Increase in Measles Cases - United States, January 1-April 26, 2019

Dynamics of measles immunity from birth and following vaccination

Measles remains a major threat to human health despite widespread vaccination. While we know that maternal antibodies can impair vaccine-induced immunity, the relative contributions of pre-existing immunity levels, maternal and infant characteristics on vaccine responses remain unclear, hampering evidence-based vaccination policy development. Here we combine serological data from 1,505 individuals (aged 0-12 years) in a mother-infant cohort and in a child cohort with empirical models to reconstruct antibody trajectories from birth. We show that while highly heterogeneous across a population, measles antibody evolution is strongly predictive from birth at the individual level, including following vaccination. Further, we find that caesarean section births were linked with 2.56 (95% confidence interval: 1.06-6.37) increased odds of primary vaccine failure, highlighting the long-term immunological consequences of birth route. Finally, we use our new understanding of antibody evolution to critically assess the population-level consequences of different vaccination schedules, the results of which will allow country-level evaluations of vaccine policy.

2022 Polio outbreak, Rockland County, NY: Cost evaluation of strategies to prevent future outbreaks of vaccine-preventable diseases

In 1994, the World Health Organization Region of the Americas was declared polio-free. In July 2022, a confirmed case of paralytic polio in an unvaccinated adult resident of Rockland County, New York was reported by the New York State Department of Health (NYSDOH) and Rockland County Department of Health (RCDOH). While only one case was identified, a single case of paralytic polio represents a public health emergency in the United States. The patient's county of residence was identified to have low vaccination coverage indicating that the community was at risk for additional cases. Disease outbreaks are resource-intensive and incur high costs to the patient, local health departments, and to society. These costs are potentially avoidable for vaccine-preventable diseases and thus, highlight the urgency to not only interrupt transmission but to prevent future vaccine-preventable disease outbreaks by improving vaccination coverage. Following case confirmation, an investigation and response was initiated by NYSDOH, along with local health departments and the Centers for Disease Control and Prevention (CDC). After the initial investigation and response, collaborative efforts to mitigate risk and strengthen routine immunization continued, which included provider outreach and immunization record assessments of Head Start and licensed childcare facilities (primarily those with missing or incomplete required vaccination coverage reports from the previous year) in Rockland County. We estimated the costs of (1) provider outreach and (2) childcare and pre-kindergarten immunization record assessments of select licensed childcare and Head Start facilities in Rockland County. The total labor cost incurred for these activities was $138,514 with a total of 2,555 h incurred. Often there are unique opportunities in the midst of an outbreak for public health to implement activities to proactively address low vaccination and strengthen vaccination coverage and possibly prevent future outbreaks. Understanding the cost of these activities might help inform future outbreak planning.

Effect of the COVID-19 pandemic on the pediatric infectious disease landscape

This narrative review aims to present an overview of the COVID-19 pandemic's effects on the landscape of pediatric infectious diseases. While COVID-19 generally results in mild symptoms and a favorable prognosis in children, the pandemic brought forth significant consequences. These included persistent symptoms among infected children ("long COVID"), a profound transformation in healthcare utilization (notably through the widespread adoption of telemedicine), and the implementation of optimization strategies within healthcare settings. Furthermore, the pandemic resulted in alterations in the circulation patterns of respiratory pathogens, including influenza, RSV, and Streptococcus pneumoniae. The possible reasons for those changes are discussed in this review. COVID-19 effect was not limited to respiratory infectious diseases, as other diseases, including urinary tract and gastrointestinal infections, have displayed decreased transmission rates, likely attributable to heightened hygiene measures and shifts in care-seeking behaviors. Finally, the disruption of routine childhood vaccination programs has resulted in reduced immunization coverage and an upsurge in vaccine hesitancy. In addition, the pandemic was associated with issues of antibiotic misuse and over-prescription.     Conclusion: In conclusion, the COVID-19 pandemic has left a profound and multifaceted impact on the landscape of pediatric infectious diseases, ranging from the emergence of "long COVID" in children to significant changes in healthcare delivery, altered circulation patterns of various pathogens, and concerning disruptions in vaccination programs and antibiotic usage. What is Known: • COVID-19 usually presents with mild symptoms in children, although severe and late manifestations are possible. • The pandemic resulted in a dramatically increased use of health care services, as well as alterations in the circulation patterns of respiratory pathogens, decreased rates of other, non-respiratory, infections, disruption of routine childhood vaccination programs, and antibiotic misuse. What is New: • Possible strategies to tackle future outbreaks are presented, including changes in health care services utilization, implementation of updated vaccine programs and antibiotic stewardship protocols. • The decline in RSV and influenza circulation during COVID-19 was probably not primarily related to NPI measures, and rather related to other, non-NPI measures implementation, including specific pathogen-host interactions on the level of the biological niche (the nasopharynx).

Pervasive Parental Hesitancy and Resistance towards Measles Rubella Vaccination in Jordan

Measles remains a highly contagious and potentially severe infectious disease, necessitating high vaccine coverage. However, misinformation and measles vaccine hesitancy/resistance have posed significant challenges to achieving this goal. The COVID-19 pandemic further exacerbated these challenges, leading to a measles outbreak in Jordan in 2023. This study aimed to investigate the acceptance of the measles rubella (MR) vaccine among parents in Jordan and to identify its associated determinants. This cross-sectional questionnaire-based study was conducted using a previously Arabic-validated version of the Parental Attitudes towards Childhood Vaccines (PACV) survey instrument. Data collection took place in October 2023, and the final study sample comprised a total of 391 parents, with mothers representing 69.8% of the participants (n = 273). The majority of participating parents expressed either resistance (n = 169, 43.2%) or hesitancy (n = 168, 43.0%) towards MR vaccination, while only 54 participants (13.8%) expressed MR vaccine acceptance. Multivariate analysis revealed that trust in vaccine safety/efficacy, behavior, and having fewer offspring were significantly associated with MR vaccine acceptance. The current study revealed a concerning level of MR vaccine hesitancy/resistance among parents in Jordan, which could signal a public health alarm in the country. Urgent and targeted interventions are strongly recommended to address this issue, including mass campaigns aimed at building trust in the MR vaccine's safety/efficacy. Additionally, there is an urgent need for effective public health initiatives to ensure sufficient measles vaccine coverage to prevent future outbreaks of this serious disease.

Emerging Infectious Diseases Are Virulent Viruses-Are We Prepared? An Overview

The recent pandemic caused by SARS-CoV-2 affected the global population, resulting in a significant loss of lives and global economic deterioration. COVID-19 highlighted the importance of public awareness and science-based decision making, and exposed global vulnerabilities in preparedness and response systems. Emerging and re-emerging viral outbreaks are becoming more frequent due to increased international travel and global warming. These viral outbreaks impose serious public health threats and have transformed national strategies for pandemic preparedness with global economic consequences. At the molecular level, viral mutations and variations are constantly thwarting vaccine efficacy, as well as diagnostic, therapeutic, and prevention strategies. Here, we discuss viral infectious diseases that were epidemic and pandemic, currently available treatments, and surveillance measures, along with their limitations.

Measles: Contemporary considerations for the emergency physician

Measles, or rubeola, is a highly contagious acute febrile viral illness. Despite the availability of an effective vaccine since 1963, measles outbreaks continue worldwide. This article seeks to provide emergency physicians with the contemporary knowledge required to rapidly diagnose potential measles cases and bolster public health measures to reduce ongoing transmission.

Can delay discounting predict vaccine hesitancy 4-years later? A study among US young adults

Despite being a major threat to health, vaccine hesitancy (i.e., refusal or reluctance to vaccinate despite vaccine availability) is on the rise. Using a longitudinal cohort of young adults (N = 1260) from Los Angeles County, California we investigated the neurobehavioral mechanisms underlying COVID-19 vaccine hesitancy. Data were collected at two time points: during adolescence (12th grade; fall 2016; average age = 16.96 (±0.42)) and during young adulthood (spring 2021; average age = 21.33 (±0.49)). Main outcomes and measures were delay discounting (DD; fall 2016) and tendency to act rashly when experiencing positive and negative emotions (UPPS-P; fall 2016); self-reported vaccine hesitancy and vaccine beliefs/knowledge (spring 2021). A principal components analysis determined four COVID-19 vaccine beliefs/knowledge themes: Collective Responsibility, Confidence and Risk Calculation, Complacency, and Convenience. Significant relationships were found between themes, COVID-19 vaccine hesitancy, and DD. Collective Responsibility (β = -1.158[-1.213,-1.102]) and Convenience (β = -0.132[-0.185,-0.078]) scores were negatively associated, while Confidence and Risk Calculation (β = 0.283[0.230,0.337]) and Complacency (β = 0.412[0.358,0.466]) scores were positively associated with COVID-19 vaccine hesitancy. Additionally, Collective Responsibility (β = -0.060[-0.101,-0.018]) was negatively associated, and Complacency (β = -0.063[0.021,0.105]) was positively associated with DD from fall 2016. Mediation analysis revealed immediacy bias during adolescence, measured by DD, predicted vaccine hesitancy 4 years later while being mediated by two types of vaccine beliefs/knowledge: Collective Responsibility (β = 0.069[0.022,0.116]) and Complacency (β = 0.026[0.008,0.044]). These findings provide a further understanding of individual vaccine-related decision-making among young adults and inform public health messaging to increase vaccination acceptance.

State of the Art: Acute Encephalitis

Encephalitis is a devastating neurologic disease often complicated by prolonged neurologic deficits. Best practices for the management of adult patients include universal testing for a core group of etiologies, including herpes simplex virus (HSV)-1, varicella zoster virus (VZV), enteroviruses, West Nile virus, and anti-N-methyl-D-aspartate receptor (anti-NMDAR) antibody encephalitis. Empiric acyclovir therapy should be started at presentation and in selected cases continued until a second HSV-1 polymerase chain reaction test is negative. Acyclovir dose can be increased for VZV encephalitis. Supportive care is necessary for other viral etiologies. Patients in whom no cause for encephalitis is identified represent a particular challenge. Management includes repeat brain magnetic resonance imaging, imaging for occult malignancy, and empiric immunomodulatory treatment for autoimmune conditions. Next-generation sequencing (NGS) or brain biopsy should be considered. The rapid pace of discovery regarding autoimmune encephalitis and the development of advanced molecular tests such as NGS have improved diagnosis and outcomes. Research priorities include development of novel therapeutics.

Vaccination and Trust in the National Health System among HIV+ Patients: An Italian Cross-Sectional Survey

BACKGROUND

This study aimed to evaluate the knowledge, attitudes, and practises (KAP) of individuals living with HIV (PLWH) regarding vaccines and their trust in the Italian national health system (NHS).

METHODS

A cross-sectional survey was conducted at Amedeo di Savoia Hospital in Turin, Italy, involving 160 HIV-positive patients. Descriptive statistics were utilised to analyse variables such as vaccination status and intention, perceived risk of infection, and disease severity. The infections were categorised into sexually transmitted diseases and other vaccine-preventable diseases.

RESULTS

Except for the perceived severity of infection, there were no significant differences in the percentages between the two infection groups for the variables examined. Concerning patients' perception of the Italian NHS, a high percentage of the sample believed in the information provided by healthcare workers (HCWs) (95.6%) and considered HCWs up-to-date on vaccines (93.1%). However, a considerable proportion expressed concerns about insufficient information on vaccine risks from HCWs (33.3%), perceived judgement by HCWs for vaccine refusal (40.3%), and suspected financial interests of HCWs in vaccination (19.5%).

CONCLUSIONS

Some HIV+ patients may hesitate to be vaccinated or hold misconceptions about the severity of certain infectious diseases. Additionally, there are concerns about trust in the Italian NHS and communication by HCWs.

Are all underimmunized measles clusters equally critical?

This research develops a novel system science approach to examine the potential risk of outbreaks caused by geographical clustering of underimmunized individuals for an infectious disease like measles. We use an activity-based population network model and school immunization records to identify underimmunized clusters of zip codes in the Commonwealth of Virginia. Although Virginia has high vaccine coverage for measles at the state level, finer-scale investigation at the zip code level finds three statistically significant underimmunized clusters. This research examines why some underimmunized geographical clusters are more critical in causing outbreaks and how their criticality changes with a possible drop in overall vaccination coverage. Results show that different clusters can cause vastly different outbreaks in a region, depending on their size, location, immunization rate and network characteristics. Among the three underimmunized clusters, we find one to be critical and the other two to be benign in terms of an outbreak risk. However, when the vaccine coverage among children drops by just 5% (or 0.8% overall in the population), one of the benign clusters becomes highly critical. This work also examines the demographic and network properties of these clusters to identify factors that are responsible for affecting the criticality of the clusters. Although this work focuses on measles, the methodology is generic and can be applied to study other infectious diseases.

Are all underimmunized measles clusters equally critical?

Disruptions in routine immunizations due to the COVID-19 pandemic have been a cause of significant concern for health organizations worldwide. This research develops a system science approach to examine the potential risk of geographical clustering of underimmunized individuals for an infectious disease like measles. We use an activity-based population network model and school immunization records to identify underimmunized clusters of zip codes in the Commonwealth of Virginia. Although Virginia has high vaccine coverage at the state level for measles, finer-scale investigation at the zip code level finds three statistically significant underimmunized clusters. To estimate the criticality of these clusters, a stochastic agent-based network epidemic model is used. Results show that different clusters can cause vastly different outbreaks in the region, depending on their size, location, and network characteristics. This research aims to understand why some underimmunized geographical clusters do not cause a large outbreak while others do. A detailed network analysis shows that it is not the average degree of the cluster or the percentage of underimmunized individuals in the cluster but the average eigenvector centrality of the cluster that is important in determining its potential risk.

Spotting a potential threat: Measles among pediatric solid organ transplantation recipients

BACKGROUND

Low-vaccination rates worldwide have led to the re-emergence of vaccine-preventable infections, including measles. Immunocompromised patients, including pediatric solid organ transplant (SOT) recipients, are at risk for measles because of suboptimal vaccination, reduced or waning vaccine immunity, lifelong immunosuppression, and global re-emergence of measles.

OBJECTIVES

To review published cases of measles in pediatric SOT recipients to heighten awareness of its clinical manifestations, summarize diagnostic and treatment strategies, and identify opportunities to optimize prevention.

METHODS

We conducted a literature review of published natural measles infections in SOT recipients ≤21 years of age, summarizing management and outcomes. We describe measles epidemiology, recommended diagnostics, treatment, and highlight prevention strategies.

RESULTS

There are seven published reports of measles infection in 12 pediatric SOT recipients, the majority of whom were unvaccinated or incompletely vaccinated. Subjects had atypical or severe clinical presentations, including lack of rash and complications, most frequently with encephalitis and pneumonitis, resulting in 33% mortality. Updated recommendations on testing and vaccination are provided. Treatment options beyond supportive care and vitamin A are limited, with no approved antivirals.

CONCLUSION

While measles is infrequently reported in pediatric SOT recipients, morbidity and mortality remain significant. A high index of suspicion is warranted in susceptible SOT recipients with clinically compatible illness or exposure. Providers must recognize this risk, educate families, and be aware of both classic and atypical presentations of measles to rapidly identify, isolate, and diagnose measles in pediatric SOT recipients. Continued efforts to optimize measles vaccination both pre- and post-SOT are warranted.

Performance Characteristics of Six Immunoglobulin M Enzyme-Linked Immunosorbent Assays Used for Laboratory Confirmation of Measles

Laboratory confirmation of infection is an essential component of measles surveillance. Detection of measles-specific IgM in serum by enzyme-linked immunosorbent assay (ELISA) is the most common method used to confirm measles infection. ELISA formats vary, as does the sensitivity and specificity of each assay. Specimens collected within 3 days of rash onset can yield a false-negative result, which can delay confirmation of measles cases. Interfering substances can yield a false-positive result, leading to unnecessary public health interventions. The IgM capture assay developed at the Centers for Disease Control (CDC) was compared against five commercially available ELISA kits for the ability to detect measles virus-specific IgM in a panel of 90 well-characterized specimens. Serum samples were tested in triplicate using each commercial kit as recommended by the manufacturer. Using the CDC measles IgM capture assay as the reference test; the sensitivity and specificity for each commercial kit ranged from 50 to 83% and 86.9 to 98%, respectively. Discrepant results were observed for samples tested with all five commercial kits and ranged from 13.8 to 28.8% of the specimens tested. False-positive results occurred in 2.0 to 13.1% of sera, while negative results were observed in 16.7 to 50% of sera that were positive by the CDC measles IgM capture assay. Evaluation and interpretation of measles IgM serologic results can be complex, particularly in measles elimination settings. The performance characteristics of a measles IgM assay should be carefully considered when selecting an assay to achieve high-quality measles surveillance.

Debunking Misinformation About a Causal Link Between Vaccines and Autism: Two Preregistered Tests of Dual-Process Versus Single-Process Predictions (With Conflicting Results)

Dual-process and single-process theories lead to conflicting predictions about whether debunking messages negating a state of affairs should change responses on implicit measures in a manner intended by the message. Two preregistered studies (N1 = 550; N2 = 880) tested these predictions using official health information from the U.S. Centers for Disease Control and Prevention debunking the idea that vaccines would cause autism. Consistent with predictions derived from dual-process learning theories, Experiment 1 found that debunking-via-negation increased responses linking vaccines to autism on implicit measures, although it effectively reduced self-reported judgments linking vaccines to autism on explicit measures. Using the same measures and materials, Experiment 2 found that debunking-via-negation effectively reduced responses linking vaccines to autism on both implicit and explicit measures, consistent with predictions derived from single-process propositional theories. Potential reasons for the conflicting outcomes are discussed, including their implications for the debate between dual-process and single-process theories.

Association of parent influenza vaccination and early childhood vaccinations using linked electronic health record data

INTRODUCTION

Parent and child vaccination behavior is related for human papillomavirus (HPV) and flu vaccine. Thus, it is likely that parental vaccination status is also associated with their children's adherence to guideline-concordant childhood vaccination schedules. We hypothesized that parent influenza (flu) vaccination would be associated with their child's vaccination status at age two.

METHODS

We used electronic health record data to identify children and linked parents seen in a community health center (CHC) within the OCHIN network (292 CHCs in 16 states). We randomly selected a child aged <2 years with ≥1 ambulatory visit between 2009-2018. Employing a retrospective, cohort study design, we used general estimating equations logistic regression to estimate the odds of a child being up-to-date on vaccinations based on their linked parents' flu vaccination status. We adjusted for relevant parent and child covariates and stratified by mother only, father only, and two-parent samples.

RESULTS

The study included 40,007 family-units: mother only = 35,444, father only = 2,784, and two parents = 1,779. A higher percentage of children were fully vaccinated if their parent or parents received a flu vaccine. Children in the two-parent sample whose parents both received a flu vaccine had more than twice the odds of being fully vaccinated, and two and a half times the odds of being fully vaccinated except flu vaccine compared to children with two parents who did not receive a flu vaccine (covariate-adjusted odds ratio [aOR] = 2.39, 95% CI = 1.67, 3.43 and aOR = 2.54, 95% CI = 1.54, 4.19, respectively).

CONCLUSIONS

Parent flu vaccination is associated with routine child vaccination. Future research is needed to understand if this relationship persists over time and in different settings.

Predicting Measles Outbreaks in the United States: Evaluation of Machine Learning Approaches (Preprint)

BACKGROUND

Measles, a highly contagious viral infection, is resurging in the United States, driven by international importation and declining domestic vaccination coverage. Despite this resurgence, measles outbreaks are still rare events that are difficult to predict. Improved methods to predict outbreaks at the county level would facilitate the optimal allocation of public health resources.

OBJECTIVE

We aimed to validate and compare extreme gradient boosting (XGBoost) and logistic regression, 2 supervised learning approaches, to predict the US counties most likely to experience measles cases. We also aimed to assess the performance of hybrid versions of these models that incorporated additional predictors generated by 2 clustering algorithms, hierarchical density-based spatial clustering of applications with noise (HDBSCAN) and unsupervised random forest (uRF).

METHODS

We constructed a supervised machine learning model based on XGBoost and unsupervised models based on HDBSCAN and uRF. The unsupervised models were used to investigate clustering patterns among counties with measles outbreaks; these clustering data were also incorporated into hybrid XGBoost models as additional input variables. The machine learning models were then compared to logistic regression models with and without input from the unsupervised models.

RESULTS

Both HDBSCAN and uRF identified clusters that included a high percentage of counties with measles outbreaks. XGBoost and XGBoost hybrid models outperformed logistic regression and logistic regression hybrid models, with the area under the receiver operating curve values of 0.920-0.926 versus 0.900-0.908, the area under the precision-recall curve values of 0.522-0.532 versus 0.485-0.513, and F₂ scores of 0.595-0.601 versus 0.385-0.426. Logistic regression or logistic regression hybrid models had higher sensitivity than XGBoost or XGBoost hybrid models (0.837-0.857 vs 0.704-0.735) but a lower positive predictive value (0.122-0.141 vs 0.340-0.367) and specificity (0.793-0.821 vs 0.952-0.958). The hybrid versions of the logistic regression and XGBoost models had slightly higher areas under the precision-recall curve, specificity, and positive predictive values than the respective models that did not include any unsupervised features.

CONCLUSIONS

XGBoost provided more accurate predictions of measles cases at the county level compared with logistic regression. The threshold of prediction in this model can be adjusted to align with each county's resources, priorities, and risk for measles. While clustering pattern data from unsupervised machine learning approaches improved some aspects of model performance in this imbalanced data set, the optimal approach for the integration of such approaches with supervised machine learning models requires further investigation.

Attitudes and Beliefs around the Value of Vaccination in the United States

Despite the benefits of immunization, differences in attitudes persist toward vaccines. We captured individuals’ perceptions of vaccines and vaccination across the United States (US) to inform vaccine-related policy development. A survey was completed by 5000 respondents from 10 states. Respondents were screened for inclusion, which included individuals ≥ 18 years of age that had received a vaccine or were unvaccinated but indicated a favorable or neutral attitude towards vaccinations. Participants were excluded if they indicated they did not support the idea of vaccinations. Questions explored perceptions of vaccines for all age groups. Among unvaccinated individuals, the most common concerns were about safety (38%). Most respondents (95%) highlighted the importance of state immunization programs for disease prevention. Access to health and immunization records and immunization information systems were important to 96% and 88% of respondents, respectively, for future health planning. Doctors and healthcare professionals (HCPs) were considered trusted sources for vaccine information (95%). Overall, respondents recognized the importance of vaccination, but documented concerns among the unvaccinated indicated a need for greater promotion regarding vaccine safety. Doctors and HCPs, as trusted information sources, should continue to and increasingly advocate for the importance of immunization to increase vaccine uptake.

A population study of the NYS measles epidemic: Lessons learned

OBJECTIVES

In 2019 the United States experienced the largest outbreak of measles in 27 years, 19 years after the United States declared measles eliminated. The purpose of this paper was to present a population study of a measles outbreak within Orthodox Jewish communities in New York that led to the elimination of religious exemption for school mandated vaccines.

METHODS

Peer reviewed articles, news media, health department, and government resources were used to investigate environmental factors that led to this outbreak. State, county, and city immunization records were accessed to explore measles compliance rates before and after policy change.

RESULTS

Rockland County had low compliance rates compared to the rest of the state, and the elimination of religious exemptions raised compliance rate almost to state level. In all but one affected New York City zip codes, compliance following policy change rose to 97.95%-99.15%.

CONCLUSIONS

Overall, changes in measles compliance rates reflect policy goals, but localized differences imply a need for more customized interventions for each unique community. Public health planning to promote vaccination should be sensitive to the concerns and perceptions of each community in order for health interventions to have a positive effect.

Comparison of the medical burden of COVID-19 with seasonal influenza and measles outbreaks

AIM

To examine and compare the medical burden of measles, influenza and COVID-19 outbreaks in the city of Bnei Brak, Israel.

METHODS

The study was conducted during 2018-2021. The numbers of hospitalisations for these infections and their complications were recorded. Hospitalisation rates were determined by using the number of children residing in Bnei Brak and hospitalised with these infections during the study period as the numerators. The denominators were the estimated paediatric cases of measles, influenza and COVID-19 in Bnei Brak and were calculated under both pragmatic and conservative assumptions.

RESULTS

A total of 247, 65 and 32 children were hospitalised with influenza, COVID-19 and measles respectively. Complication rates were higher following measles than after influenza and SARS-CoV-2 infections. Hospitalisation rates were 10% for measles, 0.6%-1.2% for influenza and 0.15% - 0.25% for COVID-19 infections. Relative risks (RR) with 95% confidence intervals (CI) for hospitalisation following measles compared with COVID-19 ranged from 42 (26.3-67.3) to 70.1 (43.8-112.1), while the relative risks for influenza hospitalisation ranged from 2.5 (1.83-3.41) to 8.2 (6.0-11.2), compared with COVID-19 infection.

CONCLUSION

Hospitalisation rates and direct medical burdens of measles and influenza were significantly higher than those of COVID-19 infection in children.

Impact of COVID ‐19 pandemic on routine vaccination coverage of children and adolescents: A systematic review

Background and Aims

Scientists and healthcare workers have expressed their concerns on the impacts of the COVID‐19 pandemic on vaccination coverage in children and adolescents. Therefore, we aimed to systematically review the studies addressing this issue worldwide.

Methods

We conducted a systematic search of relevant studies using the keywords on databases of PubMed, Web of Science, and Cochrane on May 22, 2021. The identified records were imported into EndNote software and underwent a two‐phase screening process consisting of title/abstract and full‐text screenings against inclusion criteria. The data of the included studies were summarized into a table and the findings were analyzed in a systematic approach.

Results

From 26 eligible studies, 21 studies demonstrated decreased vaccination rates in the children during the COVID‐19 pandemic, while three studies found increased or no significant changes only in influenza vaccination. The two remaining studies from Brazil and Sweden also showed no significant changes in vaccination rates in the children during the pandemic.

Conclusion

Most of the reports worldwide reported a decline or delay in vaccination at the time of the COVID‐19 pandemic. A sustained catch‐up program seems to be necessary, especially in low‐income countries, to avoid any vaccine dose missing. Facilitating the vaccination process is recommended, such as decreasing the waiting time for vaccination at the health center, addressing the fear and concerns related to COVID infection for parents, and enhancing vaccine availability, and promoting access in remote areas. Countries should ensure proper vaccination to prevent future pandemics related to vaccine‐preventable diseases.

Public Perceptions of Current COVID-19 Vaccinations. Results of a Pilot Survey

Introduction

We conducted a cross-sectional survey as a part of an educational program in collaboration with the Global Thrombosis Forum (GTF), an affiliate of North American Thrombosis Forum (NATF), and Loyola University about public perceptions of COVID-19 and COVID-19 vaccinations in the US. In this study, we are reporting the results of this survey.

Materials and Methods

The survey, in the form of a questionnaire, has been developed by GTF and faculty members. A prepared questionnaire was sent to the members of the Georgia and Illinois communities.

Results

In our current study, the COVID-19 vaccine willingness rate was 94.5% and vaccination rate was 90.9%. In multivariate analysis believing to have enough information about the safety and efficacy of COVID-19 vaccines (OR: 3.730, 95% CI: 1.199–11.603, p: 0.023) and gender (OR: 0.123, 95% CI: 0.016–0.967, p: 0.046) were significant predictors for vaccine willingness. Previous COVID-19 infection (OR: 0.215, 95% CI: 0.061–0.758, p: 0.017), moderate and severe effects of COVID-19 pandemic on participant's life (OR: 4.631, 95% CI 1.681–12.760, p: 0.003) and believing to have enough information about the safety and efficacy of COVID-19 vaccines (OR: 4.119, 95% CI: 1.508–11.253, p: 0.006) were significant predictors for final vaccination status.

Conclusion

In conclusion, currently vaccination remains one of the most effective tools in the fight against the COVID-19 pandemic. The vaccine hesitancy is a complex phenomenon that is driven by individuals' perceptions of safety, and efficiency of the vaccines. We must continue to educate the public and communities that vaccines are safe, that they are effective and that they are still required even after a COVID-19 infection.

Prevention of measles, mumps and rubella: 40 years of global experience with M-M-RII

Measles, mumps, and rubella are highly contagious diseases that caused significant global mortality and morbidity in the pre-vaccine era. Since its first approval in the United States over 40 years ago, M-M-R_II has been used in >75 countries for prevention of these diseases. The vaccine has been part of immunization programs that have achieved dramatic global reductions in case numbers and mortality rates, as well as the elimination of measles and rubella in several countries and regions. This report summarizes over four decades of global safety, immunogenicity, efficacy, and effectiveness data for the vaccine. We include studies on the use of M-M-R_II in different age groups, concomitant use with other routine childhood vaccines, administration via different routes, persistence of immunity, and vaccine effectiveness during outbreaks of measles and mumps. We conclude that M-M-R_II is well tolerated and has shown consistently high performance during routine use in multiple countries, in randomized controlled trials with diverse designs, and in outbreak settings, including use as measles postexposure prophylaxis. Physicians, parents, and the public can continue to have a high degree of confidence in the use of M-M-R_II as a vital part of global public health programs.

Impact of isolation and exclusion as a public health strategy to contain measles virus transmission during a measles outbreak

Responding to measles outbreaks in the United States puts a considerable strain on public health resources, and limited research exists about the effectiveness of containment strategies. In this paper we quantify the impact of isolation, contact tracing, and exclusion in reducing transmission during a measles outbreak in an under-vaccinated community.

Catch-up immunization for adolescents and young adults during pre-travel consultation in Japan

Rubella and measles outbreaks in adults occur because of unimmunized or partially immunized status. Travel clinics play an important role in catch-up measles, rubella, mumps, and varicella immunization for adults. We evaluated the need for catch-up measles, rubella, mumps, and varicella immunization by young adults at our travel clinic. This retrospective observational study was conducted at the National Center for Global Health and Medicine from June 1, 2017 to May 31, 2018. Adults aged 16-49 years who received pre-travel consultation and had childhood immunization records were included. Individuals who fully or partially received planned measles, rubella, mumps, and varicella catch-up immunization were classified as "immunized." We calculated the proportion of "immunized" individuals and analyzed the factors associated with catch-up measles, rubella, mumps, and varicella immunization at pre-travel consultation using logistic regression analysis. Overall, 3,456 individuals received pre-travel consultations during the study period; 827 (336 men, median age 22 years) had childhood immunization records. The most common trip purposes were study (33%) and tourism (24%). The most common destination was Asia (39%). Catch-up immunization of any measles, rubella, mumps, and varicella vaccine was needed by 755 individuals. After consultation, 20-46% of these participants who needed catchup immunization received at least one dose of immunization. Factors that are negatively associated with measles, rubella, mumps, and varicella catch-up immunization were tourism (odds ratio 0.37 to 0.58), yellow fever vaccination (0.45 to 0.50) (excluding varicella), and each disease history (0.13 to 0.40) (excluding rubella and varicella). Further studies are needed to identify barriers to catch-up immunization.

Pharmacy student perceptions of their preparedness to address vaccine hesitancy and refusal

INTRODUCTION

Vaccine hesitancy/refusal is a growing issue worldwide. Pharmacists are well suited to address vaccine hesitancy; however, the extent to which they feel trained to do so may vary. The objective of this study was to determine pharmacy student confidence in addressing vaccine hesitancy/refusal.

METHODS

Students in their penultimate didactic and experiential years at United States schools of pharmacy were invited to participate in a 30-item electronic survey concerning perceptions of preparedness to address vaccine hesitancy/refusal. The primary outcome was pharmacy students' perception of their ability to address vaccine hesitancy/refusal. Secondary outcomes included student confidence in their knowledge of and ability to speak to vaccine controversies and support for pharmacist/patient vaccine responsibilities. Outcomes were addressed using five-point Likert-type items. Median values and interquartile ranges were reported, with chi-square analysis accounting for possible heterogeneity between groups.

RESULTS

A total of 1433 students (estimated response rate = 20%) completed the survey. Respondents indicated confidence in their preparedness to address patient immunization concerns, hesitancy, and refusal with a median score of 4 (scale of 5, with 1 = the least confident and 5 = the most confident). Secondary outcome analysis revealed varying degrees of confidence regarding specific vaccine hesitancy controversies.

CONCLUSIONS

Pharmacy students were confident in their ability to address vaccine hesitancy/refusal. Students held beliefs of responsibility for limiting non-vaccination, but felt less confident in addressing concerns regarding specific vaccine components and immune system overload.

"It's Like 1998 Again": Why Parents Still Refuse and Delay Vaccines

We conducted a qualitative study from 2018 to 2019 to update the reasons why US parents’ refuse or delay vaccines. Four focus groups and 4 semi-structured interviews involving 33 primary care pediatric providers were conducted in Washington and Colorado. A thematic analysis was conducted to identify themes related to reasons for parental refusal or delay. Five predominant themes were identified: (1) vaccine safety, (2) relative influence of information sources, decision-makers, and timing, (3) low perceived risk of contracting vaccine-preventable disease, (4) lack of trust, and (5) religious objection. Vaccine safety was the theme mentioned most frequently by providers (N = 45 times by 26 providers) and religious objection to vaccination was referred to the least (N = 6 times by 6 providers). Provider-reported reasons for parental refusal or delay of childhood vaccines in 2018 to 2019 remain similar to those reported in previous studies.

Understanding Vaccine Hesitancy Among Parents of Children With Autism Spectrum Disorder and Parents of Children With Non-Autism Developmental Delays

Parents of children with autism spectrum disorder (ASD) may be at greater risk for developing antivaccine beliefs that lead to vaccine delays and/or refusals for their children. We investigated current parental vaccine hesitancy, parents' beliefs about causes of children's developmental delays, and children's vaccination histories among parents of children with ASD or non-ASD developmental delays. Data were analyzed from 89/511 parents (17.4%) who completed the Parent Attitudes About Childhood Vaccines questionnaire and the Revised Illness Perception Questionnaire; 46.1% had childhood vaccination records available. Overall, 21/89 (23.6%, 95% confidence interval [CI]: 15.0-34.0) of parents were vaccine hesitant (ASD n = 19/21 [90.5%], non-ASD n = 2/21 [9.5%]). Parents of children with ASD were significantly more likely to agree with "toxins in vaccines" as a cause of their child's developmental delays (28.4% vs 5.0%, P = .034). The odds of being vaccine hesitant were 11.9 times (95% CI 2.9-48.0) greater among parents who agreed versus disagreed that toxins in vaccines caused their children's developmental delays. Rates of prior vaccine receipt did not differ between hesitant and nonhesitant groups.

Vitamin A in Children Hospitalized for Measles in a High-income Country

BACKGROUND

Worldwide medical authorities recommend vitamin A supplementation for severe measles requiring hospitalization; however, evidence supporting its use in high-income countries is lacking. A nationwide vitamin A shortage reported in concomitance with a recent measles outbreak in Italy provided an opportunity to test the effectiveness of vitamin A in a high-income setting, approximating an unbiased allocation.

METHODS

We conducted a prospective controlled cohort study involving children admitted for measles to a tertiary-care hospital in Southern Italy. The primary outcome was the duration of fever. Secondary outcomes included the length of hospitalization, rate of complications, need for antibiotic treatment and body temperature.

RESULTS

A total of 108 inpatient children (36% female, median age 16.3 months) were enrolled; 36 received 2 doses of oil-based vitamin A according to age, and 72 matched controls received standard care. There were no significant differences between the study groups in the duration of fever (7.03 ± 2.67 vs. 6.82 ± 3.27, P = 0.72), length of hospitalization (median, 5.0 vs. 5.0 days, P = 0.50), maximum body temperature (median, 39°C in both groups, P = 0.23), rate of organ (69.4% vs. 63.9%, P = 0.72) and hematologic complications (41.7% vs. 59.7%, P = 0.12), or need for antibiotic treatment (66.7% vs. 61.1%, P = 0.72). Overall, vitamin A supplementation did not reduce the risk of any complications (relative risk, 1.33; 95% confidence intervals: 0.59-2.96).

CONCLUSION

Vitamin A does not change the clinical course of measles infection or the rate of complications in children hospitalized in a high-income country.

STUDY REGISTRATION NUMBER

EU PAS 31805.

Triple contagion: a two-fears epidemic model

We present a differential equations model in which contagious disease transmission is affected by contagious fear of the disease and contagious fear of the control, in this case vaccine. The three contagions are coupled. The two fears evolve and interact in ways that shape distancing behaviour, vaccine uptake, and their relaxation. These behavioural dynamics in turn can amplify or suppress disease transmission, which feeds back to affect behaviour. The model reveals several coupled contagion mechanisms for multiple epidemic waves. Methodologically, the paper advances infectious disease modelling by including human behavioural adaptation, drawing on the neuroscience of fear learning, extinction and transmission.

Epidemiological and genetic characterization of measles virus circulating strains at Marseille, France during 2017-2019 measles outbreak

OBJECTIVES

We attempted to establish a molecular investigation by Next Generation sequencing of the measles virus (MeV) strains circulating in Marseille-France during the last outbreak that occurred between 2017 and 2019.

METHODS

The circulating MeV were isolated from clinical samples using cell culture method and whole genomes were sequenced by Illumina Miseq Next Generation. Genotyping and comparative analyses were assessed by phylogenetic reconstructions. Clinical and epidemiological data from cases were also recorded.

RESULTS

A total of 110 MeV strains were isolated in cell culture. Our analysis based on whole genome sequences of 98 isolates confirmed that 93 strains belonged to the genotype D8 and 5 to the genotype B3. Phylogenetic analyses revealed 4 distinct MeV circulating clones in Marseille. Measles mostly occured in children < 5 years-old and in adults 30-50 years-old. Measles infection also occurred in 2 adequately vaccinated cases (2 doses). Among 63 measles cases of whom we had available clinical data informations, a total of 35 patients were hospitalized and 19 developed complications including one death case recorded.

CONCLUSIONS

Whole Genome Sequencing seems to be a useful tool for more refined genomic characterization of large measles outbreak. Vaccination strategies for measles eradication need to be re-evaluated in the current context.

Encountering Parents Who Are Hesitant or Reluctant to Vaccinate Their Children: A Meta-Ethnography

(1) Background: Health professionals play an important role in addressing parents who are hesitant or reluctant to immunise their children. Despite the importance of this topic, gaps remain in the literature about these experiences. This meta-ethnography aimed to synthesise the available body of qualitative work about the care experiences of community and hospital health professionals in encounters with parents hesitant or reluctant to vaccinate their children. The aim is to provide key information for the creation of strategies that address vaccine hesitancy or refusal and ensure public trust in vaccination programs, which are required in a pandemic context such as the current one. (2) Methods: Noblit and Hare’s interpretive meta-ethnography of 12 studies was followed. A line of argument synthesis based on a metaphor was developed. (3) Results: The metaphor “The stone that refuses to be sculpted”, accompanied by three themes, symbolises the care experiences of health professionals in their encounters with parents that hesitate or refuse to vaccinate their children. (4) Conclusions: The creation of clearer communication strategies, the establishment of a therapeutic alliance, health literacy and the empowerment of parents are recommended. The incorporation of health professionals in decision making and the strengthening of multidisciplinary teams interacting with such parents are also included.

Seroprevalence of Measles and Mumps Antibodies Among Individuals With Cancer

Importance

Although patients with cancer are at an increased risk of infection-related complications, few studies have characterized their vulnerability to measles and mumps. Given the recent outbreaks and increased community vaccine hesitancy, understanding measles and mumps immunity within this population is vital.

Objectives

To identify a point prevalence estimate of protective measles and mumps antibodies among ambulatory patients with cancer.

Design, Setting, and Participants

In this cross-sectional study, residual clinical plasma samples were obtained from consecutive patients with cancer at Seattle Cancer Care Alliance/Fred Hutchinson Cancer Research Center in Seattle, Washington, in August 2019. These samples were tested for measles and mumps IgG using a commercial enzyme-linked immunosorbent assay. Patients without cancer were excluded from the analysis.

Exposures

Patient age, sex, self-reported race and ethnicity, primary disease, receipt of chemotherapy in the past 30 days before sample collection, hematopoietic cell transplant (HCT) history, and date of most recent intravenous immunoglobulin treatment were abstracted from electronic medical records.

Main Outcomes and Measures

Measles and mumps IgG seroprevalence, defined as the proportion of patients with positive antibody test results, was measured overall and among the subgroups.

Results

Of the 959 patients included in the analysis, 510 (53%) were male individuals and the mean (SD) age at sample collection was 60 (15) years. Most patients (576 [60%]) had a malignant solid tumor, and 383 patients (40%) had a hematologic malignant neoplasm; 146 patients (15%) had an HCT history. Overall, the seroprevalence of measles antibodies was 0.75 (95% CI, 0.72-0.78), and the seroprevalence of mumps antibodies was 0.62 (95% CI, 0.59-0.65). The lowest seroprevalences were among patients with a hematologic malignant neoplasm (0.63 for measles and 0.48 for mumps), those with a history of HCT (0.46 for measles and 0.29 for mumps), and those aged 30 to 59 years (0.49-0.63 for measles and 0.41-0.58 for mumps).

Conclusions and Relevance

In this study, 25% of ambulatory patients with cancer lacked protective antibodies for measles and 38% lacked protective antibodies for mumps. Deficits in protective antibodies underscore patients' increased risk during outbreaks and emphasize the need for community-based efforts to increase herd immunity to protect this population.

Sociodemographic factors associated with acceptance of COVID-19 vaccine and clinical trials in Uganda: a cross-sectional study in western Uganda

BACKGROUND

Health experts agree that widespread use of safe and effective vaccines will rapidly contain the COVID-19 pandemic. The big question is whether these vaccines can easily be accepted by their end-users. Our study aimed at determining sociodemographic factors associated with acceptance of vaccines and clinical trials of COVID-19 in western Uganda.

METHOD

A simplified snowball sampling technique was used to select 1067 respondents of 18-70 years in western Uganda using an online questionnaire from July to September 2020. Vaccine acceptability and risk perception were assessed using odds ratio at 95% confidence interval in R software version 3.6.3.

RESULTS

There were 1067 participants in the study. The majority were males (73.2%) and age group 31-40 years (32.6%). The acceptance rate for COVID-19 vaccination was (53.6%; 572/1067) with those aged 18-20 years, males, elites at tertiary level of education (degree or diploma), students, Muslims, married, non-salary earners and rural dwellers having better odds and likeliness to accept vaccination. Only 44.6% (476/1067) showed interest in clinical trials among which; males, primary school leavers, students, Christians, un-married, respondents who didn't earn any salary and rural dwellers had better odds and likelihood to participate in clinical trials.

CONCLUSION

There was a low level of vaccine acceptance and clinical trial interest in western Uganda. Minority groups in the study i.e., Muslims, students, primary school leavers, un-married rural dwellers among others showed more interest in vaccination and clinical trials. We anticipated fears in the larger part of this community that health experts need to address through reassurance of the community that vaccines are tested and that they are safe and important if we are to rapidly contain the COVID-19 pandemic.

Development of a Measles and Rubella Multiplex Bead Serological Assay for Assessing Population Immunity

Serosurveys are important tools for estimating population immunity and providing immunization activity guidance. The measles and rubella multiplex bead assay (MBA) offers multiple advantages over standard serological assays and was validated by comparison with the enzyme-linked immunosorbent assay (ELISA) and the measles plaque reduction neutralization (PRN) assay. Results from a laboratory-produced purified measles virus whole-virus antigen MBA (MeV WVA_L) correlated better with ELISA and PRN than results from the baculovirus-expressed measles nucleoprotein (N) MBA. Therefore, a commercially produced whole-virus antigen (MeV WVA_C) was evaluated. Serum IgG antibody concentrations correlated significantly with a strong linear relationship between the MeV WVA_C and MeV WVA_L MBAs (R = 0.962 and R ² = 0.926). IgG concentrations from the MeV WVA_C MBA showed strong correlation with PRN titers (R = 0.846), with a linear relationship comparable to values obtained with the MeV WVA_L MBA and PRN assay (R ² = 0.716 and R ² = 0.768, respectively). Receiver operating characteristic (ROC) curve analysis of the MeV WVA_C using PRN titer as the comparator resulted in a seroprotection cutoff of 153 mIU/ml, similar to the established correlate of protection of 120 mIU/ml, with a sensitivity of 98% and a specificity of 83%. IgG concentrations correlated strongly between the rubella WVA MBA and ELISA (R = 0.959 and R ² = 0.919). ROC analysis of the rubella MBA using ELISA as the comparator yielded a cutoff of 9.36 IU/ml, similar to the accepted cutoff of 10 IU/ml for seroprotection, with a sensitivity of 99% and a specificity of 100%. These results support use of the MBA for multiantigen serosurveys assessing measles and rubella population immunity.

Safety and efficacy of early vaccination with live attenuated measles vaccine for hematopoietic stem cell transplant recipients and solid organ transplant recipients

BACKGROUND AND OBJECTIVE

Vaccination with the live attenuated measles vaccine is currently recommended two years after hematopoietic stem cell transplantation (HSCT) and generally contraindicated after solid organ transplantation (SOT) due to safety concerns. However, in the last few years new data on the administration of the measles vaccine to HSCT recipients less two years post-transplantation and to SOT recipients have become available. This new data may change current guidelines and practices. The objective of this review is to provide an overview of the current data on the safety and efficacy of early measles vaccination for HSCT- and SOT recipients.

METHOD

PubMed and EMBASE were searched from the earliest date available through October 2019 to identify all research that reported on the safety and efficacy of measles vaccination after SOT or less than two years after HSCT.

RESULTS

A total of ten studies was included in this review. In the six studies that evaluated the efficacy of measles vaccination after SOT, seroconversion rates ranged from 41 to 100% after one dose and 73 to 100% after two doses. In the four studies that evaluated the efficacy of measles vaccination less than two years after HSCT, seroconversion rates ranged from 33 to 100% after one dose and 100% after two doses. In all studies, the administration of the measles vaccine after transplantation was considered to be safe. There were no cases of infection with the attenuated vaccine strain, and there were no adverse events related to the vaccination.

CONCLUSION

Data on the administration of the measles vaccine after SOT and less than two years after HSCT is scarce. However, the current data available suggest that it is efficacious and well tolerable. Therefore, early measles vaccination could be considered in selected groups of SOT- and HSCT recipients during increased measles transmission or an outbreak setting.

Identifying Vaccine-associated Rash Illness Amidst a Large Measles Outbreak: Minnesota, 2017

Characteristics of vaccine-associated rash illness (VARI) and confirmed measles cases were compared during a measles outbreak. Although some clinical differences were noted, measles exposure and identification of the vaccine strain were helpful for public health decision-making. Rapid, vaccine strain-specific diagnostic assays will more efficiently distinguish VARI from measles.

Outbreak response operations during the US measles epidemic, 2017-19

BACKGROUND

To understand operational challenges involved with responding to US measles outbreaks in 2017-19 and identify applicable lessons in order to inform preparedness and response operations for future outbreaks, particularly with respect to specific operational barriers and recommendations for outbreak responses among insular communities.

METHODS

From August 2019 to January 2020, we conducted 11 telephone interviews with 18 participants representing state and local health departments and community health centers that responded to US measles outbreaks in 2017-19, with a focus on outbreaks among insular communities. We conducted qualitative, thematic coding to identify and characterize key operational challenges and lessons identified by the interviewees.

RESULTS

We categorized principal insights into 5 topic areas: scale of the response, vaccination operations, exclusion policies, community engagement, and countering anti-vaccine efforts. These topics address resource-intensive aspects of these outbreak responses, including personnel demands; guidance needed to support response operations and reduce transmission, such as excluding exposed or at-risk individuals from public spaces; operational challenges and barriers to vaccination and other response activities; and effectively engaging and educating affected populations, particularly with respect to insular and vulnerable communities.

CONCLUSIONS

Measles outbreak responses are resource intensive, which can quickly overwhelm existing public health capacities. Early and effective coordination with trusted leaders and organizations in affected communities, including to provide vaccination capacity and facilitate community engagement, can promote efficient response operations. The firsthand experiences of public health and healthcare personnel who responded to measles outbreaks, including among insular communities, provide evidence-based operational lessons that can inform future preparedness and response operations for outbreaks of highly transmissible diseases.

The Impact of a Single Educational Lecture on the Vaccine Confidence among Pregnant Women and Young Mothers

Background: We investigated the impact of a single unstructured educational lecture about vaccinations on the vaccine confidence in volunteer participants. Methods: We conducted a survey-based study during a series of open meetings related to pregnancy and parenting. Before and after the pediatrician’s lecture related to vaccinations, listeners completed the visual analogue scales (VAS, 0–15 cm), evaluating (1) self-declared knowledge on vaccinations and (2) how they perceive the safety and efficacy of this preventive method. Results: In total, 484 women aged 30 ± 4 years participated in the lecture (pregnant = 68%; ≥1 children = 56%). Participants declared to have more comprehensive knowledge on preventive vaccinations and perceived vaccines to be safer and more useful (the role for the immunity) after vs. before the lecture (median VAS: 10.4 vs. 7.2, 10.8 vs. 8.7, and 11.0 vs. 10.4 cm, all p < 0.001). Importantly, the prevalence of vaccine-related adverse events was also assessed as being higher after the lecture (median VAS: 9.9 vs. 8.0 cm, p < 0.001). The increase in self-declared knowledge on vaccinations and perceived need for vaccinations (delta VAS—VAS after minus before the lecture, expressed as % of baseline) was lower among participants who rated the lecture less vs. more useful. Importantly, both participants who liked vs. did not like the lecture comparably rated vaccines safer after vs. before the lecture (delta VAS (median, interquartile range): 16% (0–39%) vs. 18% (2–42%), p = 0.39). Conclusions: An educational lecture on vaccinations positively impacts vaccine confidence in young adult women. Irrespective of the subjective rating of the lecture, all listeners perceived vaccinations to be safer after vs. before the speech.

No Such Thing as a Free-Rider? Understanding Drivers of Childhood and Adult Vaccination through a Multicountry Discrete Choice Experiment

Increased vaccine hesitancy and refusal negatively affects vaccine uptake, leading to the reemergence of vaccine preventable diseases. We aim to quantify the relative importance of factors people consider when making vaccine decisions for themselves, or for their child, with specific attention for underlying motives arising from context, such as required effort (accessibility) and opportunism (free riding on herd immunity). We documented attitudes towards vaccination and performed a discrete choice experiment in 4802 respondents in The United Kingdom, France and Belgium, eliciting preferences for six attributes: (1) vaccine effectiveness, (2) vaccine preventable disease burden, (3) vaccine accessibility in terms of copayment, vaccinator and administrative requirements, (4) frequency of mild vaccine-related side-effects, (5) vaccination coverage in the country’s population and (6) local vaccination coverage in personal networks. We distinguished adults deciding on vaccination for themselves from parents deciding for their youngest child. While all attributes were found to be significant, vaccine effectiveness and accessibility stood out in all (sub)samples, followed by vaccine preventable disease burden. We confirmed that people attach more value to severity of disease compared to its frequency, and discovered that peer influence dominates free-rider motives, especially for the vaccination of children. These behavioral data are insightful for policy and are essential to parameterize dynamic vaccination behavior in simulation models. In contrast to what most game theoretical models assume, social norms dominate free-rider incentives. Policy-makers and healthcare workers should actively communicate on high vaccination coverage, and draw attention to the effectiveness of vaccines while optimizing their practical accessibility.

How adequate is measles surveillance in the United States? Investigations of measles-like illness, 2010-2017

Given the availability of an effective and safe vaccine, the World Health Organization (WHO) declared that global measles eradication is achievable, and measles elimination goals have since been established as interim steps toward eradication. As part of a strategy to maintain elimination, the Pan American Health Organization (PAHO) and WHO stipulate a minimum annual reporting rate of discarded non-measles cases of ≥2 per 100,000 population, in order to ensure sensitive surveillance and adequate investigative effort. With its effective vaccination program, the United States in 2000 was among the first countries to verify elimination, although subsequently, it has not routinely reported discarded rates. We estimated MLI investigation rates among insured individuals during 2010-2017, using data from the MarketScan® databases. We defined "MLI investigations" as measles serologic testing within 5 days following diagnostic codes for measles-compatible symptoms and conditions. We provide a rationale for pre-specifying three subgroups for analysis: children aged ≤15 years; males aged 16-22 years excluding data from summer months; and males aged ≥23 years. MLI investigation rates ranged from 6.6─26.4 per 100,000, remaining stable over time except during the 2015 measles outbreaks when rates increased, particularly among young children. In addition to high vaccine uptake, measles elimination requires ongoing vigilance by clinicians and high-quality, case-based surveillance. Estimated rates of MLI investigations in this U.S. population suggesting that the quality of measles surveillance is sufficiently sensitive to detect endemic measles circulation if it were to be occurring.

Knowledge for Nursing Practice: Beyond Evidence Alone

OBJECTIVE

For the past 30 years there has been a growing emphasis on evidence as the primary or exclusive basis for nursing practice.

METHODS

Critical examination of literature related to evidence-based practice from the 1990s to the present.

RESULTS

This review of the nursing literature from the 1990s to the present reveals that in the midst of the movement to promote evidence-based practice as the gold standard, there have been persistent expressions of concern. These concerns are (a) lack of alignment of evidence-based practice with nursing's disciplinary perspective; (b) wrongful privileging of empirical knowledge over other sources of knowledge; (c) underappreciation of the complexity of practice and practice wisdom;(d) possibilities of evidence-based practice thwarting innovation and creativity;(e) vulnerabilities of empirical evidence to be flawed, inconsistent, and influenced by competing interests; (f) situational realities that limit access to and critical appraisal of evidence that access to and critical appraisal of evidence is not feasible or practical; and (g) lack of relationship of evidence-based practice to theory.

CONCLUSIONS

We call for a recalibrated practice epistemology that promotes a greater appreciation for the myriad sources of knowledge for nursing practice, and offer recommendations for international change in education, literature, scholarship, and public media.

Tracking Demographic Movements and Immunization Status to Improve Children's Access to Immunization (TDM-IAI): Protocol for a Field-Based Randomized Controlled Trial

Background

In Cameroon, the coverage, completeness, and timeliness of the Expanded Programme on Immunization (EPI) vaccines administration in children have remained heterogeneous and below the national and districts targets in several districts. In an effort to solve this problem, many interventions have been tested but none has shown significant improvement of the situation.

Objective

This trial aims to test whether involving Community Volunteers to assess children vaccination status and demographic movements and using recorded data to plan catch-up immunization sessions can improve children vaccination timeliness, completeness and coverage.

Methods

Communities of the Foumban Health district, West region of Cameroon will be selected and assigned to either intervention or control groups using a restricted randomization of 2. In the intervention group, one Community Volunteer per community will be trained to visit households and record EPI-targeted children in a register, record their demographic movements, and assess their immunization status monthly for a year. The information recorded will be snapped and sent to the competent health center immunization team through WhatsApp. These will be used to plan and implement monthly community catch up immunization sessions in collaboration with the community volunteer. In the control group, the routine immunization sessions will be conducted with health centers organizing either weekly vaccination sessions for communities situated not farther than 5 kilometers away from the health facility or monthly vaccination sessions in communities situated more than 5 kilometers away from the health center. Baseline, mid-term and end-line surveys will be conducted to assess and compare immunization coverage, timeliness, and completeness.

Results

Funded in 2018, data collection started in 2018 and has been completed. Data analysis and reporting are ongoing.

Conclusions

This trial is expecting to test an innovative approach to improving children’s immunization timeliness, completeness and coverage of immunization by tracking EPI targeted population vaccination status and denominator at household level and building collaboration between the community and health facilities vaccination teams to organize monthly community-based response vaccination sessions. This intervention is expected to improve children sustainable access to EPI vaccination as it offers assessing and responding to their immunization needs at monthly basis using low cost local human resources.

Trial Registration

Pan African Clinical Trials Registry ID PACTR201808527428720; tinyurl.com/u058qnse

International Registered Report Identifier (IRRID)

DERR1-10.2196/21734

Dealing with vaccine hesitancy in Africa: the prospective COVID-19 vaccine context

The outbreak of the novel coronavirus disease (COVID-19) has resulted in many cases of morbidity and mortality across the globe, and the lack of the COVID-19 vaccine has contributed greatly to this experience. COVID-19 vaccines have currently been rolled out, and are available in some countries. However, strategies need to be put in place to prevent COVID-19 vaccine hesitancy (VH) especially in Africa; a continent where VH has been previously reported following the introduction of new vaccines. For this cause, we, therefore, recommend optimal community involvement in the structure and modalities for the delivery of the prospective COVID-19 vaccine. Also, feedback mechanisms for the acknowledgement of community efforts in previous health interventions should be improved upon to encourage the acceptance of the prospective COVID-19 vaccine. In addition, improved multi-sectoral collaboration should be initiated and promoted to enhance the acceptance of COVID-19 vaccines through the provision of more resources required to address COVID-19 VH. Furthermore, integration of the COVID-19 vaccine into the routine immunization schedule would strengthen the health system, improve uptake of the COVID-19 vaccine, and improve the health of all persons living on the African continent.