Vaccination, information and parental confidence in the digital age in England

Background

Immunisation programmes have led to substantial reductions in vaccine-preventable infectious diseases globally. A variety of factors have been shown to impact parental confidence and uptake of childhood vaccines, from concerns about vaccine safety to a lack of perceived need. Determinants of vaccine decision making include information, risk perceptions, and modifying factors such as attitude, identity, norms, habit and barriers. With the rise of the internet and social media, there has been a vast increase in information available about vaccines, not all scientifically-based and well-informed.

Methods

285 locations in England were randomly selected to survey a nationally representative sample of the English population. 1735 primary care givers of children aged between 2 months and <5 years old from England were randomly selected and surveyed via face-to-face interviews between January and March 2019.

Results

A much higher percentage of parents surveyed trust health care workers, the NHS, pharmacists and government for advice about immunisation, in comparison to media, the internet and social media. Most parents use official sources to obtain information on vaccines including parents who use the internet. The small proportion of parents who reported having seen negative information about vaccines were more likely to find it on the internet. Parents who felt they did not have enough information were more likely to have delayed or refused a vaccine for their child.

Interpretation

This study showed that for parents of young children in England, vaccination continues to be the social norm but this can rapidly change and clear, consistent messaging from trusted sources continues to be important. Although a proportion do seek vaccine information on the internet, the majority use official sources. Representative attitudinal surveys continue to be key in identifying any emerging threats to parental vaccine confidence.

The impact of the COVID-19 pandemic on the provision & utilisation of primary health care services in Goma, Democratic Republic of the Congo, Kambia district, Sierra Leone & Masaka district, Uganda

INTRODUCTION

This study aimed to determine whether the COVID-19 pandemic had an impact on essential primary healthcare services at public primary healthcare facilities.

METHODS

The number of weekly consultations for antenatal care (ANC), outpatient (OPD), immunisations (EPI), family planning (FP) and HIV services, between January 2018 and December 2020, were collected from 25 facilities in Masaka district, Uganda, 21 in Goma, and 29 in Kambia district, Sierra Leone. Negative binomial regression models accounting for clustering and season were used to analyse changes in activity levels between 2018, 2019 and 2020.

RESULTS

In Goma, we found no change in OPD, EPI or ANC consultations, FP was 17% lower in March-July 2020 compared to 2019, but this recovered by December 2020. New diagnoses of HIV were 34% lower throughout 2020 compared to 2019. In Sierra Leone, compared to the same periods in 2019, facilities had 18-29% fewer OPD consultations throughout 2020, and 27% fewer DTP3 doses in March-July 2020. There was no evidence of differences in other services. In Uganda there were 20-35% fewer under-5 OPD consultations, 21-66% fewer MCV1 doses, and 48-51% fewer new diagnoses of HIV throughout 2020, compared to 2019. There was no difference in the number of HPV doses delivered.

CONCLUSIONS

The level of disruption varied across the different settings and qualitatively appeared to correlate with the strength of lockdown measures and reported attitudes towards the risk posed by COVID-19. Mitigation strategies such as health communications campaigns and outreach services may be important to limit the impact of lockdowns on primary healthcare services.

Strategies to increase catch-up vaccination among migrants: a qualitative study and rapid review

Background

WHO’s Immunization Agenda 2030 has placed renewed focus on catch-up vaccination across the life course to meet global targets for reduction in vaccine-preventable diseases through increased vaccine coverage, including among migrant groups who may require catch-up vaccination to align them with host country vaccination schedules.

Methods

We did a global rapid review (01/2010 to 04/2022) to explore drivers of vaccine hesitancy among migrants followed by an in-depth qualitative study (semi-structured, telephone interviews) among recently arrived adult migrants (foreign-born, &gt;18 years old, residing in the UK &lt; 10 years). Interviews explored views on routine vaccination including accessibility, confidence and awareness. Data were analysed iteratively using thematic analysis.

Results

63 papers were included in the rapid review, including data from 22 countries/regions. Multiple factors driving under-immunisation and hesitancy in migrants were reported, including language barriers, low health literacy, social exclusion, low cultural competency and accessibility in healthcare systems. Our qualitative study recruited 40 migrants (mean age: 36.7 years; 62.5% female) resident in the UK (6 refugees, 19 asylum-seekers, 8 undocumented, 7 labour migrants). Major barriers to catch-up vaccination included a lack of provider recommendation and low awareness, with vaccination viewed as only relevant to children. Hesitancy around specific vaccines, such as MMR, was often influenced by misinformation. Participants suggested that novel strategies such as walk-in or mobile access points, consistent provider recommendations, and translation of information into relevant languages, may enhance accessibility and uptake of routine vaccinations.

Conclusions

Targeted and tailored information campaigns, versatile and proactive access pathways and education for healthcare staff on cultural competency will be needed to ensure uptake of catch-up vaccination among marginalised migrant groups.

Key messages

• Newly arrived adult migrants face barriers to catch-up vaccination in host countries, which may hinder immunisation coverage and increase the risk of vaccine-preventable disease outbreaks.

• Health systems must develop novel mechanisms to proactively offer culturally competent and accessible catch-up vaccination services to adult migrants on and after arrival.

Women’s experiences of accessing vaccines during pregnancy and for their babies during COVID-19

Background

COVID-19 changed access to healthcare, including vaccinations, in the United Kingdom (UK). This study explored UK women’s experiences of accessing pertussis vaccination during pregnancy and infant vaccinations during COVID-19.

Methods

An online cross-sectional survey was completed, between 3rd August-11th October 2020, by 1404 women aged 16+ years who were pregnant at some point after the first UK lockdown from March 23rd 2020. Ten follow-up semi-structured interviews were conducted.

Results

Most women surveyed were pregnant (65.7%) and a third postnatal (34.3%). Almost all women (95.6%) were aware that pertussis vaccination is recommended in pregnancy. Most pregnant (72.1%) and postnatal women (84.0%) had received pertussis vaccination however, access issues were reported. Over a third (39.6%) of women had a pregnancy vaccination appointment changed. COVID-19 made it physically difficult to access pregnancy vaccinations for one fifth (21.5%) of women and physically difficult to access infant vaccinations for almost half of women (45.8%). Nearly half of women (45.2%) reported feeling less safe attending pregnancy vaccinations and over three quarters (76.3%) less safe attending infant vaccinations due to COVID-19. The majority (94.2%) felt it was important to get their baby vaccinated during COVID-19. Pregnant women from ethnic-minorities and lower-income households were less likely to have been vaccinated. Minority-ethnicity women were more likely to report access problems and feeling less safe attending vaccinations for both themselves and their babies. Qualitative analysis found women experienced difficulties accessing antenatal care and relied on knowledge from previous pregnancies to access vaccine appointments.

Conclusions

COVID-19 disrupted access to vaccinations in the UK. Vaccine services must ensure equitable access to vaccine appointments during ongoing and future pandemics including tailoring services for lower income and ethnic minority families.

Key messages

• Pregnancy and infant vaccines was disrupted by COVID-19 with women feeling less safe and having difficulties accessing vaccinations with ethnic minority women more likely to report access issues.

• Equitable access to routine pregnancy and infant vaccine appointments must be prioritised during future pandemics, including considering tailoring services for different population groups.

Strengthening HPV vaccination delivery: findings from a qualitative service evaluation of the adolescent girls' HPV vaccination programme in England

BACKGROUND

In 2014, the number of HPV vaccine doses given to adolescent girls as part of the English school-based immunization programme was reduced from three to two. This was based on evidence that a two-dose schedule provides long-lasting protection against HPV infection. In 2015/16 a small decline in HPV vaccination coverage in adolescent girls was noted; from 86.7% for the three-dose schedule in 2013/14 to 85.1% for the two-dose schedule. This evaluation examined whether service-related factors contributed to this decline.

METHODS

In May-August 2017, we conducted semi-structured qualitative interviews with 39 participants responsible for commissioning or delivering immunization programmes in six local authorities in the South West, North Central Midlands and South Central Midlands, England.

RESULTS

Effective planning and data management were key for successful service provision of HPV vaccination, as well as close collaboration between commissioners, service providers and data system managers, a team skill mix with experienced staff, pro-active engagement with schools and service providers equipped to respond to parental concerns.

CONCLUSIONS

To maintain and improve the high HPV adolescent girls' vaccine coverage rates achieved in England, in the context of an expanding school-based immunization programme, it is essential to strengthen the organizational capacity of the delivery system.

Migration and outbreaks of vaccine-preventable disease in Europe: a systematic analysis (1990-2019)

Background

Migrant populations (defined as foreign-born) in the EU/EEA may be one of several under-immunised populations yet their role in outbreaks of vaccine-preventable diseases (VPDs) has been poorly defined to date.

Methods

We did both a temporal analysis to map published reports of migrant-related outbreaks against data from the ECDC's Surveillance Atlas of Infectious Disease, and a systematic review (PROSPERO CRD42019157473; 1990-2019) adhering to PRISMA guidelines, to explore whether migrants are involved in outbreaks in Europe and which particular subpopulations may be at increased risk. Studies on VPD outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, N meningitidis, and H influenzae) in migrants residing in the EU/EEA were included.

Results

46 studies were included, reporting on 50 VPD outbreaks across 13 EU/EEA countries, of which 98% (n = 49) occured since January 2000. Measles had the highest number of reports of outbreaks involving migrants (n = 21; 5043 cases), followed by varicella (n = 10; 595 cases) and hepatitis A (n = 10; 1226 cases). 21 (40%) of outbreaks were reported from shelters for asylum seekers and refugees (mainly varicella or measles). Of 27 outbreaks where the index case was defined, 20 (74.1%) were migrants, including 9 (33.3%) from Eastern Europe and 6 (22.2%) from Africa. When mapped against the ECDC timeline of measles outbreaks, migrant-related outbreaks coincide with Europe-wide peaks in measles incidence (in 2006, 2010, and 2018).

Conclusions

Migrants represent one key group involved in VPD outbreaks, with refugees/asylum seekers residing in shelters or camps particularly at risk. Measles accounted for 38% of all reported outbreaks. Improved data collection on migrant status across Europe is crucial to understanding the complex relationship between migration and occurrence of VPD outbreaks to inform policy decisions on the most effective strategies to prevent future outbreaks.

Key messages

Migrants represent one key group involved in vaccine-preventable diseases outbreaks in Europe. Refugees and asylum seekers may be particularly at risk.

The value of demonstration projects for new interventions: The case of human papillomavirus vaccine introduction in low- and middle-income countries

Demonstration projects or pilots of new public health interventions aim to build learning and capacity to inform country-wide implementation. Authors examined the value of HPV vaccination demonstration projects and initial national programmes in low-income and lower-middle-income countries, including potential drawbacks and how value for national scale-up might be increased. Data from a systematic review and key informant interviews, analyzed thematically, included 55 demonstration projects and 8 national programmes implemented between 2007-2015 (89 years' experience). Initial demonstration projects quickly provided consistent lessons. Value would increase if projects were designed to inform sustainable national scale-up. Well-designed projects can test multiple delivery strategies, implementation for challenging areas and populations, and integration with national systems. Introduction of vaccines or other health interventions, particularly those involving new target groups or delivery strategies, needs flexible funding approaches to address specific questions of scalability and sustainability, including learning lessons through phased national expansion.

Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review

BACKGROUND

Completion of multiple dose vaccine schedules is crucial to ensure a protective immune response, and maximise vaccine cost-effectiveness. While barriers and facilitators to vaccine uptake have recently been reviewed, there is no comprehensive review of factors influencing subsequent adherence or completion, which is key to achieving vaccine effectiveness. This study identifies and summarises the literature on factors affecting completion of multi-dose vaccine schedules by adolescents.

METHODS

Ten online databases and four websites were searched (February 2014). Studies with analysis of factors predicting completion of multi-dose vaccines were included. Study participants within 9-19 years of age were included in the review. The defined outcome was completion of the vaccine series within 1 year among those who received the first dose.

RESULTS

Overall, 6159 abstracts were screened, and 502 full texts were reviewed. Sixty one studies were eligible for this review. All except two were set in high-income countries. Included studies evaluated human papillomavirus vaccine, hepatitis A, hepatitis B, and varicella vaccines. Reported vaccine completion rates, among those who initiated vaccination, ranged from 27% to over 90%. Minority racial or ethnic groups and inadequate health insurance coverage were risk factors for low completion, irrespective of initiation rates. Parental healthcare seeking behaviour was positively associated with completion. Vaccine delivery in schools was associated with higher completion than delivery in the community or health facilities. Gender, prior healthcare use and socio-economic status rarely remained significant risks or protective factors in multivariate analysis.

CONCLUSIONS

Almost all studies investigating factors affecting completion have been carried out in developed countries and investigate a limited range of variables. Increased understanding of barriers to completion in adolescents will be invaluable to future new vaccine introductions and the further development of an adolescent health platform. PROSPERO reg# CRD42014006765.

Assessing the effects of HIV/AIDS and TB disease control programmes on health systems in low- and middle-income countries of Southeast Asia: a semi-systematic review of the literature

OBJECTIVE

To systematically review the literature on if and how HIV/AIDS and TB programmes have impacted on general healthcare systems in Association of Southeast Asian Nations (ASEAN) countries.

METHODS

Medline, Embase, Global Health and CINHAL were searched for English language literature published between 1st January 2003 and 31st March 2011. Papers included had to focus on: HIV and/or TB control programmes; the low- and-middle-income ASEAN countries; and factors related to any health systems functions. The effects were examined along six system functions: Stewardship and Governance; Financing; Planning; Service Delivery; Monitoring and Evaluation; and Demand Generation. A comprehensive thematic analytical tool aligned with the above six health systems functions was developed to support data extraction and analysis.

FINDINGS

88 papers met the inclusion criteria. Most programme effects highlighted were related with health service delivery. The other five health system functions were seldom scrutinized, and each covered by less than a quarter of papers. Overall 69% of effects highlighted were positive effects whereas 31% were negative.

CONCLUSION

There was a paucity of robust evidence. Effects on health systems were rarely a focus of research protocols but more often a minor component in the Results/Discussion sections. Particular attention should be paid by Global Health Initiatives to the negative effects that emerged from this study, such as the development of parallel systems, specific incentives not available to the general health systems, and lack of integration of services with private healthcare providers.

New vaccine adoption: qualitative study of national decision-making processes in seven low- and middle-income countries

As more new and improved vaccines become available, decisions on which to adopt into routine programmes become more frequent and complex. This qualitative study aimed to explore processes of national decision-making around new vaccine adoption and to understand the factors affecting these decisions. Ninety-five key informant interviews were conducted in seven low- and middle-income countries: Bangladesh, Cameroon, Ethiopia, Guatemala, Kenya, Mali and South Africa. Framework analysis was used to explore issues both within and between countries. The underlying driver for adoption decisions in GAVI-eligible countries was the desire to seize GAVI windows of opportunity for funding. By contrast, in South Africa and Guatemala, non-GAVI-eligible countries, the decision-making process was more rooted in internal and political dynamics. Decisions to adopt new vaccines are, by nature, political. The main drivers influencing decisions were the availability of funding, political prioritization of vaccination or the vaccine-preventable disease and the burden of disease. Other factors, such as financial sustainability and feasibility of introduction, were not as influential. Although GAVI procedures have established more formality in decision-making, they did not always result in consideration of all relevant factors. As familiarity with GAVI procedures increased, questioning by decision-makers about whether a country should apply for funding appeared to have diminished. This is one of the first studies to empirically investigate national processes of new vaccine adoption decision-making using rigorous methods. Our findings show that previous decision-making frameworks (developed to guide or study national decision-making) bore little resemblance to real-life decisions, which were dominated by domestic politics. Understanding the realities of vaccine policy decision-making is critical for developing strategies to encourage improved evidence-informed decision-making about new vaccine adoptions. The potential for international initiatives to encourage evidence-informed decision-making should be realised, not assumed.

Resource mapping and emergency preparedness to infectious diseases in human and animal populations in Kibaha and Ngorongoro districts, Tanzania

A rapid situation analysis was conducted in Kibaha and Ngorongoro districts in Tanzania to map resources as well as analysing emergency preparedness to infectious diseases in animal (domestic and wild) and human populations. Kibaha was chosen as a district close to a commercial city (Dar es Salaam) while Ngorongoro represented a remote, border district with high interactions between humans, domestic and wild animals. In this study, data on resources and personnel as well as emergency preparedness were collected from all wards (n = 22), human health facilities (n = 40) and livestock facilities in the two districts using interview checklists and questionnaires. Descriptive statistics for resources were calculated and mapped by district. Kibaha district had a higher human population density, more health workers, better equipped health facilities and better communication and transport systems. On the other hand, Ngorongoro had a higher population of livestock and more animal health facilities but a poorer ratio of animal health workers to livestock. The average ratio of health personnel to population in catchment areas of the health facilities was 1:147 (range of 1:17−1:1200). The ratio of personnel to human population was significantly higher in Kibaha (1:95) than in Ngorongoro (1:203) district (p = 0 < 0.001). Considering the limited resources available to both human and animal health sectors and their different strengths and weaknesses there are opportunities for greater collaboration and resource-sharing between human and animal health for improved surveillance and emergency-preparedness.

Impact of measles elimination activities on immunization services and health systems: findings from six countries

BACKGROUND

One of the key concerns in determining the appropriateness of establishing a measles eradication goal is its potential impact on routine immunization services and the overall health system. The objective of this study was to evaluate the impact of accelerated measles elimination activities (AMEAs) on immunization services and health systems in 6 countries: Bangladesh, Brazil, Cameroon, Ethiopia, Tajikistan, and Vietnam.

METHODS

Primary data were collected from key informant interviews and staff profiling surveys. Secondary data were collected from policy documents, studies, and reports. Data analysis used qualitative approaches.

RESULTS

This study found that the impact of AMEAs varied, with positive and negative implications in specific immunization and health system functions. On balance, the impacts on immunization services were largely positive in Bangladesh, Brazil, Tajikistan, and Vietnam, while negative impacts were more significant in Cameroon and Ethiopia.

CONCLUSIONS

We conclude that while weaker health systems may not be able to benefit sufficiently from AMEAs, in more developed health systems, disruptions to health service delivery are unlikely to occur. Opportunities to strengthen the routine immunization service and health system should be actively sought to address system bottlenecks in order to incur benefits to eradication program itself as well as other health priorities.

HIV testing strategies across European countries

With universal access to effective combination antiretroviral therapy (ART), people in need can gain effective treatment but are only able to benefit from these advances if they are aware of their serostatus and have effectively accessed testing services. Despite the expectation that ART would lead individuals to seek earlier testing, this trend has not been observed in practice, with stable or even increasing rates of late diagnosis in Europe being witnessed. Ahead of a gathering of key European stakeholders in Brussels in November 2007, we reviewed testing strategies across European countries. We show differences in policy and practices. Moreover, HIV testing strategies are changing, in line with new global guidelines issued by World Health Organization headquarters, and a number of countries are promoting an expansion of routine and opt-out testing. However, gaps in our understanding of effective testing strategies remain and, as a consequence, national policies across Europe remain incoherent and often lack an evidence base. This is likely to have serious public health implications.

Public health law and tuberculosis control in Europe

BACKGROUND

Tuberculosis control is an important public health challenge in many European countries. Law is an important tool that policy-makers can draw upon to support control efforts and, according to the World Health Organization, represents a tangible expression of political commitment and will. Despite this, little national research, and even less cross-national comparative research, has been conducted to describe and analyse legislative approaches to tuberculosis control.

METHODS

We conducted a survey of 14 European countries to identify, describe, map and analyse legislative tools used to support tuberculosis control.

RESULTS

We found a wide range of legislative models. Legal measures available to nation states, such as compulsory examination, compulsory screening, compulsory detention, compulsory treatment and compulsory vaccination, vary widely in both scope and number. We identified a typology of legal frameworks, from the most authoritarian to the least restrictive. It seems likely that the application of some laws might not withstand scrutiny under the European Convention for the Protection of Human Rights and Fundamental Freedoms.

CONCLUSIONS

Harmonization of legislative response to infectious diseases, based upon sound evidence, may be necessary if collaborative efforts in support of infectious disease control, as envisaged in the new International Health Regulations, are to be most effective and are to reflect more appropriately a globalized 21st century world.

Further thoughts on the limitations of a recently published review of national influenza pandemic plans in Europe

In their critique of our analysis of national pandemic influenza preparedness plans in Europe, Nicoll and Kaiser raise a number of issues