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

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

Magnitude and associated factors of delayed vaccination among children aged 11-23 months in, Tigray, Ethiopia, 2018

BACKGROUND

Delay in receiving the vaccination is a major public health problem that has been associated with vaccine-preventable disease epidemics. In Ethiopia, many children have not received the benefits of age-appropriate vaccination; thus more than 90% of child deaths are largely due to preventable communicable diseases.

OBJECTIVE

The present study assessed the magnitude and associated factors of delayed vaccination among 12-23 months old children in Tigray, Ethiopia.

METHODS

A community-based cross-sectional study was carried out among 393, 12-23 months old children from July 1 to 30, 2018. Data were collected using a structured interviewer-administered questionnaire. The questionnaire includes socio-demographic, economic factors, Maternal/caregiver factors, Child's factors, and Service-related factors. We applied bivariable and multivariable logistic regression to determine predictors for delayed Vaccination. The odds ratio with 95% CI was computed to evaluate the strength of the association.

RESULTS

393 participants were involved in the study. The magnitude of delayed vaccination was 29.5% (95% CI 26.7-45). Mothers who attend tertiary (University/college) education (AOR 0.169, 95% CI 0.032-0.882), and secondary education (AOR 0.269, 95% CI 0.114-0.636) had the protective effect of delayed vaccination. But the sickness of a child (AOR = 11.8, 95% CI 6.16-22.65) was a risk for delayed vaccination.

CONCLUSIONS

The magnitude of delayed vaccination was high, particularly among participants with Mother's education, and Mother's consideration in the child's wellness to take the vaccine. This implies that it is important to give emphasis, especially for the mothers who have an uneducated and sick child to increase awareness about the advantage of vaccination, which will improve on-time vaccination.

Developing Adult Vaccination Ecosystem in India: Current Perspective and the Way Forward

Introduction

A high burden of vaccine-preventable diseases, increasing elderly population, immunosenescence, and emerging drug resistance emphasize the need for robust adult immunization in India. While immunization guidelines from various societies exist, there is inadequate implementation of the same.

Aim

We undertook this narrative review of the adult vaccination ecosystem in India to (i) gain insights into existing adult vaccination practices, (ii) identify barriers to adult vaccination and possible solutions, and (iii) improve collaboration between various stakeholders to help establish adult vaccination centers in the country.

Results

Besides the high cost and lack of insurance coverage, the lack of adult vaccination centers contributes to the low coverage of adult immunization.

Discussion

These challenges can be addressed through multiple approaches including community awareness and immunization programs, setting up mobile vaccination vans, patient/consumer education, and adequate training of healthcare providers. Successful implementation of these strategies requires active collaboration between the government, hospitals, different stakeholders, and policymakers.

Twenty-Year Public Health Impact of 7- and 13-Valent Pneumococcal Conjugate Vaccines in US Children

Pneumococcal conjugate vaccines (PCVs) have been used in the United States since 2000. To assess the cumulative 20-year effect of PCVs on invasive pneumococcal disease (IPD) incidence among children <5 years of age, we analyzed Active Bacterial Core Surveillance data, conducted a literature review, and modeled expected and observed disease. We found that PCVs have averted >282,000 cases of IPD, including ≈16,000 meningitis, ≈172,000 bacteremia, and ≈55,000 bacteremic pneumonia cases. In addition, vaccination has prevented 97 million healthcare visits for otitis media, 438,914-706,345 hospitalizations for pneumonia, and 2,780 total deaths. IPD cases declined 91%, from 15,707 in 1997 to 1,382 in 2019. Average annual visits for otitis media declined 41%, from 78 visits/100 children before PCV introduction to 46 visits/100 children after PCV13 introduction. Annual pneumonia hospitalizations declined 66%-79%, from 110,000-175,000 in 1997 to 37,000 in 2019. These findings confirm the substantial benefits of PCVs for preventing IPD in children.

Addressing Reemergence of Diphtheria among Adolescents through Program Integration in India

We report a diphtheria outbreak mostly among children (median 12 years; range 4–26 years) of a religious minority in urban India. Case-fatality rate (15%, 19/124) was higher among unimmunized patients (relative risk 4.1, 95% CI 1.5–11.7). We recommend mandating and integrating immunization into school health programs to prevent reemergence.

Coordinated Response to Imported Vaccine-Derived Poliovirus Infection, Barcelona, Spain, 2019-2020

In 2019, the Public Health Agency of Barcelona, Spain, was notified of a vaccine-derived poliovirus infection. The patient had an underlying common variable immunodeficiency and no signs of acute flaccid paralysis. We describe the ongoing coordinated response to contain the infection, which included compassionate-use treatment with pocapavir.

Isolate-Based Surveillance of Bordetella pertussis, Austria, 2018-2020

Pertussis is a vaccine-preventable disease, and its recent resurgence might be attributable to the emergence of strains that differ genetically from the vaccine strain. We describe a novel pertussis isolate-based surveillance system and a core genome multilocus sequence typing scheme to assess Bordetella pertussis genetic variability and investigate the increased incidence of pertussis in Austria. During 2018–2020, we obtained 123 B. pertussis isolates and typed them with the new scheme (2,983 targets and preliminary cluster threshold of <6 alleles). B. pertussis isolates in Austria differed genetically from the vaccine strain, both in their core genomes and in their vaccine antigen genes; 31.7% of the isolates were pertactin-deficient. We detected 8 clusters, 1 of them with pertactin-deficient isolates and possibly part of a local outbreak. National expansion of the isolate-based surveillance system is needed to implement pertussis-control strategies.

Assessing Community Vulnerability over 3 Waves of COVID-19 Pandemic, Hong Kong, China

We constructed a coronavirus disease community vulnerability index using micro district-level socioeconomic and demographic data and analyzed its correlations with case counts across the 3 pandemic waves in Hong Kong, China. We found that districts with greater vulnerability reported more cases in the third wave when widespread community outbreaks occurred.

Statin Use and Influenza Vaccine Effectiveness in Persons >65 Years of Age, Taiwan

Influenza vaccine effectively reduced risks for in-hospital death or hospitalization, regardless of statin use.

Debates on whether statin use reduces the effectiveness of influenza vaccines against critical illness and death among persons >65 years of age continue. We conducted a study of 9,427,392 persons >65 years of age who did and did not receive influenza vaccinations during 12 consecutive influenza seasons, 2000–01 through 2011–12. Using data from Taiwan’s National Health Insurance Research Database, we performed propensity score-matching to compare vaccinated persons with unvaccinated controls. After propensity score-matching, the vaccinated group had lower risks for in-hospital death from influenza and pneumonia and for hospitalization for pneumonia and influenza, circulatory conditions, and critical illnesses compared with the unvaccinated group. We stratified the 2 groups by statin use and analyzed data by interaction analysis and saw no statistically significant difference. We found that influenza vaccine effectively reduced risks for hospitalization and death in persons >65 years of age, regardless of statin use.

Effectiveness of 23-Valent Pneumococcal Polysaccharide Vaccine against Invasive Pneumococcal Disease in Adults, Japan, 2013-2017

The decline in the proportion of pneumococcal conjugate vaccine (PCV)–covered serotypes among adult invasive pneumococcal disease (IPD) patients might change the overall effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) because its effectiveness differs according to serotype. Using the indirect cohort method, we calculated the effectiveness of PPSV23 against IPD among adults in Japan to assess the impact of the national pediatric PCV program. Clinical and epidemiologic information and pneumococcal isolates were collected from IPD patients >20 years of age through enhanced IPD surveillance during April 2013–December 2017. Adjusted effectiveness against PPSV23-serotype IPD was 42.2%. Despite a substantial decline in the proportion of 13-valent PCV serotypes during the study period (45% to 31%), the change in effectiveness for PPSV23-serotype IPD was limited (47.1% to 39.3%) and only marginal in the elderly population (39.9% to 39.4%). The pediatric PCV program had limited impact on PPSV23 effectiveness against IPD in adults.

Etiology of Severe Acute Respiratory Infections, Bangladesh, 2017

In April 2017, surveillance detected a surge in severe acute respiratory infections (SARI) in Bangladesh. We collected specimens from SARI patients and asymptomatic controls for analysis with multipathogen diagnostic tests. Influenza A(H1N1)pdm09 was associated with the SARI epidemic, suggesting that introducing vaccines and empiric antiviral drugs could be beneficial.

Impact of Human Papillomavirus Vaccination, Rwanda and Bhutan

Rwanda and Bhutan, 2 low- and middle-income countries, implemented primarily school-based national human papillomavirus (HPV) vaccination in 2011 (Rwanda) and 2010 (Bhutan). We estimated vaccination effectiveness through urine-based HPV prevalence surveys in schools in 2013–2014 and 2017. In Rwanda, 912 participants from baseline surveys and 1,087 from repeat surveys were included, and in Bhutan, 973 participants from baseline surveys and 909 from repeat surveys were included. The overall effectiveness against vaccine-targeted HPV types (i.e., HPV-6/11/16/18) was 78% (95% CI 51%–90%) in Rwanda, and 88% (6%–99%) in Bhutan and against other α-9 types was 58% (21–78) in Rwanda and 63% (27–82) in Bhutan. No effect against other HPV types was detectable. Prevalence of vaccine-targeted HPV types decreased significantly, as well as that of other α-9 types, suggesting cross-protection. These findings provide direct evidence from low- and middle-income countries of the marked effectiveness of high-coverage school-based, national HPV vaccination programs.

Hepatitis A Hospitalization Costs, United States, 2017

The United States is in the midst of unprecedented person-to-person hepatitis A outbreaks. By using Healthcare Cost and Utilization Project data, we estimated the average costs per hepatitis A-related hospitalization in 2017. These estimates can guide investment in outbreak prevention efforts to stop the spread of this vaccine-preventable disease.

Measuring Timeliness of Outbreak Response in the World Health Organization African Region, 2017-2019

Large-scale protracted outbreaks can be prevented through early detection, notification, and rapid control. We assessed trends in timeliness of detecting and responding to outbreaks in the African Region reported to the World Health Organization during 2017–2019. We computed the median time to each outbreak milestone and assessed the rates of change over time using univariable and multivariable Cox proportional hazard regression analyses. We selected 296 outbreaks from 348 public reported health events and evaluated 184 for time to detection, 232 for time to notification, and 201 for time to end. Time to detection and end decreased over time, whereas time to notification increased. Multiple factors can account for these findings, including scaling up support to member states after the World Health Organization established its Health Emergencies Programme and support given to countries from donors and partners to strengthen their core capacities for meeting International Health Regulations.

Challenges to Achieving Measles Elimination, Georgia, 2013-2018

Controlling measles outbreaks in the country of Georgia and throughout Europe is crucial for achieving the measles elimination goal for the World Health Organization’s European Region. However, large-scale measles outbreaks occurred in Georgia during 2013–2015 and 2017–2018. The epidemiology of these outbreaks indicates widespread circulation and genetic diversity of measles viruses and reveals persistent gaps in population immunity across a wide age range that have not been sufficiently addressed thus far. Historic problems and recent challenges with the immunization program contributed to outbreaks. Addressing population susceptibility across all age groups is needed urgently. However, conducting large-scale mass immunization campaigns under the current health system is not feasible, so more selective response strategies are being implemented. Lessons from the measles outbreaks in Georgia could be useful for other countries that have immunization programs facing challenges related to health-system transitions and the presence of age cohorts with historically low immunization coverage.

Nowcasting (Short-Term Forecasting) of Influenza Epidemics in Local Settings, Sweden, 2008-2019

The timing of influenza case incidence during epidemics can differ between regions within nations and states. We conducted a prospective 10-year evaluation (January 2008–February 2019) of a local influenza nowcasting (short-term forecasting) method in 3 urban counties in Sweden with independent public health administrations by using routine health information system data. Detection-of-epidemic-start (detection), peak timing, and peak intensity were nowcasted. Detection displayed satisfactory performance in 2 of the 3 counties for all nonpandemic influenza seasons and in 6 of 9 seasons for the third county. Peak-timing prediction showed satisfactory performance from the influenza season 2011–12 onward. Peak-intensity prediction also was satisfactory for influenza seasons in 2 of the counties but poor in 1 county. Local influenza nowcasting was satisfactory for seasonal influenza in 2 of 3 counties. The less satisfactory performance in 1 of the study counties might be attributable to population mixing with a neighboring metropolitan area.

Immunity to vaccine-preventable diseases among paediatric healthcare workers in Denmark, 2019

Background

Healthcare workers (HCW) have been identified as index cases in disease outbreaks of vaccine-preventable diseases (VPD) in hospitals.

Aim

We investigated whether Danish paediatric HCW were protected against selected serious VPD.

Methods

We included 90% of staff members from two paediatric departments. All 555 HCW (496 women) supplied a blood sample for serology and filled in a questionnaire. Antibodies were measured with enzyme immunoassay against measles, mumps, rubella (MMR), varicella zoster, pertussis toxin and diphtheria toxin.

Results

Protective levels of IgG were found for measles (90.3%), mumps (86.5%), rubella (92.3%), varicella (98.6%) and diphtheria (80.5%). We found seropositivity for all three MMR components in 421 (75.9%) HCW, lowest in those younger than 36 years (63.3%). Only 28 (5%) HCW had measurable IgG to pertussis. HCW with self-reported immunity defined as previous infection or vaccination, had protective levels of IgG against measles, mumps, rubella and varicella in 87.4–98.8% of cases, not significantly higher than in those not reporting immunity. Previous history of disease had a high positive predictive value (PPV) of 96.8–98.8%. The PPV for previous vaccination ranged from 82.5% to 90.3%. In contrast, negative predictive values of self-reported history of disease and vaccination were remarkably low for all diseases.

Conclusion

The immunity gaps found primarily in young HCW indicate a need for a screening and vaccination strategy for this group. Considering the poor correlation between self-reported immunity and seropositivity, efforts should be made to check HCW’s immune status in order to identify those who would benefit from vaccination.

Probable rabies in a child in a Bhutanese town bordering India, 2020

Rabies is a neglected tropical disease that causes mortality and high economic burden in many developing countries. Rabies is a vaccine-preventable disease if timely post-exposure prophylaxis is available after animal exposure. The control of rabies requires limiting the transmission of the virus in the animal reservoir, effective public health measures to control outbreaks and increasing accessibility and uptake of rabies post-exposure prophylaxis. Bhutan is a small Himalayan country where rabies is endemic. In this article, we describe the death of a 3-year-old female child due to probable rabies in a Bhutanese village located along the border with India. The child had a furious form of rabies with encephalitic syndrome developing 57 days after a category III dog bite on the chest. The child was managed at a district hospital with the available resources. This is the first rabies death in Bhutan in the last 5 years and the 18^th since 2006. This case report focuses on the efforts required to increase the timely uptake of post-exposure prophylaxis in a free healthcare system in Bhutan.

Impact of immunization programs on 11 childhood vaccine-preventable diseases in China: 1950-2018

To evaluate the achievements of China's immunization program between 1950 and 2018, we chose 11 vaccine-preventable diseases (VPDs) as representative notifiable diseases and used annual surveillance data obtained between 1950 and 2018 to derive disease incidence and mortality trends. Quasi-Poisson and polynomial regression models were used to estimate the impacts of specific vaccine programs, and life-table methods were used to calculate the loss of life expectancy, years of life lost, and loss of working years. The total notification number for the 11 VPDs was 211,866,000 from 1950 to 2018. The greatest number occurred in 1959, with a total incidence of 1,723 per million persons. From 1978 to 2018, a substantial decline was observed in the incidence of major infectious diseases. The incidence of pertussis fell 98% from 126.35 to 1.58 per million, and the incidences of measles, meningococcal meningitis, and Japanese encephalitis fell 99%, 99%, and 98%, respectively. The regression models showed that most of the 11 diseases exhibited dramatic declines in morbidity after their integration into the Expanded Program on Immunization (EPI), while varicella and paratyphoid fever, which were not integrated into the EPI, showed increased morbidity. From 1978 to 2018, the total life expectancy for the 11 VPDs increased by 0.79 years, and similar results were obtained for different age groups. China has had great success in controlling VPDs in recent decades, and improving vaccination coverage is a key aspect of controlling VPDs in China.

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11 vaccine-preventable diseases (VPDs) were examined to measure the impact of the national immunization program

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Most of the 11 VPDs exhibited dramatic declines in morbidity rate after their integration into the Expanded Program on Immunization (EPI)

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From 1978 to 2018, the total life expectancy for the 11 VPDs increased by 0.79 years, and similar results were obtained for different age groups

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Improving vaccination coverage is a key aspect of controlling VPDs in China

Role of Oral Rabies Vaccines in the Elimination of Dog-Mediated Human Rabies Deaths

Domestic dogs are responsible for nearly all the »59,000 global human rabies deaths that occur annually. Numerous control measures have been successful at eliminating dog-mediated human rabies deaths in upper-income countries, including dog population management, parenteral dog vaccination programs, access to human rabies vaccines, and education programs for bite prevention and wound treatment. Implementing these techniques in resource-poor settings can be challenging; perhaps the greatest challenge is maintaining adequate herd immunity in free-roaming dog populations. Oral rabies vaccines have been a cornerstone in rabies virus elimination from wildlife populations; however, oral vaccines have never been effectively used to control dog-mediated rabies. Here, we convey the perspectives of the World Organisation for Animal Health Rabies Reference Laboratory Directors, the World Organisation for Animal Health expert committee on dog rabies control, and World Health Organization regarding the role of oral vaccines for dogs. We also issue recommendations for overcoming hesitations to expedited field use of appropriate oral vaccines.

Achieving High Poliovirus Antibody Seroprevalence in Areas at Risk of Vaccine-Derived Poliovirus Transmission-Niger Experience

Background

Outbreaks of vaccine-derived poliovirus type 2 (VDPV2) continue to expand across Africa. We conducted a serological survey of polio antibodies in high–polio risk areas of Niger to assess risk of poliovirus outbreaks.

Methods

Children between 1 and 5 years of age were enrolled from structures randomly selected using satellite imaging enumeration in Diffa Province, Niger, in July 2019. After obtaining informed consent, dried blood spot cards were collected. Neutralizing antibodies against 3 poliovirus serotypes were detected using microneutralization assay at the Centers for Disease Control and Prevention.

Results

We obtained analyzable data from 309/322 (95.9%) enrolled children. Seroprevalence of polio antibodies was 290/309 (93.9%), 272/309 (88.0%), and 254/309 (82.2%) for serotypes 1, 2, and 3, respectively. For serotypes 1 and 2, the seroprevalence did not significantly change with age (P = .09 and P = .44, respectively); for serotype 3, it increased with age (from 65% in 1–2-year-olds to 91.1% in 4–5-year olds; P < .001). We did not identify any risk factors for type 2 seronegativity.

Conclusions

With type 2 seroprevalence close to 90%, the risk of emergence of new cVDPV2 outbreaks in Niger is low; however, the risk of cVDPV2 importations from neighboring countries leading to local transmission persists. Niger should maintain its outbreak response readiness capacity and further strengthen its routine immunization.

Contingent Valuation: A Pilot Study for Eliciting Willingness to Pay for a Reduction in Mortality From Vaccine-Preventable Illnesses for Children and Adults in Bangladesh

OBJECTIVES

The contingent valuation (CV) method elicits willingness to pay (WTP) for calculating the value of statistical life (VSL). CV approaches for assessing VSL are uncommon in many low and middle-income countries (LMICs). Between 2008 and 2018 only 44 articles utilized WTP in a health-related field and of these only 5 (11%) utilized CV to assess the WTP for a mortality risk reduction. We elicit WTP estimates and compute VSL using the CV method in Bangladesh.

METHODS

The pilot study was primarily aimed at developing best practice guidelines for CV studies in LMICs to get more robust WTP estimates. To this end, we explored three methodological a) Varying the name of the intervention, keeping all other characteristics constant; b) varying the effectiveness of the health intervention and c) offering an overnight period to think about the WTP scenario. The survey was administered 413 randomly selected participants. VSL was for a 1/3000 mortality risk reduction.

RESULTS

We had more males (54%) than females (46%) and the mean annual self-reported income was $5,683.36. Mean VSL is $11,339.70 with a median of $10,413. The ratio of child: adult WTP is approximately 1 by both gender and age category. The vaccine intervention had the largest amount of $0 WTP and protest responses (52% and 58% respectively). 93% of the participants were able to describe (teach-back) the vaccine effectiveness using their own family as an example.

CONCLUSION

Our study provides empirical evidence on how to better generate CV surveys to produce more robust WTP estimates.

Thresholds versus Anomaly Detection for Surveillance of Pneumonia and Influenza Mortality

Computational surveillance of pneumonia and influenza mortality in the United States using FluView uses epidemic thresholds to identify high mortality rates but is limited by statistical issues such as seasonality and autocorrelation. We used time series anomaly detection to improve recognition of high mortality rates. Results suggest that anomaly detection can complement mortality reporting.

Highly Pathogenic Avian Influenza A(H5N8) Virus in Swans, China, 2020

In October 2020, highly pathogenic avian influenza A(H5N8) viruses were detected in 2 dead swans in Inner Mongolia, China. Genetic analysis showed that the H5N8 isolates belong to clade 2.3.4.4b and that the isolates cluster with the H5N8 viruses isolated in Eurasia in the fall of 2020.

HPV Type-Specific Prevalence a Decade after the Implementation of the Vaccination Program: Results from a Pilot Study

Human papillomavirus infection is a cause of the development of invasive cervical cancer. Three types of vaccine are currently available to prevent precancerous/cancerous lesions due to persistent infection, which is supported mainly by 7 different high-risk genotypes. The aim of this pilot study was to acquire preliminary data on type-specific prevalence 10 years after the implementation of the HPV vaccination program in Italy, in order to subsequently plan appropriate observational studies in the Italian population. First-voided urine samples were collected from 393 consenting subjects, both females and males, aged 18–40 years, and HPV DNA was detected by PCR amplification of a 450 bp L1 fragment. All amplified products were genotyped by means of the Restriction Fragment Length Polymorphism (RFLP) method. The female population was divided into three cohorts (“vaccine-eligible”, “pre-screening” and “screening” cohorts) according to the preventive intervention scheduled by age; males were included in the same three cohorts according to their year of birth. The overall prevalence of HPV infection was 19%, being higher in females than in males (22.1% vs. 13.6%, p = 0.03729). In the female population, 10 years after the start of the national immunization program, we observed a reduction in the prevalence of vaccine types and the number of circulating genotypes, especially in the “vaccine-eligible” cohort. The frequency of HPV vaccine types increased with age, particularly in males in the “pre-screening” and “screening” cohorts. Our study highlights the importance of monitoring HPV infection in both genders, to validate the effect of the HPV vaccination program.