Vaccine decision-making begins in pregnancy: Correlation between vaccine concerns, intentions and maternal vaccination with subsequent childhood vaccine uptake

'My primary purpose is to protect the unborn child': Understanding pregnant women's perceptions of maternal vaccination and vaccine trials in Europe

Despite the important benefits of maternal vaccination for pregnant women and newborns, vaccination uptake is low in many European countries. Differences in vaccination policies and recommendations, as well as concerns about vaccine safety can partly explain inadequate coverage rates and women's hesitancy to get vaccinated during pregnancy. This study aims to explore pregnant women's experiences, decision-making processes and perceptions towards maternal vaccination and maternal vaccine trials in France, Germany, Italy, Spain and the United Kingdom. Qualitative interviews and focus groups were conducted with 258 pregnant women identified through local research panels and snowballing. Topic guides translated in local languages were designed to explore women's awareness and perceptions of maternal vaccination, and willingness to participate in vaccine trials during pregnancy. A thematic analysis was conducted. Pregnant women were found to have low awareness about maternal vaccination, with many reporting not having received a recommendation to vaccinate from their doctors. Strong trust in health professionals indicate that strengthened recommendations could improve vaccination uptake. Vaccination decision-making in pregnancy was described in the context of a highly emotional period, generating anxiety and fears around the safety of vaccines. Pregnancy was also discussed as a period during which women develop nurturing and protective identities. However, depending on the information they received as well as influences from experts, families and peers, women either perceived vaccination as a threat to their babies' safety or as a means to protect them. Attitudes towards maternal vaccine trials were less ambiguous, with most pregnant women strongly rejecting the notion of taking part in trials. While strategies to improve pregnant women's awareness and perceptions of maternal vaccination are needed, it is equally important to understand why healthcare professionals may not be recommending vaccination. More coordinated strategies across Europe could help strengthen communication and trust in maternal vaccination.

Beyond the "information deficit model" - understanding vaccine-hesitant attitudes of midwives in Austria: a qualitative study

BACKGROUND

Healthcare workers are considered key stakeholders in efforts to address vaccine hesitancy. Midwives' influence in advising expectant parents on early-childhood vaccinations is unquestioned, yet they remain an understudied group. The literature on midwives' attitudes towards vaccinations is also inconclusive. We therefore conducted an explorative qualitative study on midwives' vaccine-hesitant attitudes towards MMR (measles-mumps-rubella) vaccinations in Austria.

METHODS

We conducted 12 in-depth interviews on their knowledge, concerns, and beliefs with midwives who self-identified as hesitant or resistant towards early-childhood MMR vaccinations. We analyzed the data using a grounded theory approach to distill common themes and meanings.

RESULTS

Healthcare workers' stewardship to address vaccine hesitancy is commonly framed in terms of the "information deficit model": disseminate the right information and remedy publics' information deficits. Our findings suggest that this approach is too simplistic: Midwives' professional self-understanding, their notions of "good care" and "good parenthood" inflect how they engage with vaccine information and how they address it to their clients. Midwives' model of care prioritized good counseling rather than sharing scientific information in a "right the wrong"-manner. They saw themselves as critical consumers of that information and as promoting "empowered patients" who were free, and affluent enough, to make their own choices about vaccinations. In so doing, they also often promoted traditional notions of motherhood.

CONCLUSIONS

Research shows that, for parents, vaccine decision-making builds on trust and dialogue with healthcare professionals and is more than a technical issue. In order to foster these interactions, understanding healthcare professionals' means of engaging with information is key to understanding how they engage with their constituents. Healthcare workers are more than neutral resources; their daily praxis influenced by their professional standing in the healthcare system. Similarly, healthcare professionals' views on vaccinations cannot be remedied with more information either. Building better and more diverse curricula for different groups of healthcare workers must attend to their respective roles, ethics of care, and professional beliefs. Taken together, better models for addressing vaccine hesitancy can only be developed by espousing a multi-faceted view of decision-making processes and interactions of healthcare workers with constituents.

Influenza and pertussis vaccine uptake during pregnancy among Australian women in south-east Queensland, Australia

OBJECTIVES

Population-specific studies of vaccine uptake in pregnancy are necessary to monitor progress and ensure enablers to vaccination are locally relevant. We aimed to determine the uptake of influenza and pertussis vaccine during pregnancy in women in south-east Queensland and the reasons why women were choosing not to vaccinate.

METHODS

A secondary analysis of data collected in a prospective cohort study. Data were collected at enrolment during pregnancy and within six weeks of giving birth. The primary outcome was the proportion of women vaccinated during pregnancy.

RESULTS

Among 310 pregnant women, 45.8% and 69.7% were vaccinated against influenza and pertussis, respectively; 123 (39.7%) had received both vaccines. The common predictor of vaccine uptake for influenza, pertussis or both was having had any vaccine in the 12 months prior to pregnancy. Not considering the vaccines necessary and perceptions of the risk of infection were common reasons for not intending to vaccinate.

CONCLUSIONS

Antenatal vaccine uptake remains suboptimal in women in south-east Queensland. Barriers to vaccination during pregnancy are complex and vary depending on context and population. Implications for public health: More efforts are needed to promote antenatal uptake, particularly for influenza vaccine and having both the influenza and pertussis vaccines during pregnancy.

Pro-Vaxxers Get Out: Anti-Vaccination Advocates Influence Undecided First-Time, Pregnant, and New Mothers on Facebook

Social media has revolutionized health information-seeking behavior with crowd-based medical advice. Decreased vaccination uptake and subsequent disease outbreaks have generally occurred in localized clusters based on social norms; however, geographically unrestricted Facebook networks promote parental vaccination refusal congruent with digital identity formation. Interactions within the largest closed Facebook group for vaccination choice were analyzed through the lens of Social Influence Theory. Anti-vaccination advocates impacted first-time mothers' expressed vaccination intentions through both informational and normative influence processes. Six overarching themes were identified as strategies used by these individuals to persuade fence sitting parents to delay or decline vaccinations, including: natural solutions, maternal empowerment, distrust of conventional medicine establishment, fear appeals, 'Russian Roulette' risk benefit analysis, and misinformation and misunderstandings.

What Affects Maternal Response to Measles Vaccinations? Examining the Health Beliefs Model (HBM)

Background: Renewed measles outbreaks in recent years indicate that despite the routine availability of vaccines for a disease that is considered contagious, dangerous and deadly, many anti-vaccinationists do not vaccinate their children, which consequently endangers public health. This study aimed to investigate the factors that influence mothers to vaccinate their children, and whether the Health Belief Model (HBM) could predict compliance or non-compliance. Methods: This was a quantitative correlational research, using a 40-item questionnaire administered to 181 mothers in Israel. Results: The findings indicated two main factors that affected mothers’ intention to vaccinate their children against measles: first, their perception of the vaccine’s advantages, and second, their perception of the severity of the disease. It was also found that the HBM variables significantly affected the intention to administer vaccines. Conclusion: Consequently, raising public awareness of the vaccine’s advantages and importance to preventing mass infection, as well as attempts by the health system and practitioners to understand the motivations of anti-vaccinationists (including health beliefs and cultural sensitivities) could significantly increase the percentage of vaccinated children, and eradicate the measles epidemic.

Vaccine hesitancy in the era of COVID-19

Objectives

In 2019, a new coronavirus has been identified and many efforts have been directed toward the development of effective vaccines. However, the willingness for vaccination is deeply influenced by several factors. So the aim of our review was to analyze the theme of vaccine hesitancy during COVID-19 pandemic, with a particular focus on vaccine hesitancy toward COVID-19 vaccine.

Study design

Narrative review.

Methods

In November 2020, we performed a search for original peer-reviewed articles in the electronic database PubMed (MEDLINE). The key search terms were “Vaccine hesitancy AND COVID-19”. We searched for studies published during COVID-19 pandemic and reporting information about the phenomenon of vaccine hesitancy.

Results

Fifteen studies were included in the review. The percentage of COVID-19 vaccine acceptance was not so high (up to 86.1% students or 77.6% general population); for influenza vaccine, the maximum percentage was 69%. Several factors influenced the acceptance or refusal (ethnicity, working status, religiosity, politics, gender, age, education, income, etc.).

The most given reasons to refuse vaccine were as follows: being against vaccines in general, concerns about safety/thinking that a vaccine produced in a rush is too dangerous, considering the vaccine useless because of the harmless nature of COVID-19, general lack of trust, doubts about the efficiency of the vaccine, belief to be already immunized, doubt about the provenience of vaccine.

Conclusions

The high vaccine hesitancy, also during COVID-19 pandemic, represents an important problem, and further efforts should be done to support people and give them correct information about vaccines.

Enhancement of Vaccination Attitude and Flu Vaccination Coverage among Pregnant Women Attending Birthing Preparation Course

Most vaccinations are recommended within the 15th month of life, in order to reduce risks and to protect children from the initial stages of their lives. A vaccination training session was carried out during the birthing preparation course, aimed at increasing the attitude toward vaccination in maternal-child age. A questionnaire on vaccination awareness was administered before and after the training session and on-site flu vaccination was offered to women and their companions. The percentage of participants who consider the preparatory course a useful tool to obtain information about vaccines increases significantly from 30.34% at pre-intervention to 64.56% at post-intervention (p < 0.001). There is a significant increase in the mean number of vaccinations that the participants want their children to get. The number of participants believing that there is no relationship between vaccination and autism rose from 41.05 to 72.97% (p < 0.001). In total, 48 out of 119 (40.34%) pregnant women participating in the course and 39 companions were vaccinated for influenza. Vaccination knowledge and attitude significantly increased after a training session dedicated to vaccination as a part of the pregnant pre-birth course, whose aim can be therefore extended to the management of the health of the child, well beyond the period of pregnancy, according to the life-course approach to health.

The Model of "Informed Refusal" for Vaccination: How to Fight against Anti-Vaccinationist Misinformation without Disregarding the Principle of Self-Determination

Vaccines are arguably a public health success story as well as an incredibly cost-effective medical resource. Despite this, worldwide concerns about their safety are growing, with the risk of increased morbidity and mortality in vaccine-preventable diseases because of vaccine refusal. The global political trend in developed countries is to increasingly reduce mandates and the compulsory nature of vaccination programs. This is due to strong opposition from anti-vaccination movements and groups. While these have existed since the beginnings of vaccinology, they have recently gained a strong foothold through massive exploitation of the media and especially the internet. This has led to widespread misinformation and greater difficulty for governments and health institutions in dealing with parents’ concerns and misconceptions. Common strategies in order to maintain a high degree of public acceptance of vaccines include the enhancement of adverse effect reporting systems, the enrichment of scientific literature, and the dissemination of targeted information to parents and health care providers. Vaccine risk perception, in fact, largely exceeds the evidence and is linked to well-known general population cognitive bias, which must be recognized and corrected. Although there is no doubt about the convenience of universal vaccination, a lively international debate is underway with regard to the legitimacy of mandatory vaccination programs. Most scientists agree that the individual’s right to self-determination should be preserved. The only way to simultaneously protect the right to health is to introduce an informed refusal model, which aims to guarantee the highest coverage rates for vaccination.

Infant vaccination education preferences among low-income pregnant women

Childhood vaccination is an important public health intervention, yet many children remain under-vaccinated. The objective of this study was to examine infant vaccination education preferences in a population of low-income pregnant women by ethnicity, nativity, and language. Pregnant women 14–44 y old (n = 335) attending a participating low-income reproductive health clinic in southeast Texas from May 26-July 21, 2017, and who completed a paper survey offered in English and Spanish were included. Participants were asked to complete questions about their demographic characteristics and preferences about infant vaccination education. To examine differences in vaccine education preferences by participant demographic characteristics, chi-squared tests, or Fisher’s exact tests and one-way analysis of variance (ANOVA) were conducted using Stata SE Version 15.1 with α = 0.05. Nearly half (47.5%) of participants considered pregnancy the best time to get information about infant vaccination and were most likely (40.6%) to indicate the nurse who gives vaccines during pregnancy as the health-care worker with whom they would like to discuss infant vaccination. There were no demographic differences in preferred timing of vaccine education delivery or provider who delivers vaccine education. Prenatal, nurse-delivered vaccine educational programs would be well accepted in this low-income population.

Evaluation of a midwife-led, hospital based vaccination service for pregnant women

Background: Vaccines against whooping cough (pertussis) and seasonal-influenza are recommended for pregnant women in England. Uptake however varies regionally and by ethnicity. Pregnant women are traditionally vaccinated in primary care, though some hospitals now offer vaccines through antenatal clinics. This mixed-methods evaluation describes the demographic characteristics of women seen in a hospital midwife-led antenatal vaccine clinic and explores vaccine decision making. Methods: Descriptive statistics of women seen in a London hospital's midwife-led vaccine clinic were generated from electronic routine maternity records, including data on ethnicity, parity, age and deprivation indices. Reasons for vaccine decline given by women to midwives were categorized by themes. Qualitative interviews of women seen in the clinic were also undertaken. Results: Between 1st April 2017 and 31st March 2018 the vaccine clinic saw 1501 pregnant women. Of these, 83% received pertussis vaccine and (during flu season) 51% received influenza vaccine, from the clinic. Fewer Black Afro-Caribbean women seen by the clinic were vaccinated, compared to other ethnicities with only 68% receiving pertussis and 34% flu vaccines respectively (p < .05). Among all women delivering at the hospital over the year, 42%, (1334/3147) were vaccinated by the clinic. Qualitative interviews found that reassurance from healthcare professionals, particularly midwives, was the most important factor influencing maternal vaccine decisions. Conclusions: Midwife-led hospital clinics can offer an effective alternative to primary care provision for vaccines in pregnancy. Consistent with previous work, vaccine uptake varied by ethnicity. Midwives play a key role in the provision of vaccine services and influence women's vaccine decisions.

Education, Healthy Ageing and Vaccine Literacy

Importance and Objective: The Covid pandemic is a timely opportunity to try to broaden our understanding of the links between education and health literacy and explore the vaccine-decision process with a view to identifying interventions that will positively influence vaccine uptake.

EVIDENCE

Health and vaccine literacy encompass people's knowledge, motivation, and competence to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning health care, disease prevention and health promotion.

FINDINGS

Appropriate vaccine communication, which depends greatly on personal and contextual determinants, as well as on societal and environmental circumstances, is essential to reassure people about vaccine efficacy, safety, and possible side effects. However, vaccine confidence is not solely a question of trust in the vaccine's efficacy, safety. and individual protective benefit of vaccination. It also encompasses the mechanism(s) of vaccine activity, immunization schedules, organization and trust in the healthcare system that promotes and delivers the vaccines, and at what costs. When healthcare professionals as science brokers of vaccine knowledge attempt to increase vaccine knowledge and confidence, they must adjust their communication to the educational or health literacy level of their intended audience. Even if their messages are apparently clear and simple, they absolutely need to verify that they are properly understood.

RELEVANCE

Specific vaccine communication training appears essential to increase vaccine communication skills among healthcare providers. Moreover, further randomized controlled studies are warranted to improve vaccine empowerment among different populations, from a variety of educational backgrounds.

Strengthening Vaccine Confidence and Acceptance in the Pediatric Provider Office

Although vaccine acceptance and uptake are overall high among children in the United States, vaccine delays or refusals are a growing concern. Vaccine hesitancy is a challenge for the pediatric provider, given the diverse factors associated with hesitancy and the limited evidence on effective strategies for addressing vaccine hesitancy in the provider office. In this article, we review available evidence and approaches for vaccine communication, including the importance of using a whole-team approach, building trust, starting the conversation early, using a presumptive approach for vaccine recommendations, motivational interviewing with parents who have concerns for vaccines, and additional techniques for responding to parent questions. We also review organizational strategies to help create a culture of immunization in the practice, including evidence-based approaches for increasing vaccine uptake and efficiency. Although these communication approaches and organizational strategies are intended to reassure parents who are vaccine hesitant that all routine, universally recommended vaccines are safe and effective, they likely will take on increased significance as the development, implementation, and evaluation of coronavirus disease 2019 vaccines continue to unfold. [Pediatr Ann. 2020;49(12):e523-e531.].

Predictors of immunization coverage among 12-23 month old children in Ethiopia: systematic review and meta-analysis

Background

Immunization is one of modern medicine’s greatest achievements in the last three decades. Annually it can prevent nearly 2 to 3 million deaths. Understanding the determinants of effective immunization coverage is a critical undertaking. Accordingly, we set out to check the best available evidence of outstanding predictors of immunization coverage among children aged 12–23 months in Ethiopia.

Method

Electronic databases including PubMed, Google Scholar, HINARI, and SCOPUS, Web of Science, African Journals Online, Ethiopian Medical Journals were searched. The search process, study selection, critical appraisal, and data extraction were done independently by two reviewers using Joanna Briggs Institute Meta-analysis for Review Instrument (JBI-MAStARI). The difference between reviewers was resolved with a third person. The risk of bias was assessed by the Newcastle Ottawa Tool for observational studies. Data were extracted using the Microsoft Excel checklist and exported to STATA 13. Heterogeneity was assessed using I², Funnel plot and Egger’s test was used to check for publication bias.

Results

We identified 26 studies with 15,042 children with mothers/caretakers to assess factors associated with immunization coverage and significant factors were: maternal formal education, (OR = 2.45; 95% CI: 1.62–3.72), paternal formal education, (OR = 1.01; 95% CI: 0.27–3.77), residence, (OR = 2.11; 95% CI: 1.00–4.45), birth at health facility (OR = 1.86; 95% CI: 0.99–3.49), family size less than four, (OR = 1.81; 95% CI: 1.16–2.84), knowledge on age of immunization to be completed (OR = 6.18;95% CI: 3.07–12.43), knowledge on immunization schedule (OR = 2.49; 95% CI: 1.35–4.59), time to travel to health faculties, (OR = 1.74; 95% CI: 0.62–4.89), antennal care, (OR = 3.11; 95% CI: 1.64–5.88), and tetanus toxoid vaccination, (OR = 4.82; 95% CI: 2.99–7.75).

Conclusion

Our findings showed that literacy, residence, awareness, family size, maternal health services use, and proximity of the health facilities were factors associated with full immunization. This implies that there is a need for primary health service expansion and health education to “hard to reach areas” to improve immunization coverage for children aged 12–23 months.

Vaccination Attitude and Communication in Early Settings: An Exploratory Study

Background: This study assesses attitudes towards vaccination in mothers of new-born babies and explores its association with different exposures to communication. Methods: Data were collected through questionnaires administered by means of interviews. Results: Data highlighted that 20% of mothers showed an orientation towards vaccine hesitancy. As for the reasons behind the attitude to vaccine hesitancy, data showed that concern is a common feature. As for the different exposures to communication, 49% of mothers did not remember having received or looked for any information about vaccination during pregnancy and post-partum; 25% stated they received information from several healthcare and non-healthcare sources; 26% declared having received or looked for information by means of healthcare and non-healthcare sources, as well as having taken part in a specific meeting during antenatal classes or at birth centres. The attitude towards vaccine hesitancy tends to reduce as exposure to different communication increases. Conclusions: This study supports the hypothesis that participation in interactive meetings in small groups focused on vaccination during the prenatal course or at the birth point may act as an enabling factor contributing to a decrease in the tendency to experience vaccine hesitation.

Decision-making on maternal pertussis vaccination among women in a vaccine-hesitant religious group: Stages and needs

INTRODUCTION

As of December 2019, pregnant women in the Netherlands are offered pertussis vaccination to protect their newborn infant against pertussis infection. However, the manner in which pregnant women decide about this maternal pertussis vaccination is largely unknown. The aim of this study is to gain insight into the decision-making process regarding maternal pertussis vaccination, and to explore the related needs among the vaccine-hesitant subgroup of orthodox Protestant women.

METHODS

Charmaz's grounded theory approach was used to develop a decision-making framework. To construct this framework we used an explorative multimethod approach in which in-depth interviews and online focus groups were supplemented by a literature search and research group meetings. This study was carried out in a hypothetical situation since the maternal pertussis vaccination had yet to be implemented in the Dutch immunisation programme at the time of the study.

RESULTS

Twenty-five orthodox Protestant women participated in an interview, an online focus group, or in both. The findings of this study resulted in a decision-making framework that included three stages of decision-making; an Orientation stage, a value-based Deliberation stage, and Final decision stage. The Orientation stage included the needs for decision-making categorised into Information needs and Conversation needs. Women indicated that -if they were to receive sufficient time for Orientation and Deliberation- they would be able to reach the stage of Final decision.

CONCLUSION

The decision-making framework resulting from our findings can be used by health care professionals to provide women with information and consultation in the decision-making process. Future studies should investigate whether the stages of and needs for decision-making can be found across other vaccine-hesitant subgroups and vaccinations.

Knowledge, attitudes and practices about vaccine-preventable diseases and vaccinations of children among pregnant women in Greece

Vaccine hesitancy has been recognized by the World Health Organization as one of ten threats to public health globally in 2019. Pregnant women constitute an extremely important group for the study of knowledge and attitudes towards pediatric vaccinations. This is a cross-sectional survey conducted in two maternity hospitals in Athens. A standardized questionnaire was used. A total of 814 pregnant women with a mean age of 33.1 years and a mean gestational age of 24.4 weeks were studied. Overall, 717 (89%) of 804 pregnant women reported that they intend to vaccinate their baby in accordance with the National Vaccination Program, 7 (1%) that they do not, while 80 (10%) reported that they have not decided yet. The women provided a mean of 11.4 correct replies out of 14 questions about vaccine-preventable diseases and vaccines (mean knowledge score: 81.5%). A pediatrician has been recognized as the source for information about vaccines in most cases (611/809, 75.5%), while in 215 (26.6%) the internet was also used. Overall, pregnant women trusted physicians about information for vaccines ("very much trusted" in 55.9% and "quite trusted" in 40% of cases). Lastly, 642 (81%) women agreed with the statement "vaccinations should be mandatory for school entry" while 70 (9%) women agreed with the statement "parents should have the right to refuse their children vaccinations". A multivariate analysis found that a gestational age of ≤20 weeks (OR = 2.33, CIs: 1.27-4.28, p-value = 0.006), having another child (OR = 4.44, CIs: 2.30-8.58, p-value < 0.001), a history of influenza vaccination (OR = 2.54, CIs = 1.37-4.71, p-value = 0.003), and a higher knowledge score about vaccine-preventable diseases and vaccines (OR = 1.33, CIs: 1.23-1.45, p-value < 0.001) were significantly associated with an increased probability to get their child vaccinated in accordance with the National Vaccination Program.

Resources for assessing parents' vaccine hesitancy: a systematic review of the literature

The concept of Vaccine Hesitancy has begun to appear in the scientific landscape, referring to the reluctance of a growing proportion of people to accept the vaccination offer. A variety of factors were identified as being associated with vaccine hesitancy but there was no universal algorithm and currently there aren’t any established metrics to assess either the presence or impact of vaccine hesitancy. The aim of this study was to systematically review the published questionnaires evaluating parental vaccine hesitancy, to highlight the differences among these surveys and offer a general overview on this matter. This study offers a deeper perspective on the available questionnaires, helping future researches to identify the most suitable one according to their own aim and study setting.

The Association of Prenatal Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccination With Attention-Deficit/Hyperactivity Disorder

As prenatal vaccinations become more prevalent, it is important to assess potential safety events. In a retrospective cohort study of Kaiser Permanente Southern California (Pasadena, California) mother-child pairs with birth dates during January 1, 2011-December 31, 2014, we investigated the association between prenatal tetanus, diphtheria, and acellular pertussis (Tdap) vaccination and risk of attention-deficit/hyperactivity disorder (ADHD) in offspring. Information on Tdap vaccination during pregnancy was obtained from electronic medical records. ADHD was defined by International Classification of Diseases codes (Ninth or Tenth Revision) and dispensed ADHD medication after age 3 years. Children were followed to the date of their first ADHD diagnosis, the end of Kaiser Permanente membership, or the end of follow-up (December 31, 2018). In Cox proportional hazards models, we estimated unadjusted and adjusted hazard ratios for the association between maternal Tdap vaccination and ADHD, with inverse probability of treatment weighting (IPTW) used to adjust for confounding. Of 128,756 eligible mother-child pairs, 85,607 were included in the final sample. The ADHD incidence rate was 3.41 per 1,000 person-years in the Tdap-vaccinated women and 3.93 per 1,000 person-years in the unvaccinated (hazard ratio = 1.01, 95% confidence interval: 0.88, 1.16). The IPTW-adjusted analyses showed no association between prenatal Tdap vaccination and ADHD in offspring (hazard ratio = 1.00, 95% confidence interval: 0.88, 1.14). In this study, prenatal Tdap vaccination was not associated with ADHD risk in offspring, supporting recommendations to vaccinate pregnant women.

Pregnant women's perspectives about maternal immunization in Latin America

BACKGROUND

Maternal immunization rates and vaccine uptake in Latin America vary from country to country. This variability stems from factors related to pregnant women, vaccine recommendations from healthcare providers and the health system. The aim of this paper is to describe women's knowledge and attitudes to maternal immunziation, and barriers to access and vaccination related decision-making processes in Latin American countries.

METHODS

We conducted focus group discussions (FGD) with pregnant women in five middle-income countries: Argentina, Brazil, Honduras, Mexico and Peru, between July 2016 and July 2018. The FGDs were conducted by trained qualitative researchers in diverse clinics located in the capital cities of these countries.

RESULTS

A total of 162 pregnant women participated in the FGDs. In general, participants were aware of the recommendation to receive vaccines during pregnancy but lacked knowledge regarding the diseases prevented by these vaccines. Pregnant women expressed a desire for clearer and more detailed communication on maternal vaccines by their healthcare professionals instead of relying on other sources of information such as the internet. Overall, participants had positive attitudes towards maternal immunization and were open to receiving vaccines in pregnancy based on general trust they have in recommendations made by their healthcare providers. The main obstacles pregnant women said they encounter were mainly centered around their clinical experience: long waiting times, vaccine shortages, and impolite behavior of healthcare providers or clinical staff.

CONCLUSION

Important advances have been made in Latin America to promote maternal immunization. Results from this study show that an important aspect that remains to be addressed, and is crucial in improving vaccine uptake in pregnancy, is women's clinical experience. We recommend pregnant women to be treated as a priority population for providing immunization and related healthcare education. It is imperative to train healthcare providers in health communication so they can effectively communicate with pregnant women regarding maternal vaccines and can fill knowledge gaps that otherwise might be covered by unreliable sources dispensing inaccurate information.

Midwifery care of non-vaccinating families - Insights from the Byron Shire

PROBLEM

Midwives may feel ill-equipped to manage clinical encounters with non-vaccinating parents.

BACKGROUND

Pregnancy is a peak time in the formation of parents' vaccination views and intention. Midwives are central to maternity care in Australia. While most midwives will have infrequent contact with families who intend not to vaccinate, when they do, they must feel equipped to communicate with them in a manner which fulfils their professional responsibilities, acknowledges parental autonomy and facilitates continued engagement.

AIM

To understand how midwives can most effectively communicate with non-vaccinating parents.

METHODS

We conducted in-depth interviews with 32 non-vaccinating parents and six key informant health professionals, and a focus group of six midwives. Data collection occurred in the Byron Shire of New South Wales, where childhood vaccination rates are persistently lower than national averages.

FINDINGS

This study explores four central codes. The first, 'hold on…I'm not sure about this' providing insights into moments of doubt preceding parents' decisions not to vaccinate. The second 'Pregnancy: a decision-making focal point' reinforces the importance of effective vaccination recommendations in the antenatal period. 'Manipulation and ambivalence' examines why overzealous or unclear recommendations about vaccination are unhelpful, and the fourth central code 'engage, inform and encourage' summarise recommendations from health professionals who are experienced in communicating, apparently effectively, with non-vaccinating families.

DISCUSSION

Insights from this study are used to recommend practical strategies which may be employed by midwives and maternity units to successfully and professionally manage clinical encounters with non-vaccinating parents.

CONCLUSION

Midwives are well positioned to provide clear recommendations to parents regarding childhood vaccination whilst maintaining engagement and meeting the goals of woman-centred care.

A Consent Support Resource with Benefits and Harms of Vaccination Does Not Increase Hesitancy in Parents-An Acceptability Study

It is unclear whether information given about the benefits and risks of routine childhood vaccination during consent may cue parental vaccine hesitancy. Parents were surveyed before and after reading vaccine consent information at a public expo event in Sydney, Australia. We measured vaccine hesitancy with Parent Attitudes about Childhood Vaccine Short Scale (PACV-SS), informed decision-making with Informed Subscale of the Decisional Conflict Scale (DCS-IS), items from Stage of Decision Making, Positive Attitude Assessment, Vaccine Safety and Side Effect Concern, and Vaccine Communication Framework (VCF) tools. Overall, 416 parents showed no change in vaccine hesitancy (mean PACV-SS score pre = 1.97, post = 1.94; diff = −0.02 95% CI −0.10 to 0.15) but were more informed (mean DCS-IS score pre = 29.05, post = 7.41; diff = −21.63 95% CI −24.17 to −18.56), were more positive towards vaccination (pre = 43.8% post = 50.4%; diff = 6.5% 95% CI 3.0% to 10.0%), less concerned about vaccine safety (pre = 28.5%, post = 23.0%, diff = −5.6% 95% CI −2.3% to −8.8%) and side effects (pre = 37.0%, post = 29.0%, diff = −8.0% 95% CI −4.0% to −12.0%) with no change in stage of decision-making or intention to vaccinate. Providing information about the benefits and risks of routine childhood vaccination increases parents’ informed decision-making without increasing vaccine hesitancy.

Social-psychological determinants of maternal pertussis vaccination acceptance during pregnancy among women in the Netherlands

BACKGROUND

Maternal Pertussis Vaccination (MPV) during pregnancy became part of the National Immunization Program in the Netherlands late 2019. This study aims to identify social-psychological factors associated with MPV acceptance among Dutch women to add to the current understanding of vaccine hesitancy worldwide, and to inform the development of communication and information campaigns about MPV.

METHODS

We conducted a cross-sectional study using an online survey among 611 women (174 pregnant women, 205 women who had given birth in the past two years and 232 women of 20-35 years old). The primary and secondary outcomes were vaccination intention and attitude towards MPV, respectively. Pearson's correlation and regression analyses were used to examine social-psychological and socio-demographic determinants of the outcomes.

RESULTS

Vaccination intention was most explained by attitudes towards MPV, beliefs about safety, moral norm and the belief about the effectiveness of MPV (R² = 0.79). Other factors associated were injunctive norm, anticipated regret of vaccinating, and decisional certainty. Attitudes towards MPV were further explained by descriptive norm, risk perceptions of side effects, and risk perceptions of the baby getting pertussis when not vaccinating, and fear of MPV and of the disease (R² = 0.76). Finally, pregnant women had a significantly lower intention and less positive attitude towards MPV than non-pregnant women.

CONCLUSIONS

Communication about MPV should address the most important determinants of MPV intention and attitude, i.e. beliefs about safety and effectiveness and moral norms. Furthermore, such information may benefit from taking into account affective feelings of pregnant women such as anticipated regret and fear towards MPV. Further research could explore this. The timing of communication about MPV can be important as determinants of MPV acceptance may vary depending on pregnancy status.

Early Childhood Health Outcomes Following In Utero Exposure to Influenza Vaccines: A Systematic Review

CONTEXT

Vaccination during pregnancy is an effective strategy for preventing infant disease; however, little is known about early childhood health after maternal vaccination.

OBJECTIVES

To systematically review the literature on early childhood health associated with exposure to influenza vaccines in utero.

DATA SOURCES

We searched CINAHL Plus, Embase, Medline, Scopus, and Web of Science for relevant articles published from inception to July 24, 2019.

STUDY SELECTION

We included studies published in English reporting original data with measurement of in utero exposure to influenza vaccines and health outcomes among children <5 years of age.

DATA EXTRACTION

Two authors independently assessed eligibility and extracted data on study design, setting, population, vaccines, outcomes, and results.

RESULTS

The search yielded 3647 records, of which 9 studies met the inclusion criteria. Studies examined infectious, atopic, autoimmune, and neurodevelopmental outcomes, and all-cause morbidity and mortality. Authors of 2 studies reported an inverse association between pandemic influenza vaccination and upper respiratory tract infections, gastrointestinal infections, and all-cause hospitalizations; and authors of 2 studies reported modest increased association between several childhood disorders and pandemic or seasonal influenza vaccination, which, after adjusting for confounding and multiple comparisons, were not statistically significant.

LIMITATIONS

Given the small number of studies addressing similarly defined outcomes, meta-analyses were deemed not possible.

CONCLUSIONS

Results from the few studies in which researchers have examined outcomes in children older than 6 months of age did not identify an association between exposure to influenza vaccines in utero and adverse childhood health outcomes.

Designing a multi-component intervention (P3-MumBubVax) to promote vaccination in antenatal care in Australia

ISSUE ADDRESSED

Coverage of maternal influenza and pertussis vaccines remains suboptimal in Australia, and pockets of low childhood vaccine coverage persist nationwide. Maternal vaccine uptake is estimated to be between 35% and 60% for influenza vaccination and between 65% and 80% for pertussis vaccination. Australian midwives are highly trusted and ideally placed to discuss vaccines with expectant parents, but there are no evidence-based interventions to optimise these discussions and promote maternal and childhood vaccine acceptance in the Australian public antenatal setting.

METHODS

We gathered qualitative data from Australian midwives, reviewed theoretical models, and adapted existing vaccine communication tools to develop the multi-component P3-MumBubVax intervention. Through 12 interviews at two Australian hospitals, we explored midwives' vaccination attitudes and values, perceived role in vaccine advocacy and delivery, and barriers and enablers to intervention implementation. Applying the theory-based P3 intervention model, we designed intervention components targeting the Practice, Provider and Parent levels. Midwives provided feedback on prototype intervention features through two focus groups.

RESULTS

The P3-MumBubVax intervention includes practice-level prompts and identification of a vaccine champion. Provider-level components are a vaccine communication training module, learning exercise, and website with printable fact sheets. Parent-level intervention components include text message reminders to receive influenza and pertussis vaccines in pregnancy, as well as online information on vaccine safety, effectiveness and disease severity.

CONCLUSIONS

The P3-MumBubVax intervention is the first Australian antenatal intervention designed to support both maternal and childhood vaccine uptake. A pilot study is underway to inform a planned cluster randomised controlled trial. SO WHAT?: Barriers to vaccine acceptance and uptake are complex. The P3 model is a promising evidence-informed multi-component intervention strategy targeting all three levels influencing health care decision-making.

Unvaccinated children as community parasites in National Qualitative Study from Turkey

Background

This national qualitative study explores (1) the experiences, observations, and opinions of health care workers (HCWs) about beliefs, socioeconomic, cultural, and environmental characteristics of parents refusing vaccination and (2) regional differences in the identified risk factors; (3) recommended solutions to improve vaccine acceptance in each of 12 regions in Turkey.

Methods

In total, we carried out 14 individual semi-structured in-depth interviews and 10 focus group discussions with 163 HCWs from 36 provinces. A thematic analysis was performed to explore HCWs’ observations about the parents’ decisions to reject vaccination and possible solutions for vaccine advocacy.

Results

Within the analyzed data framework, vaccine refusal statements could be defined as vaccine safety, the necessity of vaccines, assumptions of freedom of choice, health workers’ vaccine hesitancy, lack of information about national vaccination schedule and components, not trusting the health system, anti-vaccine publications in social media and newspapers, and refugees. Suggestions based on the HCWs suggestions can be summarized as interventions including (1) creating visual cards with scientific data on vaccine content and disease prevention and using them in counseling patients, (2) writing the vaccine components in a way understandable to ordinary people, (3) highlighting the national quality control and production in the vaccine box and labels, (4) conducting interviews with community opinion leaders, (5) training anti-vaccine HCWs with insufficient scientific knowledge and (6) reducing the tax of parents whose children are fully and punctually vaccinated.

Conclusions

The solution to vaccine rejection begins with the right approaches to vaccination during pregnancy. Prepared written and visual information notes should present the information as “vaccination acceptance” rather than “vaccination refusal”. Further studies on vaccine refusal rates should be carried out in various regions of the world so that region-specific actions are implemented to decrease the anti-vaxxer movement and to prevent an outbreak of infectious diseases.

Global Perspectives on Immunization During Pregnancy and Priorities for Future Research and Development: An International Consensus Statement

Immunization during pregnancy has been recommended in an increasing number of countries. The aim of this strategy is to protect pregnant women and infants from severe infectious disease, morbidity and mortality and is currently limited to tetanus, inactivated influenza, and pertussis-containing vaccines. There have been recent advancements in the development of vaccines designed primarily for use in pregnant women (respiratory syncytial virus and group B Streptococcus vaccines). Although there is increasing evidence to support vaccination in pregnancy, important gaps in knowledge still exist and need to be addressed by future studies. This collaborative consensus paper provides a review of the current literature on immunization during pregnancy and highlights the gaps in knowledge and a consensus of priorities for future research initiatives, in order to optimize protection for both the mother and the infant.

Influenza Vaccination Experiences of Pregnant Women as a Predictor of the Intention to Become Vaccinated in Future Pregnancies in Spain

A good perception of the vaccines administered during pregnancy favors immunization coverage, which is still not optimal for the influenza vaccine. To understand the predisposition towards vaccination in future pregnancies, a study was performed that evaluated the experiences of women with the vaccine or influenza. A cross-sectional study was conducted through telephone interviews given to a total of 683 postpartum women in two health departments from the Valencia Community (Spain). This interview asked about their intention of becoming vaccinated in future pregnancies and whether they were favor or against vaccination. Most of them, 98.5% (n = 673 [95% CI: 97.6–99.4]) (p < 0.001) declared having received the systematic vaccines throughout their lives. The ones who were vaccinated against influenza, 91.9% (n = 387 [95% CI: 89.2–94.6]) (p < 0.001) manifested they would do so in future pregnancies. The probability of future non-vaccination was modeled, which was related to an unfavorable opinion towards vaccines (OR = 4.07 [95% CI: 2.01–8.24]) (p < 0.001), having suffered from influenza during pregnancy (OR = 3.84 [95% CI: 1.41–10.42]) (p < 0.05), and not having been vaccinated during previous pregnancies (OR = 38.47 [95% CI: 23.58–62.76]) (p < 0.001). Vaccination during pregnancy increases the intent of vaccination in the future.

Active SMS-based surveillance of adverse events following immunisation with influenza and pertussis-containing vaccines in Australian pregnant women using AusVaxSafety

BACKGROUND

Maternal immunisation is important to protect both mother and baby, but safety concerns can lead to low uptake. AusVaxSafety participant-based surveillance actively monitors adverse events following immunisation (AEFI) in Australia. We aimed to analyse AEFI in the days following vaccination with seasonal inactivated influenza vaccine (IIV) and/or reduced antigen diphtheria-tetanus-acellular pertussis vaccine (dTpa) in pregnant women in Australia.

METHODS

De-identified AEFI reports were solicited from vaccine recipients via automated SMS survey (using SmartVax software) following routine vaccination with IIV and/or dTpa at 219 national sentinel surveillance sites from 2015 to 2018. AEFI rates were compared by vaccine group (IIV alone, dTpa alone, or IIV and dTpa together), vaccine brand, trimester (IIV only) and vaccination period (April to August 2016-2018; IIV only). Women who had two vaccination encounters during surveillance were identified and AEFI rates compared for each dose.

RESULTS

Among 13,758 participants, overall AEFI rates were lower following IIV (4.9%) than dTpa (6.4%) or IIV and dTpa given concomitantly (7.4%). The AEFI profile was similar for both vaccines, with injection site reactions, tiredness, and headache most commonly reported. Injection site pain and swelling/redness were significantly more common in women who received dTpa than IIV. Reports of medical attendance following immunisation were similar (0.3%) for each vaccine group. AEFI rates did not differ by IIV brand (FluQuadri®, Fluarix® Tetra), dTpa brand (Boostrix®, Adacel®), or by trimester. Among women with sequential dTpa vaccinations, 6.0% (7/116) had an AEFI following their second dTpa dose.

CONCLUSIONS

Self-reported AEFI rates did not differ by trimester (IIV), or by vaccine brand (IIV or dTpa). Concomitant influenza and pertussis vaccination was associated with more frequent, but low rates of minor, expected AEFI. These real world 'citizen science-based' data provide further reassuring evidence of the safety of maternal vaccination.

Feasibility and acceptability of the multi-component P3-MumBubVax antenatal intervention to promote maternal and childhood vaccination: A pilot study

BACKGROUND

Pregnancy is a critical time for vaccine decision-making, but coverage remains suboptimal for maternal influenza (45-60%) and pertussis vaccination (65-80%) in Australia. The multi-component P3-MumBubVax intervention has been designed for Australian midwives to optimise antenatal vaccine discussions and improve maternal and childhood vaccine uptake. A pilot study was conducted to assess intervention feasibility and acceptability.

METHODS

P3-MumBubVax includes components at three levels: 1. Practice ('vaccine champions'; stickers to prompt and record vaccine discussions/delivery); 2. Provider (website with vaccine communication training; learning exercise; fact sheets; links to child vaccination resources); 3. Parent (SMS reminders; website; fact sheets). Midwives and pregnant women 18-22 weeks gestation were recruited at the Royal Women's Hospital, Melbourne. Post-intervention online surveys assessed intervention feasibility, implementation, acceptability and impact on vaccine uptake.

RESULTS

Twenty-five midwives and 62 pregnant women were recruited and 19/25 midwives completed training. Surveys were returned by 18/25 midwives and 56/62 women. 14/18 midwives reported using the sticker prompts, 10/18 reported using or referring to the website, and 11/18 reported using the fact sheets. 48/56 pregnant women (86%) reported discussing influenza and 46/56 (82%) discussed pertussis vaccines with their midwives. These conversations were reported to be short (1-3 min) for 48/56 women (87%). All midwives were satisfied with the intervention and 17/18 reported feeling more confident discussing vaccines following the intervention. Women were very satisfied with SMS content (50/56; 94%) and timing (49/55; 89%), and with their vaccine discussions in general (34/56; 63%). However, 16/54 (30%) wanted more discussion about childhood vaccines. Self-reported maternal vaccine uptake was 82% (45/55) and 93% (51/55) for influenza and pertussis (baseline 2017-2018: 43% influenza, 60% pertussis) and 96% (50/52) of infants were fully vaccinated at 12 weeks.

DISCUSSION

The P3-MumBubVax intervention is feasible and acceptable in the Australian public antenatal setting. Further evaluation is required to determine effectiveness.

Disparities in parental awareness of children's seasonal influenza vaccination recommendations and influencers of vaccination

Objective

To determine parental awareness of influenza vaccination recommendations for children and explore associations with awareness.

Design

Cross-sectional survey.

Setting/participants

South Australian parents with a telephone listing in the Electronic White Pages were randomly selected.

Methods

Participants were interviewed using Computer Assisted Telephone Interviewing (CATI) during May–July 2016. Univariable and multivariable analyses explored characteristics associated with awareness; with the survey data weighted to reflect the population of SA and the probability of selection within a household.

Results

Of 539 parents, 33% were aware of the recommendation that all children (<5 years) should receive the influenza vaccine annually with 51.9% aware that children with special risk medical conditions (SRMC) should also receive the vaccine annually. Characteristics strongly associated with parental awareness of the recommendation for children aged < 5 years were knowledge of recommendation for children with a SRMC (adjusted Odds Ratio [aOR] 10.46, CI 4.44–24.63) or living in a metropolitan area (aOR 2.91, CI 1.19–7.09). There was lack of awareness in those not working (aOR 0.13, CI 0.04–0.47), with trade level education (compared with high school) (aOR 0.25 CI, 0.09–0.71) and in those born in the UK or Ireland (aOR 0.19, CI 0.04–0.85). Awareness of the recommendation for children with SRMC to receive the vaccine was strongly associated with knowledge of the influenza recommendation for children <5 years (aOR 10.22, CI 4.39–23.77) or not being born in Australia [UK/ Ireland (aOR 7.63, CI 1.86–31.31); other (aOR 3.93, CI 0.94–16.42)]. The most influential cues to future receipt were a general practitioner (GP) recommendation (63.8%) and providing influenza vaccine free for all children (37.6%). More parents who delayed or excluded vaccines believed that their children’s vaccinations (in general) were unnecessary, as other children were vaccinated (42.8%) compared to those with no or minor concerns (11.1%) (p<0.0001).

Conclusions

Parental awareness of children’s influenza vaccine recommendations is low. Targeted communication strategies and resources are required to establish broader community awareness of recommendations. Healthcare provider endorsement of the vaccine remains key and health care professionals, particularly GPs and paediatric specialists should be encouraged to discuss influenza vaccine with parents at every opportunity. Many parents have vaccine concerns and addressing concerns across the spectrum of hesitancy is crucial.

Hepatitis B Birth Dose Effects on Childhood Immunization in the U.S

INTRODUCTION

The Advisory Committee on Immunization Practices recommends administering the first dose of hepatitis B vaccine at birth, making it the first vaccine that many children receive. However, few studies examine whether children who miss the birth dose are at increased risk of vaccination delay. This study investigates birth dose as a determinant of up-to-date immunization status at age 18 months, considering 7 core childhood vaccine series: diphtheria, tetanus, and acellular pertussis; polio; measles, mumps, and rubella; Haemophilus influenzae type B; varicella; hepatitis B; and pneumococcal conjugate vaccine.

METHODS

Cross-sectional data were collected in 2017 by National Immunization Survey-Child, a nationally representative survey of children aged 19-35 months living in the U.S., and were analyzed in 2019. The primary outcome was combined 7-vaccine series (4:3:1:3:3:1:4) up-to-date status at 18 months. Doubly robust estimates of association were calculated using survey logistic regression and propensity scores estimated with boosted classification and regression trees.

RESULTS

Children who received the birth dose had 2.01 (95% CI=1.74, 2.33) times the odds of being up-to-date on the combined 7-vaccine series as children who did not. ORs for all the 7 individual vaccine series were positive, ranging from 1.59 (95% CI=1.28, 1.97) for measles, mumps, and rubella to 4.97 (95% CI=3.97, 6.24) for hepatitis B.

CONCLUSIONS

Receiving the birth dose is positively associated with up-to-date status later in childhood, highlighting the importance of starting vaccination early. The association is insensitive to confounding by factors observed in National Immunization Survey-Child, but investigation of unobserved factors such as vaccine hesitancy could provide critical information to guide intervention strategy.

Midwives' knowledge, attitudes and confidence in discussing maternal and childhood immunisation with parents: A national study

INTRODUCTION

Despite the enormous benefits of childhood and maternal immunisation to individual and population health, the uptake of maternal vaccines during pregnancy remains suboptimal. Midwives are a trusted information source for parents and play an important role in the provision of immunisation information. Understanding midwives' attitudes and vaccine knowledge, along with their confidence to discuss maternal and childhood immunisation with parents, is key to reducing parental decisional conflict and achieving immunisation goals.

METHODS

An online study was conducted to investigate midwives' knowledge and attitudes towards maternal and childhood vaccination along with their confidence to answer parents' vaccine-related questions. Midwives were recruited by email via the midwifery peek body, the Australian College of Midwives.

RESULTS

A total of 359 midwives completed the online survey. The majority of midwives supported maternal (influenza 83%, pertussis 90.5%) and childhood immunisation (85.8%); however, 69.4% of respondents wanted further training about immunisation. Midwives who felt their midwifery education adequately covered immunisation were more confident advising parents about maternal (p = 0.007) and childhood immunisation (p < 0.001). Similarly, Midwives were significantly more likely to confidently advise parents about maternal (p < 0.001) and childhood immunisations (p < 0.001) if they had completed a specific immunisation training course outside of their midwifery course.

CONCLUSION

Most midwives working in Australia support vaccination. However, access to contemporary, culturally appropriate education that enables midwives to engage confidently with parents about immunisation is lacking. Education based on a women-centred approach within the pre-registration curriculum along with continuing professional development programs could enable midwives to reduce the evidence to practice gap by increasing vaccine uptake.

Factors affecting the vaccination choices of pregnant women for their children: a systematic review of the literature

In recent years, an increase in vaccine hesitancy has led to a decrease in vaccination coverage in several countries. We conducted a systematic review of studies that assessed knowledge of and attitudes toward pediatric vaccinations, and the vaccination choices and their determinants among pregnant women. A total of 6,277 records were retrieved, and 16 full texts were included in the narrative synthesis. The published literature on the topic shows that, overall, pregnant women believe that vaccines are important for the protection of their children and the community, but various concerns and misunderstandings persist around vaccine safety and efficacy, which reduce the trust of expectant mothers in immunization. Nevertheless, such attitudes and choices vary depending on the vaccine being considered and the corresponding determinants should therefore be studied in the context of each specific vaccination. Further research on this topic is needed, particularly in non-western countries.

The association between vaccination confidence, vaccination behavior, and willingness to recommend vaccines among Finnish healthcare workers

Information and assurance from healthcare workers (HCWs) is reported by laypeople as a key factor in their decision to get vaccinated. However, previous research has shown that, as in the general population, hesitancy towards vaccines exists among HCWs as well. Previous studies further suggest that HCWs with a higher confidence in vaccinations and vaccine providers are more willing to take the vaccines themselves and to recommend vaccines to patients. In the present study with 2962 Finnish HCWs (doctors, head nurses, nurses, and practical nurses), we explored the associations between HCWs' vaccination confidence (perceived benefit and safety of vaccines and trust in health professionals), their decisions to accept vaccines for themselves and their children, and their willingness to recommend vaccines to patients. The results showed that although the majority of HCWs had high confidence in vaccinations, a notable share reported low vaccination confidence. Moreover, in line with previous research, HCWs with higher confidence in the benefits and safety of vaccines were more likely to accept vaccines for their children and themselves, and to recommend vaccines to their patients. Trust in other health professionals was not directly related to vaccination or recommendation behavior. Confidence in the benefits and safety of vaccines was highest among doctors, and increased along with the educational level of the HCWs, suggesting a link between confidence and the degree of medical training. Ensuring high confidence in vaccines among HCWs may be important in maintaining high vaccine uptake in the general population.

Attitudes about and access to influenza vaccination experienced by parents of children hospitalised for influenza in Australia

INTRODUCTION

In Australia, influenza hospitalises more children than any other vaccine preventable disease does. Children aged six months or older are recommended to receive annual influenza vaccines, and pregnant women are recommended vaccination to protect infants aged up to six months. However, vaccine uptake is low. This study explored influenza vaccination knowledge and behaviours of parents of children who were hospitalised for influenza, in order to inform strategies that target barriers to uptake.

METHODS

We conducted 27 semi-structured interviews with parents/caregivers during or shortly after their child's hospitalisation for laboratory-confirmed influenza in 2017. Questions were guided by the Social Ecological Model exploring all levels of influence on vaccination uptake from the intrapersonal through to policy, via the parents' perspective. Transcripts were inductively analysed. Themes were categorised into the components of the Capability-Opportunity-Motivation-Behaviour (COM-B) model.

RESULTS

20/27 children were aged six months or older; 16/20 had not received an influenza vaccine in 2017. Mothers of 4/7 infants aged less than six months were not vaccinated in pregnancy. The themes regarding barriers to influenza vaccination were: (1) Limited Capability - misinterpretations and knowledge gaps, (2) Lack of Opportunity - inconvenient vaccination pathway, missing recommendations, absence of promotion to all, and the social norm, and (3) Missing Motivation - hierarchy of perceived seriousness, safety concerns, a preference for 'natural' ways. Though most parents, now aware of the severity of influenza, intended to vaccinate their child in future seasons, some harboured reservations about necessity and safety. When parents were asked how to help them vaccinate their children, SMS reminders and information campaigns delivered through social media, schools and childcare were suggested.

CONCLUSION

Improving parents' and providers' knowledge and confidence in influenza vaccination safety, efficacy, and benefits should be prioritised. This, together with making influenza vaccination more convenient for parents, would likely raise vaccine coverage.

Does the availability of influenza vaccine at prenatal care visits and of immediate vaccination improve vaccination coverage of pregnant women?

Introduction

Although vaccination against influenza is recommended for pregnant women in France because it exposes them to a risk of death and severe respiratory complications, their vaccination coverage in 2016 was estimated at 7%. This study's principal objective was to assess the association between the availability of influenza vaccination at prenatal care visits and vaccination coverage.

Material and methods

This multicenter survey took place in 3 Paris-area public hospital (AP-HP) maternity wards (A, B, and C). Only maternity ward A offered the vaccine and vaccination without charge at prenatal visits. Data were collected from parturients during 10 days in January 2017 by a self-administered anonymous questionnaire.

Results

Data from 248 women showed overall vaccination coverage of 19.4% (48/248): 35.4% (46/130) in maternity unit A, 2.7% (2/75) in B, and 0% (0/43) in C (P<0.01). After adjustment for socio-demographic characteristics, women at maternity ward A were significantly more likely to be vaccinated than those at B and C (aOR 25.52, 95%CI [5.76–113.10]). Other factors significantly associated with higher vaccination coverage were the mother’s French birth (aOR 2.37 CI [1.03–5.46]) and previous influenza vaccination (aOR 3.13, 95%CI [1.25–7.86]). Vaccinated women generally considered they had received adequate information (aOR 4.15 CI [2.10–8.22]), principally from the professional providing their prenatal care. Nonvaccination was attributed to the absence of an offer of vaccination (81.5%), fear of fetal side effects (59.5%), and inadequate information (51.4%).

Conclusion

Our results show that availability of influenza vaccination, free of charge, at prenatal consultations at the maternity ward increases vaccination coverage significantly.

Low immunization coverage in Wonago district, southern Ethiopia: A community-based cross-sectional study

INTRODUCTION

Immunization is a cost-effective intervention that prevented more than 5 million deaths worldwide from 2010 to 2015. Despite increased vaccination coverage over the past four decades in many African countries, including Ethiopia, universal coverage has not yet been reached. Only 39% of children aged 12-23 months received full vaccinations in Ethiopia, according to the 2016 Ethiopian Demographic Health Survey. This study aimed to evaluate immunization coverage and identify individual and community factors that explain incomplete vaccination coverage among children aged 6-36 months in the Wonago district of southern Ethiopia.

METHODS

We conducted a community-based, cross-sectional study in three randomly selected kebeles in the Wonago district from June to July 2017. Our nested sample of 1,116 children aged 6-36 months included 923 child-mother pairs (level 1) within kebeles (level 2). We conducted multilevel regression analysis using STATA software.

RESULTS

Among participants, 85.0% of children aged 12-36 months received at least one vaccine, and 52.4% had complete immunization coverage. After controlling for several individual and community variables, we identified six significant predictor variables for complete immunization: Older mothers' age (AOR = 1.05, 95% CI: 1.00-1.09), higher utilization of antenatal care (AOR = 1.36, 95% CI: 1.14-1.62), one or more tetanus-toxoid vaccination during pregnancy (AOR = 2.64, 95% CI: 1.43-4.86), mothers knowing the age at which to complete child's vaccinations (AOR = 2.00, 95% CI: 1.25-3.20), being a female (AOR = 0.64, 95% CI: 0.43-0.95), and child receiving vitamin A supplementation within the last 6 months (AOR = 2.79, 95% CI: 1.59-4.90). We observed a clustering effect at the individual and community levels with an intra-cluster correlation coefficient of 48.1%.

CONCLUSIONS

We found low immunization coverage among children in the Wonago district of southern Ethiopia, with significant differences across communities. Promoting maternal health care and community service could enhance immunization coverage.

Vaccine discussions in pregnancy: interviews with midwives to inform design of an intervention to promote uptake of maternal and childhood vaccines

Presumptive and Motivational Interviewing communication styles have successfully promoted childhood and adolescent vaccination to parents, but less is known about effective communication approaches during pregnancy to promote maternal vaccination and childhood vaccines. In Australian public antenatal settings, midwives provide a substantial proportion of care and are highly accessed and trusted sources of vaccine information for expectant parents. However, there are no evidence-based interventions incorporating communication strategies and resources for midwives to optimize discussions and promote acceptance of maternal and childhood vaccines. This study aimed to gather qualitative data from midwives to inform the design of a feasible and acceptable vaccine communication intervention package building on an evidence-based model utilized with US obstetricians. We explored midwives' attitudes and values regarding maternal and childhood vaccination, their perceived role in vaccine advocacy and delivery, and barriers and enablers to implementation of a potential communication intervention. We recruited 12 midwives for semi-structured interviews at two Australian tertiary public hospitals (one with antenatal vaccines onsite, one without). Interviews were analyzed using thematic template analysis. Midwives supported vaccination but expressed varied views regarding its centrality to their role. Most reported receiving minimal or no training on vaccine communication. Their communication practices focused primarily on vaccine information provision rather than persuasion, although some midwives shared personal views and actively encouraged vaccination. More vaccine and communication training and resources were requested. Findings highlight the need for communication tools that align with midwifery standards for practice to support midwives to address parents' questions and concerns about maternal and childhood vaccines.

Factors influencing basic vaccination coverage in Myanmar: secondary analysis of 2015 Myanmar demographic and health survey data

BACKGROUND

Immunization is one of the most effective measures for preventing disease when vaccination coverage is sufficient. Although vaccination coverage is known to be influenced by social and cultural barriers, the determinants of childhood immunization in Myanmar remain poorly understood. This study analyzed factors that influenced complete vaccination status (one dose each for Bacillus Calmette-Guérin and measles and three doses each for diphtheria-pertussis and polio) using 2015 data from the Myanmar Demographic Health and Survey.

METHODS

Data from 12 to 23-month-old children and their mothers were extracted from the nationally representative survey results. Bivariate and multivariate analyses with survey-weighted logistic regression were performed to examine the relationships between vaccination status and various sociodemographic and medical factors. The independent variables for the analyses included area of residence, economic status, maternal age, marital status, education, literacy, employment status, antenatal care attendance, tetanus vaccination, place of delivery, postnatal evaluations, child's sex, number of children, previous child death, decision maker(s) regarding child's health, frequency of healthcare visits, paternal education, and paternal occupation.

RESULTS

A representative sample of 904 cases were extracted for the analysis. The overall complete vaccination rate was 55.4%. In the multivariate analysis with backward step-wise selection, complete vaccination was independently associated with middle or high economic status (adjusted odds ratio [AOR]: 2.64, 95% confidence interval [CI]: 1.85-3.78), older maternal age (AOR: 2.87, 95% CI: 1.62-5.10), ≥4 antenatal care visits (AOR: 1.87, 95% CI: 1.28-2.73), and maternal tetanus vaccination before delivery (AOR: 3.26, 95% CI: 1.82-5.85).

CONCLUSION

The first Demographic and Health Survey in Myanmar revealed that only approximately one-half of 12-23-year-old children had received complete vaccination, which was lower than the estimated rate from routine administrative coverage. Our results indicate that incomplete immunization status was associated with low economic status, younger maternal age, fewer antenatal care visits, and no maternal tetanus vaccination. These findings may help improve the targeting and strategic implementation of the Expanded Programme on Immunization.

Life-course immunization as a gateway to health

INTRODUCTION

Extending the benefits of vaccination against infectious diseases from childhood throughout the entire life-span is becoming an increasingly urgent priority in view of the world's aging population, emergence and reemergence of infectious diseases, and the necessity to invest more on prevention versus cure in global healthcare. Areas covered: This perspective discusses how life-course immunization could benefit human health at all stages of life. To achieve this, the current vaccination paradigm should be changed and all stakeholders have a role to play. Expert commentary: To enhance immunization confidence in the population, it is essential that stakeholders eliminate complacency toward infectious diseases, improve vaccination convenience, remove barriers among different healthcare specialties, and address prevention as a single entity. They must also consider societal and cultural mindsets by understanding and including public viewpoints. A new "4Cs' model encompassing convenience, confidence, complacency, and cultural acceptance is proposed to convert 'vaccine availability' to 'vaccination acceptance' throughout life. Life-course vaccination should become the new social norm of a healthy life-style, along with a healthy diet, adequate physical exercise, and not smoking. We are 'all in' to make life-course immunization a gateway for all people to lead longer, healthier lives.

Factors influencing refusing of flu vaccination among pregnant women in Italy: Healthcare workers' role

BACKGROUND

Pregnant women are at increased risk of influenza complications. Influenza vaccine provides them a substantial protection.

OBJECTIVE

The aim of this study was to investigate determinants associated with non-adherence to influenza vaccine recommendations in pregnant women in Italy.

METHODS

A cross-sectional study has been carried out among pregnant women attending their follow-up visit in some mother and child services in a Region of Italy from October 2016 to January 2017. The study protocol was approved by the local research Ethics. A self-administered close-ended questionnaire has been administered to the pregnant women. Differences in background, socio-demographic characteristics, knowledge and attitudes towards flu vaccine were tested in vaccinated and unvaccinated women. Multivariate analysis was performed to control for confounding factors.

RESULTS

Three hundred and sixty-six women answered the survey (97% response rate) and 96.1% (348) declared of being unvaccinated against influenza during the 2016-2017 influenza season. Frequent reasons for refusing vaccination were drugs objection and concerns about vaccines' effects. According to the refusal attitude, influenza knowledge was low in the group. Moreover, analysis showed that low adherence to vaccination is associated to lacking promotion of vaccination to pregnant women carried out by healthcare workers (P < 0.005).

CONCLUSIONS

Healthcare workers have a key role in assisting women during the gestational period, so their active involvement in vaccination promotion is essential. It is necessary to improve health care workers' knowledge about vaccine relevance in protecting pregnancy and their communication skills to properly inform pregnant women.

Vaccine refusal - what we need to know

OBJECTIVE

Opposition to vaccines is not a new event, and appeared soon after the introduction of the smallpox vaccine in the late 18th century. The purpose of this review is to educate healthcare professionals about vaccine hesitancy and refusal, its causes and consequences, and make suggestions to address this challenge.

SOURCE OF DATA

A comprehensive and non-systematic search was carried out in the PubMed, LILACS, and ScieLo databases from 1980 to the present day, using the terms "vaccine refusal," "vaccine hesitancy," and "vaccine confidence." The publications considered as the most relevant by the author were critically selected.

SYNTHESIS OF DATA

The beliefs and arguments of the anti-vaccine movements have remained unchanged in the past two centuries, but new social media has facilitated the dissemination of information against vaccines. Studies on the subject have intensified after 2010, but the author did not retrieve any published studies to quantify this behavior in Brazil. The nomenclature on the subject (vaccine hesitancy) was standardized by the World Health Organization in 2012. Discussions have been carried out on the possible causes of vaccine hesitancy and refusal, as well as on the behavior of families and health professionals. Proposals for interventions to decrease public doubts, clarify myths, and improve confidence in vaccines have been made. Guides for the health care professional to face the problem are emerging.

CONCLUSIONS

The healthcare professional is a key element to transmit information, resolve doubts and increase confidence in vaccines. They must be prepared to face this new challenge.

Maternal vaccine knowledge in low- and middle-income countries-and why it matters

Maternal vaccines have the potential to reduce the global burden of neonatal morbidity and mortality by accessing the infant immune system before a vaccine administered in childhood would be effective. Maternal vaccines for influenza, tetanus, and pertussis have been shown to reduce neonatal disease and mortality, and other candidate vaccines for group B streptococcus and respiratory syncytial virus are being developed to continue this trend. However, safe and effective maternal vaccines will only successfully reduce neonatal illness if mothers decide to receive them. Maternal knowledge, attitudes, and beliefs around vaccines are key determinants to vaccine acceptance or vaccine hesitancy, and yet this issue is often understudied in low and middle-income country settings. A deeper understanding of these factors and how they influence maternal decision-making will allow public health practitioners and global and national policymakers to design more effective interventions. Addressing barriers to immunization at the policy and programmatic levels such as mothers' knowledge, attitudes, and beliefs of maternal vaccines is essential to increasing vaccination rates at a global scale and reducing global vaccine-preventable neonatal deaths.