Investigating Italian parents' vaccine hesitancy: A cross-sectional survey

Exploring factors improving support for vaccinations among Polish primary care physicians

In Poland, primary care physicians are the most used and most trusted source of information on immunisation. We aimed to explore factors influencing support for vaccinations among physicians employed in the childhood immunisation programme, in order to inform education of healthcare workers and programme organization. In June-July 2017, we carried out a national cross-sectional survey of physicians working in randomly selected primary healthcare practices, and interviewed them by telephone. We assessed support for vaccinations using an ordinal scale (0–6) comprised of three equally weighted questions on the respondent support of the programme and vaccination of self and family. We also created a scale (0–3) based on correct answers to vaccination myths. We used ordered logistic regression to investigate factors independently influencing support for vaccinations, reporting the proportional odds ratios and 95% confidence intervals for one unit increase in the support score. Of 2,609 respondents contacted, we interviewed 500 (19%). The median vaccination support score (0–6) was 5 (IQR 2). After adjusting for other variables, we did not find significant effects of sex, medical specialty, adhering to recommendations, attending a conference in previous year, using non-scientific sources of information and self-assessed knowledge on vaccination support score. Age over 60 years, correctly addressing vaccination myths and use of one or more than one scientific sources of knowledge, significantly improved support for vaccinations (aOR = 1.97, 1.57, 3.09 and 2.68, respectively). We recommend to increase the amount, quality and accessibility of evidence-based educational materials for primary care physicians working with childhood immunisations.

HPV vaccine hesitancy among parents in Italy: a cross-sectional study

This cross-sectional survey determined the vaccine hesitancy related to Human papillomavirus (HPV) and the determinants among parents of adolescents aged 12 and 13 years in Italy. Data was collected through a self-administered questionnaire. Two-thirds of the parents (66.7%) had heard of HPV infection and knew that the vaccination was a preventive measure. Parents who had vaccinated their child against the HPV were more likely to have this knowledge. The vast majority (88%) considered the immunization useful for the prevention of HPV-related cancers with an average value of 8.4. This positive attitude was higher among parents who had heard of HPV infection and knew that vaccination was a preventive measure, who had received information from physicians, who had vaccinated their child against the HPV, who were concerned that their child could contract the HPV infection, and who needed information on HPV vaccination. More than half (57.9%) self-reported that they had vaccinated their child against HPV and only 6.2% had delayed the administration of a dose. One-third (33.3%) were hesitant toward anti-HPV vaccination with a total Parent Attitudes about Childhood Vaccines Survey (PACV) score ≥50. Unmarried respondents, those who had not heard of HPV infection and did not know that the vaccination was a preventive measure, who did not believe that the vaccination was useful for the prevention of HPV-related cancers, and who needed information on HPV vaccination were more likely to be hesitant. Communication and education strategies must be undertaken to ensure that parents are fully informed and health-care professionals should provide materials with details regarding the risk of acquiring a HPV infection and vaccine usefulness.

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.

Healthcare Workers' Knowledge, Attitudes, and Practices about Vaccinations: A Cross-Sectional Study in Italy

The cross-sectional study assessed the knowledge, attitudes, and practices regarding the recommended vaccinations and factors affecting such outcomes among a sample of healthcare workers (HCWs) in public hospitals in Italy. Only 14.1% knew all the recommended vaccinations for HCWs. Physicians and those who had received information about vaccinations from scientific journals, educational activities, or professional associations were more likely to have this knowledge, while those aged 36–45 were more likely to have less knowledge than those in the age group below 36 years. Only 57.3% agreed that the information received about vaccinations was reliable. Respondents who had children, who worked in pediatric/neonatal wards, who were more knowledgeable, or who did not need further information about vaccinations considered the available information to be reliable. Only 17.7% of respondents always recommended vaccinations to their patients. This behavior was more likely to occur in physicians, in HCWs, in pediatric/neonatal wards, in those who considered the information received about vaccinations reliable, and in those who considered themselves to be at high risk of transmitting an infectious disease to their patients. Health promotion programs and efforts are needed to improve the level of knowledge about vaccinations and immunization coverage among HCWs.

Seasonal influenza vaccination among people with diabetes: influence of patients' characteristics and healthcare use on behavioral changes

Annual seasonal influenza vaccination (SIV) is recommended for people with diabetes, but vaccine coverage remains low. We estimated the probabilities of stopping or starting SIV, their correlates, and the expected time spent in the vaccinated state over 10 seasons for different patient profiles. We set up a retrospective cohort study of patients with diabetes in 2006 (n = 16,026), identified in a representative sample of beneficiaries of the French National Health Insurance Fund. We followed them up over 10 seasons (2005/06–2015/16). We used a Markov model to estimate transition probabilities and a proportional hazards model to study covariates. Between two consecutive seasons, the probabilities of starting (0.17) or stopping (0.09) SIV were lower than those of remaining vaccinated (0.91) or unvaccinated (0.83). Men, older patients, those with type 1 diabetes, treated diabetes or more comorbidities, frequent contacts with doctors, and with any hospital stay for diabetes or influenza during the last year were more likely to start and/or less likely to stop SIV. The mean expected number of seasons with SIV uptake over 10 seasons (range: 2.6–7.9) was lowest for women <65 years with untreated diabetes and highest for men ≥65 years with type 1 diabetes. Contacts with doctors and some clinical events may play a key role in SIV adoption. Healthcare workers have a crucial role in reducing missed opportunities for SIV. The existence of empirical patient profiles with different patterns of SIV uptake should encourage their use of tailored educational approaches about SIV to address patients’ vaccine hesitancy.

Knowledge gaps and acquisition about HPV and its vaccine among Brazilian medical students

Objective

To analyze factors associated with knowledge gaps and acquisition about HPV and its vaccine among medical students.

Method

Cross-sectional and analytical study conducted at the University of São Paulo Medicine School, in 2016. A convenience sample of students completed a data collection instrument containing questions on knowledge about HPV and its vaccine, and vaccine acceptability. The level of knowledge and acceptability established as a "good level" was 80% of correct answers on the questionnaire. Internal validity was calculated with Cronbach's alpha value (α) = 0.74. Bivariate and multiple analyzes were performed using the Stata® program (Stata Corp, College Station, USA) 14.0.

Results

To evaluate the internal consistency of the instrument applied, the Cronbach's alpha equation was used, obtaining the alpha value (α) = 0.74 for this population. This value attests that the consistency of the answers obtained with this questionnaire is considered substantial and acceptable. Among the 518 medical students who completed the survey, the majority were men 312 (60.4%) with a mean age of 23 (± 2.8) years old; 199 (38.3%) of the students were in the final years of graduation (5th and 6th years). Students in the first, second and third year of study had a 51% higher risk of a knowledge gap when compared to students in the final years of graduation [PR 1.51 (1.3:1.8); p <0.001]. Men were at 22% higher risk of unsatisfactory knowledge than women are [PR 1.22 (1.07: 1.39). There was no knowledge acquisition during medical school in the following questions (p <0.05), indication of vaccine for individuals with HIV and contraindication in pregnant patients.

Conclusion

Male medical students, in the first year of medical school, and those who were not vaccinated had significant knowledge gaps about HPV. The novelty of the study includes the finding of non- acquisition of knowledge during the medical school graduation on safety and vaccination schedule and vaccine administration in specific populations.

Investigating knowledge, attitudes, and practices regarding vaccinations of community pharmacists in Italy

The purposes of this cross-sectional study were to determine the level of knowledge, attitudes, and behaviors related to vaccinations among community pharmacists in Italy and to understand the characteristics associated with the different outcomes of interest. The data were collected between September 2018 and April 2019 using semi-structured telephone interviews among a nationally representative sample of community pharmacists. Out of 550 pharmacists who were contacted, a total of 389 responded yielding a response rate of 70.7%. Only 23.9% indicated correctly all ten mandatory vaccinations for newborn. Participants with a lower number of years since degree, employee compared to owners, those who often/always collected information about public’s immunization, and who have received information from educational activities were more likely to know all ten mandatory vaccinations for newborn. Almost all (91.7%) believed that they could play a prominent role in the educational interventions on vaccinations and 75.3% that they should be more engaged in these interventions. Only 23.7% had recommended HPV vaccine to 11–12 years-old adolescents. Pharmacists who have obtained information from educational activities, who knew all ten mandatory vaccinations for newborn, and who believed that they should be more engaged in vaccination interventions were more likely to recommend the vaccine. The HPV vaccine was less likely recommended by those who have obtained information from scientific journals, mass-media and internet, and educational activities compared to those who have not received any information, who worked a higher number of hours per week, who often/always collected data on immunization, and employee pharmacists compared to owners. The findings may be useful to design interventions that can overcome the knowledge gaps of community pharmacists and to improve vaccine recommendations.

Towards elimination of measles and rubella in Italy: Progress and challenges

INTRODUCTION

In the WHO European Region, endemic transmission of measles and rubella had been interrupted by 37 and 42 of the 53 member states (MSs), respectively, by 2018. Sixteen MSs are still endemic for measles, 11 for rubella and nine for both diseases, the latter including Italy. Elimination is documented by each country's National Verification Committee (NVC) through an annual status update (ASU).

OBJECTIVE

By analysing data used to produce the ASUs, we aimed to describe the advances made by Italy towards elimination of measles and rubella. Moreover, we propose a set of major interventions that could facilitate the elimination process.

METHODS

A total of 28 indicators were identified within the six core sections of the ASU form and these were evaluated for the period 2013-2018. These indicators relate to the incidence of measles/rubella; epidemiological investigation of cases; investigation of outbreaks; performance of the surveillance system; population immunity levels; and implementation of supplemental immunization activities (SIAs).

RESULTS

From 2013 to 2018, epidemiological and laboratory analyses of measles cases in Italy improved substantially, allowing timely investigation in 2017 and 2018 of most outbreak and sporadic cases and identification of the majority of genotypic variants. Moreover, since 2017, vaccination coverage has increased significantly. Despite these improvements, several areas of concern emerged, prompting the following recommendations: i) improve outbreak monitoring; ii) strengthen the MoRoNet network; iii) increase the number of SIAs; iv) reinforce vaccination services; v) maintain regional monitoring; vi) design effective communication strategies; vii) foster the role of general practitioners and family paediatricians.

CONCLUSIONS

The review of national ASUs is a crucial step to provide the NVC with useful insights into the elimination process and to guide the development of targeted interventions. Against this background, the seven recommendations proposed by the NVC have been shared with the Italian Ministry of Health and the Technical Advisory Group on measles and rubella elimination and have been incorporated into the new Italian Elimination Plan 2019-2023 as a technical aid to facilitate the achievement of disease elimination goals.

Knowledge and beliefs on vaccines among a sample of Italian pregnant women: results from the NAVIDAD study

Background

Vaccine hesitancy is an emerging phenomenon in European countries and leads to decreasing trends in infant vaccine coverage. The aim of this study was to analyze the level of confidence and correct awareness about immunizations, which are crucial for the success of vaccination programmes.

Methods

As part of the NAVIDAD multicentre study, we examined vaccination confidence and complacency among a sample of 1820 pregnant women from 14 Italian cities. The questionnaire assessed the interviewee's knowledge, beliefs and misconceptions, as well as their socioeconomic status, information sources about vaccines and confidence in the Italian National Healthcare Service.

Results

Only 9% of women completely believed to the efficacy, necessity and safety of vaccinations. Almost 20% of them had misconceptions on most of the themes. There was a significant difference in the level of knowledge considering educational level: women with a high educational level have less probability of obtaining a low knowledge score (odds ratio (OR) 0.43 [95% confidence interval (CI) 0.34–0.54]). The level of knowledge was also influenced by the sources of information: women who received information from their general practitioner (GP) and from institutional websites had a significantly lower chance of having misconceptions (OR 0.74 [95% CI 0.58–0.96]; OR 0.59 [95% CI 0.46–0.74]). Finally, the results underlined the influence of trust in healthcare professional information on the likelihood of having misconceptions (OR 0.49 [95% CI 0.27–0.89]).

Conclusions

The data suggest the efficacy of GPs and institutional websites as a source of information to contrast misconceptions and underline the importance of confidence in the healthcare system to increase complacency and confidence in vaccines.

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.

Comparisons of Vaccine Hesitancy across Five Low- and Middle-Income Countries

Vaccine hesitancy is a continuum of behaviors ranging from delay in receipt to vaccination refusal. Prior studies have typically focused on high-income countries, where vaccine hesitancy is particularly prevalent in more affluent groups, but the relationship between socioeconomic status and vaccine hesitancy in Low- and Middle-Income Countries (LMICs) is less clear. The aim of this study was to describe vaccine hesitancy in five LMICs. Mothers of children in Sirajganj, Bangladesh (n = 60), Shanghai, China (n = 788), Addis Ababa, Ethiopia (n = 341), Guatemala City and Quetzaltenango, Guatemala (n = 767), and Chandigarh, India (n = 309), completed a survey between 2016 and 2018 using the WHO's 10-item Vaccine Hesitancy Scale. The scores of different constructs were compared across countries and by the mother's education level using linear regression models with generalized estimating equations. Compared to mothers in China, mothers in Bangladesh perceived less vaccination benefit (β: 0.56, P = 0.0001), however, mothers in Ethiopia (β: -0.54, P < 0.0001) and Guatemala (β: -0.74, P = 0.0004) perceived greater benefit. Education level was not significantly linked with vaccine hesitancy. Local circumstances are important to consider when developing programs to promote vaccines. We did not find consistent associations between education and vaccine hesitancy. More research is needed to understand socio-cultural influences on vaccine decision-making.

Implementation of the Greek national immunization program among nursery attendees in the urban area of Thessaloniki

BACKGROUND

The growing phenomenon of vaccine hesitancy and the severe economic crisis may have affected compliance with the National Immunization Program (NIP) in Greece over the last years. We investigated compliance with the NIP among children attending nurseries in the urban area of Thessaloniki.

METHODS

A cross-sectional study was conducted, including nursery attendees born between 01/01/2014-01/10/2015 in each of the municipalities of Thessaloniki urban area. Public and private nurseries were randomly selected. Immunization data were anonymously collected from the child's health booklet. Both coverage and timeliness of immunization were recorded for all recommended vaccines according to the NIP.

RESULTS

In total, 432 children with a mean age of 2.9 years were studied, of which 245 (57 %) were attending private nurseries. Full coverage was >90 % for most of the recommended vaccines except for pneumococcal (81 %), meningococcal serogroup C (68.3 % and 82 % for 2011 and 2015 schedule, respectively), hepatitis A (38.9 %) and rotavirus (25.9%) vaccine. Delay rates for one or more doses ranged between 21-90.3 % for all vaccines; time of median delay ranged between 3.8-6.7 months. Lower coverage and higher delay rates were observed for Roma children.

CONCLUSIONS

While high coverage appears to be sustained for most of the recommended vaccines, delay of scheduled shots may compromise age-appropriate protection. Suboptimal immunization against pneumococcal, meningococcal serogroup C, hepatitis A, and rotavirus infections may increase morbidity in this age group and needs to be addressed. HIPPOKRATIA 2019, 23(4): 147-153.

Healthcare workers' knowledge, beliefs, and coverage regarding vaccinations in critical care units in Italy

BACKGROUND

Low rates of vaccine coverage have resulted in a resurgence of several vaccine-preventable diseases in many European countries. Routine vaccination of healthcare workers (HCWs) is important to reduce disease transmission, and to promote vaccine awareness and acceptance in the population. The objectives of this cross-sectional study were to investigate knowledge and beliefs about vaccines and to evaluate self-reported immunization coverage with vaccines recommended for HCWs. Additionally, the effects of several factors on these outcomes have been evaluated.

METHODS

A survey was conducted between September and November 2018 among a random sample of HCWs in cardiac, adult, and neonatal critical care units of 8 randomly selected hospitals across the Campania and Calabria Regions in Italy. Multivariate logistic and linear regression analysis has been performed.

RESULTS

A total 531 HCWs returned the questionnaire for a response rate of 54.9%. Based on a vaccination knowledge score ranging from 0 to 9, more than half of the participants (55.4%) knew few of the vaccines recommended for HCWs (≤3 correct answers), 16.2% knew some vaccines (4-6 correct answers), and 28.4% knew most vaccines (≥7 correct answers), and only 13.2% knew all the vaccines recommended for HCWs. However, two-thirds (62.2%) knew that hepatitis B and influenza vaccines were recommended, and this knowledge was significantly higher among females (p < 0.001), among HCWs aged between 50 and 59 years (p = 0.01) compared with those aged < 30 years, and in those who search for information about recommended vaccines for HCWs (p = 0.012). The vaccine knowledge was significantly lower among nurses and nursing supporting staff compared with physicians (p = 0.032). Approximately two-thirds (62.7%) of HCWs considered themselves at risk of contracting vaccine-preventable infectious diseases during their professional practice. High rates of coverage were self-reported for hepatitis B (96.3%), tetanus and pertussis (93.7%), whereas they were lower for measles/mumps/rubella (80.5%), chickenpox (65.3%), and influenza (35.8%). Only 9.2% of HCWs reported prior receipt of all recommended vaccines. Male HCWs were less likely to report prior receipt of all recommended vaccines (p = 0.011). HCWs aged between 30 and 39 years compared with those aged < 30 years (p = 0.001) and those who knew some (p < 0.001) and most (p = 0.007) of all vaccines recommended for HCWs were more likely to self-report to be immunized.

CONCLUSIONS

Additional training about the vaccinations is needed to improve HCWs knowledge and to address specific concerns which may lead to better uptake among this group.

Vaccination timeliness and associated factors among preterm infants at a tertiary hospital in Uganda

Background

Preterm infants are at increased risk of infections including vaccine preventable diseases. Therefore, timely vaccination is crucial to ensure adequate disease protection. Information on whether preterm infants are vaccinated according to chronological age as recommended is limited in low-income countries.

Objectives

We evaluated the timeliness of vaccination and associated factors among preterm infants at Mulago hospital, Uganda.

Methods

We conducted a mixed methods study between July 2016 and April 2017. Vaccination dates of preterm infants aged 6–24 months were obtained from child health cards. Additional data were collected using a questionnaire. Five key informant interviews with health workers and two focus group discussions with caregivers were conducted. Cox regression analysis was used to identify factors associated with vaccination timeliness. Qualitative data was transcribed and analysed manually using content thematic approach.

Results

We enrolled 350 preterm infants, with a median age of 8.4 months (IQR 6.8–10.8). Less than half, 149/350 (42.6%) of infants received all vaccines within the recommended time range. Timely vaccination was highest for BCG (92%) and lowest for OPV (45.4%). Untimely vaccination was highest for vaccines administered at 6 weeks (DPT 1, PCV 1 and OPV 1) compared to other vaccines in the EPI schedule. Delivering from home or private clinics and vaccine stock-out were significantly associated with untimely BCG and OPV 0 vaccination. Low maternal education level and being very preterm were associated with untimely DPT 1 and DPT 3 receipt. Admission and long stay in the neonatal unit were associated with untimely DPT 1 receipt while extreme low birth weight was associated with untimely DPT 3 vaccination. Increasing parity was associated with untimely measles vaccination. Qualitative findings revealed that lack of knowledge and poor attitudes of health workers and caregivers, gaps in documentation of vaccination status and inadequate communication by health workers hindered timely vaccination.

Conclusion

More than half of preterm infants attending a specialised clinic at Mulago National Referral hospital in Uganda did not receive vaccines within the recommended time range. Specific strategies to improve vaccination timeliness in preterm infants are needed especially among the extremely low birth weight, very preterm and those with prolonged hospitalisation.

The effect of trust and proximity on vaccine propensity

The main goal of this paper is to study the effects of (1) trust in government medical experts and (2) proximity to a recent disease outbreak on vaccine propensity. More specifically, we explore how these variables affect attitudes with regards to measles. Using original survey data, collected in January/February 2017, we obtain three main empirical findings. First, contrary to our expectations, an individual's proximity to a recent measles outbreak has no independent effect on vaccination attitudes. Second, corroborating previous studies in the field, we find that trust in institutions such as the CDC has a positive effect on our dependent variable. Third, there is a significant interactive relationship between proximity and trust in governmental medical experts. While distance from a previous measles outbreak has no effect on vaccination attitudes for respondents with medium or high levels of trust, the variable exerts a negative effect for subjects with little confidence in government medical experts. In other words: low-trust individuals who live farther away from a recent measles outbreak harbor less favorable views about vaccination for this particular disease than low-trust respondents who live close to an affected area. This implies that citizens who are skeptical of the CDC and similar institutions base their vaccination decision-making to some degree on whether or not a given disease occurs in close vicinity to their community.

Knowledge, practice and attitude towards HPV vaccination among college students in Beijing, China

This cross-sectional study aimed to assess the knowledge, practice and attitude towards HPV vaccination among college students in Beijing, China. Furthermore, the factors influencing vaccination were analyzed. The data were collected via self-administered anonymous questionnaires completed by 884 college students who were recruited from a random sample at Peking University in China between September and December 2018. In total, 72.6% of the participants had previously heard of but had insufficient knowledge about HPV and the vaccine. The level of knowledge was significantly associated with the participants' age, major, and family members' or friends' vaccination status. In total, 68.8% of the students viewed college education as the primary source from which they hoped to receive information about the vaccine. Only 9.5% of the females had received the vaccine. Relationships with doctors, sexual experience and a high level of knowledge were positive predictors of vaccine uptake. Limited knowledge about the HPV vaccine was the primary and most common reason for refusing vaccination and not recommending the vaccine to others. Knowledge of the HPV vaccine among college students at Peking University was low to moderate, and the vaccine uptake was low. Policies and measures, such as college health education, are needed to increase college students knowledge of HPV and the vaccine, which may help improve the vaccination rate.

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.

Towards a further understanding of measles vaccine hesitancy in Khartoum state, Sudan: A qualitative study

BACKGROUND

Vaccine hesitancy is one of the contributors to low vaccination coverage in both developed and developing countries. Sudan is one of the countries that suffers from low measles vaccine coverage and from measles outbreaks. In order to facilitate the future development of interventions, this study aimed at exploring the opinions of Expanded Program on Immunization officers at ministries of health, WHO, UNICEF and vaccine care providers at Khartoum-based primary healthcare centers.

METHODS

Qualitative data were collected using semi-structured interviews during the period January-March 2018. Data (i.e. quotes) were matched to the categories and the sub-categories of a framework that was developed by the WHO-SAGE Working Group called ''Determinants of Vaccine Hesitancy Matrix''.

FINDINGS

The interviews were conducted with 14 participants. The majority of participants confirmed the existence of measles vaccine hesitancy in Khartoum state. They further identified various determinants that were grouped into three domains including contextual, groups and vaccination influences. The main contextual determinant as reported is the presence of people who can be qualified as "anti-vaccination". They mostly belong to particular religious and ethnic groups. Parents' beliefs about prevention and treatment from measles are the main determinants of the group influences. Attitude of the vaccine providers, measles vaccine schedule and its mode of delivery were the main vaccine related determinants.

CONCLUSION

Measles vaccine hesitancy in Sudan appears complex and highly specific to local circumstances. To better understand the magnitude and the context-specific causes of measles vaccine hesitancy and to develop adapted strategies to address them, there is clearly a further need to investigate measles vaccine hesitancy among parents.

Knowledge, Attitudes, and Behaviors of Parents towards Recommended Adult Vaccinations: An Explanatory Survey in the Geographic Area of Naples, Italy

The purposes of this study were to explore the knowledge, attitudes, and behaviors towards the recommended vaccinations for adults between 19–64 years of age and the associated factors among parents. The survey was conducted from October to December 2018 among a sample of parents randomly selected from five preschools and primary, secondary, and high schools in the geographic area of Naples, Italy. The mean age of participants was 45.2 years (range 19–71). Only 16% of the parents knew all vaccinations recommended to adults between 19–64 years of age. Those being healthcare professionals, having a chronic condition, having received information about vaccinations from physicians, and having a lower educational level were more likely to know the vaccinations recommended to adults between 19–64 years of age. Female participants, those who had received information about vaccinations from physicians, and those who had a lower number of children were more likely to have a positive attitude toward the usefulness of the administration of vaccinations recommended to adults between 19–64 years of age. Among unvaccinated respondents, more than half reported a positive attitude toward willingness to receive a recommended vaccination. This positive attitude was significantly higher among those who considered vaccinations as being useful and among who had received information from physicians. Only 16.9% self-reported to have received at least one vaccination recommended to adults between 19–64 years of age. Those who were healthcare professionals, who had at least one chronic condition, and who considered the administration of the vaccinations as being useful were more likely to have received at least one recommended vaccination. Greater efforts by policy makers and healthcare providers are needed to increase parents’ knowledge on recommended vaccines, and it is also crucial that healthcare providers have a high knowledge and favorable attitudes in order to increase vaccine coverage.

Development of motivational interviewing skills in immunization (MISI): a questionnaire to assess MI learning, knowledge and skills for vaccination promotion

Objective: Vaccine hesitancy is a complex problem. We previously demonstrated that motivational interviewing (MI) could be helpful to enhance parents' motivation to vaccinate their child. The aim of this study is to develop a new, simple and robust evaluation tool that is suitable for evaluating MI learning of vaccination health professionals. Methods: We designed the Motivational Interviewing Skills in Immunization (MISI), a short written questionnaire to evaluate the MI knowledge and skills of participants in an immunization context. It covers three key areas: knowledge of MI, ability to apply MI-related skills, participant self-confidence in using MI. Questionnaire content and face validity were assessed by MI experts and internal consistency, reliability and effect size were analyzed using a multiple pretest-posttest design. Results: Psychometric measures showed good to excellent internal consistency of the questionnaire for all three areas (Cronbach's and KR coefficient: 0.70 to 0.88). Test-retest reliability showed good measurement stability (ICC: 0.53). Good sensitivity to change was also obtained (Cohen's d: 0.80 to 1.66). Conclusion: The MISI questionnaire is the first paper/pencil evaluation method to assess MI training specific to immunization. Psychometric measures showed high reliability. Practice implications: This questionnaire could provide a convenient and inexpensive method to evaluate knowledge and competencies following immunization-specific MI training.

Rotavirus Infection and Vaccination: Knowledge, Beliefs, and Behaviors among Parents in Italy

This study was designed to investigate the knowledge, beliefs, and behaviors about rotavirus infection and its vaccination in a sample of parents in Naples, Italy. The survey was conducted between June and December 2018 among parents of children aged 3 months to 3 years. A total of 40.7% of the study subjects declared that they had heard about rotavirus infection and 60.8% and 59.2% were aware about the vaccination and of its availability in Italy. Parents with a child aged <1 year and those who reported the physicians as source of information were more likely to have heard about rotavirus infection and to know that the vaccination is available in Italy. More than half (56.4%) were worried that their children could have a rotavirus gastroenteritis and this was most likely to occur in those who have heard about rotavirus infection. Only 15.3% declared that they had immunized their children against rotavirus infection. Parents who considered it dangerous for their children to contract the rotavirus gastroenteritis, those who considered the rotavirus vaccine useful, and those who had received information by physicians were more likely to have vaccinated their children against the infection. More than half of the parents who did not immunize their children expressed their willingness to vaccinate them. Developing and implementing additional public education programs are needed for better knowledge toward rotavirus infection and vaccination and a high coverage among parents.

Influenza vaccination of pregnant women in Paris, France: Knowledge, attitudes and practices among midwives

INTRODUCTION

In France, midwives have been authorized to prescribe vaccines since 2016. Yet vaccination coverage among pregnant women remains low. Understanding the knowledge, attitudes and practices of midwives regarding influenza vaccination could help improve coverage.

METHODS

A cross-sectional survey was conducted in 2017 among midwives practicing in the public and private sectors in Paris using an online questionnaire. Multivariate logistic regression analysis of the data was conducted.

RESULTS

The response rate was 31% (n = 208/669). Overall, knowledge of influenza vaccine recommendations and of vaccine safety and effectiveness was high except regarding new-born immunity and influenza vaccine characteristics. Only 10% of midwives systematically prescribed the vaccine. Reported influenza vaccine uptake among midwives was 39%.

CONCLUSION

Efforts to improve the knowledge of midwives regarding the safety and effectiveness of vaccinating pregnant women in order to prevent influenza infection in newborns are necessary. Increasing vaccine uptake in both midwives and pregnant women will require adjusting education strategies.

A complementary approach to the vaccination promotion continuum: An immunization-specific motivational-interview training for nurses

AIM

To develop and validate immunization-specific motivational-interview (MI) training for immunization nurses.

BACKGROUND

We previously demonstrated that a MI-based intervention on immunisation, performed during postpartum by MI-trained healthcare workers at the hospital maternity ward, reduced parental vaccine hesitancy (VH) and increased vaccine coverage of their children. In this study, we propose immunization-specific MI training for immunization nurses. Together, MI-based training and interventions provide complementary approaches to existing strategies along the vaccination promotion continuum.

DESIGN

Multiple pretest/posttest design with questionnaires self-administered before and after each training days (4 time points).

METHODS

We developed an in-person immunization-specific MI-training workshop for immunization nurses, held on two days three months apart, with 7 h of MI-training dispensed on day 1, and 4 h on day 2. The self-administered Motivational Interviewing Skills in Immunization (MISI) questionnaire was used at four time points (before and after each of the 2 training days) to evaluate three core aspects of participant MI training: (1) MI-knowledge acquisition; (2) MI-skills application and (3) self-rated self-confidence in applying MI knowledge and skills in vaccination clinical practice. Between November 2016 to December 2017, 34 immunization nurses enrolled in our MI-training workshops.

RESULTS

The immunization-specific MI-training improved the three core areas evaluated in participants i.e. MI-knowledge acquisition, MI-skills application, and self-rated self-confidence in applying these in vaccination clinical practice.

CONCLUSIONS

Our immunization-specific MI-training enabled immunization nurses to significantly improve MI knowledge, skills and self-confidence in applying MI in the clinic. These results, taken together with those on the MI-based intervention for parents that we previously reported, support the notion of proposing validated immunization-specific MI training for immunization nurses in order to curb parental VH.

IMPACT

Immunization-specific MI-training would be easily amenable for the training of other health professionals in the field of immunization to help promote vaccination and curb parental VH.

Development of a Spanish version of the parent attitudes about childhood vaccines survey

The Parent Attitudes about Childhood Vaccines (PACV) survey is a validated instrument for identifying vaccine-hesitant parents; however, a Spanish version is not available. Utilizing the WHO framework for translating survey instruments, we used an iterative process for developing the Spanish PACV that included forward translation, expert panel review, back translation and pre-testing that utilized cognitive interviewing. We made revisions to the Spanish PACV at each step, focusing on addressing inclusivity, readability, clarity and conceptual equivalence. The expert panel was comprised of 6 Spanish-speaking medical and research professionals who worked alongside 3 study team members. Pre-testing was conducted using convenience sampling of Spanish-speaking parents (N = 35) who had a child receiving care at the residents' continuity clinic at Texas Children's Hospital. Most pre-testing participants were married (80.6%), mothers (97.1%), ≥30 years of age (88.2%) and had a high school education or less (70.6%). While the majority of participants stated the survey was easy to complete, the translation of 5 PACV items was further revised to improve interpretability. We conclude that the final Spanish PACV is conceptually equivalent and culturally appropriate for most Hispanic populations.

Perception and knowledge of HPV-related and vaccine-related conditions among a large cohort of university students in Italy

HPV is involved in cervical, anal, penile, vulvar and oropharyngeal cancers, as well as genital warts. It is important to investigate knowledge and attitudes among university students, considering in this age a shift in healthcare decision-making from parents to students themselves. The aim of this study was to estimate knowledge and perception of HPV in terms of potential shame for HPV-related conditions, trust in vaccine efficacy and worry for potential side effects. The study involved students (18-25 years old) from the Universities of Padua and Verona, Italy. Socio-demographic and behavioural characteristics were collected with a questionnaire (n = 9988). Female gender and older age were positively associated with higher knowledge. The adjusted logistic regression showed an association between the set of perceptions investigated and the vaccination status, while a direct connection with knowledge was not found. However, another adjusted linear regression showed that a good set of perceptions could be partially explained by a high level of knowledge. Perceptions seem to fill an intermediate position between the knowledge and the decision to get vaccinated. The potential shame deriving from asking for HPV-vaccination was not identified as a relevant barrier. Having received information from healthcare workers, family and school showed to be positively associated with the adhesion to the vaccination policy. This study identifies university students as a possible target for HPV vaccination and pinpoints specific areas that might be targeted as first to encourage vaccine uptake. Primary prevention together with screening programmes remains essential in further reducing the burden of HPV-related diseases.

Addressing HPV vaccine myths: practical information for healthcare providers

Human papillomavirus (HPV) vaccine uptake consistently lags behind that of other adolescent vaccines. In 2017, uptake of a single HPV vaccine dose and HPV vaccine series completion was 66% and 49%, respectively, compared to uptake of tetanus, diphtheria, and acellular pertussis vaccine (89%) and quadrivalent meningococcal conjugate vaccine (85%). Reasons for not vaccinating adolescents again HPV are varied, and in many cases, are rooted in commonly spread myths and misperceptions about the vaccine. In this review, we address five key myths - HPV vaccination is not effective at preventing cancer; Pap smears are sufficient to prevent cervical cancer; HPV vaccination is not safe; HPV vaccination is not needed since most infections are naturally cleared by the immune system; 11-12 years of age is too young to vaccinate. For each myth, we summarize the scientific evidence refuting the myth and provide speaking prompts for healthcare professionals to communicate about HPV vaccination.

Knowledge, attitudes and awareness of the human papillomavirus among health professionals in New Zealand

Background

Human papillomavirus (HPV) is a common sexually transmitted infection that is implicated in 99.7% of cervical cancers and several other cancers that affect both men and women. Despite the role that HPV plays in an estimated 5% of all cancers and the evolving role of HPV vaccination and testing in protecting the public against these cancers, preliminary research in New Zealand health professionals suggest knowledge about HPV may not be sufficient.

Methods

A total of 230 practice nurses, smear takers and other clinical and laboratory staff who attended a range of training events completed a cross-sectional survey between April 2016 and July 2017. The survey explored four broad areas: demographics and level of experience, HPV knowledge (general HPV knowledge, HPV triage and test of cure (TOC) knowledge and HPV vaccine knowledge), attitudes towards the HPV vaccine and self-perceived adequacy of HPV knowledge.

Results

The mean score on the general HPV knowledge questions was 13.2 out of 15, with only 25.2% of respondents scoring 100%. In response to an additional question, 12.7% thought (or were unsure) that HPV causes HIV/AIDS. The mean score on the HPV Triage and TOC knowledge questions was 7.4 out of 10, with only 9.1% scoring 100%. The mean score on the HPV vaccine knowledge questions was 6.0 out of 7 and 44.3% scored 100%. Only 63.7% of respondents agreed or strongly agreed that they were adequately informed about HPV, although 73.3% agreed or strongly agreed that they could confidently answer HPV-related questions asked by patients. Multivariate analyses revealed that knowledge in each domain predicted confidence in responding to patient questions. Furthermore, the number of years since training predicted both HPV knowledge and Triage and TOC knowledge.

Discussion

Although overall level of knowledge was adequate, there were significant gaps in knowledge, particularly about the role of HPV testing in the New Zealand National Cervical Screening Programme. More education is required to ensure that misinformation and stigma do not inadvertently result from interactions between health professionals and the public.

Correcting misinformation by health organizations during measles outbreaks: A controlled experiment

BACKGROUND

During epidemic crises, some of the information the public receives on social media is misinformation. Health organizations are required to respond and correct the information to gain the public's trust and influence it to follow the recommended instructions.

OBJECTIVES

(1) To examine ways for health organizations to correct misinformation concerning the measles vaccination on social networks for two groups: pro-vaccination and hesitant; (2) To examine the types of reactions of two subgroups (pro-vaccination, hesitant) to misinformation correction; and (3) To examine the effect of misinformation correction on these two subgroups regarding reliability, satisfaction, self-efficacy and intentions.

METHODS

A controlled experiment with participants divided randomly into two conditions. In both experiment conditions a dilemma was presented as to sending a child to kindergarten, followed by an identical Facebook post voicing the children mothers' concerns. In the third stage the correction by the health organization is presented differently in two conditions: Condition 1 -common information correction, and Condition 2 -recommended (theory-based) information correction, mainly communicating information transparently and addressing the public's concerns. The study included (n = 243) graduate students from the Faculty of Social Welfare and Health Sciences at Haifa University.

RESULTS

A statistically significant difference was found in the reliability level attributed to information correction by the Health Ministry between the Control condition and Experimental condition (sig<0.001), with the average reliability level of the subjects in Condition 2 (M = 5.68) being considerably higher than the average reliability level of subjects in Condition 1 (4.64). A significant difference was found between Condition 1 and Condition 2 (sig<0.001), with the average satisfaction from the Health Ministry's response of Condition 2 subjects (M = 5.75) being significantly higher than the average satisfaction level of Condition 1 subjects (4.66). Similarly, when we tested the pro and hesitant groups separately, we found that both preferred the response presented in Condition 2.

CONCLUSION

It is very important for the organizations to correct misinformation transparently, and to address the emotional aspects for both the pro-vaccination and the hesitant groups. The pro-vaccination group is not a captive audience, and it too requires a full response that addresses the public's fears and concerns.

The demographics of vaccine hesitancy in Shanghai, China

BACKGROUND

Vaccine hesitancy has been little studied in low- and middle-income countries but is a potential concern because vaccine refusal may increase the burden of infectious diseases and impede control efforts. The aim of this study was to compare vaccine hesitancy between locals, long-time city residents, and non-locals, who have more recently moved to the city from either other urban or rural areas, in Shanghai, China.

METHODS

Parents of infants ≤3 months of age were surveyed at immunization clinics in Shanghai, China. Participants completed a paper questionnaire utilizing the 10-item Vaccine Hesitancy Scale, which was developed by the World Health Organization Strategic Advisory Group of Experts on Immunization. Items were grouped based on internal consistency, and regressed onto demographic variables using a negative binomial model.

RESULTS

In total, 1,188 (92.5%) individuals participated. For most items on the scale, parents expressed positive beliefs about vaccines. However, about half of parents somewhat or strongly agreed that new vaccines carried more risks than older vaccines, and 71.6% somewhat or strongly agreed that they were concerned about serious adverse effects. Seven items from the Vaccine Hesitancy Scale were highly correlated and mapped onto "lack of confidence"; the other three items were analysed separately. Compared to mothers, fathers had less lack of confidence (β: -0.06, 95% CI: -0.12, -0.01), and individuals living in the outer suburbs (β: 0.13, 95% CI: 0.01, 0.25) and rural non-locals (β: 0.10, 95% CI: 0.02, 0.18) had greater lack of confidence in vaccines compared to their urban or local counterparts, respectively.

DISCUSSION

Shanghai parents professed confidence in certain vaccine benefits, but vaccine messaging could focus on addressing misconceptions about vaccines for diseases no longer common, newer vaccines, and adverse effects associated with vaccination. These messages may need to be separately tailored to locals and non-locals, who have differing concerns.

Beyond confidence: Development of a measure assessing the 5C psychological antecedents of vaccination

BACKGROUND

Monitoring the reasons why a considerable number of people do not receive recommended vaccinations allows identification of important trends over time, and designing and evaluating strategies to address vaccine hesitancy and increase vaccine uptake. Existing validated measures assessing vaccine hesitancy focus primarily on confidence in vaccines and the system that delivers them. However, empirical and theoretical work has stated that complacency (not perceiving diseases as high risk), constraints (structural and psychological barriers), calculation (engagement in extensive information searching), and aspects pertaining to collective responsibility (willingness to protect others) also play a role in explaining vaccination behavior. The objective was therefore to develop a validated measure of these 5C psychological antecedents of vaccination.

METHODS AND FINDINGS

Three cross-sectional studies were conducted. Study 1 uses factor analysis to develop an initial scale and assesses the sub-scales' convergent, discriminant, and concurrent validity (N = 1,445, two German convenience-samples). In Study 2, a sample representative regarding age and gender for the German population (N = 1,003) completed the measure for vaccination in general and for specific vaccinations to assess the potential need for a vaccine-specific wording of items. Study 3 compared the novel scale's performance with six existing measures of vaccine hesitancy (N = 350, US convenience-sample). As an outcome, a long (15-item) and short (5-item) 5C scale were developed as reliable and valid indicators of confidence, complacency, constraints, calculation, and collective responsibility. The 5C sub-scales correlated with relevant psychological concepts, such as attitude (confidence), perceived personal health status and invulnerability (complacency), self-control (constraints), preference for deliberation (calculation), and communal orientation (collective responsibility), among others. The new scale provided similar results when formulated in a general vs. vaccine-specific way (Study 2). In a comparison of seven measures the 5C scale was constantly among the scales that explained the highest amounts of variance in analyses predicting single vaccinations (between 20% and 40%; Study 3). The present studies are limited to the concurrent validity of the scales.

CONCLUSIONS

The 5C scale provides a novel tool to monitor psychological antecedents of vaccination and facilitates diagnosis, intervention design and evaluation. Its short version is suitable for field settings and regular global monitoring of relevant antecedents of vaccination.

Low coverage of HPV vaccination in the national immunization programme in Brazil: Parental vaccine refusal or barriers in health-service based vaccine delivery?

Background

The World Health Organization has recommended the introduction of HPV vaccines into national immunization programme (NIP), but vaccination coverage remains low worldwide. We assessed the coverage and the parental acceptance of female and male HPV vaccination in Brazil after its introduction into the NIP.

Methods

We conducted a random-digit-dial survey of parents in seven major Brazilian cities from July-2015 to October-2016. A knowledge, attitude and practices questionnaire was developed and validated by expert analysis, semantic analysis, and pre-testing.

Results

826 out of 2,324 (35.5%) eligible parents completed the interview. Parental acceptance of the HPV vaccine for daughters and sons 18 years of age or less was high (92% and 86%, respectively). Parents refusing vaccination were less likely to know that: HPV is sexually transmitted and causes genital warts, HPV vaccination is more beneficial before sexual debut, and HPV vaccine reactions are minor, and they were more likely to believe HPV vaccination can cause severe adverse events. Parents accepting HPV vaccine for daughters but not forsons were more likely to ignore that the vaccine is recommended for boys. Attitudes associated with HPV vaccine acceptance included: general belief in vaccines, trust in the NIP and in the HPV vaccine efficacy. Among girls eligible for HPV vaccination through the NIP, 58.4% had received a two-dose scheme and 71.1% at least one dose. “No vaccination/missed vaccination at school” was the most common reason for missed HPV vaccination in theNIP.

Conclusions

One year after introduction in the NIP, most parents surveyed in Brazil accepted HPV vaccination for their daughters and sons. Low coverage in the NIP seemed to be due to challenges in adolescent vaccine delivery and HPV vaccination barriers at health-care centers, rather than to vaccine refusal.

Factors affecting complete and timely childhood immunization coverage in Sindh, Pakistan; A secondary analysis of cross-sectional survey data

BACKGROUND

Pakistan has a high burden of newborn mortality, which would be significantly preventable through appropriate routine immunization. The purpose of this study was to measure the basic timely childhood immunization coverage and to identify determinants of factors influencing childhood immunization coverage in Sindh, Pakistan.

METHODS

Data from Maternal and Child Health Program Indicator Survey 2013-2014 which was conducted in Sindh province of Pakistan was used. Outcome measure was full coverage of the basic immunization schedule from child's vaccination card. The association of receiving basic immunization with demographic factors, socioeconomic status, mother and child health information sources, and perinatal care factors were tested by binary logistic regression.

RESULTS

Among 2,253 children, 1,156 (51.3%) received age-based full basic immunization. The basic immunization rates were 69.1% for under five weeks old, 38.3% for six to nine weeks, 18.8% for 10-13 weeks, 44.0% for 14 weeks-eight months, 60.4% for nine to 11 months, and 59.1% for over one year. Child's age, number of living children, parents' education level, wealth, the source of mother and child health information, number of antenatal care, and assistance during delivery were associated with completing basic immunization.

CONCLUSIONS

The overall full basic immunization coverage in Pakistan was still low. Policy makers should identify children at risk of low immunization coverage and obstacles of receiving antenatal care, implement educational interventions targeting on less educated parents, and conduct mass immunization campaigns for timely and complete immunization.

Knowledge and attitudes toward HPV infection and vaccination among immigrants and refugees in Italy

BACKGROUND

The objectives of the present cross-sectional study were to investigate the level of knowledge and attitudes regarding Human papillomavirus (HPV) infection and its vaccination and to understand the impact of different determinants among immigrants and refugees in Italy.

METHODS

Between September 2016 and March 2018, a total of 519 potential participants were randomly recruited. The information was collected through a questionnaire administered by two researchers.

RESULTS

Only 15.9% reported that they had heard of HPV infection before completing the survey and 83.8% of them were aware that the infection could be transmitted through sexual intercourses, 32.3% that it can lead to cervical cancer, 22% to warts, 16.2% to penile cancer, 13.2% to oral cancer, 39.7% that cervical cancer is a very severe disease, 47.1% that receiving the vaccine could protect against the infection, and 44.1% that a vaccine against HPV is available in Italy. Females, those who originated from Eastern Europe, Asia and South America, those who lived in a house compared to those who lived in a street, and those who had 1-10 years and 11 or more years of education compared to those illiterate were more likely to have heard about the HPV infection before completing the survey. Only 3 participants (0.7%) received the HPV vaccination. Out of the unvaccinated who had heard of HPV, 50.7% and 59% of those between the ages of 12 and 26 and of those who had at least one child aged 12-26 years, were willing to receive vaccination for themselves as well as their children.

CONCLUSION

The results underscored the necessity to develop health education and promotion aimed at improving the knowledge and vaccination practice in immigrants and refugees.

Regional reports for the subnational monitoring of measles elimination in Italy and the identification of local barriers to the attainment of the elimination goal

Although most countries in the WHO European Region were verified in 2017 as having interrupted endemic measles transmission, nine countries were still endemic. Among these, Italy accounted for the second highest number of measles cases reported in Europe in 2017. The elimination of measles is verified at national level by each country's National Verification Committee (NVC) through the production of an Annual Status Update (ASU). Since in Italy decentralization has led to an inhomogeneous implementation of immunization strategies among the 21 administrative Regions, the Italian NVC proposed that measles elimination should also be documented at the subnational level through regional ASUs and Synthetic Regional Reports (SRRs). The regional ASUs and the SRRs for 2014, 2015 and 2016 were produced and appraised by the NVC to evaluate the Regions' performances in each individual year as well as over the whole period. A specific analysis of vaccination coverage, including official immunization data for 2017, was performed. Moreover, the measles epidemic of 2017 was examined. Firstly, in the period 2014-2016, low immunization rates were registered in most Regions. Sixty-three per cent of southern Regions reported rates below the national mean and an overall low-quality performance. The approval of Italy's mandatory vaccination law in 2017 resulted in a marked increase in vaccination coverage; however, this increase was not homogeneous among Regions. Secondly, more than 50% of Regions did not report any supplemental immunization activity (SIA) for the period 2014-2016. Thirdly, from 2014 to 2016, fewer than one-third of Regions improved their reporting of outbreaks. Finally, over the study period, only two Regions reached the target required by the WHO for measles laboratory investigations. In countries with decentralized health policies, subnational monitoring can help identify local barriers to measles elimination. In Italy it has highlighted the need for further SIAs and a stronger surveillance system.

Overview of knowledge, attitudes, beliefs, vaccine hesitancy and vaccine acceptance among mothers of infants in Quebec, Canada

BACKGROUND

Vaccine hesitancy (VH) is a growing problem. The first step in addressing VH is to have an understanding of who are the hesitant individuals and what are their specific concerns. The aim of this survey was to assess mothers' level of vaccine hesitancy and vaccination knowledge, attitudes, and beliefs.

METHODS

Mothers of newly-born infants in four maternity wards in Quebec (Canada) completed a self-administered questionnaire. The questionnaire included items to assess VH and intention to vaccinate. VH scores were calculated using the Parents Attitudes about Childhood Vaccines (PACV) survey. Multivariate logistic regression was performed to determine variables associated with intention to vaccinate (OR; 95% CI).

RESULTS

Overall, 2645 questionnaires were included in this analysis and 77.5% of respondents certainly intended to vaccinate their infant at 2 months of age. Based on the PACV 100-point scale, 56.4% of mothers had a 0 to ˂30 score (low level of VH); 28.6% had a 30 to ˂50 and 15.0% had a score of 50 and higher (high level of VH).The main determinants of mothers' intention to vaccinate were the perceived importance of vaccinating infants at 2 months of age (OR = 9.2; 5.9-14.5) and a low score of VH (OR = 7.4; 5.3-10.3).

DISCUSSION

Although the majority of mothers held positive attitudes toward vaccination, a large proportion were moderately or highly vaccine hesitant. Mothers' level of VH was strongly associated with their intention to vaccinate their infants, showing the potential detrimental impact of VH on vaccine uptake rates and the importance of addressing this phenomenon.