B and T cell responses to the 3rd and 4th dose of the BNT162b2 vaccine in dialysis patients

Patients on dialysis (PoD) are at high risk of severe morbidity and mortality from COVID-19. Characterizing long-term vaccine immune responses in these patients will help optimize vaccine schedule for PoD. This study aimed to determine whether long-term humoral and B and T cell-responses post 3rd and 4th dose of the BNT162b2 vaccine differed between PoD and controls. Non-infected PoD and controls vaccinated with BNT162b2 were recruited in Ziv Medical Center, Israel, between 2021 and 2022. Specimens were collected 1-2 months pre 3rd dose; 1-3 months post 3rd dose; 4-5 months post 3rd dose and 3-5 months post the 4th dose. Anti-SARS-CoV-2 spike (spike) specific antibodies, spike specific memory B cells, and spike specific CD154+ T cells as well as cytokines producing CD4+/CD8+ T cells were measured using standardized assays and compared between PoD and controls at each time point using Mann Whitney and Fisher's exact tests. We recruited 22 PoD and 20 controls. Antibody levels in PoD were lower compared to controls pre 3rd dose but not post 3rd and 4th doses. Frequencies of spike specific memory B cell populations were similar between PoD and controls overall. Frequencies of spike specific T cells, including those producing IFNγ and TNFα, were not lower in PoD. B and T cell mediated immune response in PoD following a 3rd and a 4th dose of the BNT162b2 vaccine was not inferior to controls up to 5 months post vaccination. Our results suggest that standard BNT162b2 vaccination is suitable for this group.

Understanding the health system barriers and enablers to childhood MMR and HPV vaccination among disadvantaged, minority or underserved populations in middle- and high-income countries: a systematic review

BACKGROUND

Child vaccinations are among the most effective public health interventions. However, wide gaps in child vaccination remain among different groups with uptake in most minorities or ethnic communities in Europe substantially lower compared to the general population. A systematic review was conducted to understand health system barriers and enablers to measles, mumps and rubella (MMR) and human papilloma virus (HPV) child vaccination among disadvantaged, minority populations in middle- and high-income countries.

METHODS

We searched Medline, Cochrane, CINAHL, ProQuest and EMBASE for articles published from 2010 to 2021. Following title and abstract screening, full texts were assessed for relevance. Study quality was appraised using Critical Appraisal Skills Program checklists. Data extraction and analysis were performed. Health system barriers and enablers to vaccination were mapped to the World Health Organization health system building blocks.

RESULTS

A total of 1658 search results were identified from five databases and 24 from reference lists. After removing duplicates, 1556 titles were screened and 496 were eligible. Eighty-six full texts were assessed for eligibility, 28 articles met all inclusion criteria. Factors that affected MMR and HPV vaccination among disadvantaged populations included service delivery (limited time, geographic distance, lack of culturally appropriate translated materials, difficulties navigating healthcare system), healthcare workforce (language and poor communication skills), financial costs and feelings of discrimination.

CONCLUSION

Policymakers must consider health system barriers to vaccination faced by disadvantaged, minority populations while recognizing specific cultural contexts of each population. To ensure maximum policy impact, approaches to encourage vaccinations should be tailored to the unique population's needs. A one-size-fits-all approach is not effective.

Association between multiple sclerosis and urinary levels of toxic metals and organophosphates: A cross-sectional study in Israel

BACKGROUND

Multiple sclerosis (MS) is a multifactorial disease of uncertain etiology damaging myelin sheaths around axons of the central nervous system. Myelin protects the axon from potentially harmful exogenous factors. The aetiological role of environmental exposure metals and organophosphates is unclear.

OBJECTIVE

Identify whether urinary levels of metals and organophosphates differed in MS patients and controls.

METHODS

We recruited MS patients from Ziv Medical Centre and healthy controls. MS patients were evaluated according to Expanded Disability Status Scale into mild and moderate-severe conditions. Each participant provided a urine sample and completed epidemiological questionnaires. The levels of six metal (Aluminum, Cadmium, Chromium, Lead, Mercury, Nickel) and one metalloid (Arsenic) and common organophosphates pesticide metabolites (6 dialkylphosphates, DAP) were measured in urine using inductively coupled plasma-mass spectrometry and gas-chromatography mass-spectrometry. We compared cases with controls in terms of urinary levels of these compounds using Mann-Whitney and Kruskall-Wallis tests.

RESULTS

Urinary cadmium and mercury levels were higher in the 49 MS patients than the 37 controls (p < 0.01). Cadmium levels were higher in moderate-severe MS patients (n = 24) than mild MS patients (n = 25) (p = 0.003).

CONCLUSION

Urinary cadmium and mercury levels were higher among MS patients than controls. Cadmium levels correlated with disease severity. Further studies are needed to explore potential causal pathways between these compounds and MS pathogenesis.

The immune status of migrant populations in Europe and implications for vaccine-preventable disease control: a systematic review and meta-analysis

BACKGROUND

Ensuring vaccination coverage reaches established herd immunity thresholds (HIT) is the cornerstone of any vaccination programme. Diverse migrant populations in European countries have been associated with cases of vaccine-preventable diseases (VPD) and outbreaks, yet it is not clear to what extent they are an under-immunised group.

METHODS

We did a systematic review and meta-analysis to synthesise peer-reviewed published primary research reporting data on the immune status of migrants in EU/EEA countries, the UK and Switzerland, calculating their pooled immunity coverage for measles, mumps, rubella, and diphtheria using random-effects models. We searched on Web of Science, Embase, Global Health and MEDLINE (January 1st 2000 to June 10th 2022), with no language restrictions. The protocol is registered with PROSPERO (CRD42018103666).

FINDINGS

Of 1103 abstracts screened, 62 met eligibility criteria, of which 39 were included in the meta-analysis. The meta-analysis included 75 089 migrants, predominantly from outside Europe. Pooled immunity coverage among migrant populations was well below the recommended HIT for diphtheria (n = 7, 57.4% [95% CI: 43.1-71.7%] I2 = 99% vs HIT 83-86%), measles (n = 21, 83.7% [95% CI: 79.2-88.2] I2 = 99% vs HIT 93-95%), and mumps (n = 8, 67.1% [95% CI: 50.6-83.6] I2 = 99% vs HIT 88-93%), and midway for rubella (n = 29, 85.6% [95% CI: 83.1-88.1%] I2 = 99% vs HIT 83-94%), with high heterogeneity across studies.

INTERPRETATION

Migrants in Europe are an under-immunised group for a range of important VPDs, with this study reinforcing the importance of engaging children, adolescents, and adults in 'catch-up' vaccination initiatives on arrival for vaccines, doses, and boosters they may have missed in their home countries. Co-designing strategies to strengthen catch-up vaccination across the life-course in under-immunised groups is an important next step if we are to meet European and global targets for VPD elimination and control and ensure vaccine equity.

Barriers to HPV vaccination in marginalized Roma communities in Slovakia

Introduction

Limited access to healthcare services leads to lower vaccination rates in marginalized Roma communities (MRCs). This study aimed to explore health system barriers to HPV vaccination faced by people from MRCs from multiple perspectives.

Methods

The qualitative study was conducted in Slovakia in 2021/22 with 43 community members and health professionals. Data were analyzed using a combination of content analysis and consensual qualitative research.

Results

A substantial barrier to vaccination is limited coverage of vaccination expenses for certain age categories by health insurance. Moreover, Slovakia faces a significant shortage of healthcare personnel, leading to work overload and a lack of capacity and motivation to address HPV vaccination. Impaired relationships between health care providers and people from MRCs lead to the avoidance of healthcare services, which contributes to insufficient delivery of information and a lack of awareness regarding HPV-related diseases and vaccination.

Conclusion

Strengthening the capacities of health care providers, expanding the age group covered by health insurance and providing tailored information to people from MRCs are necessary prerequisites to increase the availability of HPV vaccination and enable people to make informed decisions about HPV vaccination.

Pediatric injury attendances in different population groups in Israel before, during, and after COVID-19 lockdowns: a descriptive study, 2018-2022

BACKGROUND

Lockdowns and quarantines during the COVID-19 pandemic influenced healthcare services' usage patterns such as emergency department (ED) attendance. During the pandemic, Israel issued three lockdowns (March-May 2020, September-October 2020, and December 2020-February 2021) to mitigate the spread of COVID-19. Little is known about the impact of these lockdowns on ED attendance for injuries in the diverse population of Northern Israel.

METHODS

We described patterns of ED attendance before, during, and after COVID-19 lockdowns. We extracted data from medical records of all northern Israeli children aged 0-17 years old who attended Ziv Medical Center (ZMC) emergency department (ED) due to injury, between 01/01/2018 and 10/02/2022. We compared the volume and characteristics of ED attendance during lockdown periods to the same time periods in the 2 years before the pandemic and 1 year after the lockdowns, using chi-square tests.

RESULTS

Seven thousand six hundred nineteen northern children attended ZMC ED during the time periods of the study for injuries and were analyzed. Mean attendance numbers during lockdowns decreased compared to previous years, with an increase in injuries proportion (67.8% (1502/2216) vs. 52.7% (2038/3868) p < 0.001). The proportion of 0-4-year-olds attending for injuries during the lockdown increased compared to pre-pandemic (39.68% vs. 30.7%, p < 0.0001). Minority population attendance decreased (27.47% vs. 30.71% p = 0.02). Hospitalization rates increased (13.21% vs. 10.65% p = 0.01). Post-lockdown periods saw a return to the pre-pandemic age and ethnicity distribution.

CONCLUSIONS

Compared to previous years, the volume of injuries was lower during lockdowns for all ages, with a relative increase in the proportion of injuries among younger children attending the ED. A lower proportion of attendance from minority groups suggests different health-seeking behavior patterns during emergencies compared to the general population. Understanding these differences will help better plan for future emergencies.

Barriers and enablers to vaccination in the ultra-orthodox Jewish population: a systematic review

Background

The Jewish Ultra-Orthodox (UO) population is an under-vaccinated minority group that has been disproportionally affected by outbreaks of vaccine-preventable diseases (VPD) such as measles and polio. Underlying reasons remain poorly characterized. We aimed to identify vaccination barriers and enablers in this population.

Methods

We systematically reviewed the literature (PROSPERO: CRD42021273001), searching Pub-med, Web of science, Medline, PsychNet and Scopus from 1995 to 2021 for quantitative and qualitative primary research in English. Studies published outside the date range, not including barriers or enablers, or that were non-primary research were excluded. We assessed included publications for quality and extracted relevant data based on the 5As taxonomy: access, awareness, affordability, acceptance and activation.

Results

We included nine qualitative and seven quantitative studies from the 125 studies identified. Access barriers included scheduling difficulties, inconvenient opening hours, and logistical difficulties related to having multiple young children. Acceptance barriers included safety concerns. Insufficient knowledge about the importance of vaccine and timely vaccination and the perception of being shielded from infections because of seclusion from wider society were key awareness barriers. Competing priorities, such as work and housework, were the main affordability barriers. Mainstream religious leadership's support for vaccination was an enabler, although recent studies suggest their influence on vaccination behavior is decreasing and influence of anti-vaccination messages is growing.

Discussion

Barriers to vaccination among the UO were mainly logistical, with little religious framing. Safety and efficacy concerns were similar to those reported in the wider community. Decreasing influence of the traditionally pro-vaccine mainstream religious leadership and growing influence of anti-vaccination movements targeting the UO community are new phenomena that require close monitoring. Tailored interventions are required to protect the community and wider society against future VPD outbreaks.

Systematic review registration

PROSPERO: CRD42021273001.

Vaccine-induced and hybrid immunity to SARS-CoV-2 after three or four doses of BNT162b2 - results from 22 months follow-up of a healthcare workers cohort, Israel, 2020-2022

OBJECTIVES

SARS-CoV-2 remains a global health concern 3 years after its emergence. Safe and effective vaccines mitigate the pandemic impact, but the optimal schedule remains unclear, especially in a context where a high proportion of the population is infected.

METHODS

We periodically measured anti-spike SARS-CoV-2 immunoglobulin (Ig)G titers using a quantitative assay in an Israeli healthcare worker cohort who all received at least two BNT162b2 doses and either received further doses and/or were subsequently infected up to 22 months after dose two, and compared geometric mean concentrations according to number of doses received and infection status using analysis of variance.

RESULTS

Among the 993 included participants, infection after dose two led to higher geometric mean concentration IgG titers than a third dose (4285 vs 2845 arbitrary unit/ml 1-2 months after infection/vaccination, P = 0.03). In 16-18 months after dose two, those infected and those who received three or four vaccine doses all had IgG geometric mean concentration levels above 500 arbitrary unit/ml with no significant differences among groups (P = 0.6). IgG levels plateaued 16-22 months after dose two.

CONCLUSION

Three BNT162b2 doses provide long-term immunogenicity comparable to breakthrough infection after dose two. Dose four transiently increases IgG levels and may be especially important for providing additional protection to vulnerable individuals during periods of increased transmission risk.

Association between BNT162b2 vaccination and health-related quality of life up to 18 months post-SARS-CoV-2 infection in Israel

We determined whether COVID-19 vaccination was associated with Quality of Life (QoL) changes among individuals previously infected with SARS-CoV-2 in Israel. Using a validated questionnaire, we collected information about socio-demographics, SARS-CoV-2 infection, COVID-19 vaccination and QoL (using the EQ-5D-5L tool) 3-18 months post-infection among adults tested for SARS-CoV-2 by polymerase chain reaction in Northern Israel between March 2020-June 2022. We compared post-COVID QoL between those vaccinated against COVID-19 at the time of infection and those not, using an adjusted linear regression model, stratified by time elapsed since infection. Of 951 participants, mean EQ-5D Utility Index (EQ-5D UI) was 0.82 (SD = 0.26) and 0.83 (SD = 0.25) among the 227 double and 250 triple vaccinated respectively, compared to 0.76 (SD = 0.33) among those who received 0 dose (n = 243). The size of the effect of vaccination was small (Cohen's d = 0.2). In the adjusted model, previously infected individuals vaccinated with two or more doses reported a QoL score post- infection 0.05 points higher (CI = 0.01-0.10, p = 0.02) compared with those unvaccinated when infected. No association between vaccination and QoL was detected beyond 12 months post-infection. Vaccination with two or more doses of COVID19 vaccine, or at least the BNT162b2 vaccine, may modestly mitigate QoL losses associated with post-acute COVID-19 symptoms, at least in the first 12 months post-infection.

Characterization of post-COVID syndromes by symptom cluster and time period up to 12 months post-infection: A systematic review and meta-analysis

OBJECTIVES

The objective of this study was to characterize post-COVID condition symptoms and symptom clusters, their duration, and prevalence.

METHODS

We conducted a systematic review and random-effects meta-analysis of studies reporting post-COVID-19 symptoms and clusters, respectively. We searched MEDLINE (via PubMed), Scopus, Web of Science, Science Direct, Google Scholar, EBSCOhost, EMBASE, PsycINFO, Cochrane Library, and Mednar for literature reporting on the post-COVID condition up to August 2022.

RESULTS

In the 76 included studies, we found that although most symptoms were reported less frequently 7-12 months after infection compared to earlier, over 20% of patients reported at least one post-COVID condition-compatible symptom. In the seven studies reporting post-COVID symptom clusters, neurological clustering was consistently identified, followed by cardiorespiratory and systemic/inflammatory.

CONCLUSION

Post-COVID symptom clustering provides direction for research into the etiology, diagnosis, and management of post-COVID conditions. Studies reporting post-COVID symptom clusters remain rare due to the focus on individual symptom reporting. Studies on post-COVID symptom clusters should replace individual symptom reporting to accelerate our understanding of this emerging public health issue.

Changes in Quality of Life Following SARS-CoV-2 Infection Among Jewish and Arab Populations in Israel: A Cross-Sectional Study

Objectives: The long-term impact of COVID-19 on health inequalities is under-researched. We investigated changes in health-related inequalities following SARS-CoV-2 infection between the Jewish majority and the Arab/Druze minority in Israel. Methods: Patients with a positive SARS-CoV-2 RT-PCR test processed from one of the Northern-Israeli government hospitals between 03/2021 and 05/2022 were invited to participate. We collected socio-demographic, COVID-19-related, and health-related quality of life (HRQoL) information using a validated questionnaire. We compared pre- and post COVID-19 HRQoL changes between Jews and Arabs/Druze, up to 12+ months post-infection using an adjusted linear regression model. Results: Among the 881 included participants the average post-COVID HRQoL score was lower among Arabs/Druze than Jews (0.83 vs. 0.88; p = 0.005). Until 12 months post-infection, HRQoL changes were similar for Arabs/Druze and Jews. After 12 months, HRQoL dropped significantly more among Arabs/Druze than among Jews (0.11 points difference between the groups; p = 0.014), despite adjusting for socioeconomic variables. Conclusion: 12 months post-infection, COVID-19 affected the HRQoL of Arabs/Druze more than Jews, with the gap not fully explained by socio-economic differences. The COVID-19 pandemic may widen pre-existing long-term health inequalities.

Maternal and cord anti-SARS-CoV-2-spike IgG following COVID-19 vaccination vs. infection during pregnancy: a prospective study, Israel October 2021-March 2022

OBJECTIVES

Defining how pregnant women respond to SARS-CoV-2 infection and vaccination is critical to optimize vaccination strategies that protect mother and infant at the epidemic. This study aimed to compare Anti-SARS-CoV-2-spike IgG of vaccinated vs. infected women and to determine the optimal timing of maternal vaccination during pregnancy at the time of epidemic.

STUDY DESIGN

We collected maternal/cord blood at delivery (October 2021-March 2022) and measured Anti-SARS-CoV-2-spike-IgG geometric mean concentrations (IgG-GMC), using a quantitative immunoassay. We compared groups according to timing and number of doses and correlated maternal and fetal IgG levels. We described the proportion of women with IgG-levels above the 150 AU/ml positivity threshold according to the timing of infection/vaccination and performed a sub-analysis for maternal IgG-GMC levels pre and during the Omicron wave.

RESULTS

We included 238 vaccinated women, 125 who received two doses and 113 three; and 48 unvaccinated infected women. All groups infected/vaccinated in the second or third-trimester had an IgG-GMC above the positivity threshold. Third-trimester vaccination (second/third dose) resulted in higher maternal and cord-blood IgG-GMC compared to the second-trimester (maternal-IgG:10232 vs. 4325 AU/mL,p<0.001; cord-IgG:12113 vs. 8112 AU/mL,p<0.001). Compared with infected-only women, a higher proportion of vaccinated-women with >two doses and their newborns had IgG-levels above the positivity threshold at all time points. In vaccinated-women, there were higher maternal IgG-GMC levels during the Omicron wave than pre-Omicron.

CONCLUSIONS

At the time of epidemic, receiving an additional COVID-19 vaccine dose in the third-trimester resulted in a higher IgG-GMC compared to the second-trimester. Relatively higher levels of maternal and cord IgG-GMC were achieved following vaccination than infection. Women infected during or before the first-trimester might benefit from an additional third-trimester dose to prevent peripartum infection and to passively immunize their newborn. The higher levels of maternal IgG-GMC in the Omicron period are suggestive of hybrid immunity.

Addressing Determinants of Immunization Inequities Requires Objective Tools to Devise Local Solutions

Universal immunization substantially reduces morbidity and mortality from vaccine-preventable diseases. In recent years, routine immunization coverage has varied considerably among countries across the WHO European Region, and among different populations and districts within countries. It has even declined in some countries. Sub-optimal immunization coverage contributes to accumulations of susceptible individuals and can lead to outbreaks of vaccine-preventable diseases. The European Immunization Agenda 2030 (EIA2030) seeks to build better health in the WHO European Region by ensuring equity in immunization and supporting immunization stakeholders in devising local solutions to local challenges. The factors that influence routine immunization uptake are context specific and multifactorial; addressing immunization inequities will require overcoming or removing barriers to vaccination for underserved individuals or populations. Local level immunization stakeholders must first identify the underlying causes of inequities, and based on this information, tailor resources, or service provision to the local context, as per the organization and characteristics of the health care system in their countries. To do this, in addition to using the tools already available to broadly identify immunization inequities at the national and regional levels, they will need new pragmatic guidance and tools to address the identified local challenges. It is time to develop the necessary guidance and tools and support immunization stakeholders at all levels, especially those at the subnational or local health centre levels, to make the vision of EIA2030 a reality.

Health System Barriers to Child Mandatory and Optional Vaccination among Ukrainian Migrants in Poland in the Context of MMR and HPV Vaccines-A Qualitative Study

Background Migrants' access to healthcare services is limited. This study aimed to identify health system barriers to vaccination, specifically HPV/MMR vaccination among children in Ukrainian economic migrants (UMs). Methods Between December 2021-March 2022, a qualitative study of UMs living in Poland was conducted. Six focus groups were held with 53 UMs aged 15-45; in-depth interviews with 12 healthcare workers (HCWs) were also performed. A thematic analysis was conducted based on the six WHO health system building blocks. Results HCWs described gaps in integrating migrant status in accessible healthcare data which impeded active management of vaccination procedures. UMs reported that the digitization of healthcare services, intensified during the COVID-19 pandemic, reduced their access to primary care. Inadequate health information systems caused problems with the provision of credible vaccine information in translated forms, and language difficulties, experienced by both UMs and HCWs; this was enhanced by a lack of professional interpreting services. Although most UMs reported vaccinating children according to the Polish schedule, the variations in schedules across countries caused concern among UMs and increased HCWs' uncertainty about how to interpret vaccination cards, particularly in the context of possible false certificates. UMs were affected by discrimination through HCWs. HPV was deprioritized by UMs due to misconceptions about non-mandatory vaccinations; the cost was also a barrier. Conclusions The study findings have implications for migrant vaccination delivery targeting children in Poland, and other UMs receiving countries. A concerted effort is required to improve UM's awareness of the significance of vaccinations. Barriers to healthcare access must be recognized by policymakers. Importantly, removing the cost barrier may increase the uptake of the HPV vaccine among Ukrainian migrant adolescents.

Reasons underlying the intention to vaccinate children aged 5-11 against COVID-19: A cross-sectional study of parents in Israel, November 2021

Vaccination is a key tool to mitigate impacts of the COVID-19 pandemic. In Israel, COVID-19 vaccines became available to adults in December 2020 and to 5-11-year-old children in November 2021. Ahead of the vaccine roll-out in children, we aimed to determine whether surveyed parents intended to vaccinate their children and describe reasons for their intentions. We collected information on parental socio-demographic characteristics, COVID-19 vaccine history, intention to vaccinate their children against COVID-19, and reasons for parental decisions using an anonymous online survey. We identified associations between parental characteristics and plans to vaccinate children using a logistic regression model and described reasons for intentions to vaccinate or not. Parental non-vaccination and having experienced major vaccination side effects were strongly associated with non-intention to vaccinate their children (OR 0.09 and 0.18 respectively, p < .001). Parents who were younger, lived in the socio-economically deprived periphery, and belonged to the Arab population had lower intentions to vaccinate their children. Reasons for non-intention to vaccinate included concerns about vaccine safety and efficacy (53%, 95%CI 50-56) and the belief that COVID-19 is a mild disease (73%, 95%CI 73-79), while a frequent motive for vaccination was the return to normal social and educational life (89%, 95%CI 87-91). Understanding rationales for COVID-19 vaccine rejection or acceptance, as well as parental demographic data, can pave the way for intentional educational campaigns to encourage not only vaccination against COVID-19, but also regular childhood vaccine programming.

Improving childhood vaccination in minorities: a realist review of health system interventions

Background

Most minority populations in Europe have lower childhood vaccine uptake than the general population. Improving uptake in these populations requires specifically developed, context-specific interventions. As part of the EU-funded RIVER-EU project, we conducted a realist review to identify interventions effective at improving vaccine uptake among underserved communities.

Methods

We searched MEDLINE, EMBASE, CINAHL, COCHRANE, and Proquest for articles published between 2005 and 2022, using combination keyword searches in English. Following title and abstract screening, full texts were assessed for relevance. We also searched grey literature and references of references. Data extraction and analysis was performed by two reviewers. Programme theories were generated from included articles and data extraction were carried out paying particular attention to context, mechanisms, and outcome configurations.

Results

From 1942 screened titles we selected 87 studies for full-text review of which 34 were included. We identified 10 primary intervention categories: parental and youth education; clinic outreach; quality improvement; health provider training; school-based education; technology interventions; cash incentives; home visits; comic books; community leaders education; and consent policy changes. The analysis highlighting contextual factors enabling or hindering each intervention category’s success is ongoing.

Conclusions

Several intervention categories can potentially improve vaccine coverage among underserved minority populations. We will describe their effectiveness and the contextual factors contributing to their success or failure to inform the development of tailored interventions targeting these populations.

Key messages

• Improving vaccination in underserved minority populations requires identification of effective interventions, barriers/enablers to their success, specific to the context in which they are implemented.

• Appropriately tailored health system interventions are effective at improving vaccine uptake among underserved minority communities.

Equity of the Meningitis B vaccination programme in England, 2016-2018

In England, the Meningitis B (MenB) vaccine is scheduled at eight and 16 weeks with a booster dose at one year of age and protects children against invasive bacterial meningococcal disease caused by Neisseria meningitidis serogroup B. Coverage of the second dose of MenB vaccine at 12 months was >92% in 2017/18, but this may mask inequalities in coverage in particular population groups. MenB vaccination records for children aged six, 12 and 18 months of age from December 2016 to May 2018 were routinely extracted from GP patient management systems every month in England via a web-based platform for national monitoring of vaccine coverage. We determined the association between ethnicity, deprivation and area of residence, vaccine coverage and drop-out rates (between dose one and dose two), using binomial regression. After adjusting for other factors, ethnic groups with lowest dose one coverage (Black or Black British-Caribbean, White-Any other White background, White-Irish) also had lowest dose two coverage, but in addition, these ethnic groups also had the largest drop-out rates between dose one and dose two. The drop-out rate for Black or Black British-Caribbean children was 5.7 percentage points higher than for White-British children. Vaccine coverage decreased with increasing deprivation quintile, and this was most marked for the booster coverage (6.2 percentage points lower in the most deprived compared to least deprived quintile, p < 0.001). To achieve high coverage for completed courses across all ethnic groups and deprivation quintiles both high initiation rates and a reduction in drop-out rates for ethnic groups with lowest coverage is necessary. A qualitative approach to better understand reasons behind lower coverage and higher drop-out rates in the most underserved ethnic groups is required to develop tailored approaches addressing these inequalities.

Effects of hemodialysis with cooled dialysate on high-sensitivity cardiac troponin I and brain natriuretic peptide

BACKGROUND

Hemodialysis (HD) triggers recurrent and cumulative ischemic insults to the brain and the heart. Cooled dialysate may have a protective effect on major organs and improve hemodynamic tolerability of dialysis. The aim of the study was to compare HD with cooled dialysate with routine dialysis in terms of hemodynamic stability and levels of high-sensitivity Troponin I (hs-TnI) and N-terminal pro b-type natriuretic peptide (NTproBNP) pre and postdialysis.

METHODS

The 45 patients were randomized into two groups. The first group received a 35.5°C dialysate first (hypothermic dialysis) and the second group a 36.5°C dialysate first (routine dialysis). Then groups crossed over, so each group received the alternate dialysate (self-controls) For each patient, the first sample was collected at the beginning of dialysis, and a second sample was taken at the end of dialysis.

RESULTS AND CONCLUSION

hs-TnI and NTproBNP increased after routine HD by 10.7 ng\ml (p < 0.001) and (12.0 pg/μl) (p < 0.001), respectively, and by -3.1 ng\ml (p = 0.25) and (4.3 pg/μl) (p < 0.001), respectively after hypothermic HD. Our study results showed a tendency towards less rise in hsTnI and NTproBNP during hypothermic HD (35.5°C) as compared to routine HD (36.5°C). Neither arm experienced statistically significant changes in blood pressure. Further studies in larger cohorts and long follow up are warranted in order to confirm that lower rise in (hs-TnI) and NTproBNP actually translate into lower clinical risk for cardiovascular events.

Association between BNT162b2 vaccination and reported incidence of post-COVID-19 symptoms: cross-sectional study 2020-21, Israel

The effectiveness of Coronavirus disease 2019 (COVID-19) vaccines against the long-term COVID-19 symptoms expressed by a substantial proportion of patients is not well understood. We determined whether vaccination with the BNT162b2 mRNA vaccine was associated with incidence of reporting long-term symptoms post-SARS-CoV-2 infection. We invited individuals PCR-tested for SARS-CoV-2 infection at participating hospitals between March 2020 and November 2021 to fill an online questionnaire that included information about demographics, acute COVID-19 episode and symptoms they were currently experiencing. Using binomial regression, we compared vaccinated individuals with those unvaccinated and those uninfected, in terms of post-acute self-reported symptoms. Of the 951 infected, 637(67%) were vaccinated. In the study population, the most prevalent symptoms were: fatigue (22%), headache (20%), weakness of limbs (13%), and persistent muscle pain (10%). After adjusting for age, time from beginning of symptoms to responding to the survey, and baseline symptoms, those who received two vaccine doses were less likely than unvaccinated individuals to report any of these symptoms (fatigue, headache, weakness of limbs, persistent muscle pain) by 62%, 50%, 62%, and 66% respectively, (Risk ratios 0.38, 0.50, 0.38, 0.34, p < 0.04 in the listed sequence). Compared to the 2447 included individuals who never reported SARS-CoV-2 infection, double-vaccinated participants were no more likely to report any of the mentioned symptoms. Vaccination with 2+ doses of BNT162b2 was associated with a reduced risk of reporting most of the common post-acute COVID-19 symptoms. Our results suggest that BNT162b2 vaccination may have a protective effect against longer term COVID-19 symptoms.

Protective Effects of BNT162b2 Vaccination on Aerobic Capacity Following Mild to Moderate SARS-CoV-2 Infection: A Cross-Sectional Study Israel

Patients previously infected with acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may experience post-acute adverse health outcomes, known as long COVID. The most reported symptoms are fatigue, headache and attention/concentration issues, dyspnea and myalgia. In addition, reduced aerobic capacity has been demonstrated in both mild and moderate COVID-19 patients. It is unknown whether COVID-19 vaccination mitigates against reduced aerobic capacity. Our aim was to compare the aerobic capacity of vaccinated and unvaccinated individuals previously infected with SARS-CoV-2. Methods: Individuals aged 18 to 65 years with laboratory-confirmed mild to moderate COVID-19 disease were invited to Ziv Medical Centre, Israel, three months after SARS-CoV-2 infection. We compared individuals unvaccinated at the time of infection to those vaccinated in terms of aerobic capacity, measured using symptom-limited cardiopulmonary exercise test (CPET). Results: We recruited 28 unvaccinated and 22 vaccinated patients. There were no differences in baseline demographic and pulmonary function testing (PFT) parameters. Compared with unvaccinated individuals, those vaccinated had higher V’O2/kg at peak exercise and at the anaerobic threshold. The V’O2/kg peak in the unvaccinated group was 83% of predicted vs. 100% in the vaccinated (p < 0.002). At the anaerobic threshold (AT), vaccinated individuals had a higher V’O2/kg than those unvaccinated. Conclusions: Vaccinated individuals had significantly better exercise performance. Compared with vaccinated individuals, a higher proportion of those unvaccinated performed substantially worse than expected on CPET. These results suggest that vaccination at the time of infection is associated with better aerobic capacity following SARS-CoV-2 infection.

Characterisation of the long-term physical and mental health consequences of SARS-CoV-2 infection: A systematic review and meta-analysis protocol

Background

As of July 2021, there has been more than 185 million documented cases of the novel coronavirus (SARS-CoV-2) infections and more than 4 million deaths globally. Despite more than 90% of documented cases being classified as “recovered” from SARS-CoV-2 infection, a proportion of patients reported a wide variety of persisting symptoms after the initial onset or acute phase of the infection, often referred to as “Long Covid”. As data on the symptomatology of post-acute SARS-CoV-2 infection gradually becomes available, there is an urgent need to organise and synthesise the data in order to define what constitutes Long Covid and assist with its management in clinical and community settings.

Methods

This protocol follows the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines. A comprehensive literature search strategy will be developed in accordance with the Cochrane highly sensitive search guidelines. The following electronic databases will be searched for studies to include in the systematic review and meta-analysis: MEDLINE (via PubMed), Scopus, Google Scholar, Web of Science (Web of Knowledge), Science direct, EMBASE, Mednar, Psych INFO, and EBSCOhost. Dual screening will be applied at every screening stage. Two reviewers will independently screen titles, abstracts and full text of potentially eligible studies following the predefined inclusion and exclusion criteria in order to select studies to include in the review. As heterogeneity is anticipated between the included studies, data will be pooled in a meta-analysis using a random effects model. A clustering analytic approach will be applied to identify symptoms groupings and assign the symptoms into clusters. R statistical software will be used for the meta-analysis. Highly heterogenous data will be synthesised narratively. The studies will be assessed, for quality using quality assessment tools appropriate for each study design. Two reviewers will independently undertake the quality of studies assessments.

Dissemination plans

Findings of the systematic review will be disseminated through a peer-reviewed publication and presentation of findings at conferences, workshops and government and private sector stakeholder engagement meetings.

Clinical trial registration

PROSPERO registration number: CRD4202126589. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD4202126589.

Using SARS-CoV-2 anti-S IgG levels as a marker of previous infection: Example from an Israeli Healthcare worker cohort

Objectives: Determining COVID-19 status is important for global epidemiology and individual-level vaccination decision-making. SARS-CoV-2 infection can generally only be detected during a 7–10-day period using polymerase chain reaction or rapid antigen testing, and infection-specific antinucleocapsid IgG assays are not universally available. We determined whether SARS-CoV-2 antispike (anti-S) IgG levels could discriminate between vaccination and previous infection when interpreted alongside vaccination timing.

Methods: We measured SARS-CoV-2 anti-S-IgG level in 535 vaccinated Israeli healthcare workers with known previous infection status 6–8 months after the second dose.

Results: Anti-S IgG levels above 1000 AU/ml at that time point was 93.3% predictive of infection in the previous 3 months, whereas the negative predictive value for infection in the past 3 months of a level below that threshold was 99.5%.

Conclusion: When interpreted alongside vaccination timing, anti-S serological assays can confirm or exclude previous infections within the previous 3 months.

Antibody-mediated Immunogenicity against SARS-CoV-2 following priming, boosting and hybrid immunity: insights from 11 months of follow-up of a healthcare worker cohort in Israel, December 2020-October 2021

Background

We determined circulating anti-S severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG) antibody titers in a vaccinated healthcare workers (HCWs) cohort from Northern Israel in the 11 months following primary vaccination according to age, ethnicity, and previous infection status.

Methods

All consenting HCWs were invited to have their IgG levels measured before vaccination and at 6 subsequent timepoints using a quantitative S1/S2 IgG assay. All HCWs with suspected coronavirus disease 2019 (COVID-19) were polymerase chain reaction (PCR) tested. We described trends in circulating IgG geometric mean concentration (GMC) by age, ethnicity, timing of boosting, and previous infection status and compared strata using Kruskall-Wallis tests.

Results

Among 985 vaccinated HCWs, IgG titers between 1 month post 2nd dose to pre-boosting gradually decreased in all age groups. Younger or previously infected individuals had higher initial post-vaccination IgG levels (P < .001 in both cases); differences substantially decreased or disappeared at 7–9 months, before boosting. The proportion of individuals infected prior to initiating vaccination and re-infected after dose 1 was comparable to the proportion of breakthrough infection post-dose 2 in those not previously infected (4.2 vs 4.7%). Pre-infection IgG levels in the 40 participants with breakthrough infection after dose 2 were similar to levels measured at the same timepoint in vaccinated HCWs who remained uninfected (P > .3). Post-dose3 IgG levels were more than 10-fold those 1 month post-dose 2.

Conclusions

Immunity waned in all age groups and previously infected individuals, reversed by boosting. IgG titers decrease and reinfections in individuals with hybrid immunity (infection + vaccination) suggests they may also require further doses. Our study also highlights the difficulty in determining protective IgG levels.

Characteristics associated with COVID-19 vaccine uptake among adults aged 50 years and above in England (8 December 2020-17 May 2021): a population-level observational study

OBJECTIVE

To determine characteristics associated with COVID-19 vaccine coverage among individuals aged 50 years and above in England since the beginning of the programme.

DESIGN

Observational cross-sectional study assessed by logistic regression and mean prevalence margins.

SETTING

COVID-19 vaccinations delivered in England from 8 December 2020 to 17 May 2021.

PARTICIPANTS

30 624 257/61 967 781 (49.4%) and 17 360 045/61 967 781 (28.1%) individuals in England were recorded as vaccinated in the National Immunisation Management System with a first dose and a second dose of a COVID-19 vaccine, respectively.

INTERVENTIONS

Vaccination status with COVID-19 vaccinations.

MAIN OUTCOME MEASURES

Proportion, adjusted ORs and mean prevalence margins for individuals not vaccinated with dose 1 among those aged 50-69 years and dose 1 and 2 among those aged 70 years and above.

RESULTS

Of individuals aged 50 years and above, black/African/Caribbean ethnic group was the least likely of all ethnic groups to be vaccinated with dose 1 of the COVID-19 vaccine. However, of those aged 70 years and above, the odds of not having dose 2 was 5.53 (95% CI 5.42 to 5.63) and 5.36 (95% CI 5.29 to 5.43) greater among Pakistani and black/African/Caribbean compared with white British ethnicity, respectively. The odds of not receiving dose 2 was 1.18 (95% CI 1.16 to 1.20) higher among individuals who lived in a care home compared with those who did not. This was the opposite to that observed for dose 1, where the odds of being unvaccinated was significantly higher among those not living in a care home (0.89 (95% CI 0.87 to 0.91)).

CONCLUSIONS

We found that there are characteristics associated with low COVID-19 vaccine coverage. Inequalities, such as ethnicity are a major contributor to suboptimal coverage and tailored interventions are required to improve coverage and protect the population from SARS-CoV-2.

Providing early indication of regional anomalies in COVID-19 case counts in England using search engine queries

Prior work has shown the utility of using Internet searches to track the incidence of different respiratory illnesses. Similarly, people who suffer from COVID-19 may query for their symptoms prior to accessing the medical system (or in lieu of it). To assist in the UK government's response to the COVID-19 pandemic we analyzed searches for relevant symptoms on the Bing web search engine from users in England to identify areas of the country where unexpected rises in relevant symptom searches occurred. These were reported weekly to the UK Health Security Agency to assist in their monitoring of the pandemic. Our analysis shows that searches for "fever" and "cough" were the most correlated with future case counts during the initial stages of the pandemic, with searches preceding case counts by up to 21 days. Unexpected rises in search patterns were predictive of anomalous rises in future case counts within a week, reaching an Area Under Curve of 0.82 during the initial phase of the pandemic, and later reducing due to changes in symptom presentation. Thus, analysis of regional searches for symptoms can provide an early indicator (of more than one week) of increases in COVID-19 case counts.

Pre-infection 25-hydroxyvitamin D3 levels and association with severity of COVID-19 illness

Objective

Studies have demonstrated a potential correlation between low vitamin D status and both an increased risk of infection with SARS-CoV-2 and poorer clinical outcomes. This retrospective study examines if, and to what degree, a relationship exists between pre-infection serum 25-hydroxyvitamin D (25(OH)D) level and disease severity and mortality due to SARS-CoV-2.

Participants

The records of individuals admitted between April 7^th, 2020 and February 4^th, 2021 to the Galilee Medical Center (GMC) in Nahariya, Israel, with positive polymerase chain reaction (PCR) tests for SARS-CoV-2 (COVID-19) were searched for historical 25(OH)D levels measured 14 to 730 days prior to the positive PCR test.

Design

Patients admitted to GMC with COVID-19 were categorized according to disease severity and level of 25(OH)D. An association between pre-infection 25(OH)D levels, divided between four categories (deficient, insufficient, adequate, and high-normal), and COVID-19 severity was ascertained utilizing a multivariable regression analysis. To isolate the possible influence of the sinusoidal pattern of seasonal 25(OH)D changes throughout the year, a cosinor model was used.

Results

Of 1176 patients admitted, 253 had records of a 25(OH)D level prior to COVID-19 infection. A lower vitamin D status was more common in patients with the severe or critical disease (<20 ng/mL [87.4%]) than in individuals with mild or moderate disease (<20 ng/mL [34.3%] p < 0.001). Patients with vitamin D deficiency (<20 ng/mL) were 14 times more likely to have severe or critical disease than patients with 25(OH)D ≥40 ng/mL (odds ratio [OR], 14; 95% confidence interval [CI], 4 to 51; p < 0.001).

Conclusions

Among hospitalized COVID-19 patients, pre-infection deficiency of vitamin D was associated with increased disease severity and mortality.

Impact of an accelerated measles-mumps-rubella (MMR) vaccine schedule on vaccine coverage: An ecological study among London children, 2012-2018

BACKGROUND

Vaccination coverage of dose two of MMR (MMR2) at 5th birthday has been consistently low in London and measured 76.3% in 2018/19. Since the early 2000s seven boroughs in London started offering dose two earlier, from 15 to 18 months onwards instead of the recommended 3 years 4 months. In this study we investigate whether the accelerated schedule of MMR2 leads to a change in coverage of MMR2 and other childhood vaccines with an ecological study using childhood immunisation data from 2009 to 2018 in London.

METHODS

We modelled coverage used generalized estimating equations (GEE) adjusted for year and DTaP/IPV/Hib3 coverage measured at 2nd birthday as a proxy for baseline local vaccination programme performance to determine the percentage point difference in coverage of MMR2 and other childhood vaccines.

RESULTS

Average MMR2 coverage was higher among early implementing boroughs from 2012/13 onwards. Coverage difference was highest in 2017/18 (9.2 percentage points, 95% CI 4.8, 13.5, p < 0.001). On average over the 6 years, compared to London boroughs on the routine schedule, MMR2 coverage among early implementing boroughs was 3.3 percentage points higher (95% CI 1.3, 5.3, p = 0.01) after adjusting for DTaP/IPV/Hib3 coverage, IMD score and year.

CONCLUSION

Earlier vaccination of MMR2 is associated with significantly higher coverage at five years for this vaccine in London. Further research is needed to assess the association at a more granular level, but our findings underline a potential opportunity to increase MMR coverage.

Inequalities in initiation of COVID19 vaccination by age and population group in Israel- December 2020-July 2021

Background

COVID19 vaccination coverage in Israel varies among population groups. Comparing crude coverage between groups is misleading because of different age structures and socio-economic differences. To describe inequalities in COVID19 vaccine initiation in Israel we analysed the interaction of age and population groups in terms of dose 1 vaccine coverage.

Methods

We calculated cumulative age-specific first COVID19 vaccine coverage by population group (Ultra-Orthodox Jewish, Arab, General Jewish). We calculated the relative differences in vaccine coverage between population groups within each age group, and between age groups within each population, using ANOVA and binomial regression after adjusting for socio-economic status.

Findings

8,507,723 individuals in 268 cities were included. Compared with the general Jewish population, coverage was lowest in the Ultra-Orthodox population in all age groups (range -12% among 60+ to -52.8% among 10-19 years olds, p<0.001). In all groups, the proportion of vaccinated individuals in younger age groups relative to those aged 60+ decreased with decreasing age and were smallest in the Ultra-Orthodox groups. For example, within the general Jewish population, people aged 20-29 were 14% less likely to be vaccinated than those aged 60+ while within the Ultra-Orthodox population it was 34.5.

Interpretation

In all age groups, the Ultra-Orthodox population had the lowest vaccine coverage. Differences persisted after adjusting for socio-economic status. The younger the age group, the more Ultra-Orthodox Jews were diverging from age peers in terms of initiating COVID19 vaccination, suggesting a generational effect. Tailored approaches are urgently required to encourage vaccination among under-immunized groups in Israel.

Funding

No specific funding was received.

Migration and outbreaks of vaccine-preventable disease in Europe: a systematic review

Migrant populations are one of several underimmunised groups in the EU or European Economic Area (EU/EEA), yet little is known about their involvement in outbreaks of vaccine-preventable diseases. This information is vital to develop targeted strategies to improve the health of diverse migrant communities. We did a systematic review (PROSPERO CRD42019157473; Jan 1, 2000, to May 22, 2020) adhering to PRISMA guidelines, to identify studies on vaccine-preventable disease outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, varicella, Neisseria meningitidis, and Haemophilus influenzae) involving migrants residing in the EU/EEA and Switzerland. We identified 45 studies, reporting on 47 distinct vaccine-preventable disease outbreaks across 13 countries. Most reported outbreaks involving migrants were of measles (n=24; 6496 cases), followed by varicella (n=11; 505 cases), hepatitis A (n=7; 1356 cases), rubella (n=3; 487 cases), and mumps (n=2; 293 cases). 19 (40%) outbreaks, predominantly varicella and measles, were reported in temporary refugee camps or shelters. Of 11 varicella outbreaks, nine (82%) were associated with adult migrants. Half of measles outbreaks (n=11) were associated with migrants from eastern European countries. In conclusion, migrants are involved in vaccine-preventable disease outbreaks in Europe, with adult and child refugees residing in shelters or temporary camps at particular risk, alongside specific nationality groups. Vulnerability varies by disease, setting, and demographics, highlighting the importance of tailoring catch-up vaccination interventions to specific groups in order to meet regional and global vaccination targets as recommended by the new Immunisation Agenda 2030 framework for action. A better understanding of vaccine access and intent in migrant groups and a greater focus on co-designing interventions is urgently needed, with direct implications for COVID-19 vaccine delivery.

Social determinants of pertussis and influenza vaccine uptake in pregnancy: a national cohort study in England using electronic health records

OBJECTIVE

To examine the social determinants of influenza and pertussis vaccine uptake among pregnant women in England.

DESIGN

Nationwide population-based cohort study.

SETTING

The study used anonymised primary care data from the Clinical Practice Research Datalink and linked Hospital Episode Statistics secondary care data.

PARTICIPANTS

Pregnant women eligible for pertussis (2012-2015, n=68 090) or influenza (2010/2011-2015/2016, n=152 132) vaccination in England.

MAIN OUTCOME MEASURES

Influenza and pertussis vaccine uptake.

RESULTS

Vaccine uptake was 67.3% for pertussis and 39.1% for influenza. Uptake of both vaccines varied by region, with the lowest uptakes in London and the North East. Lower vaccine uptake was associated with greater deprivation: almost 10% lower in the most deprived quintiles compared with the least deprived for influenza (34.5% vs 44.0%), and almost 20% lower for pertussis (57.7% vs 76.0%). Lower uptake for both vaccines was also associated with non-white ethnicity (lowest among women of black ethnicity), maternal age under 20 years and a greater number of children in the household. The associations between all social factors and vaccine uptake were broadly unchanged in fully adjusted models, suggesting the social determinants of uptake were largely independent of one another. Among 3111 women vaccinated against pertussis in their first eligible pregnancy and pregnant again, 1234 (40%) were not vaccinated in their second eligible pregnancy.

CONCLUSIONS

Targeting promotional campaigns to pregnant women who are younger, of non-white ethnicity, with more children, living in areas of greater deprivation or the London or North East regions, has potential to reduce vaccine-preventable disease among infants and pregnant women, and to reduce health inequalities. Vaccination promotion needs to be sustained across successive pregnancies. Further research is needed into whether the effectiveness of vaccine promotion strategies may vary according to social factors.

The impact of social and physical distancing measures on COVID-19 activity in England: findings from a multi-tiered surveillance system

BackgroundA multi-tiered surveillance system based on influenza surveillance was adopted in the United Kingdom in the early stages of the coronavirus disease (COVID-19) epidemic to monitor different stages of the disease. Mandatory social and physical distancing measures (SPDM) were introduced on 23 March 2020 to attempt to limit transmission.AimTo describe the impact of SPDM on COVID-19 activity as detected through the different surveillance systems.MethodsData from national population surveys, web-based indicators, syndromic surveillance, sentinel swabbing, respiratory outbreaks, secondary care admissions and mortality indicators from the start of the epidemic to week 18 2020 were used to identify the timing of peaks in surveillance indicators relative to the introduction of SPDM. This timing was compared with median time from symptom onset to different stages of illness and levels of care or interactions with healthcare services.ResultsThe impact of SPDM was detected within 1 week through population surveys, web search indicators and sentinel swabbing reported by onset date. There were detectable impacts on syndromic surveillance indicators for difficulty breathing, influenza-like illness and COVID-19 coding at 2, 7 and 12 days respectively, hospitalisations and critical care admissions (both 12 days), laboratory positivity (14 days), deaths (17 days) and nursing home outbreaks (4 weeks).ConclusionThe impact of SPDM on COVID-19 activity was detectable within 1 week through community surveillance indicators, highlighting their importance in early detection of changes in activity. Community swabbing surveillance may be increasingly important as a specific indicator, should circulation of seasonal respiratory viruses increase.

Tracking COVID-19 using online search

Previous research has demonstrated that various properties of infectious diseases can be inferred from online search behaviour. In this work we use time series of online search query frequencies to gain insights about the prevalence of COVID-19 in multiple countries. We first develop unsupervised modelling techniques based on associated symptom categories identified by the United Kingdom’s National Health Service and Public Health England. We then attempt to minimise an expected bias in these signals caused by public interest—as opposed to infections—using the proportion of news media coverage devoted to COVID-19 as a proxy indicator. Our analysis indicates that models based on online searches precede the reported confirmed cases and deaths by 16.7 (10.2–23.2) and 22.1 (17.4–26.9) days, respectively. We also investigate transfer learning techniques for mapping supervised models from countries where the spread of the disease has progressed extensively to countries that are in earlier phases of their respective epidemic curves. Furthermore, we compare time series of online search activity against confirmed COVID-19 cases or deaths jointly across multiple countries, uncovering interesting querying patterns, including the finding that rarer symptoms are better predictors than common ones. Finally, we show that web searches improve the short-term forecasting accuracy of autoregressive models for COVID-19 deaths. Our work provides evidence that online search data can be used to develop complementary public health surveillance methods to help inform the COVID-19 response in conjunction with more established approaches.

Impact of age, ethnicity, sex and prior infection status on immunogenicity following a single dose of the BNT162b2 mRNA COVID-19 vaccine: real-world evidence from healthcare workers, Israel, December 2020 to January 2021

The BNT162b2 mRNA COVID-19 vaccine showed high efficacy in clinical trials but observational data from populations not included in trials are needed. We describe immunogenicity 21 days post-dose 1 among 514 Israeli healthcare workers by age, ethnicity, sex and prior COVID-19 infection. Immunogenicity was similar by ethnicity and sex but decreased with age. Those with prior infection had antibody titres one magnitude order higher than naïve individuals regardless of the presence of detectable IgG antibodies pre-vaccination.

SARS-CoV-2 infection in London, England: changes to community point prevalence around lockdown time, March-May 2020

BACKGROUND

The UK has been one of the European countries most affected by COVID-19 pandemic. The UK implemented a lockdown in March 2020, when testing policy at the time was focusing on hospitalised cases. Limited information is therefore available on the impact of the lockdown on point prevalence in the community. We assessed COVID-19 point prevalence in London between early April and early May 2020, which approximately reflect infection around the time of the lockdown and 3-5 weeks into lockdown.

METHODS

We tested 1064 participants of a community surveillance cohort for acute COVID-19 infection using PCR in London in April and May 2020 and described positivity as well as characteristics and symptoms of the participants.

RESULTS

Point prevalence decreased from 2.2% (95% CI 1.4 to 3.5) in early April to 0.2% (95% CI 0.03 to 1.6) in early May. 22% of those who tested positive in April were asymptomatic. Extrapolation from reports of confirmed cases suggest that 5-7.6% of total infections were confirmed by testing during this period.

CONCLUSION

COVID-19 point prevalence in the community sharply decreased after lockdown was implemented. This study is based on a small sample and regular seroprevalence studies are needed to better characterise population-level immunity.

Impact of a nurse-led enhanced monitoring, management and contact tracing intervention for chronic hepatitis B in England, 2015-2017

Around 200,000 people live with chronic hepatitis B in England. Despite national guidance on identification and management of cases and their close contacts, testing rates of close contacts is as low as 43% in high prevalence areas of London. Our study aimed to determine whether a nurse-led enhanced management and contact tracing of chronically infected individuals improved testing uptake, vaccination and onward referral of close contacts. The study was conducted across Greater Manchester and East of England regions between October 2015 and July 2017. All HBV chronically infected individuals registered with a GP and their close contacts were eligible for recruitment. The proportion of contacts who were tested, vaccinated and referred where appropriate were compared before and after the nurse-led intervention. Baseline and outcome information was collected using questionnaires. The intervention improved case referral rates by an additional 14% (from 86% (88/102 cases) to 99.7%; 648/650 cases). The proportion of contacts tested increased from 34% to 72%-94% with 18 new cases of HBV diagnosed. Amongst close contacts tested, vaccination rates of at least three doses increased from 77% (43/56) to 93% (452/491) during the study. Our study has shown that nurse-led enhanced management greatly improves identification, testing and vaccination of close contacts. The identification of new acute and chronic cases is likely to make the intervention cost effective and local health commissioners should consider providing a nurse-led service as part of hepatitis B care pathways.

Does electronic consent improve the logistics and uptake of HPV vaccination in adolescent girls? A mixed-methods theory informed evaluation of a pilot intervention

OBJECTIVES

To evaluate the usability and acceptability of an electronic consent pilot intervention for school-based immunisations and assess its impact on consent form returns and human papilloma virus (HPV) vaccine uptake.

DESIGN

Mixed-methods theory-informed study applying qualitative methods to examine the usability and acceptability of the intervention and quantitative methods to assess its impact.

SETTING AND PARTICIPANTS

The intervention was piloted in 14 secondary schools in seven London boroughs in 2018. Intervention schools were matched with schools using paper consent based on the proportion of students with English as a second language and students receiving free school meals. Participants included nurses, data managers, school-link staff, parents and adolescents.

INTERVENTIONS

An electronic consent portal where parents could record whether they agreed to or declined vaccination, and nurses could access data to help them manage the immunisation programme.

PRIMARY AND SECONDARY OUTCOME MEASURES

Comparison of consent form return rates and HPV vaccine uptake between intervention and matched schools.

RESULTS

HPV vaccination uptake did not differ between intervention and matched schools, but timely consent form return was significantly lower in intervention schools (73.3% vs 91.6%, p=0.008). The transition to using electronic consent was not straightforward, while schools and staff understood the potential benefits, they found it difficult to adapt to new ways of working which removed some level of control from schools. Reasons for lower consent form return in e-consent schools included difficulties encountered by some parents in accessing and using the intervention. Adolescents highlighted the potential for electronic consent to by-pass their information needs.

CONCLUSIONS

The pilot intervention did not improve consent form return or vaccine uptake due to challenges encountered in transitioning to new working practice. New technologies require embedding before they become incorporated in everyday practice. A re-evaluation once stakeholders are accustomed with electronic consent may be required to understand its impact.

Improving the quality and use of immunization and surveillance data: Summary report of the Working Group of the Strategic Advisory Group of Experts on Immunization

Concerns about the quality and use of immunization and vaccine-preventable disease (VPD) surveillance data have been highlighted on the global agenda for over two decades. In August 2017, the Strategic Advisory Group of Experts (SAGE) established a Working Group (WG) onthe Quality and Use of Global Immunization and Surveillance Data to review the current status and evidence to make recommendations, which were presented to SAGE in October 2019. The WG synthesized evidence from landscape analyses, literature reviews, country case-studies, a data triangulation analysis, as well as surveys of experts. Data quality (DQ) was defined as data that are accurate, precise, relevant, complete, and timely enough for the intended purpose (fit-for-purpose), and data use as the degree to which data are actually used for defined purposes, e.g., immunization programme management, performance monitoring, decision-making. The WG outlined roles and responsibilities for immunization and surveillance DQ and use by programme level. The WG found that while DQ is dependent on quality data collection at health facilities, many interventions have targeted national and subnational levels, or have focused on new technologies, rather than the people and enabling environments required for functional information systems. The WG concluded that sustainable improvements in immunization and surveillance DQ and use will require efforts across the health system - governance, people, tools, and processes, including use of data for continuous quality improvement (CQI) - and that the approaches need to be context-specific, country-owned and driven from the frontline up. At the country level, major efforts are needed to: (1) embed monitoring DQ and use alongside monitoring of immunization and surveillance performance, (2) increase workforce capacity and capability for DQ and use, starting at the facility level, (3) improve the accuracy of immunization programme targets (denominators), (4) enhance use of existing data for tailored programme action (e.g., immunization programme planning, management and policy-change), (5) adopt a data-driven CQI approach as part of health system strengthening, (6) strengthen governance around piloting and implementation of new information and communication technology tools, and (7) improve data sharing and knowledge management across areas and organizations for improved transparency and efficiency. Global and regional partners are requested to support countries in adopting relevant recommendations for their setting and to continue strengthening the reporting and monitoring of immunization and VPD surveillance data through processes periodic needs assessment and revision processes. This summary of the WG's findings and recommendations can support "data-guided" implementation of the new Immunization Agenda 2030.

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.

First real world evidence of meningococcal group B vaccine, 4CMenB, protection against meningococcal group W disease; prospective enhanced national surveillance, England

BACKGROUND

4CMenB is a protein-based meningococcal group B vaccine but the vaccine antigens may also be present on non-group B meningococci. In September 2015, the UK implemented 4CMenB into the national infant immunisation programme, alongside an emergency adolescent meningococcal ACWY (MenACWY) programme to control a national outbreak of group W (MenW) disease caused by a hypervirulent strain belonging to the ST11 clonal complex. The adolescent programme aimed to provide direct protection for adolescents and, over time, indirect (herd) protection across the population.

METHODS

Public Health England conducts meningococcal disease surveillance in England. MenW cases confirmed during four years before and four years after implementation of both vaccines were analysed. Poisson models were constructed to estimate direct protection against MenW disease offered by the infant 4CMenB programme on top of the indirect impact of the adolescent MenACWY programme in children eligible for 4CMenB but not MenACWY.

RESULTS

Model estimates showed 69% (adjusted incidence rate ratio (IRR) 0.31, 95%CI, 0.20-0.67) and 52% (aIRR 0.48, 95%CI 0.28-0.81) fewer MenW cases than predicted among age-cohorts that were fully-eligible and partly-eligible for 4CMenB, respectively. There were 138 MenW cases in &5 year-olds. 4CMenB directly prevented 98 (95%CI, 34-201) cases, while the MenACWY programme indirectly prevented an additional 114 (conservative) to 899 (extreme) cases over four years. Disease severity was similar in 4CMenB-immunised and unimmunised children.

CONCLUSIONS

Our results provide the first real-world evidence of the direct protection afforded by 4CMenB against MenW:cc11 disease. 4CMenB has the potential to provide some protection against all meningococcal serogroups.

Implementation and evaluation of the human papillomavirus (HPV) vaccination pilot for men who have sex with men (MSM), England, April 2016 to March 2017

Background: Opportunistic human papillomavirus (HPV) vaccination for men who have sex with men (MSM) was piloted in sexual health clinics (SHC) in England between 2016 and 2018.

Aim: to evaluate the pilot’s first year (April 2016–March 2017) in terms of feasibility, acceptability, uptake, impact and equity and interpret the outcome in the context of wide HPV vaccination policy.

Methods: Attendance and uptake data from routine SHC surveillance datasets and a cross-sectional survey administered to individuals receiving the vaccine were analysed.

Results: Among 18,875 eligible MSM, 8,580 (45.5%) were recorded as having received one HPV vaccine dose, decreasing slightly with increasing age, and uptake was higher in rural than urban areas. Survey results suggested that of those receiving the first dose of HPV vaccine, 8% were new attendees and that among those, less than 11% attended just to receive the vaccine. Of those having their first HPV vaccination, 95% indicated they would like to receive the next vaccine doses at the same clinic and 85% of patients reported accessing other services when visiting SHC for the first dose of vaccine.

Conclusion: An opportunistic HPV vaccination programme for MSM can be delivered in an acceptable and, as far as can be evaluated, equitable manner, without major disruption to SHC and HIV clinics.

Does the use of personal electronic health records increase vaccine uptake? A systematic review

BACKGROUND

Although Personal Electronic Health Records (PEHR) have been identified as innovative tools enabling the provision of patient-centered care and prevention, evidence on the impact of their use is scant. With PEHRs being more and more marketed as easily implementable and cost-effective instruments to provide people with direct control on their health, the question on whether their use might be associated with the priority to improve vaccine coverage arises.

METHODS

We conducted a systematic review following the PRISMA guidelines to retrieve, quantitatively pool and critically appraise the effectiveness of PEHR access on vaccine uptake. Analysis on PEHR effectiveness were carried out for the following comparison strata: i) PEHR access vs no intervention (standard care, no access to PEHR), ii) PEHR access only vs access to PEHR with additional features (e.g. health education materials, active reminders).

RESULTS

Of 3114 identified citations, 8 studies were included, the majority published in the US and before 2015; 62% were randomized trials, the rest having an observational study design. Evidence suggests a moderate positive impact of PEHR access in increasing vaccine uptake, with data available for influenza and pneumococcal vaccines, diabetic patients and childhood immunization. Pooled data report the addition of digital communication features, i.e. the delivery of educational messages, reminders and availability of scheduling features might increase vaccine uptake, as compared to PEHR access alone. However, evidence is not conclusive.

CONCLUSION

While immunization programs are struggling to achieve optimal coverage targets, it seems the potential of PEHRSs supporting informed adherence to vaccines recommendations is neither fully exploited nor explored. Which factors mediate the association between PEHRs access and vaccine uptake? Which PEHRs' design and functional components can maximize their impact? On which target populations? Which PEHR models works better for high-risk populations? Our findings can only partially answer those questions and further experimental research is needed.

Delivering prenatal pertussis vaccine through maternity services in England: What is the impact on vaccine coverage?

BACKGROUND

Prenatal pertussis vaccination was introduced in 2012 in England and is primarily delivered through general practice. Since 2017 some maternity services are commissioned to offer it too. We aimed to describe the maternity service delivery of prenatal pertussis vaccination and its impact on vaccine uptake.

METHODS

We described the proportion of maternity services in England commissioned to offer pertussis vaccination to pregnant women in 2017/18 and the proportion of women vaccinated in this setting using a self-administered survey of NHS commissioners. We categorised clinical commissioning groups (CCGs) in England into "implementing" and "non-implementing" pertussis vaccination in maternity services. We identified CCGs where vaccination data was reliably transferred from maternity services to primary care records (source of routine data on vaccine uptake) and among those compared changes in vaccine uptake in implementing vs non-implementing CCGs between March 2016 (before implementation) and March 2018 (after).

FINDINGS

Of 141 maternity service units in England, 61% delivered prenatal pertussis vaccine in 2017/18. Of those 57.0% of maternity services immunized less than 10% of pregnant women and only 7.1% of maternity services immunized more than 40% of pregnant women. Between March 2016 and March 2018, coverage increased by 19.6% among non-implementing CCGs compared with 17.8% among all implementing CCGs (difference -2.2, p = 0.48) and 28.2% among implementing CCGs with reliable methods of data transfer (difference 8.6, p = 0.04). This difference translated to a difference of 1.6 percentage points in absolute terms.

INTERPRETATION

Delivering pertussis vaccine through maternity services has a moderate but important impact on vaccine uptake. There is a need to improve data transfer on vaccines administered in maternity service units to primary care. Maternity services should offer the vaccine to improve coverage and thus optimise protection for young infants. Barriers to effective programme implementation should be investigated and addressed.

Keep calm and carry on vaccinating: Is anti-vaccination sentiment contributing to declining vaccine coverage in England?

BACKGROUND

In England, coverage for childhood vaccines have decreased since 2012/13 in the context of an increasingly visible anti-vaccination discourse. We determined whether anti-vaccination sentiment is the likely cause of this decline in coverage.

METHODS

Descriptive study triangulating a range of data sources (vaccine coverage, cross-sectional survey of attitudes towards vaccination, UK-specific Twitter social media) and assessing them against the following Bradford Hill criteria: strength of association, consistency, specificity, temporality, biological gradient and coherence.

RESULTS

Strength of association: compared with well-documented vaccine scares, the decline in childhood vaccination seen since 2012/13 is 4-20 times smaller; consistency: while coverage for completed courses of the hexavalent and meningococcal vaccines decreased by 0.5-1.2 percentage points (pp) between 2017 and 2019, coverage for the first dose of these vaccines increased 0.5-0.7 pp; specificity: Since 2012-13, coverage decreased for some vaccines (hexavalent, MMR, HPV, shingles) and increased for others (MenACWY, Td/IPV, antenatal pertussis, influenza in 2 years of children), with no age-specific patterns. Temporality and biological gradient: the decline in vaccine coverage was preceded by an increase in vaccine confidence and a decrease in the proportion of parents encountering anti-vaccination materials. Coherence: attitudes towards vaccination expressed on Twitter in the UK became increasingly positive between 2017 and 2019 as vaccine coverage for childhood vaccines decreased.

CONCLUSIONS

In England, trends in vaccine coverage between 2012/13 and 2018/19 were not homogenous and varied in magnitude and direction according to vaccine, dose and region. In addition, confidence in vaccines increased during the same period. These findings are not compatible with anti-vaccination sentiment causing a decline in vaccine coverage In England.

Early impact of the coronavirus disease (COVID-19) pandemic and physical distancing measures on routine childhood vaccinations in England, January to April 2020

Using electronic health records, we assessed the early impact of coronavirus disease (COVID-19) on routine childhood vaccination in England by 26 April 2020. Measles-mumps-rubella vaccination counts fell from February 2020, and in the 3 weeks after introduction of physical distancing measures were 19.8% lower (95% confidence interval: −20.7 to −18.9) than the same period in 2019, before improving in mid-April. A gradual decline in hexavalent vaccination counts throughout 2020 was not accentuated by physical distancing.