Effectiveness of vaccination mandates in improving uptake of COVID-19 vaccines in the USA

Megastudy shows that reminders boost vaccination but adding free rides does not

Encouraging routine COVID-19 vaccinations is likely to be a crucial policy challenge for decades to come. To avert hundreds of thousands of unnecessary hospitalizations and deaths, adoption will need to be higher than it was in the autumn of 2022 or 2023, when less than one-fifth of Americans received booster vaccines1,2. One approach to encouraging vaccination is to eliminate the friction of transportation hurdles. Previous research has shown that friction can hinder follow-through3 and that individuals who live farther from COVID-19 vaccination sites are less likely to get vaccinated4. However, the value of providing free round-trip transportation to vaccination sites is unknown. Here we show that offering people free round-trip Lyft rides to pharmacies has no benefit over and above sending them behaviourally informed text messages reminding them to get vaccinated. We determined this by running a megastudy with millions of CVS Pharmacy patients in the United States testing the effects of (1) free round-trip Lyft rides to CVS Pharmacies for vaccination appointments and (2) seven different sets of behaviourally informed vaccine reminder messages. Our results suggest that offering previously vaccinated individuals free rides to vaccination sites is not a good investment in the United States, contrary to the high expectations of both expert and lay forecasters. Instead, people in the United States should be sent behaviourally informed COVID-19 vaccination reminders, which increased the 30-day COVID-19 booster uptake by 21% (1.05 percentage points) and spilled over to increase 30-day influenza vaccinations by 8% (0.34 percentage points) in our megastudy. More rigorous testing of interventions to promote vaccination is needed to ensure that evidence-based solutions are deployed widely and that ineffective but intuitively appealing tools are discontinued.

Personal rights over public Health: Anti-vaccine rhetoric in the Texas Legislature

During the COVID-19 pandemic, there was an observed increase in anti-vaccine sentiment linked with requirements for the vaccines. But how did these ideas impact the politics of vaccines? In this paper, the authors analyze witness statements from the 2021 Texas Legislative Session during vaccine-related hearings. Specifically, the research focused on five hearings for bills that related to vaccine requirements or vaccine transparency laws filed during the 2021Texas Legislative Session and witnesses who opposed these measures. From the 128 witnesses cataloged and analyzed, we found 84 witnesses opposed to vaccines. Medical freedom and the right to opt-out of a medical procedure as well as concerns about vaccine safety and effectiveness were most frequently used by witnesses to justify their stance against vaccine requirements or vaccines. While some witnesses were opposed to all vaccines, most focused their objections on the COVID-19 vaccine specifically.

Low COVID-19 vaccine uptake in people living with HIV and those with hypertension and diabetes without HIV at Mbarara and Masaka regional referral hospitals: A cross-sectional survey

Chronic diseases such as HIV, hypertension, and diabetes increase the risk of severe coronavirus disease 2019 (COVID-19) and death. Thus, COVID-19 vaccine uptake data among these priority populations are needed to inform immunization programs. We assessed COVID-19 vaccine uptake among people living with HIV (PLWH) and those with hypertension/diabetes without HIV (PWoH) in Southwestern and Southcentral Uganda and determined factors influencing vaccination. We conducted a cross-sectional study from January to April 2023. We enrolled a random sample of participants aged 18 years and older seeking HIV, hypertension, or diabetes care at two regional referral hospitals (RRHs) in Mbarara and Masaka in Uganda. Using vaccination records abstraction and interviewer-administered questionnaires, we collected data on COVID-19 vaccine uptake, sociodemographic data, and reasons for non-uptake in unvaccinated persons. We compared COVID-19 vaccination uptake between PLWH and PWoH and applied modified Poisson regression to determine sociodemographic factors associated with vaccine uptake. The reasons for non-vaccine uptake were presented as percentages. Of the 1,376 enrolled participants, 65.6% were fully vaccinated against COVID-19. Vaccination coverage was 65% among PWLH versus 67% among PWoH. Higher education attainment and older age were associated with COVID vaccination. Participants with secondary education and those aged ≥50 years achieved >70% coverage. Fear of side effects was the most cited reason (67%) for non-vaccination among 330 unvaccinated participants, followed by vaccine mistrust (24.5%). People with chronic diseases in Southwestern Uganda had slightly lower than 70% COVID-19 vaccine coverage as recommended by WHO. Higher educational attainment and older age were linked to increased vaccine uptake. However, mistrust and fear of vaccine side effects were the main reasons for non-vaccination. To increase COVID-19 vaccine uptake, programs must reach those with lower educational attainment and younger age groups, and address the fear of vaccine side effects and mistrust among persons with underlying diseases in Uganda.

Motivators and Demotivators for COVID-19 Vaccination Based on Co-Occurrence Networks of Verbal Reasons for Vaccination Acceptance and Resistance: Repetitive Cross-Sectional Surveys and Network Analysis

BACKGROUND

Vaccine hesitancy is complex and multifaced. People may accept or reject a vaccine due to multiple and interconnected reasons, with some reasons being more salient in influencing vaccine acceptance or resistance and hence the most important intervention targets for addressing vaccine hesitancy.

OBJECTIVE

This study was aimed at assessing the connections and relative importance of motivators and demotivators for COVID-19 vaccination in Hong Kong based on co-occurrence networks of verbal reasons for vaccination acceptance and resistance from repetitive cross-sectional surveys.

METHODS

We conducted a series of random digit dialing telephone surveys to examine COVID-19 vaccine hesitancy among general Hong Kong adults between March 2021 and July 2022. A total of 5559 and 982 participants provided verbal reasons for accepting and resisting (rejecting or hesitating) a COVID-19 vaccine, respectively. The verbal reasons were initially coded to generate categories of motivators and demotivators for COVID-19 vaccination using a bottom-up approach. Then, all the generated codes were mapped onto the 5C model of vaccine hesitancy. On the basis of the identified reasons, we conducted a co-occurrence network analysis to understand how motivating or demotivating reasons were comentioned to shape people's vaccination decisions. Each reason's eigenvector centrality was calculated to quantify their relative importance in the network. Analyses were also stratified by age group.

RESULTS

The co-occurrence network analysis found that the perception of personal risk to the disease (egicentrality=0.80) and the social responsibility to protect others (egicentrality=0.58) were the most important comentioned reasons that motivate COVID-19 vaccination, while lack of vaccine confidence (egicentrality=0.89) and complacency (perceived low disease risk and low importance of vaccination; egicentrality=0.45) were the most important comentioned reasons that demotivate COVID-19 vaccination. For older people aged ≥65 years, protecting others was a more important motivator (egicentrality=0.57), while the concern about poor health status was a more important demotivator (egicentrality=0.42); for young people aged 18 to 24 years, recovering life normalcy (egicentrality=0.20) and vaccine mandates (egicentrality=0.26) were the more important motivators, while complacency (egicentrality=0.77) was a more important demotivator for COVID-19 vaccination uptake.

CONCLUSIONS

When disease risk is perceived to be high, promoting social responsibility to protect others is more important for boosting vaccination acceptance. However, when disease risk is perceived to be low and complacency exists, fostering confidence in vaccines to address vaccine hesitancy becomes more important. Interventions for promoting vaccination acceptance and reducing vaccine hesitancy should be tailored by age.

How perceived coercion polarizes unvaccinated people: The mediating role of conspiracy beliefs

During the COVID-19 pandemic, different policies were implemented to increase vaccination uptake. Meanwhile, conspiracy theories spread widely, and vaccinated versus unvaccinated people increasingly polarized against each other. This study examined the associations between perceived vaccination coercion, conspiracy beliefs and polarization. We tested the relationship of vaccination status with perceived vaccination coercion, conspiracy beliefs, and polarization, with a total sample size of N = 1202 (n = 400 in China, n = 401 in the US, and n = 401 in the UK), among them n = 603 were vaccinated and n = 599 were unvaccinated. As pre-registered, unvaccinated people perceived more vaccination coercion and endorsed more conspiracy theories. Conspiracy mentality was positively related to perceived coercion. Contrary to our hypotheses, vaccinated people were more polarized toward unvaccinated people than vice versa. Finally, conspiracy beliefs mediated the link between perceived coercion and polarization among unvaccinated people.

Public attitudes towards COVID-19 vaccine mandates and vaccine certificates in Canada: a time series study

INTRODUCTION

Since the beginning of the pandemic, numerous public health measures such as COVID-19 vaccines, vaccine mandates and vaccination certificates have been introduced to mitigate the spread of COVID-19. Public opinion and attitudes towards these measures have fluctuated in response to the dynamic political, social, and cultural landscape of the pandemic.

METHODS

We conducted a time-series study consisting of national cross-sectional surveys between November 2021 to March 2022 to evaluate the Canadian public's attitudes towards COVID-19 vaccine mandates and vaccine certificates.

RESULTS

When examining public sentiment towards COVID-19 vaccine certificates and proof of vaccination measures, there was a shift in responses over time. The proportion of participants "strongly supporting" these measures decreased from 66.0 to 43.1% between W25(Capacity Limits), -W32 (Mask Mandate Removed), whereas "strongly oppose" was the second most common response and rose from 15.9 to 20.6% during this same time period. Concurrently, when examining participants views surrounding mandates, many participants believed that their province was reopening at "about the right pace", which remained relatively stable over time (33.0-35.4%) between W28 (Emergency Act)-W32 (Mask Mandate Removed).

CONCLUSION

Our study's findings on the public's attitudes towards COVID-19 vaccine mandates and vaccine certificates in Canada may aid to guide and streamline the implementation of future similar public health interventions. Future research should include extended follow-up and a more comprehensive examination of trust in government institutions and polarized perspectives on vaccine mandates.

Vaccine conspiracy association with higher COVID-19 vaccination side effects and negative attitude towards booster COVID-19, influenza and monkeypox vaccines: A pilot study in Saudi Universities

Conspiracies regarding vaccines are widely prevalent, with negative consequences on health-seeking behaviors. The current study aimed to investigate the possible association between the embrace of vaccine conspiracies and the attitude to booster COVID-19, seasonal influenza, and monkeypox (mpox) vaccinations as well as the perceived side effects following COVID-19 vaccination. The target population involved academic staff and university students in health colleges in the Kingdom of Saudi Arabia. A self-administered questionnaire was distributed in January 2023 to collect data on participants' demographics, self-reported side effects following each dose, willingness to get booster COVID-19, seasonal influenza, and mpox vaccinations, as well as an evaluation of vaccine conspiracies and attitude to mandatory vaccination. Among the 273 participants, the willingness to receive yearly booster COVID-19 vaccination was observed among 26.0% of the participants, while it was 46.9% and 34.1% for seasonal influenza and mpox vaccinations, respectively. Multinomial logistic regression analyses demonstrated a significant correlation between endorsing vaccine conspiracies and higher frequency of self-reported side effects following uptake of the second and third doses of COVID-19 vaccines. Vaccine conspiracies were also correlated with attitude toward booster COVID-19, influenza, mpox, and mandatory vaccination. The findings of this pilot study highlighted the potential adverse impact of the preexisting notions and negative attitudes toward vaccines, which could have contributed to heightened perceived side effects following COVID-19 vaccination. The study also highlighted the ongoing divisions concerning mandatory vaccination policies, emphasizing the need for cautious implementation of this strategy as a last resort for public health benefit.

Impact of a hypothetical COVID-19 vaccine mandate on parental likelihood to vaccinate children: Exploring school-related concerns and vaccination decision-making

OBJECTIVE

We assessed the impact of a hypothetical school-entry COVID-19 vaccine mandate on parental likelihood to vaccinate their child.

METHODS

We collected demographics, COVID-19-related school concerns, and parental likelihood to vaccinate their child from parents of patients aged 3-16 years seen across nine pediatric Emergency Departments from 06/07/2021 to 08/13/2021. Wilcoxon signed-rank test compared pre- and post-mandate vaccination likelihood. Multivariate linear and logistic regression analyses explored associations between parental concerns with baseline and change in vaccination likelihood, respectively.

RESULTS

Vaccination likelihood increased from 43% to 50% with a hypothetical vaccine mandate (Z = -6.69, p < 0.001), although most parents (63%) had no change, while 26% increased and 11% decreased their vaccination likelihood. Parent concerns about their child contracting COVID-19 was associated with greater baseline vaccination likelihood. No single school-related concern explained the increased vaccination likelihood with a mandate.

CONCLUSION

Parental school-related concerns did not drive changes in likelihood to vaccinate with a mandate.

Unraveling the association between vaccine attitude, vaccine conspiracies and self-reported side effects following COVID-19 vaccination among nurses and physicians in Jordan

Background

The negative impact of vaccine conspiracies is linked with negative health behavior. The aim of the current study was to examine the association between attitudes toward booster COVID-19, influenza, and monkeypox (mpox) vaccinations with post-COVID-19 vaccine side effects, vaccine conspiracies, and attitude towards mandatory vaccination among nurses and physicians in Jordan.

Methods

A structured closed-ended questionnaire was used to collect data on demographics, COVID-19 history, COVID-19 vaccine type and doses received, self-reported side effects post-COVID-19 vaccination, acceptance of booster COVID-19, seasonal influenza, and mpox vaccinations, attitudes towards mandatory vaccination, and beliefs in vaccine conspiracies.

Results

The study sample comprised a total of 341 participants. Acceptance of yearly booster COVID-19 vaccination was expressed by 46.6% of the sample, while 73.3% accepted seasonal influenza vaccination, and only 37.0% accepted mpox vaccination. A higher frequency of self-reported side effects following the first COVID-19 vaccine dose was associated with embrace of vaccine conspiracies and vaccine type. For the second vaccine dose, a higher frequency of self-reported side effects was associated with the embrace of vaccine conspiracies, older age, and affiliation to private sector. In multinomial logistic regression analyses, the lower embrace of vaccine conspiracies was associated with lower odds of reporting side effects post-COVID-19 vaccination. The lower embrace of vaccine conspiracies and favorable attitude towards mandatory vaccination were associated with the willingness to get COVID-19, influenza, and mpox vaccinations.

Conclusion

The study findings highlighted the negative impact of embracing vaccine conspiracies on health-seeking behavior among nurses and physicians. The findings indicated that the willingness to get vaccinated was associated with lower endorsement of vaccine conspiracies. Additionally, the lower embrace of vaccine conspiracies was associated with a lower frequency of self-reported side effects following COVID-19 vaccination. These results emphasize the importance of addressing vaccine misinformation and promoting accurate information to ensure optimal vaccine uptake and public health outcomes.

Achieving COVID-19 vaccination equity in South Eastern Metropolitan Victoria, Australia: a population-based study

Background

We describe COVID-19 first and second vaccine uptake across Local Government Areas (LGAs) in Victoria using southeast metropolitan Melbourne catchment as a case study. We explore key policy and implementation strategies that contributed to equitable uptake.

Methods

Population level data within the South East Public Health Unit (SEPHU) was used to compare trends in COVID-19 vaccination first and second dose uptake for each of the 11 LGAs in year 2021. Changes in vaccination uptake over the year were reviewed against social and public health measures used during the COVID-19 pandemic in Victoria and strategies in the SEPHU vaccination program.

Findings

By September 2021, 57% of the eligible population in the least disadvantaged LGA, Bayside, had received their second dose vaccination compared to 32% in the most disadvantaged LGA, Greater Dandenong. By end of 2021, the gap had narrowed with 95% in Bayside and 92% in Greater Dandenong having received their second dose. The increase in vaccination uptake for both LGAs was bimodal. Government policies on vaccine eligibility and the opening of mass vaccination sites preceded the first peak in vaccination uptake. Strong community engagement, addressing misinformation, providing culturally appropriate vaccination services and mass outbreaks preceded the second peak in vaccination uptake.

Interpretation

Vaccine equity across culturally and economically diverse populations can be achieved through a combination of robust, targeted community engagement, mass deployment of appropriate workforce, vaccination services tailored to cultural needs and sensitivities and accessibility to mass vaccination sites on a backdrop of state-wide policies that incentivise vaccination.

Funding

None.

Exploring COVID-19 education to support vaccine confidence amongst the general adult population with special considerations for healthcare and long-term care staff: A scoping review

Background

Despite the demonstrated efficacy of approved COVID-19 vaccines, high levels of hesitancy were observed in the first few months of the COVID-19 vaccines' rollout. Factors contributing to vaccine hesitancy are well-described in the literature. Among the various strategies for promoting vaccine confidence, educational interventions provide a foundationally and widely implemented set of approaches for supporting individuals in their vaccine decisions. However, the evidence around the measurable impact of various educational strategies to improve vaccine confidence is limited. We conducted a scoping review with the aim of exploring and characterizing educational interventions delivered during the pandemic to support COVID-19 vaccine confidence in adults.

Methods

We developed a search strategy with a medical information scientist and searched five databases, including Ovid MEDLINE and Web of Science, as well as grey literature. We considered all study designs and reports. Interventions delivered to children or adolescents, interventions on non-COVID-19 vaccines, as well as national or mass vaccination campaigns without documented interaction(s) between facilitator(s) and a specific audience were excluded. Articles were independently screened by three reviewers. After screening 4602 titles and abstracts and 174 full-text articles across two rounds of searches, 22 articles met our inclusion criteria. Ten additional studies were identified through hand searching. Data from included studies were charted and results were described narratively.

Results

We included 32 studies and synthesized their educational delivery structure, participants (i.e., facilitators and priority audience), and content. Formal, group-based presentations were the most common type of educational intervention in the included studies (75%). A third of studies (34%) used multiple strategies, with many formal group-based presentations being coupled with additional individual-based interventions (29%). Given the novelty of the COVID-19 vaccines and the unique current context, studies reported personalized conversations, question periods, and addressing misinformation as important components of the educational approaches reviewed.

Conclusions

Various educational interventions were delivered during the COVID-19 pandemic, with many initiatives involving multifaceted interventions utilizing both formal and informal approaches that leveraged community (cultural, religious) partnerships when developing and facilitating COVID-19 vaccine education. Train-the-trainer approaches with recognized community members could be of value as trust and personal connections were identified as strong enablers throughout the review.

Vaccination Mandates-An Old Public Health Tool Faces New Challenges

This Viewpoint discusses how federal vaccine requirements have helped thwart vaccine-preventable diseases as well as how growing public resistance to vaccines and judicial and legislative limits to vaccination mandates may change that.

Determinants of COVID-19 vaccine Hesitancy: 2020 California Health Interview Survey

Although the COVID-19 vaccine is a key intervention against the ongoing COVID-19 pandemic, vaccine hesitancy is a barrier to vaccination coverage, leading to a higher risk of COVID-19-related morbidity and mortality. To reduce vaccine hesitancy, the factors affecting it must be addressed. Based on the determinants of health approach, this study aimed to investigate whether the distribution of determinants of health differed between the vaccine hesitancy group and the vaccine acceptance group and to identify determinants of participants' hesitancy to receive the COVID-19 vaccine if it was available. This study utilized the 2020 California Health Interview Survey Data collected between May and December 2020. Data were collected using a population-based web and telephone health survey. Data from 21,949 participants in California were included, and 4,183 (23.4 %) showed vaccine hesitancy. The following determinants were positively associated with vaccine hesitancy: female sex, Black and American Indian/Alaskan Native ethnicity, smoking, poverty, U.S.-born citizen, frequent use of social media, food insecurity, and limited healthcare access. Older age, not having severe psychological distress, not having diabetes, and high perceived safety in the neighborhood were negatively associated with COVID-19 vaccine hesitancy. This study also found that higher use of social media potentially threatened vaccine uptake, whereas frequent internet use was negatively associated with vaccine hesitancy. Public health and other relevant service providers should address the determinants of vaccine hesitancy and develop effective strategies and interventions for vaccine-hesitant groups.

Projected Health Outcomes Associated With 3 US Supreme Court Decisions in 2022 on COVID-19 Workplace Protections, Handgun-Carry Restrictions, and Abortion Rights

Importance

Several recent US Supreme Court rulings have drawn criticism from the medical community, but their health consequences have not been quantitatively evaluated.

Objective

To model health outcomes associated with 3 Supreme Court rulings in 2022 that invalidated workplace COVID-19 vaccine or mask-and-test requirements, voided state handgun-carry restrictions, and revoked the constitutional right to abortion.

Design, Setting, and Participants

This decision analytical modeling study estimated outcomes associated with 3 Supreme Court rulings in 2022: (1) National Federation of Independent Business v Department of Labor, Occupational Safety and Health Administration (OSHA), which invalidated COVID-19 workplace protections; (2) New York State Rifle and Pistol Association Inc v Bruen, Superintendent of New York State Police (Bruen), which voided state laws restricting handgun carry; and (3) Dobbs v Jackson Women's Health Organization (Dobbs), which revoked the constitutional right to abortion. Data analysis was performed from July 1, 2022, to April 7, 2023.

Main Outcomes and Measures

For the OSHA ruling, multiple data sources were used to calculate deaths attributable to COVID-19 among unvaccinated workers from January 4 to May 28, 2022, and the share of these deaths that would have been prevented by the voided protections. To model the Bruen decision, published estimates of the consequences of right-to-carry laws were applied to 2020 firearm-related deaths (and injuries) in 7 affected jurisdictions. For the Dobbs ruling, the model assessed unwanted pregnancy continuations, resulting from the change in distance to the closest abortion facility, and then excess deaths (and peripartum complications) from forcing these unwanted pregnancies to term.

Results

The decision model projected that the OSHA decision was associated with 1402 additional COVID-19 deaths (and 22 830 hospitalizations) in early 2022. In addition, the model projected that 152 additional firearm-related deaths (and 377 nonfatal injuries) annually will result from the Bruen decision. Finally, the model projected that 30 440 fewer abortions will occur annually due to current abortion bans stemming from Dobbs, with 76 612 fewer abortions if states at high risk for such bans also were to ban the procedure; these bans will be associated with an estimated 6 to 15 additional pregnancy-related deaths each year, respectively, and hundreds of additional cases of peripartum morbidity.

Conclusions and Relevance

These findings suggest that outcomes from 3 Supreme Court decisions in 2022 could lead to substantial harms to public health, including nearly 3000 excess deaths (and possibly many more) over a decade.

Development and Beta-Testing of the CONFIDENCE Intervention to Increase Pediatric COVID-19 Vaccination

INTRODUCTION

Innovative strategies are needed to improve pediatric COVID-19 vaccination rates. We describe the process for developing a clinic-based intervention, CONFIDENCE, to improve pediatric COVID-19 vaccine uptake and present results of our beta-test for feasibility and acceptability.

METHOD

CONFIDENCE included communication training with providers, a poster campaign, and parent-facing educational materials. We assessed feasibility and acceptability through interviews and measured preliminary vaccine intention outcomes with a pre-post parent survey. Interviews were analyzed using rapid qualitative methods. We generated descriptive statistics for variables on the parent survey and used Fisher's exact test to assess pre-post differences.

RESULTS

Participating providers (n = 4) reported high levels of feasibility and acceptability. We observed positive trends in parents' (n = 69) reports of discussing vaccination with their provider and the parental decision to accept COVID-19 vaccination.

DISCUSSION

Our next steps will be to use more rigorous methods to establish the efficacy and effectiveness of the CONFIDENCE intervention.

Factors Affecting the Public Intention to Repeat the COVID-19 Vaccination: Implications for Vaccine Communication

Although most of the pandemic-related mandatory restrictions have been lifted or eased, vaccination is still recommended as an effective measure to minimize the damage from COVID-19 infection. Since COVID-19 eradication is unlikely, it is necessary to understand the factors affecting the public's vaccination intention when COVID-19 vaccination is continuously recommended. This study aims to explore the factors that affect the intention to repeat the COVID-19 vaccination in South Korea. An online survey was conducted in January 2022 with adults living in Gyeonggi-do, South Korea. In a hierarchical logistic regression analysis, sociodemographic factors, COVID-19 infection-related factors, COVID-19 vaccination-related factors, sociocultural factors, and communication factors were taken into account. In this study, more than three-quarters (78.1%) of Koreans were willing to repeat the COVID-19 vaccination. People who had high-risk perceptions, had been vaccinated against COVID-19 at least once, had more authoritarian attitudes, regarded the vaccination as a social responsibility, and had positive attitudes toward health authorities' regular briefings were more likely to repeat the vaccination. In contrast, those who directly or indirectly experienced COVID-19 vaccine side effects and who showed psychological reactance against the government's vaccination recommendation were less likely to repeat the vaccination. Our research indicates that empathetic communication, promotion of the prosocial aspect of vaccination, and regular and transparent provision of vaccine information are essential for promoting the intention to repeat the COVID-19 vaccination.

Safety and immunogenicity of a protein subunit COVID-19 vaccine (ZF2001) in healthy children and adolescents aged 3-17 years in China: a randomised, double-blind, placebo-controlled, phase 1 trial and an open-label, non-randomised, non-inferiority, phase 2 trial

BACKGROUND

ZF2001 is a recombinant protein subunit vaccine against SARS-CoV-2 that has been approved for use in China, Colombia, Indonesia, and Uzbekistan in adults aged 18 years or older, but not yet in children and adolescents younger than 18 years. We aimed to evaluate the safety and immunogenicity of ZF2001 in children and adolescents aged 3-17 years in China.

METHODS

The randomised, double-blind, placebo-controlled, phase 1 trial and the open-label, non-randomised, non-inferiority, phase 2 trial were done at the Xiangtan Center for Disease Control and Prevention (Hunan Province, China). Healthy children and adolescents aged 3-17 years, without a history of SARS-CoV-2 vaccination, without a history of COVID-19, without COVID-19 at the time of the study, and without contact with patients with confirmed or suspected COVID-19 were included in the phase 1 and phase 2 trials. In the phase 1 trial, participants were divided into three groups according to age (3-5 years, 6-11 years, and 12-17 years). Each group was randomly assigned (4:1), using block randomisation with five blocks, each with a block size of five, to receive three 25 μg doses of the vaccine, ZF2001, or placebo intramuscularly in the arm 30 days apart. The participants and investigators were masked to treatment allocation. In the phase 2 trial, participants received three 25 μg doses of ZF2001 30 days apart and remained stratified by age group. For phase 1, the primary endpoint was safety and the secondary endpoint was immunogenicity (humoral immune response on day 30 after the third vaccine dose: geometric mean titre [GMT] of prototype SARS-CoV-2 neutralising antibodies and seroconversion rate, and geometric mean concentration [GMC] of prototype SARS-CoV-2 receptor-binding domain [RBD]-binding IgG antibodies and seroconversion rate). For phase 2, the primary endpoint was the GMT of SARS-CoV-2 neutralising antibodies with seroconversion rate on day 14 after the third vaccine dose, and the secondary endpoints included the GMT of RBD-binding antibodies and seroconversion rate on day 14 after the third vaccine dose, the GMT of neutralising antibodies against the omicron BA.2 subvariant and seroconversion rate on day 14 after the third vaccine dose, and safety. Safety was analysed in participants who received at least one dose of the vaccine or placebo. Immunogenicity was analysed in the full-analysis set (ie, participants who received at least one dose and had antibody results) by intention to treat and in the per-protocol set (ie, participants who completed the whole vaccination course and had antibody results). Non-inferiority in the phase 2 trial (neutralising antibody titre of participants from this trial aged 3-17 years vs that of participants aged 18-59 years from a separate phase 3 trial) for clinical outcome assessment was based on the geometric mean ratio (GMR) and was considered met if the lower bound of the 95% CI for the GMR was 0·67 or greater. These trials are registered with ClinicalTrials.gov, NCT04961359 (phase 1) and NCT05109598 (phase 2).

FINDINGS

Between July 10 and Sept 4, 2021, 75 children and adolescents were randomly assigned to receive ZF2001 (n=60) or placebo (n=15) in the phase 1 trial and were included in safety and immunogenicity analyses. Between Nov 5, 2021, and Feb 14, 2022, 400 participants (130 aged 3-7 years, 210 aged 6-11 years, and 60 aged 12-17 years) were included in the phase 2 trial and were included in the safety analysis; six participants were excluded from the immunogenicity analyses. 25 (42%) of 60 participants in the ZF2001 group and seven (47%) of 15 participants in the placebo group in phase 1, and 179 (45%) of 400 participants in phase 2, had adverse events within 30 days after the third vaccination, without a significant difference between groups in phase 1. Most adverse events were grade 1 or 2 (73 [97%] of 75 in the phase 1 trial, and 391 [98%] of 400 in the phase 2 trial). One participant in the phase 1 trial and three in the phase 2 trial who received ZF2001 had serious adverse events. One serious adverse event (acute allergic dermatitis) in the phase 2 trial was possibly related to the vaccine. In the phase 1 trial, on day 30 after the third dose, in the ZF2001 group, seroconversion of neutralising antibodies against SARS-CoV-2 was observed in 56 (93%; 95% CI 84-98) of 60 participants, with a GMT of 176·5 (95% CI 118·6-262·8), and seroconversion of RBD-binding antibodies was observed in all 60 (100%; 95% CI 94-100) participants, with a GMC of 47·7 IU/mL (95% CI 40·1-56·6). In the phase 2 trial, on day 14 after the third dose, seroconversion of neutralising antibodies against SARS-CoV-2 was seen in 392 (99%; 95% CI 98-100) participants, with a GMT of 245·4 (95% CI 220·0-273·7), and seroconversion of RBD-binding antibodies was observed in all 394 (100%; 99-100) participants, with a GMT of 8021 (7366-8734). On day 14 after the third dose, seroconversion of neutralising antibodies against the omicron subvariant BA.2 was observed in 375 (95%; 95% CI 93-97) of 394 participants, with a GMT of 42·9 (95% CI 37·9-48·5). For the non-inferiority comparison of participants aged 3-17 years with those aged 18-59 years for SARS-CoV-2 neutralising antibodies, the adjusted GMR was 8·6 (95% CI 7·0-10·4), with the lower bound of the GMR greater than 0·67.

INTERPRETATION

ZF2001 is safe, well tolerated, and immunogenic in children and adolescents aged 3-17 years. Vaccine-elicited sera can neutralise the omicron BA.2 subvariant, but with reduced activity. The results support further studies of ZF2001 in children and adolescents.

FUNDING

Anhui Zhifei Longcom Biopharmaceutical and the Excellent Young Scientist Program from National Natural Science Foundation of China.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

COVID-19 Vaccination Program Data Analysis Based on Regional Status and Day Type: A Study from West Java Province, Indonesia

Vaccination is a strategy to control the COVID-19 pandemic and holds a crucial impact on global health. A better understanding of factors associated with vaccination is needed to establish a good vaccination program in a population. The purpose of this study is to analyze COVID-19 vaccination program data based on regional status and day type in the West Java Province of Indonesia and contribute to discovering other characteristics of the COVID-19 vaccination program. This study is a cross-sectional study using secondary data (N = 7922) from West Java's COVID-19 Information and Coordination Center (PIKOBAR) from January to November 2021. Independent t-test with an alternative non-parametric Mann-Whitney U test (p-value < 0.05) is used as a statistical test in this study. The result reported significant differences in vaccination coverage between the city area and the regency area (p < 0.001). Significant differences in vaccination on working day and holiday were also found in both settings (p < 0.001). Vaccination was confirmed to be higher in the city compared to the regency and decreased on holiday compared to the working day. In conclusion, factors linked to regional status and day type must be considered as important factors for developing and accelerating vaccination programs.

Increases In COVID-19 Vaccination Among NYC Municipal Employees After Implementation Of Vaccination Requirements

In July 2021 New York City (NYC) instituted a requirement for all municipal employees to be vaccinated against COVID-19 or undergo weekly testing. The city eliminated the testing option November 1 of that year. We used general linear regression to compare changes in weekly primary vaccination series completion among NYC municipal employees ages 18-64 living in the city and a comparison group of all other NYC residents in this age group during May-December 2021. The rate of change in vaccination prevalence among NYC municipal employees was greater than that of the comparison group only after the testing option was eliminated (employee slope = 12.0; comparison slope = 5.3). Among racial and ethnic groups, the rate of change in vaccination prevalence among municipal employees was higher than the comparison group for Black and White people. The requirements were associated with narrowing the gap in vaccination prevalence between municipal employees and the comparison group overall and between Black municipal employees and employees from other racial and ethnic groups. Workplace requirements are a promising strategy for increasing vaccination among adults and reducing racial and ethnic disparities in vaccination uptake.

Factors Affecting Vaccine Attitudes Influenced by the COVID-19 Pandemic

The development of vaccines has significantly contributed to the success of disease prevention. However, there has been a sharp decline in immunization rates since COVID-19 spread globally. Seemingly overnight, the world shut down and most non-essential medical procedures were postponed. Since the COVID-19 vaccine became available, and the world started going back to normal these vaccine rates have not recovered. In this paper, we review the published literature to explore how convenience factors, perceived risk of vaccination, media or anti-vaccination ideals/movements, and healthcare professionals affect an individual’s compliance to be vaccinated to better understand the factors that contribute to the change in overall vaccination rates.

Indiana Parental Perceptions of the Acceptability of General and HPV-Specific State Vaccine Requirements

State vaccine requirements are a tool for improving child and adolescent vaccination immunization coverage, but to be effective, parental buy-in is needed. The objective of this study was to assess the demographic, healthcare characteristics, and health beliefs associated with parental acceptance of general and HPV-specific state vaccine requirements. Indiana parents (N = 601) with children ages 11-17 years old completed a survey during March 2020.Results showed that 47.2% and 43.1% of parents believed there should always be general and HPV-specific state vaccine requirements, respectively. In multivariable analysis, higher odds of parental support for general state vaccine requirements were associated with being unsure whether HPV-associated cancer is a problem in the participant's county and having higher perceived benefits of HPV vaccines. Lower odds were associated with private insurance, having less than a bachelor's degree, and having less confidence in vaccines. In comparison, parents had higher odds of agreeing with HPV-specific state vaccine requirements if they reported higher interpersonal altruism and higher perceived benefits of HPV vaccines; they had lower odds if they were non-Hispanic White. Findings indicate that while similar percentages of parents agreed with general and HPV-specific state vaccine requirements, there were different characteristics associated with acceptance of each. Results can inform the development of tailored interventions for improving parental support for general and HPV-specific state vaccine requirements.

A survey of COVID-19 vaccine acceptance across 23 countries in 2022

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continued to mutate and spread in 2022 despite the introduction of safe, effective vaccines and medications. Vaccine hesitancy remains substantial, fueled in part by misinformation. Our third study of Coronavirus Disease 2019 (COVID-19) vaccine hesitancy among 23,000 respondents in 23 countries (Brazil, Canada, China, Ecuador, France, Germany, Ghana, India, Italy, Kenya, Mexico, Nigeria, Peru, Poland, Russia, Singapore, South Africa, South Korea, Spain, Sweden, Turkey, the United Kingdom and the United States), surveyed from 29 June to 10 July 2022, found willingness to accept vaccination at 79.1%, up 5.2% from June 2021. Hesitancy increased in eight countries, however, ranging from 1.0% (United Kingdom) to 21.1% (South Africa). Almost one in eight (12.1%) vaccinated respondents are hesitant about booster doses. Overall support for vaccinating children under 18 years of age increased slightly but declined among parents who were personally hesitant. Almost two in five (38.6%) respondents reported paying less attention to new COVID-19 information than previously, and support for vaccination mandates decreased. Almost a quarter (24%) of those who became ill reported taking medications to combat COVID-19 symptoms. Vaccination remains a cornerstone of the COVID-19 pandemic response, but broad public support remains elusive. These data can be used by health system decisionmakers, practitioners, advocates and researchers to address COVID-19 vaccine hesitancy more effectively.

Vaccine Mandates in the COVID-19 Era: Changing Paradigm or Public Health Opportunity? Comment on "Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates"

The debate around vaccine mandates has flourished over the last decade, with several countries introducing or extending mandatory childhood vaccinations. In a recent study, Attwell and Hannah explore how functional and political pressures added to public health threats in selected countries, motivating governments to increase the coerciveness of their childhood vaccine regimes. In this commentary, we reflect on whether such model applies to the coronavirus disease 2019 (COVID-19) case and how the pandemic has re-shuffled the deck around vaccine mandates. We identify COVID-19 immunisation policies' distinctive aspects as we make the case of countries implementing mass immunisation programmes while relying on digital COVID-19 certificates as an indirect form of mandate to increase vaccine uptake. We conclude by acknowledging that different forms of mandatory vaccination might serve as a shortcut to protect population health in times of emergency, underlining, however, that the ultimate public health goal is to promote voluntary, informed, and responsible adherence to preventive behaviours.