The Public Health Impact of the So-Called "Fluad Effect" on the 2014/2015 Influenza Vaccination Campaign in Italy: Ethical Implications for Health-Care Workers and Health Communication Practitioners

A review of factors influencing vaccination policies and programs for older adults globally

Policies and programs to increase vaccine coverage rates among adults 50 years of age or older are limited and vaccine uptake is often suboptimal. Our review evaluated evidence on the effectiveness and success of adult-targeted vaccination interventions and identified literature gaps. Literature was retrieved (2021) from PubMed, Embase, and Google Scholar databases. Outcomes assessed included data on an intervention's effectiveness and impact on vaccine uptake. Interventions were characterized thematically: affordability (n = 9), awareness (n = 25), and vaccination access (n = 6); and included influenza, pneumococcal, tetanus-containing, and herpes zoster vaccines. Interactive interventions directed toward patients, including provider-led educational initiatives and provider recommendations showed more positive associations than less interactive interventions, such as posters and reminder-recall letters. Provider interventions, including awareness campaigns, incentives, affordability efforts, or vaccination site expansion generally showed positive associations. Combining interventions was found to be successful across several studies. Barriers and interventions varied for population subgroups, therefore, tailoring programs is critical.

The ghost of polio haunts us once again. The appeal of the scientific community is clear: "Vaccinate your kids today!"

INTRODUCTION

In the summer of 2022, a vaccination campaign for the prevention of poliomyelitis was launched and "The CDC recommend that all children be vaccinated against polio, or poliomyelitis". The scientific community is on the alert for new cases of polio, which is spreading. Although polio seemed to have been almost completely eradicated throughout the world, the disease has surprisingly reappeared in some Western countries. The risk of international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC).

METHOD

The authors reviewed recent polio cases in some western countries which have caused significant public health concern and they underline the meaning and weight of this issue emphasizing the importance of vaccination.

DISCUSSION

In June 2022, the British authorities announced that they had detected traces of a form of polio derived from a vaccine strain in the wastewater of some London boroughs. Although no cases of disease were identified, the British government immediately announced that it was proceeding to reinstate polio vaccination for all children. A few weeks later, on July 18, 2022, the New Jersey Department of Health notified the CDCP of the detection of type-2 poliovirus in an unvaccinated young man in the New York metropolitan area. This case immediately triggered an appeal from the CDCP to get vaccinated and, above all, to vaccinate children. Low vaccination coverage means that the population is constantly at risk of further cases of paralytic poliomyelitis.

CONCLUSION

The appeal to vaccinate children against polio is crucial, as prevention through vaccination is the only defense against the disease. We think that an efficient vaccination campaign can positively influence the process of eliminating the virus. At the same time, however, it demonstrates that simply lowering one's guard can quickly lead to a resurgence of polio cases. Hence, until polio is eradicated, we can be sure that contagion by the wild virus and the risk of vaccine-derived poliovirus will remain possible.

Predicting COVID-19 vaccination intentions: the roles of threat appraisal, coping appraisal, subjective norms, and negative affect

BACKGROUND

As a new disease, communities possess little natural immunity to COVID-19 and vaccines are considered critical to preventing and reducing the incidence of severe illness. This study, inspired by Protection Motivation Theory (PMT), examines the relationship between citizens' threat appraisal, coping appraisal, subjective norms, negative affect, and their COVID-19 vaccination intentions.

METHODS

A sample of 340 citizens from two main cities in Mainland China, Xi'an and Wuxi, was used for data analysis. Structural Equation Modeling (SEM) was employed with latent and observed variables to test hypotheses. Data were analyzed using AMOS 24.0.

RESULTS

Several findings extend current understanding. Firstly, our proposed model explains 73% of the variance in vaccination intentions. Secondly, perceived severity only indirectly shapes COVID-19 vaccination intentions through negative affect. Thirdly, negative affect and response costs are negatively related to COVID-19 vaccination intentions. Finally, Perceived probability, subjective norms, response efficacy and self-efficacy are positively related to COVID-19 vaccination intentions; among them, self-efficacy contributes the most, followed by response efficacy and subjective norms, and lastly perceived probability.

CONCLUSION

Theoretically, this study increases current understanding about subjective norms and affective responses. We provoke a certain amount of thought about the role of affect response in relation to threat appraisal and vaccination intentions. Specifically, governments must be vigilant that citizens' negative affect, such as fear, may cause vaccine hesitation.

Vaccine hesitancy, misinformation in the era of Covid-19: Lessons from the past

Background

As the world has challenged/argued with the Covid-19 pandemic over the last two years, there has been an increase in vaccine misinformation. Although immunity against Covid-19 infection is limited to 4-6 months and requires at least three doses of vaccine to be maximally effective, the current vaccination campaign in industrialized countries shows that vaccinated citizens experience greater immunological protection against severe forms of the disease than unvaccinated citizens.

Methodology

A perusal of the literature was performed in order to reconstruct the communication methods applied in the managing of the Covid-19 pandemic; the management of the current pandemic was compared with the management of another scourge of the past: poliomyelitis.

Results/Discussion

In order to raise public awareness on public health issues, it is essential that governments and institutions communicate scientific data to all sections of the population in an unambiguous way. In this sense, it is essential to apply "prebunking", which is a layered defense system available to society that prevents misinformation before it is spread. This is to avoid the subsequent debunking of false information, which generates insecurity and fuels fears. Belief in medical misinformation represents a meaningful problem for public health efforts to fight Covid-19 through vaccination.

Conclusion/Perspectives

In this sense an example of proper management of one of the many epidemics of the recent past, poliomyelitis, should make us reflect on the effectiveness of past approaches. This testimony from the past can provide us with food for thought regarding how to face the present Covid-19 pandemic and to prepare for the future. Certainly, it shows us how the awful pandemics/epidemics from the past was handled and finally overcome, despite perceived risk and vaccine hesitancy.

Efficacy information influences intention to take COVID-19 vaccine

OBJECTIVES

A successful response to the COVID-19 pandemic requires achieving high levels of vaccine uptake. We tested whether directly contrasting the high efficacy of COVID-19 vaccines with the lower efficacy of the annual flu vaccine would increase intentions to take a COVID-19 vaccine.

DESIGN

A pre-registered online study of 481 participants compared four information conditions: (1) no information; (2) COVID-19 Vaccine Information Only; and COVID-19 Vaccine Information combined with flu vaccine information suggesting either (3) 60% efficacy or (4) 40% efficacy; we measured COVID-19 and flu vaccine intentions along with several other vaccine-related variables.

METHODS

The Prolific platform was used to recruit 481 UK participants (64% female; aged between 18 and 85 years) who had been pre-screened to have intermediate levels of vaccine hesitancy. After reading a short text (~200 words) about COVID-19 vaccines, participants were asked about their vaccination intentions.

RESULTS

Providing information about the safety and efficacy of the new COVID-19 vaccines resulted in vaccination intentions that were, on average, 0.39 standard deviations (SDs) higher than those in the no information condition; providing the same COVID vaccine efficacy information in the context of information about flu vaccine efficacy resulted in a further significant increase in vaccination intentions that were 0.68 SD higher than those in the no information condition. This positive contrast effect for the COVID-19 vaccine was not associated with reduced flu vaccine intentions.

CONCLUSIONS

Vaccination intentions can be strengthened through a simple messaging intervention that utilizes context effects to increase perceived response efficacy.

Young adults' preferences for influenza vaccination campaign messages: Implications for COVID-19 vaccine intervention design and development

Background

Health campaign interventions, particularly those tailored to the target audience's needs and preferences, can cost-effectively change people's attitudes and behaviors towards better health decision-making. However, there is limited research on how to best tailor seasonal influenza vaccination campaigns for young adults. Vaccination is vital in protecting young adults and their social circles (vulnerable populations like older adults) from the influenza virus and critical in shaping these emerging adults' vaccination habits in the long run. However, amid the prevalence of easily-accessible, attention-grabbing, and often malicious false and misinformation (e.g., COVID-19 vaccine conspiracy theories), it may be more challenging to develop vaccination messages that resonate with young adults well enough to attract their attention. Therefore, to bridge the research gap, this study examines young adults' preferences for seasonal influenza vaccination campaigns to inform effective intervention design and development.

Methods

Qualitative survey questions were developed to gauge young adults' preferences for seasonal influenza vaccination campaigns. A total of 545 young adults (73.9% female, Mage ​= ​19.89, SD ​= ​1.44) from a large University offered complete answers to a cross-sectional online survey. Braun and Clarke's thematic analysis procedures were adopted to guide the data analysis process.

Results

Thematic analysis revealed that young adults prefer seasonal influenza vaccination campaigns that rely on (1) quality and balanced information from (2) credible information sources, positioned in the (3) relevant health contexts, (4) emphasize actionable messages, and incorporate (5) persuasive campaign design. Interestingly, while many participants underscored the importance of fear-appeal messages in persuading them to take health actions, some young adults also suggested avoiding fear campaigns due to discomfort.

Conclusions

Insights of the study can inform seasonal influenza vaccination design and development, and have the potential to shed light on vaccination messaging in other vaccine contexts, such as COVID-19 vaccines. Results also underscore the need for health experts and government officials to adopt a more nuanced approach when selecting persuasive campaign appeals. While some young adults may resonate well with fear appeals, others may not. Future research could examine the underlying mechanisms that drive young adults' preference for vaccination campaign intervention to enrich the literature further.

Analysis of the Feasibility of a Vaccination Campaign against Influenza Epidemic and COVID-19 Pandemic in French Emergency Departments: A National Survey

Background: Vaccination is one of the most effective ways to fight the influenza epidemic and the coronavirus disease 2019 (COVID-19) pandemic, which represent a major public issue. The objective was to investigate the adherence of heads of French emergency departments (ED) and nursing departments on a potential vaccination campaign of healthcare workers (HCW) and patients in ED. Method: In February 2021, ED and nursing department heads were asked to answer a national survey. It included 24 questions designed to cover some dimensions, including characteristics of the hospital and emergency departments (ED) and questions on vaccination. Results: 414 responses out of 800 questionnaires (51.8%) were collected. Scores out of 10 were, respectively, 7 (6–8) and 8 (6–9) for vaccination against influenza and COVID-19 for HCW and 2 (2–3) and 2 (2–4) for ED patients (H = 989.3; p < 0.0001). Multivariate logistic regression found that the existence of a vaccine program in the hospital and the use of point of care influenza PCR in ED were positively associated with the acceptance of influenza vaccination campaign for HCW (p = 0.003) and patients (p = 0.015). Factors limiting adherence to a vaccination program of HCW and patients were lack of medical staff (p = 0.041 for HCW and p < 0.0001 for patients), overcrowded ED (p < 0.001), and the inability to follow up with patients after the ED visit (p < 0.0001). Conclusions: There have been many missed opportunities for influenza vaccination, and there is pressure to vaccinate against COVID-19 as soon as possible. Vaccination campaigns in ED could help to improve vaccination coverage. ED staff are more likely to vaccinate HCW than patients. There are factors that support the implementation of such programs, which can be grouped into a culture of diagnosis, control, and prevention of viral infectious diseases within the hospital and ED. On the other hand, there are limiting factors, such as overcrowding and lack of personnel.

Impact of Media Coverage on Influenza Vaccine Coverage in Elderly Individuals from 2020 to 2021 in the Republic of Korea

Increased awareness of adverse events following immunization (AEFI) can disrupt vaccination programs. In South Korea, a report of alleged influenza vaccine-related deaths attracted significant media attention in 2020. We retrieved the vaccination coverage and AEFI data to determine their association with media coverage. Between 2015 and 2019, the vaccination coverage rate ranged between 80.5% and 83.3%; however, the vaccination coverage rate declined significantly from 2020 to 2021 to 73.6% (p < 0.0001). During the 43rd week of 2020, following a large amount of media coverage on vaccine safety issues, the number of cases with AEFI reached 60. Between 2015 and 2020, the mortality rate ratios for influenza vaccines and non-vaccines ranged between 0.1296 (95% confidence interval (CI), 0.1262–0.1331, p < 0.0001) and 0.1608 (95% CI, 0.1572–0.1644, p < 0.0001). Vaccine safety surveillance should be continued in conjunction with investigation and transparent risk communication to maintain public trust in vaccines and vaccinations.

Diffusion modeling of COVID-19 under lockdown

Viral immune evasion by sequence variation is a significant barrier to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine design and coronavirus disease-2019 diffusion under lockdown are unpredictable with subsequent waves. Our group has developed a computational model rooted in physics to address this challenge, aiming to predict the fitness landscape of SARS-CoV-2 diffusion using a variant of the bidimensional Ising model (2DIMV) connected seasonally. The 2DIMV works in a closed system composed of limited interaction subjects and conditioned by only temperature changes. Markov chain Monte Carlo method shows that an increase in temperature implicates reduced virus diffusion and increased mobility, leading to increased virus diffusion.

The Implementation of the Professional Role of the Community Pharmacist in the Immunization Practices in Italy to Counteract Vaccine Hesitancy

In Italy, the National Vaccinal Prevention Plan has renewed the commitment of the Italian government to promote a culture of vaccination practices in the general population and especially among healthcare professionals, considering it as a strategic goal. The search for useful tools and techniques to promote a layered and widespread information network capable of restoring a climate of trust and confidence towards vaccination, leads us to reflect on the possibility, already adopted in numerous countries, of enlisting community pharmacies in immunization campaigns also in Italy, positively implementing the professional role of the community pharmacist in immunization. The pharmacist is often the first point of contact with both the patients and the public, both for the relationship of trust and confidence that binds him to the citizens, and for the ease of access in relation to the widespread distribution of community pharmacies in the territory, the availability of prolonged operating hours, the absence of need for appointments and positions near/outside of healthcare facilities. Currently, in Italy the role of the community pharmacist is limited to counseling and providing advice and information regarding the benefits and/or any risks of vaccination practices, but does not imply a direct engagement in immunization programs, rather a collaboration to avoid straining and overwhelming the vaccination centers. Some recent questionnaire-based studies have shown that Italian community pharmacists have attitudes that are favorable to vaccinations, even though their knowledge is rather limited. Together with expanding the engagement of community pharmacists in immunization programs, their educational gap should be addressed in order to significantly improve and enhance the protection of the public health.

Countering vaccine hesitancy through immunization information systems, a narrative review

Immunization is one of the most important public health interventions to contrast infectious disease; however, many people nowadays refuse vaccination. Vaccine hesitancy (VH) is due to several factors that influence the complex decision-making process. Information technology tools might play an important role in vaccination programs. In particular, immunization information systems (IISs) have the potential to improve performance of vaccination programs and to increase vaccine uptake. This review aimed to present IIS functionalities in order to counter VH. In detail, we analyzed the automatic reminder/recall system, the interoperability of the system, the decision support system, the web page interface and the possibility to record adverse events following immunization. IIS could concretely represent a valid instrument to increase vaccine confidence, especially trust in both health-care workers and decision makers. There are not enough trials aimed to evaluate the efficacy of IIS to counter VH. Further researches might focalize on this aspect.

Enhanced passive surveillance of influenza vaccination in England, 2016-2017- an observational study using an adverse events reporting card

Influenza is a major public health burden, mainly prevented by vaccination. Recommendations on influenza vaccine composition are updated annually and constant benefit-risk monitoring is therefore needed. We conducted near-real-time enhanced passive surveillance (EPS) for the influenza vaccine, Fluarix Tetra, according to European Medicines Agency guidance, in 10 volunteer general practices in England using Fluarix Tetra as their principal influenza vaccine brand, from 1-Sep to 30-Nov-2016. The EPS method used a combination of routinely collected data from electronic health records (EHR) and a customized adverse events reporting card (AERC) distributed to participants vaccinated with Fluarix Tetra. For participants vaccinated with a different influenza vaccine, data were derived exclusively from the EHR. We reported weekly and cumulative incidence of pre-defined adverse events of interest (AEI) occurring within 7 days post-vaccination, adjusted for clustering effect. Of the 97,754 eligible participants, 19,334 (19.8%) received influenza vaccination, of whom 13,861 (71.7%) received Fluarix Tetra. A total of 1,049 participants receiving Fluarix Tetra reported AEIs; 703 (67%) used the AERC (adjusted cumulative incidence rate 4.96% [95% CI: 3.92−6.25]). Analysis by individual pre-specified AEI categories identified no safety signal for Fluarix Tetra. A total of 62 individuals reported an AEI with a known brand of non-GSK influenza vaccine and 54 with an unknown brand (adjusted cumulative incidence rate 2.59% [1.93−3.47] and 1.77% [1.42−2.20], respectively). In conclusion, the study identified no safety signal for Fluarix Tetra and showed that the AERC was a useful tool that complemented routine pharmacovigilance by allowing more comprehensive capture of AEIs.10.1080/21645515.2019.1565258-UF0001

Emergency Department influenza vaccination campaign allows increasing influenza vaccination coverage without disrupting time interval quality indicators

To evaluate the impact of an influenza vaccination (IV) coverage (IVC) in a vaccination campaign of an Emergency Department (EDVC) and its impact on ED time interval quality indicators. We conducted a 4 year observational study, with an intervention during the 4th year. IVC was calculated during pre-and early-epidemic periods. During the final period, a 12 weeks EDVC was implemented. Physicians and nurses were trained and sensitized in the importance of vaccination, and their role in the prevention of severe forms of influenza was reinforced. The vaccine was proposed by physicians and nurses, and delivered by them. Repeated measures ANOVA is a validated method for related not independent groups ( https://statistics.laerd.com/statistical-guides/repeated-measures-anova-statistical-guide.php ). Overall, IVC was 987/3191 (30.9%) with an increasing trend from 28.8 to 33.2%. In the fourth period, out of 868 patients identified with IV indication, 288 had already been vaccinated (IVC 33.2%). After excluding patients presenting criteria of exclusion, IV was proposed to 475 patients: 317 (66.7%) accepted. The vaccination rate after patient's acceptance was 89.6% (288/317). At the end of the EDVC, influenza vaccination coverage was 572 (284 + 288)/868 (65.9%). The delay between arrival at the ED and seeing the triage nurse and physician as well as the overall ED length of stay were not modified during the study period and before and during EDVC. EDVC effectively doubled the influenza vaccination coverage, without modifying ED time interval quality indicators.

Capturing public interest toward new tools for controlling human immunodeficiency virus (HIV) infection exploiting data from Google Trends

Human immunodeficiency virus vaccination and pre-exposure prophylaxis represent two different emerging preventive tools. Google Trends was used to assess the public interest toward these tools in terms of digital activities. Worldwide web searches concerning the human immunodeficiency virus vaccine represented 0.34 percent, 0.03 percent, and 46.97 percent of human immunodeficiency virus, acquired immune deficiency syndrome, and human immunodeficiency virus/acquired immune deficiency syndrome treatment-related Google Trends queries, respectively. Concerning temporal trends, digital activities were shown to increase from 0 percent as of 1 January 2004 percent to 46 percent as of 8 October 2017 with two spikes observed in May and July 2012, coinciding with the US Food and Drug Administration approval. Bursts in search number and volume were recorded as human immunodeficiency virus vaccine trials emerged. This search topic has decreased in the past decade in parallel to the increase in Truvada-related topics. Concentrated searches were noticed among African countries with high human immunodeficiency virus/acquired immune deficiency syndrome prevalence. Stakeholders should take advantage of public interest especially in preventive medicine in high disease burden countries.

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

Patient's behaviors and missed opportunities for vaccination against seasonal epidemic influenza and evaluation of their impact on patient's influenza vaccine uptake

Objectives

Influenza vaccination (IV) coverage remains low in France. Objectives were to assess patient knowledge and behaviors and missed opportunities for vaccination (MO) and their impact on vaccine uptake.

Methods

This is a prospective-observational study, including emergency department patients at risk for severe influenza. Patients were interviewed about their knowledge and behaviors. We evaluated the health-care voucher scheme (HCVS) and MO.

Results

868 patients were included. Vaccine uptake was 33.2%, 42% of patients knew about the possible severity of influenza, 23% thought that they were not at risk for severe influenza, 39% knew that they have an indication for the vaccine, and 4.3% to 11.5% expressed reservations concerning IV side effects and effectiveness. HCVS was used by 44.3% of patients, but only 14.8% had been vaccinated. MO were reported by 484 patients (69.4%) declaring 1104 consultations and 148 IV propositions (86.6%). Predictors of vaccine uptake (p<0.0001) were: knowledge of serious and fatal influenza forms [OR 0.36 (CI95% 0.25–0.5)]; confidence in influenza vaccine effectiveness [0.38 (0.2–0.7)]; opposition to vaccines [0.22 (0.1–0.48)]; visit to general practitioner [4.53 (2.9–7.1)]; general practitioner proposed IV [2.1 (1.2–3.4)].

Conclusion

Our results indicate that high rate of missed opportunities, some patient behaviors and general practitioner visits may explain low influenza vaccine uptake, and that HCVS use is a complex process. Of interest, we found that the patient’s knowledge of the potential severity of influenza is not sufficient to promote vaccine, suggesting that the information strategy must be adapted to each patient behavior.

An infodemiological investigation of the so-called "Fluad effect" during the 2014/2015 influenza vaccination campaign in Italy: Ethical and historical implications

Influenza vaccines represent a major tool to contain the clinical and epidemiological burden generated by influenza. However, in spite of their effectiveness, vaccines are victims of prejudices and false myths, which contribute to the increasing phenomenon of vaccine hesitancy and loss of confidence. Media and, mainly, new media, and information and communication technologies play a major role in disseminating health-related information. While, on the one hand, they can be extremely promising in promoting disease prevention, on the other hand, they can also have a negative impact on population's health attitudes and behaviors when delivering information not based on scientific evidences. The "Fluad-case" is an excellent example of the crucial role of an adequate information campaign. Following the cluster of deaths allegedly related to the administration of the adjuvanted influenza vaccine "Fluad" during the 2014-2015 influenza campaign, the Italian health authorities and regulatory bodies decided the withdrawal of two potentially contaminated Fluad batches. This fostered a huge media coverage, with resulted in negatively impacting on influenza vaccination coverage. Monitoring and tracking the Fluad-related web searches, we showed that Liguria resulted the Italian region with the highest number of Fluad-related website searches and that, interestingly, Fluad was searched also in Regions in which this vaccine was not distributed. A positive moderate correlation between accessing Fluad-related websites and overall influenza vaccination coverage was found (r = 0.66 ([95%CI 0.29-0.86], p = 0.0026). Considering subjects ≥65 years, who are the subjects for which the Fluad vaccination is recommended, the correlation resulted r = 0.49 ([95%CI 0.03-0.78], p = 0.0397). As such, health authorities and decision-makers should promote high-quality communication campaigns in order to raise awareness of vaccination practices.