Barriers and facilitators of vaccine hesitancy for COVID-19, influenza, and pertussis during pregnancy and in mothers of infants under two years: An umbrella review

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

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

Attitudes towards vaccination against COVID-19 during pregnancy and its determinants among people of reproductive age

The attitudes of reproductive-age individuals toward COVID-19 vaccination during pregnancy are still not well understood. We aimed to explore the attitudes toward COVID-19 vaccines during pregnancy and the determinants among the Chinese reproductive-age population. An anonymous cross-sectional study was conducted in China from July 4 to August 11, 2023. Structured questionnaires on vaccine hesitancy during pregnancy, socio-demographic characteristics, behavior characteristics, health-related factors, and mental health status were sent online to reproductive-age individuals (both males and females). Among 2966 participants of reproductive age, 86.9% exhibited significant hesitancy toward receiving the COVID-19 vaccine during pregnancy. Participants of older age (30-34: aOR = 1.71, 95% CI: 1.62-2.52; 35-39: aOR = 1.72, 95% CI: 1.11-2.66), nonsmokers (aOR = 1.42, 95% CI: 1.07-1.89), with a longer duration since their last COVID-19 vaccination (aOR = 2.37, 95% CI: 1.20-4.70), and exhibiting marked pandemic fatigue (moderate: aOR = 1.98, 95% CI: 1.56-2.52; high: aOR = 3.49, 95% CI: 2.41-5.05) were prone to refuse COVID-19 vaccines during pregnancy. The presence of generalized anxiety disorder may push the vaccination (aOR = 0.75, 95% CI: 0.57-0.99). The top three reasons for hesitation were concerns about the adverse health effects of vaccines on pregnant women (77.72%), fetuses (72.13%), and newborns/infants (58.77%), respectively. Therefore, under the context of the existing circumstances and the WHO's encouragement, this study provides data support for possible future policy changes and emphasizes the importance of public health strategies.

Knowledge, attitudes, barriers and uptake rate of influenza virus vaccine among children from 6 months to 5 years of age in Jordan: a multicentric cross-sectional study

BACKGROUND

Vaccination against influenza is the major primary preventive measure to reduce the major health and economic burden of influenza infections. Children aged 6 months to five years, have been identified as the highest risk group for influenza complications, therefore, it is essential to ensure a high uptake rate of influenza vaccine amongst this age group.

METHODS

A structured questionnaire based on the Health Belief Model was used to collect data from parents through face-to-face interview on influenza vaccine uptake among children from 6 months to 5 years of age in Jordan. It also aimed to assess knowledge, attitudes and barriers towards influenza vaccine for this age group.

RESULTS

477 parents completed the study questionnaire. The study revealed a low influenza vaccine uptake rate of 12.0% for the 2022/2023 influenza season. Around one fifth (19.3%) of study participants reported to ever had their child vaccinated against influenza. The study identified several factors motivating parents to get their children vaccinated; such as healthcare professional advice, higher income and history of previous severe influenza infection requiring hospitalization. On the other hand, several barriers related to influenza vaccine were identified; such as cost and concerns about the vaccine safety.

CONCLUSIONS

There is an overall low uptake of influenza vaccine amongst children in Jordan. There is a need for public health programs and more involvement of the healthcare professionals to improve the reported rates of vaccination from Jordan. This is in addition to focusing these programs on reported barriers for the influenza vaccine uptake.

Safety and Efficacy of Vaccination During Lactation: A Comprehensive Review of Vaccines for Maternal and Infant Health Utilizing a Large Language Model Citation Screening System

Newborns are born with an immature immune system, making them susceptible to infections early in life. Human milk provides essential nutrients and immunological factors that support infant immunity. Maternal vaccination during lactation has the potential to enhance these benefits by triggering an immune response in the mother, potentially extending protection to her child. However, lactating individuals are often excluded from vaccine trials, leading to uncertainties about vaccine safety and efficacy during the postpartum period. This study critically evaluates the effectiveness of vaccines in enhancing the immune-supporting properties of human milk and assesses their safety and efficacy for lactating mothers and their infants. By examining potential benefits alongside safety concerns, we aim to provide a comprehensive understanding of postpartum vaccination's impact on maternal and infant health. We utilized large-language models (LLMs) to enhance the review process and performed a structured literature search across Ovid/Medline, Embase, and Clarivate Analytics using terms like "breastfeeding", "postpartum", and "vaccination". A three-stage screening process involving human and LLM-assisted evaluation focused on postpartum vaccines and their implications for maternal and infant health. We identified 73 studies covering vaccines against COVID-19, cholera, influenza, pertussis, pneumococcal, rabies, polio, rotavirus, rubella, varicella, typhoid, smallpox, and yellow fever. Most vaccines, such as those for COVID-19 and influenza, appear safe and effective for postpartum use without requiring precautionary measures. However, caution is advised with vaccines such as the yellow fever vaccine, where temporary breastfeeding cessation is recommended. Overall, this review underscores the compatibility of most vaccines with lactation and suggests its benefits for both mother and infant.

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

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

Appraisal of umbrella reviews on vaccines

Umbrella reviews are systematic reviews of all systematic reviews on a given question and can provide a higher-level view of current available evidence on broad research topics. Given the importance and possible consequences of the insights derived from umbrella reviews, it is fundamental to ensure accurate, comprehensive reporting and methodological rigor in these papers. Here, we present the potential and limitations of these evolving evidence synthesis tools by looking at umbrella reviews published on vaccine research. Vaccines are essential tools in modern medicine for preventing disease and promoting public health. The scientific literature on vaccines grows rapidly as researchers work to improve existing vaccines and develop new ones. More than half a million scientific papers on vaccines have already been published, including several thousands of systematic reviews that aim to appraise and summarize this growing literature. However, as the published systematic reviews are only able to cover a small proportion of the literature it is important to also provide higher-level evidence syntheses. and discuss further improvements that could be made to integrate evidence on vaccines.

Assessment of COVID-19 Vaccine Knowledge, Uptake, and Factors Influencing its Uptake Among Medical Students at the University of Jos

Background

COVID-19 vaccination is crucial to containing the pandemic. COVID-19 vaccine knowledge, attitudes, and uptake among medical students are vital, as they are future healthcare professionals expected to promote vaccination. This study assessed the knowledge of the COVID-19 vaccine, its uptake, and associated factors among medical students.

Methodology

A cross-sectional study was conducted among 245 medical students at the University of Jos, Nigeria. Participants were selected using stratified random sampling. Data was collected via a self-administered questionnaire and analysed using descriptive and inferential statistics.

Results

The median knowledge score was 8, with an interquartile range (IQR) of 3. Most participants had low knowledge of the COVID-19 vaccine (65.7%), while a minority had high knowledge (34.3%). The overall vaccine coverage was 20%. Gender and tribe were significantly associated with vaccine uptake. Males were more likely to receive the vaccine than females (24.3% vs. 12.9%, p = 0.039), and participants from the Igbo tribe were less likely to receive the vaccine than those from the Yoruba tribe (0% vs. 29.4%, p = 0.002). Additionally, being tested for COVID-19 was significantly associated with vaccine uptake (p < 0.001). Factors influencing COVID-19 vaccination decisions were access to accurate information (68.9%, p < 0.001), healthcare professionals' recommendations (31.1%, p < 0.001), concerns about safety and side effects (26.6%, p < 0.006), self-protection (19.5%, p = 0.011), government guidelines (39.6%, p < 0.001), vaccine availability (38.0%, p = 0.005), and the availability and convenience of vaccination centres (33.7%, p < 0.001).

Conclusions

There was low COVID-19 vaccine knowledge and uptake among medical students. Gender, tribe, access to information, healthcare guidance, and practical barriers influenced vaccination decisions. Targeted education and provider involvement are needed to address hesitancy in this critical population.

Factors Influencing COVID-19 Vaccine Hesitancy in Pregnant and Breastfeeding/Puerperium Women: A Cross-Sectional Study

Vaccination among pregnant and breastfeeding women is critical for protecting this vulnerable population and their children. COVID-19 vaccination is recommended both during pregnancy and breastfeeding; however, we still do not fully understand the determinants that influence hesitancy towards COVID-19 vaccination. This study aimed to identify the determinants of vaccine hesitancy in pregnant and breastfeeding, puerperium women. A multicenter, cross-sectional study, involving 435 pregnant and breastfeeding women, was conducted. Vaccination hesitancy was evaluated by administering the Vaccination Attitudes (VAX) Scale and the Zung Anxiety Self-Assessment Scale (SAS) was adopted to measure anxiety levels. Overall, 14% of the participants reported that they did not receive the COVID-19 vaccine, and 78.3% received their first dose during pregnancy or while breastfeeding. The descriptive statistics for the VAX scale showed a total mean score of 3.35 (±1.6), and 75% of participants reported an anxiety index equal to or lower than the threshold. Vaccine hesitancy increased as "adverse events after vaccination" increased (p < 0.01), while SAS levels positively correlated with the participants' mean age (p < 0.05). Investigating the factors influencing vaccine hesitancy enables the development of targeted health policies and SARS-CoV-2 vaccination programs.

What factors influence the uptake of vaccinations amongst pregnant women following the Covid-19 pandemic: A qualitative study

BACKGROUND

Pregnant women and their unborn babies are at increased risk from serious complications, hospitalisation and death from infectious diseases. Vaccinations for influenza (flu), pertussis (whooping cough) and Covid-19 are available for free for pregnant women in the UK, but uptake of these repeatedly remains low. This qualitative study aimed to explore how pregnant women feel about these vaccinations, and what factors influence the uptake of vaccinations amongst pregnant women since the onset of the Covid-19 pandemic.

METHODS

Pregnant women were recruited via two participating hospitals in one geographic area of the UK, and via one community group offering support to pregnant women from ethnic minorities. Semi-structured interviews were conducted remotely using telephone, were anonymised and transcribed, and analysed using thematic analysis.

FINDINGS

Interviews were conducted remotely with 43 pregnant women. The following themes were identified as influencing uptake of vaccinations amongst pregnant women: internal factors and beliefs, vaccination related factors, external influences and Covid-19 and changing perceptions of the pandemic.

DISCUSSION

Findings of this study increase awareness of some of the factors influencing vaccination decisions of pregnant women. It informs practice regarding healthcare professionals' discussions with pregnant women about vaccinations, and future vaccination campaigns and interventions that are targeting an increase in vaccination uptake amongst this population.

Facilitators and barriers to vaccination uptake in pregnancy: A qualitative systematic review

INTRODUCTION

Vaccination during pregnancy protects both the mother and the foetus from vaccine-preventable diseases. However, uptake of the recommended vaccines (influenza, pertussis, COVID-19) by pregnant women remains low in Europe and the USA. Understanding the reasons for this is crucial to inform strategies to increase vaccination rates in pregnant women. This qualitative systematic review aimed to identify the barriers and facilitators to vaccination against influenza, pertussis/whooping cough and COVID-19 during pregnancy and identify possible strategies to increase vaccination rates.

METHODS

We conducted a comprehensive search of electronic databases, including Medline, PsycINFO, CINAHL, Web of Science, WHO database, Embase and grey literature to identify qualitative studies that explored barriers and facilitators to vaccine uptake among pregnant women (PROSPERO CRD42023399488). The search was limited to studies published between 2012 and 2022 conducted in high-income countries with established vaccination programmes during pregnancy. Studies were thematically analysed and underwent quality assessment using the Joanna Briggs Institute validated critical appraisal tool for qualitative research.

RESULTS

Out of 2681 articles screened, 28 studies (n = 1573 participants) were eligible for inclusion. Five overarching themes emerged relating to personal, provider and systemic factors. Barriers to vaccine uptake included concerns about vaccine safety and efficacy, lack of knowledge about vaccines' benefits and necessity, fear of adverse effects on the foetus or mother and low perception of disease severity. Facilitators included recommendations from trusted healthcare providers, easy access to vaccination, clear communication on the benefits and safety of vaccination, and positive social influences from family and friends. Strategies for increasing vaccination uptake included strong and proactive vaccine recommendations by trusted healthcare professionals, provision of vaccines during routine antenatal care, and clear and consistent communication about vaccines addressing pregnant women's concerns.

CONCLUSION

This review highlights the need for interventions that address the identified barriers to vaccine uptake among pregnant women. Recommendation from a healthcare provider can play a significant role in promoting vaccine uptake, as can clear risk/benefit communication and convenient access to vaccination. Addressing concerns about vaccine safety and providing accurate information about vaccines is also important.

SARS-CoV-2-Placental effects and association with stillbirth

SARS-CoV-2 has had a significant impact on pregnancy outcomes due to the effects of the virus and the altered healthcare environment. Stillbirth has been relatively hidden during the COVID-19 pandemic, but a clear link between SARS-CoV-2 and poor fetal outcome emerged in the Alpha and Delta waves. A small minority of women/birthing people who contracted COVID-19 developed SARS-CoV-2 placentitis. In many reported cases this was linked to intrauterine fetal death, although there are cases of delivery just before imminent fetal demise and we shall discuss how some cases are sub-clinical. What is surprising, is that SARS-CoV-2 placentitis is often not associated with severe maternal COVID-19 infection and this makes it difficult to predict. The worst outcomes seem to be with diffuse placental disease which occurs within 21 days of COVID-19 diagnosis. Poor outcomes are often pre-dated by reduced fetal movements but are not associated with ultrasound changes. In some cases, there has also been maternal thrombocytopenia, or coagulation abnormalities, which may provide a clue as to which pregnancies are at risk of fetal demise if a further variant of concern is to emerge. In future, multidisciplinary collaboration and cross-boundary working must be prioritised, to identify quickly such a phenomenon and provide clinicians with clear guidance for reducing fetal death and associated poor outcomes. While we wait to see if COVID-19 brings a future variant of concern, we must focus on appropriate future management of women who have had SARS-CoV-2 placentitis. As a placental condition with an infectious aetiology, SARS-CoV-placentitis is unlikely to recur in a subsequent pregnancy and thus a measured approach to subsequent pregnancy management is needed.

Quantitative Synthesis of Factors Associated with COVID-19 Vaccine Acceptance and Vaccine Hesitancy in 185 Countries

Mass vaccination against COVID-19 is the best method to ensure herd immunity in order to curb the effect of the pandemic on the global economy. It is therefore important to assess the determinants of COVID-19 vaccine acceptance and hesitancy on a global scale. Factors were recorded from cross-sectional studies analyzed with t-Test, ANOVA, correlation, and meta-regression analyses and synthesized to identify global trends in order to inform policy. We registered the protocol (ID: CRD42022350418) and used standard Cochrane methods and PRISMA guidelines to collect and synthesize cross-sectional articles published between January 2020 and August 2023. A total of 67 articles with 576 studies from 185 countries involving 3081,766 participants were included in this synthesis. Global COVID-19 vaccine acceptance was 65.27% (95% CI; 62.72-67.84%), while global vaccine hesitancy stood at 32.1% (95% CI; 29.05-35.17%). One-Way ANOVA showed that there was no significant difference in the percentage Gross Domestic Product spent on vaccine procurement across the World Bank income levels (p < 0.187). There was a significant difference of vaccine acceptance (p < 0.001) and vaccine hesitancy (p < 0.005) across the different World Bank Income levels. World Bank income level had a strong influence on COVID-19 vaccine acceptance (p < 0.0004) and hesitancy (p < 0.003) but percentage Gross Domestic Product spent on vaccine procurement did not. There was no correlation between percentage Gross Domestic Product spent on vaccine procurement and COVID-19 vaccine acceptance (r = -0.11, p < 0.164) or vaccine hesitancy (r = -0.09, p < 0.234). Meta-regression analysis showed that living in an urban setting (OR = 4.83, 95% CI; 0.67-212.8), rural setting (OR = 2.53, 95% CI; 0.29-119.33), older (OR = 1.98, 95% CI; 0.99-4.07), higher education (OR = 1.76, 95% CI; 0.85-3.81), and being a low income earner (OR = 2.85, 95% CI; 0.45-30.63) increased the odds of high COVID-19 vaccine acceptance. Factors that increased the odds of high COVID-19 vaccine hesitancy were no influenza vaccine (OR = 33.06, 95% CI; 5.03-1395.01), mistrust for vaccines (OR = 3.91, 95% CI; 1.92-8.24), complacency (OR = 2.86, 95% CI; 1.02-8.83), pregnancy (OR = 2.3, 95% CI; 0.12-141.76), taking traditional herbs (OR = 2.15, 95% CI; 0.52-10.42), being female (OR = 1.53, 95% CI; 0.78-3.01), and safety concerns (OR = 1.29, 95% CI; 0.67-2.51). We proposed a number of recommendations to increase vaccine acceptance and ensure global herd immunity against COVID-19.

Acceptance of influenza vaccination and associated factors among teachers in China: A cross-sectional study based on health belief model

Teachers played an important role on the transmission of influenza in schools and communities. The study aims to investigate the influenza vaccination coverage and the factors determining flu vaccination acceptance among teachers in Hangzhou, China. A total of 1039 junior high school teachers in Hangzhou were recruited. The self-made questionnaire was used to investigate the influenza vaccine coverage among teachers and the influencing factors of influenza vaccination acceptance. Univariate analysis using the chi-square test and multivariable analysis using binary logistic regression were conducted to determine the relative predictors. The Influenza vaccine coverage among teachers was 5.9% (62/1039). 52.9% of teachers had the intention to receive influenza vaccine, 25.3% (247/977)/21.8% (213/977) of participants was hesitant/did not have the intention to get influenza vaccine. The top three sources for teachers to gain knowledge about influenza were website (72%), TV/radio (66.1%) and social media (58%). Whether get influenza vaccination before, knowledge about influenza and influenza vaccine, the beliefs for the likelihood of catching flu, the severity of getting flu, the effectiveness of influenza vaccine, the possibility of side effects after vaccination, and the troublesome of vaccination, doctors' recommendation, as well as the situation of vaccination among other teachers were the associated factors of influenza vaccination acceptance. The influenza vaccination coverage was low but the intentions were relatively high among junior high school teachers. Future research should focus on the relationship between vaccination acceptance and behavior to increase influenza vaccination rates.

Factors associated with COVID-19 vaccination among pregnant women in Rio De Janeiro City, Brazil

COVID-19 vaccination during pregnancy is safe and effective in reducing the risk of complications. However, the uptake is still below targets worldwide. This study aimed to explore the factors associated with COVID-19 vaccination uptake among pregnant women since data on this topic is scarce in low-to-middle-income countries. A retrospective cohort study included linked data on COVID-19 vaccination and pregnant women who delivered a singleton live birth from August 1, 2021, to July 31, 2022, in Rio de Janeiro City, Brazil. Multiple logistic regression was performed to identify factors associated with vaccination during pregnancy, applying a hierarchical model and describing odds ratio with 95% confidence intervals. Of 65,304 pregnant women included in the study, 53.0% (95% CI, 52-53%) received at least one dose of COVID-19 vaccine during pregnancy. Higher uptake was observed among women aged older than 34 (aOR 1.21, 95%CI 1.15-1.28), black (aOR 1.10, 1.04-1.16), or parda/brown skin colour (aOR 1.05, 1.01-1.09), with less than eight years of education (aOR 1.09, 1.02-1.17), living without a partner (aOR 2.24, 2.16-2.34), more than six antenatal care appointments (aOR 1.92, 1.75-2.09), and having a previous child loss (OR 1.06, 1.02-1.11). These results highlight the need for targeted educational campaigns, trustful communication, and accessibility strategies for specific populations to improve vaccination uptake during pregnancy.

Vaccine hesitancy and knowledge regarding maternal immunization among reproductive age women in central Italy: a cross sectional study

Background

Vaccination in pregnancy offers protection to the mother and the newborn. In Italy, influenza, pertussis, and COVID-19 vaccinations are recommended in pregnancy, but vaccination coverage is still far from the National Immunization Plan goals. We aimed to assess knowledge and attitude on maternal immunization in two groups of Italian women, in pregnancy and in reproductive age (non pregnant).

Methods

A cross sectional study on Italian childbearing age women gathering information on their knowledge on maternal immunization and attitudes to receiving influenza and pertussis vaccines in pregnancy was carried out at the University of Rome Tor Vergata, between September 2019 and February 2020. Logistic and multinomial regressions were chosen as statistical tests for our analysis.

Results

1,031 women participated in the survey by answering the questionnaire. Out of these, 553 (53.6%) women were pregnant, and 478 (46.4%) were in the reproductive age. 37% (204/553) of pregnant women and 41% (198/476) of non pregnant women are aware of the existence of an immunization plan for pregnant women in Italy. The group with age between 20 and 30, for both pregnant women and women in the reproductive age, has a better knowledge of vaccination in pregnancy. Working status is a variable associated with more awareness about vaccination during pregnancy only for pregnant women (OR = 2.34, p < 0.00001). Educational status, trimester of pregnancy and knowledge on the topic are associated with vaccine hesitancy in our multivariate analysis for pregnant women. In the reproductive age group women who had a previous pregnancy are more likely to be hesitant towards vaccination in pregnancy, on the other hand the one with a higher knowledge and educational status are more likely to get vaccinated.

Conclusions

The study highlights the persistent vaccine hesitancy among Italian women of reproductive age and pregnant women. Despite healthcare providers being identified as a reliable source of information, their recommendations alone are insufficient to overcome vaccine hesitancy. Factors such as employment status, educational level, pregnancy trimester, and knowledge about vaccinations during pregnancy influence vaccine hesitancy. Tailored educational interventions and communication campaigns targeting these areas can help reduce vaccine hesitancy and promote maternal immunization.