be facilitated by trusting relationships, good communication, knowledge about the vaccine leading to confidence in recommending vaccine, electronic vaccination prompts, and presence of national guidelines. However, workload, time constraints, MHCP's perception of pregnant women's concerns, and social/cultural/environmental influences could prevent the likelihood of delivery of influenza vaccine. Knowledgeable MHCPs who were regularly updated about vaccination based on scientific evidence were more confident when discussing and recommending the influenza vaccine to pregnant women. In addition, the presence of national policies and guidelines and electronic prompts for maternal influenza vaccination would enhance the delivery of the vaccine.

CONCLUSION

Our findings suggest that approaches to enhance the vaccination uptake rate in pregnant women include addressing MHCPs barriers to discussing influenza vaccination through education, sufficient time for discussions, and electronic prompts about vaccination, as well as evidence based local and national guidelines.

Uptake, barriers and correlates of influenza vaccination among people who inject drugs in Australia

BACKGROUND

Comorbid chronic health conditions place people who inject drugs (PWID) at risk of severe health outcomes after influenza infection. However, little is known about the uptake, barriers and correlates of influenza vaccination among PWID.

METHODS

During structured surveys, 872 PWID reported whether they had received an influenza vaccination during the last year (disaggregated as pre- or post-March 2020 to ascertain current season vaccine uptake), and if not, the barriers to vaccination. Logistic regression was used to examine demographic, drug use, health and service engagement correlates of vaccine uptake.

RESULTS

Thirty-nine percent of participants reported past-year influenza vaccination, with one-quarter (24 %) vaccinated in the current season. The main barriers to vaccination were motivation-based, with few citing issues relating to affordability, supply or perceived stigma. Opioid agonist therapy in the past six months was significantly associated with vaccination.

CONCLUSIONS

Influenza vaccine uptake was lower among PWID than the Australian general population. Provision of the vaccine at services commonly accessed by PWID may increase uptake.

A critical review of measures of childhood vaccine confidence

The World Health Organization and global partners sought to identify existing measures of confidence in childhood vaccines, as part of a broader effort to measure the range of behavioural and social drivers of vaccination. We identified 14 confidence measures applicable to childhood vaccination in general, all published between 2010 and 2019. The measures examined 1-5 constructs and included a mean of 12 items. Validation studies commonly examined factor structure, internal consistency reliability, and criterion-related validity. Fewer studies examined convergent and discriminant validity, test-retest reliability, or used cognitive interviewing. Most measures were developed and validated only in high-income countries. These findings highlight the need for a childhood vaccine confidence measure validated for use in diverse global contexts.

Systematic review of the costs for vaccinators to reach vaccination sites: Incremental costs of reaching hard-to-reach populations

INTRODUCTION

Economic evidence on how much it may cost for vaccinators to reach populations is important to plan vaccination programs. Moreover, knowing the incremental costs to reach populations that have traditionally been undervaccinated, especially those hard-to-reach who are facing supply-side barriers to vaccination, is essential to expanding immunization coverage to these populations.

METHODS

We conducted a systematic review to identify estimates of costs associated with getting vaccinators to all vaccination sites. We searched PubMed and the Immunization Delivery Cost Catalogue (IDCC) in 2019 for the following costs to vaccinators: (1) training costs; (2) labor costs, per diems, and incentives; (3) identification of vaccine beneficiary location; and (4) travel costs. We assessed if any of these costs were specific to populations that are hard-to-reach for vaccination, based on a framework for examining supply-side barriers to vaccination.

RESULTS

We found 19 studies describing average vaccinator training costs at $0.67/person vaccinated or targeted (SD $0.94) and $0.10/dose delivered (SD $0.07). The average cost for vaccinator labor and incentive costs across 29 studies was $2.15/dose (SD $2.08). We identified 13 studies describing intervention costs for a vaccinator to know the location of a beneficiary, with an average cost of $19.69/person (SD $26.65), and six studies describing vaccinator travel costs, with an average cost of $0.07/dose (SD $0.03). Only eight of these studies described hard-to-reach populations for vaccination; two studies examined incremental costs per dose to reach hard-to-reach populations, which were 1.3-2 times higher than the regular costs. The incremental cost to train vaccinators was $0.02/dose, and incremental labor costs for targeting hard-to-reach populations were $0.16-$1.17/dose.

CONCLUSION

Additional comparative costing studies are needed to understand the potential differential costs for vaccinators reaching the vaccination sites that serve hard-to-reach populations. This will help immunization program planners and decision-makers better allocate resources to extend vaccination programs.

Promoting, seeking, and reaching vaccination services: A systematic review of costs to immunization programs, beneficiaries, and caregivers

INTRODUCTION

Understanding the costs to increase vaccination demand among under-vaccinated populations, as well as costs incurred by beneficiaries and caregivers for reaching vaccination sites, is essential to improving vaccination coverage. However, there have not been systematic analyses documenting such costs for beneficiaries and caregivers seeking vaccination.

METHODS

We searched PubMed, Scopus, and the Immunization Delivery Cost Catalogue (IDCC) in 2019 for the costs for beneficiaries and caregivers to 1) seek and know how to access vaccination (i.e., costs to immunization programs for social mobilization and interventions to increase vaccination demand), 2) take time off from work, chores, or school for vaccination (i.e., productivity costs), and 3) travel to vaccination sites. We assessed if these costs were specific to populations that faced other non-cost barriers, based on a framework for defining hard-to-reach and hard-to-vaccinate populations for vaccination.

RESULTS

We found 57 studies describing information, education, and communication (IEC) costs, social mobilization costs, and the costs of interventions to increase vaccination demand, with mean costs per dose at $0.41 (standard deviation (SD) $0.83), $18.86 (SD $50.65) and $28.23 (SD $76.09) in low-, middle-, and high-income countries, respectively. Five studies described productivity losses incurred by beneficiaries and caregivers seeking vaccination ($38.33 per person; SD $14.72; n = 3). We identified six studies on travel costs incurred by beneficiaries and caregivers attending vaccination sites ($11.25 per person; SD $9.54; n = 4). Two studies reported social mobilization costs per dose specific to hard-to-reach populations, which were 2-3.5 times higher than costs for the general population. Eight studies described barriers to vaccination among hard-to-reach populations.

CONCLUSION

Social mobilization/IEC costs are well-characterized, but evidence is limited on costs incurred by beneficiaries and caregivers getting to vaccination sites. Understanding the potential incremental costs for populations facing barriers to reach vaccination sites is essential to improving vaccine program financing and planning.

Using immunisation caregiver journey interviews to understand and optimise vaccination uptake: lessons from Sierra Leone

Quantitative and qualitative assessments have revealed diverse factors that influence the uptake of childhood immunisation services and shed light on reasons for vaccination delays and refusals. UNICEF and partner organisations developed the Immunisation Caregiver Journey Framework as a novel way to understand caregiver experiences in accessing and receiving immunisation services for children. This framework aims to help immunisation programmes identify vaccination barriers and opportunities to improve vaccination uptake by enhancing the overall caregiver journey in a systems-focused manner, using human-centred design principles. In this paper, we adapt the framework into a flexible qualitative inquiry approach with theoretical guidance from interpretative phenomenology. We draw from the implementation experiences in Sierra Leone to inform methodological guidance on how to design and implement the Immunisation Caregiver Journey Interviews (ICJI) to understand the lived experiences of caregivers as they navigate immunisation services for their children. Practical guidance is provided on sampling techniques, conducting interviews, data management, data analysis and the use of data to inform programmatic actions. When properly implemented, the ICJI approach generates a rich qualitative understanding of how caregivers navigate household and community dynamics, as well as primary healthcare delivery systems. We argue that understanding and improving the caregiver journey will enhance essential immunisation outcomes, such as the completion of the recommended vaccination schedule, timeliness of vaccination visits and reduction in dropouts between vaccine doses.

A systems map of the economic considerations for vaccination: Application to hard-to-reach populations

BACKGROUND

Understanding the economics of vaccination is essential to developing immunization strategies that can be employed successfully with limited resources, especially when vaccinating populations that are hard-to-reach.

METHODS

Based on the input from interviews with 24 global experts on immunization economics, we developed a systems map of the mechanisms (i.e., necessary steps or components) involved in vaccination, and associated costs and benefits, focused at the service delivery level. We used this to identify the mechanisms that may be different for hard-to-reach populations.

RESULTS

The systems map shows different mechanisms that determine whether a person may or may not get vaccinated and the potential health and economic impacts of doing so. The map is divided into two parts: 1) the costs of vaccination, representing each of the mechanisms involved in getting vaccinated (n = 23 vaccination mechanisms), their associated direct vaccination costs (n = 18 vaccination costs), and opportunity costs (n = 5 opportunity costs), 2) the impact of vaccination, representing mechanisms after vaccine delivery (n = 13 impact mechanisms), their associated health effects (n = 10 health effects for beneficiary and others), and economic benefits (n = 13 immediate and secondary economic benefits and costs). Mechanisms that, when interrupted or delayed, can result in populations becoming hard-to-reach include getting vaccines and key stakeholders (e.g., beneficiaries/caregivers, vaccinators) to a vaccination site, as well as vaccine administration at the site.

CONCLUSION

Decision-makers can use this systems map to understand where steps in the vaccination process may be interrupted or weak and identify where gaps exist in the understanding of the economics of vaccination. With improved understanding of system-wide effects, this map can help decision-makers inform targeted interventions and policies to increase vaccination coverage in hard-to-reach populations.

Pro-equity immunization and health systems strengthening strategies in select Gavi-supported countries

BACKGROUND

Achieving universal immunization coverage and reaching every child with life-saving vaccines will require the implementation of pro-equity immunization strategies, especially in poorer countries. Gavi-supported countries continue to implement and report strategies that aim to address implementation challenges and improve equity. This paper summarizes the first mapping of these strategies from country reports.

METHODS

Thirteen Gavi-supported countries were purposively selected with emphasis on Gavi's priority countries. Following a scoping of different documents submitted to Gavi by countries, 47 Gavi Joint Appraisals (JAs) for the period 2016-2019 from the 13 selected countries were included in the mapping. We used a consolidated framework synthesized from 16 different equity and health systems frameworks, which incorporated UNICEF's coverage and equity assessment approach - an adaptation of the Tanahashi model. Using search terms, the mapping was conducted using a combination of manual search and the MAXQDA qualitative analysis tool. Pro-equity strategies meeting the inclusion criteria were identified and compiled in an Excel database, and then populated on a tableau visualization dashboard.

RESULTS

In total, 258 pro-equity strategies were implemented by the 13 sampled Gavi-supported countries between 2016 and 2019. The framework determinants of social norms, utilization, and management and coordination accounted for more than three-quarters of all pro-equity strategies implemented in these countries. The median number of strategies reported per country was 17. Afghanistan, Nigeria, and Uganda reported the highest number of strategies that we considered as pro-equity.

CONCLUSION

Findings from this mapping can be useful in addressing equity gaps, reaching partially immunized, and 'zero-dose' vaccinated children, and valuable resource for countries planning to implement pro-equity strategies, especially as immunization stakeholders reimagine immunization delivery in light of COVID-19, and as Gavi finalizes its fifth organizational strategy. Future efforts should seek to identify pro-equity strategies being implemented across additional countries, and to assess the extent to which these strategies have improved immunization coverage and equity.

Assessing the feasibility and effectiveness of household-pooled universal testing to control COVID-19 epidemics

Outbreaks of SARS-CoV-2 are threatening the health care systems of several countries around the world. The initial control of SARS-CoV-2 epidemics relied on non-pharmaceutical interventions, such as social distancing, teleworking, mouth masks and contact tracing. However, as pre-symptomatic transmission remains an important driver of the epidemic, contact tracing efforts struggle to fully control SARS-CoV-2 epidemics. Therefore, in this work, we investigate to what extent the use of universal testing, i.e., an approach in which we screen the entire population, can be utilized to mitigate this epidemic. To this end, we rely on PCR test pooling of individuals that belong to the same households, to allow for a universal testing procedure that is feasible with the limited testing capacity. We evaluate two isolation strategies: on the one hand pool isolation, where we isolate all individuals that belong to a positive PCR test pool, and on the other hand individual isolation, where we determine which of the individuals that belong to the positive PCR pool are positive, through an additional testing step. We evaluate this universal testing approach in the STRIDE individual-based epidemiological model in the context of the Belgian COVID-19 epidemic. As the organisation of universal testing will be challenging, we discuss the different aspects related to sample extraction and PCR testing, to demonstrate the feasibility of universal testing when a decentralized testing approach is used. We show through simulation, that weekly universal testing is able to control the epidemic, even when many of the contact reductions are relieved. Finally, our model shows that the use of universal testing in combination with stringent contact reductions could be considered as a strategy to eradicate the virus.

Increasing vaccine acceptance using evidence-based approaches and policies: Insights from research on behavioural and social determinants presented at the 7th Annual Vaccine Acceptance Meeting

BACKGROUND

In 2019, the World Health Organization (WHO) flagged vaccine hesitancy as one of the top 10 threats to global health. The drivers of and barriers to under-vaccination include logistics (access to and awareness of affordable vaccines), as well as a complex mix of psychological, social, political, and cultural factors.

INCREASING VACCINE UPTAKE

There is a need for effective strategies to increase vaccine uptake in various settings, based on the best available evidence. Fortunately, the field of vaccine acceptance research is growing rapidly with the development, implementation, and evaluation of diverse measurement tools, as well as interventions to address the challenging range of drivers of and barriers to vaccine acceptance.

ANNUAL VACCINE ACCEPTANCE MEETINGS

Since 2011, the Mérieux Foundation has hosted Annual Vaccine Acceptance Meetings in Annecy, France that have fostered an informal community of practice on vaccination confidence and vaccine uptake. Mutual learning and sharing of knowledge has resulted directly in multiple initiatives and research projects. This article reports the discussions from the 7th Annual Vaccine Acceptance Meeting held September 23-25, 2019. During this meeting, participants discussed emergent vaccine acceptance challenges and evidence-informed ways of addressing them in a programme that included sessions on vaccine mandates, vaccine acceptance and demand, training on vaccine acceptance, and frameworks for resilience of vaccination programmes.

What We Do Not Know About the Costs of Immunization Programs in Low- and Middle-Income Countries

• For many countries, there are limited data on the costs of running immunization services, and even less on the costs of increasing immunization coverage. • When considering different approaches for scaling up coverage, countries and funders need to understand the marginal change in coverage produced, costs of introduction, and how cost and coverage effects change depending on programmatic context. • Costing studies would benefit from improved, systematic reporting and leveraging ongoing program evaluation efforts to collect costing data. Long-term investments in the health system may allow for routine data collection and improved efficiency for budgeting and planning.

Lessons from my Elders on Recruitment and Retention into Health Research

In this brief report, the author shares lessons from Loretta Jones, MA and William Jenkins, PhD, two elders who shaped her research with communities that occupy intersecting marginalized categories. These lessons were echoed and amplified by the community panelists at the RCMAR workshop on recruitment and retention of diverse elders. They include centering the priorities of communities themselves, helping community members envision the types of positive transformations that research can help bring about, engaging and valuing the contributions of diverse sectors of the community, and recognizing the desire of aging individuals and communities to leave a legacy. Because heath care, research, and governmental institutions have engendered so much mistrust in racial/ethnic minority communities, researchers must learn first the particular histories and experience of the populations they intend to study. Equipped with this knowledge, cultural humility, and a willingness to listen, researchers can then use these strategies to earn the trust necessary for successful recruitment and retention in research.

Effective coverage measurement in maternal, newborn, child, and adolescent health and nutrition: progress, future prospects, and implications for quality health systems

Intervention coverage-the proportion of the population with a health-care need who receive care-does not account for intervention quality and potentially overestimates health benefits of services provided to populations. Effective coverage introduces the dimension of quality of care to the measurement of intervention coverage. Many definitions and methodological approaches to measuring effective coverage have been developed, resulting in confusion over definition, calculation, interpretation, and monitoring of these measures. To develop a consensus on the definition and measurement of effective coverage for maternal, newborn, child, and adolescent health and nutrition (MNCAHN), WHO and UNICEF convened a group of experts, the Effective Coverage Think Tank Group, to make recommendations for standardising the definition of effective coverage, measurement approaches for effective coverage, indicators of effective coverage in MNCAHN, and to develop future effective coverage research priorities. Via a series of consultations, the group recommended that effective coverage be defined as the proportion of a population in need of a service that resulted in a positive health outcome from the service. The proposed effective coverage measures and care cascade steps can be applied to further develop effective coverage measures across a broad range of MNCAHN services. Furthermore, advances in measurement of effective coverage could improve monitoring efforts towards the achievement of universal health coverage.

A systematic review of the role of pharmacists in vaccination services in low-and middle-income countries

BACKGROUND

Pharmacists' role in vaccination has expanded in some countries with pharmacists having greater authority to perform various immunization activities, from vaccine storage, vaccine adverse event reporting, vaccination education and advocacy, to vaccine administration. However, pharmacists' present involvement in vaccination services is poorly understood across low- and middle-income countries (LMICs).

OBJECTIVE

To identify and synthesize evidence on pharmacists' roles in offering vaccination services in LMICs.

METHODS

We searched three databases (PubMed, Embase, Scopus) and the gray literature to identify articles which described pharmacist involvement in vaccination services in LMICs. We abstracted data on reported roles of pharmacists in vaccination, as well as relevant country, vaccines, and populations served.

RESULTS

From the initial 612 records we identified, twenty-five (n = 25) studies representing 25 LMICs met our inclusion criteria. The most commonly reported role of pharmacists in vaccination across identified LMICs was vaccine advocacy and education (n = 15 countries). Pharmacist administered vaccination and storage of vaccines at pharmacies was reported in 8 countries. An additional 6 countries reported allowing vaccination at community pharmacies by other healthcare professionals. Immunization related training for pharmacists was reported or required in 8 countries. Fewer studies reported that pharmacists have access to patient immunization records in their respective LMICs (n = 6 countries) or had reported pharmacist involvement in vaccine adverse event reporting (n = 4 countries).

CONCLUSIONS

Pharmacists have the potential to play an important role in increasing access to vaccines and improving coverage, yet evidence of their role in vaccinations remains limited across LMICs. Greater documentation of pharmacists' involvement in vaccination services in LMICs is needed to demonstrate the value of successful integration of pharmacists in immunization programs.

An investment case for maternal and neonatal tetanus elimination

INTRODUCTION

Globally, 13 countries have yet to eliminate maternal and neonatal tetanus. While efforts have improved access to tetanus toxoid containing vaccines (TTCVs) and increased clean delivery practices, reaching elimination targets (<1 case of neonatal tetanus per 1000 live births per district per year) may require significant resources to reach the remaining high risk and hard-to-reach districts.

METHODS

We estimated the cost to achieve maternal and neonatal tetanus elimination (MNTE) in three years in the remaining 13 countries: Afghanistan, Angola, Central African Republic, Democratic Republic of the Congo, Guinea, Mali, Nigeria, Pakistan, Papua New Guinea, Somalia, South Sudan, Sudan, and Yemen. Costs were estimated for: (1) vaccination campaigns using standard TTCVs and TT-Uniject™ targeting women of reproductive age in high risk areas, (2) additional vaccinations delivered to pregnant women at antenatal care (ANC) clinics, (3) clean delivery and umbilical cord care promotion, (4) neonatal tetanus surveillance strengthening, and (5) validation activities. We forecasted the averted mortality to assess the cost-effectiveness of achieving MNTE.

RESULTS

It will cost an estimated US$197.7 million to realize MNTE over three years. These costs include $161.4 million for vaccination campaigns, $6.1 million for routine vaccination during ANC, $23.3 million for promotion of clean delivery practices, $4 million for surveillance, and $3 million for validation of MNTE. Achieving MNTE will avert approximately 70,000 neonatal deaths over ten years of vaccine protection, resulting in approximately 4.4 million life years gained. It will cost $2,900 per death averted and $45 per life year gained.

CONCLUSION

Maternal and neonatal tetanus can be eliminated with significant financial investment, high prioritization, and strong political will. While substantial costs must be incurred to reach hard-to-reach populations, MNTE should be accomplished as a matter of health equity, and will significantly contribute to reaching the United Nations' Sustainable Development Goals.