Strengthening vaccination programmes and health systems in the European Union: A framework for action

The economic and fiscal impact of incremental use of cell-based quadrivalent influenza vaccine for the prevention of seasonal influenza among healthcare workers in Italy

BACKGROUND

Seasonal influenza has a significant impact on public health, generating substantial direct healthcare costs, production losses and fiscal effects. Understanding these consequences is crucial to effective decision-making and the development of preventive strategies. This study aimed to evaluate the economic and the fiscal impact of implementing an incremental strategy for seasonal influenza prevention using the cell-based quadrivalent influenza vaccine (QIVc) among healthcare workers (HCWs) in Italy.

METHODS

To estimate the economic impact of implementing this strategy, we performed a cost analysis that considered direct healthcare costs, productivity losses and fiscal impact. The analysis considered a 3-year time horizon. A deterministic sensitivity analysis was also conducted.

RESULTS

Assuming a vaccination coverage rate of 30% among HCWs, the analysis considered a total of 203 018 vaccinated subjects. On analysing the overall differential impact (including direct costs, indirect costs and fiscal impact), implementing QIVc vaccination as a preventative measure against influenza among HCWs in Italy would yield societal resource savings of €23 638.78 in the first year, €47 277.56 in the second year, and €70 916.35 in the third year, resulting in total resource savings of €141 832.69.

CONCLUSIONS

The study demonstrated that implementing the incremental use of QIVc as part of a preventive strategy for seasonal influenza among HCWs in Italy could yield positive economic outcomes, especially in terms of indirect costs and fiscal impact. The resources saved could be utilized to fund further public health interventions. Policy-makers should consider these findings when making decisions regarding influenza prevention strategies targeting HCWs.

How did European countries set health priorities in response to the COVID-19 threat? A comparative document analysis of 24 pandemic preparedness plans across the EURO region

The COVID-19 pandemic has forced governments across the world to consider how to prioritise the allocation of scarce resources. There are many tools and frameworks that have been designed to assist with the challenges of priority setting in health care. The purpose of this study was to examine the extent to which formal priority setting was evident in the pandemic plans produced by countries in the World Health Organisation's EURO region, during the first wave of the COVID-19 pandemic. This compliments analysis of similar plans produced in other regions of the world. Twenty four pandemic preparedness plans were obtained that had been published between March and September 2020. For data extraction, we applied a framework for identifying and assessing the elements of good priority setting to each plan, before conducting comparative analysis across the sample. Our findings suggest that while some pre-requisites for effective priority setting were present in many cases - including political commitment and a recognition of the need for allocation decisions - many other hallmarks were less evident, such as explicit ethical criteria, decision making frameworks, and engagement processes. This study provides a unique insight into the role of priority setting in the European response to the onset of the COVID-19 pandemic.

Public values to guide childhood vaccination mandates: A report on four Australian community juries

OBJECTIVE

Governments use vaccination mandates, of different degrees of coerciveness, to encourage or require childhood vaccination. We elicited the views of well-informed community members on the public acceptability of using childhood vaccination mandates in Australia.

METHODS

Four community juries were conducted in Canberra, Launceston, Cairns and Melbourne, Australia between 2021 and 2022. We recruited 51 participants from diverse backgrounds, genders and ages through random digit dialling and social media. Two juries were held in metropolitan areas, and two in regional/rural settings. Outcome measures included jury verdicts and reasons in response to structured questions.

RESULTS

All juries were concerned about collective protection and individual rights but prioritised the former over the latter. A majority in all juries supported mandates but juries disagreed with respect to the appropriate mandate types. All juries endorsed using the least restrictive or coercive means to encourage vaccination (providing incentives or education, e.g.) before imposing penalties such as financial losses and school exclusions. The overriding view was that it is fairer to place a direct burden on parents rather than children and that mandates should be designed to avoid inequitable impacts on less advantaged groups in society. Many jurors found conscientious objection acceptable as a controlled option for resolute refusers, provided that overall vaccination coverage remains high.

CONCLUSION

This paper gives policymakers access to the reasons that Australians have for supporting or opposing different mandates under conditions of high knowledge, understanding and deliberation regarding policy options. Sustaining high rates of vaccination requires high levels of co-operation between governments, public health actors and the public. Our findings highlight the importance of considering public values in the design and implementation of vaccination mandates.

PATIENT AND PUBLIC INVOLVEMENT

We sought input from individuals who did and did not vaccinate during the study design. The views and perspectives of nonvaccinating parents were presented in the evidence to juries. We deliberately excluded nonvaccinating individuals from participating, as the divisive and often hostile nature of the topic, and their minority status, made it difficult to ensure they would feel safe as members of the jury without overrepresenting their perspective in the sample. Two related projects engaged directly with these parents.

Temporal and Emotional Variations in People's Perceptions of Mass Epidemic Infectious Disease After the COVID-19 Pandemic Using Influenza A as an Example: Topic Modeling and Sentiment Analysis Based on Weibo Data

BACKGROUND

The COVID-19 pandemic has had profound impacts on society, including public health, the economy, daily life, and social interactions. Social distancing measures, travel restrictions, and the influx of pandemic-related information on social media have all led to a significant shift in how individuals perceive and respond to health crises. In this context, there is a growing awareness of the role that social media platforms such as Weibo, among the largest and most influential social media sites in China, play in shaping public sentiment and influencing people's behavior during public health emergencies.

OBJECTIVE

This study aims to gain a comprehensive understanding of the sociospatial impact of mass epidemic infectious disease by analyzing the spatiotemporal variations and emotional orientations of the public after the COVID-19 pandemic. We use the outbreak of influenza A after the COVID-19 pandemic as a case study. Through temporal and spatial analyses, we aim to uncover specific variations in the attention and emotional orientations of people living in different provinces in China regarding influenza A. We sought to understand the societal impact of large-scale infectious diseases and the public's stance after the COVID-19 pandemic to improve public health policies and communication strategies.

METHODS

We selected Weibo as the data source and collected all influenza A-related Weibo posts from November 1, 2022, to March 31, 2023. These data included user names, geographic locations, posting times, content, repost counts, comments, likes, user types, and more. Subsequently, we used latent Dirichlet allocation topic modeling to analyze the public's focus as well as the bidirectional long short-term memory model to conduct emotional analysis. We further classified the focus areas and emotional orientations of different regions.

RESULTS

The research findings indicate that, compared with China's western provinces, the eastern provinces exhibited a higher volume of Weibo posts, demonstrating a greater interest in influenza A. Moreover, inland provinces displayed elevated levels of concern compared with coastal regions. In addition, female users of Weibo exhibited a higher level of engagement than male users, with regular users comprising the majority of user types. The public's focus was categorized into 23 main themes, with the overall emotional sentiment predominantly leaning toward negativity (making up 7562 out of 9111 [83%] sentiments).

CONCLUSIONS

The results of this study underscore the profound societal impact of the COVID-19 pandemic. People tend to be pessimistic toward new large-scale infectious diseases, and disparities exist in the levels of concern and emotional sentiments across different regions. This reflects diverse societal responses to health crises. By gaining an in-depth understanding of the public's attitudes and focal points regarding these infectious diseases, governments and decision makers can better formulate policies and action plans to cater to the specific needs of different regions and enhance public health awareness.

Age-related decline in anti-HBV antibodies in vaccinated kidney transplant recipients

BACKGROUND

Hepatitis B virus (HBV) vaccination is indicated for all end stage kidney disease patients, including all solid organ transplant candidates. Maintenance of adequate immunity is especially important for immunosuppressed solid organ recipients who are at increased risk for donor or community acquired HBV. The impact of age and immunosuppression on long-term maintenance of HBV immunity postvaccination has not been fully investigated.

METHODS

We performed a single-center retrospective study of 96 kidney transplant recipients, transplanted between July 2012 and December 2020, who had Hepatitis B surface antibody (HBsAb) levels measured pretransplantation and 1-year posttransplantation. We compared the change in HBsAb levels stratified by patient's age (<45, 45-60, and >60) and by whether or not the patient received lymphocyte depleting induction therapy.

RESULTS

Our results demonstrate that HBsAb IgG levels vary by age group, decreased significantly at 1-year posttransplant (p < .0001) and were significantly lower in the older cohort (p = .03). Among recipients who received rabbit anti-thymocyte globulin induction (rATG), the log HbsAb levels were significantly lower in the older age group (2.15 in age <45, 1.75 in age 45-60 and 1.47 in age >60, p = .01). Age group (p = .004), recipient HBcAb status (p = .002), and rATG (p = .048) were independently associated with >20% reduction in log HBsAb levels posttransplant.

CONCLUSION

Significant declines in HBsAb levels occur postkidney transplantation, especially in older individuals, thus placing exposed older kidney transplant recipients at greater risk of HBV infection and associated complications.

Increasing pneumococcal vaccine uptake in older adults: a scoping review of interventions in high-income countries

BACKGROUND

There is low uptake of the pneumococcal vaccination in eligible older adults, even in high-income countries that offer routine and universal vaccination programs.

OBJECTIVE

To systematically characterize interventions aimed at improving pneumococcal vaccine uptake in older adults.

DESIGN

We conducted a scoping review following PRISMA-SCr guidelines of five interdisciplinary databases: Medline-Ovid, Embase, CINAHL, PsychInfo, and Cochrane Library. Databases were searched from January 2015 until April 2020. The interventions were summarized into three pillars according to the European Union Conceptional Framework for Action: information campaigns, prioritization of vaccination schemes, and primary care interventions.

RESULTS

Our scoping review included 39 studies that summarized interventions related to pneumococcal vaccine uptake for older adults, encompassing 2,481,887 study participants (945 healthcare providers and 2,480,942 older adults) across seven countries. Examples of interventions that were associated with increased pneumococcal vaccination rate included periodic health examinations, reminders and decision-making tools built into electronic medical records, inpatient vaccination protocols, preventative health checklists, and multimodal educational interventions. When comparing the three pillars, prioiritization of vaccination schemes had the highest evidence for improved rates of vaccination (n = 14 studies), followed by primary care interventions (n = 8 studies), then information campaigns (n = 5 studies).

CONCLUSION

Several promising interventions were associated with improved outcomes related to vaccine uptake, although controlled study designs are needed to determine which interventions are most effective.

Childhood vaccination practices and associated factors among mothers/caregivers in Debre Tabor town, Northwest Ethiopia: A cross-sectional study

BACKGROUND

Incomplete immunization and non-immunization increase the risk of disease and death among children. This study aims to assess childhood vaccination practices and associated factors among mothers and caregivers in Debre Tabor town, Amhara region, Ethiopia.

METHODS

A community-based cross-sectional study design was conducted between February 30 and April 30, 2022. The study participants were proportionally allocated to all six kebeles found in the town. A systematic random sampling technique was used to select the study participants. The collected data were checked and coded and then entered into EpiData Version 3.1 and exported into SPSS Version 26. The results were organized using frequency tables, graphs, and charts, and bivariate and multivariable logistic regression were used to test the association of covariates with childhood vaccination practices.

RESULT

Approximately 422 study mothers and caregivers participated in the study, with a response rate of 100%. The mean age was 30.63 years (11.74), which ranged from 18 to 58 years. More than half of the study participants (56.4%) expressed fears about the side effects of vaccination. A majority (78.4%) of the study participants availed of counseling services about vaccination, and 71.1% of them received regular antenatal care. This study found that approximately 280 [66.4%, 95% confidence interval (CI): 61.8-70.6] mothers/caregivers had a history of good childhood vaccination practices. The factors of the fear of side effects [adjusted odds ratio (AOR) = 3.34; 95% CI: 1.72-6.49], no workload (AOR = 6.08; 95% CI: 1.74-21.22), medium workload (AOR = 4.80; 95% CI: 1.57-14.71), being a mother of child/children (AOR = 2.55; 95% CI: 1.27-5.13), positive attitude (AOR = 2.25; 95% CI: 1.32-3.82), and sound knowledge (AOR = 3.88; 95% CI: 2.26-6.68) were significantly associated with childhood vaccination practices.

CONCLUSION

More than half of the study participants had a history of good childhood vaccination practices. However, the rate of such practices was low among mothers and caregivers. The fear of side effects, workload, motherhood, attitude, and knowledge were all factors associated with childhood vaccination practices. Awareness creation and a consideration of the workload of mothers would be helpful in dispelling fears and increasing the rate of good practices among mothers and caregivers.

A favorable impression of vaccination leads to a better vaccination rate for the human papillomavirus vaccine: A Japanese questionnaire survey investigation

Background

The Japanese vaccination rate for infants and children is seemingly excellent, except for the human papillomavirus (HPV) vaccine. Regardless of its efficacy, the inoculation rate in Japan has dropped to approximately 1 % since 2013 because of negative information about vaccine side effects. We aimed to demonstrate the factors that lead to low vaccine acceptance rates (e.g., caregiver attitudes, popular misconceptions) to inform the relevant target demographic of a stronger intention to immunize and to facilitate recovery of HPV vaccine coverage.

Methods

We conducted this study using data from two questionnaire surveys. Statistical analyses of factors affecting vaccine impressions and mediation effects of HPV vaccine impressions were performed. The difference in the knowledge about each vaccine was evaluated.

Results

Of the respondents, 95.9 % reported their intent to vaccinate their infants, whereas 58.2-78.3 % felt that they sufficiently understood the aims, efficacy, and risks of vaccination and 66.6 % had a positive impression of vaccines. Overall, 21.3 % of parents responded that they planned to have their child vaccinated against HPV, and 25.8 % had a favorable impression of this vaccine. Among factors affecting vaccine impressions, we found that parents had anxiety about vaccines when they felt that their knowledge of vaccines was insufficient. Additionally, impressions of the HPV vaccine had a mediating effect on the association between the impressions of infant vaccines and parents' intent to provide the vaccine to their children.

Conclusion

These findings show that as a society, we need to improve impressions and knowledge regarding vaccines, including but not exclusively the HPV vaccine. Moreover, although the recovery of HPV vaccine coverage is strongly desired for improving public health, simply improving impressions about the HPV vaccine or educating parents with substantive knowledge is insufficient. Instead, improving impressions and understanding of the vaccination itself is necessary.

Prevalence and management of rubella susceptibility in healthcare workers in Italy: A systematic review and meta-analysis

Introduction

In the pre-vaccination era, all adults acquired immunity status due to natural infections during childhood and adolescence, whereas universal mass vaccination has changed the seroepidemiology of rubella among adults, showing lack of immunity in some subgroups. National and international guidelines recommend evaluating all healthcare workers (HCWs) for their immune status to rubella and possibly vaccinating those who are seronegative. We conducted a systematic review and meta-analysis to estimate the susceptibility rate to rubella among HCWs in Italy and to explore possible options for the management of those found to be susceptible.

Methods

Eight studies were included in the meta-analysis, selected from scientific papers available in the MEDLINE/PubMed and Google Scholar (till page 10) databases between January 1, 2015 and November 30, 2021. The following terms were used for the search strategy: (sero* OR seroprevalence OR prevalence OR susceptibilit* OR immunit* OR immunogenict*) AND (healthcare worker* OR health personnel OR physician* OR nurse OR student*) AND (rubella OR german measles OR TORCH) AND (Italy)

Results

The prevalence of rubella-susceptible HCWs was 9.0 % (95 %CI: 6.4–12.1 %). In a comparison of female vs. male serosusceptible HCWs, the RR was 0.67 (95 %CI = 0.51–0.88). Occupational medicine examinations for rubella screening with possible subsequent vaccination of seronegatives and exclusion of susceptible HCWs from high-risk settings were common management strategies.

Conclusions

HCWs susceptible to rubella are an important epidemiological concern in Italy, and efforts to identify and actively offer the vaccine to this population should be increased.

Trust and vaccination intentions: Evidence from Lithuania during the COVID-19 pandemic

In this paper, we study the relationship between trust and COVID-19 vaccination intentions. Vaccinating a large share of the population is essential for containing the COVID-19 pandemic. However, many individuals refuse to get vaccinated, which might be related to a lack of trust. Using unique survey data from Lithuania during the COVID-19 pandemic, we show that trust in government authorities, science, and pharmaceutical companies are important predictors of individual vaccination intentions. We do not find evidence that trust in strangers, the healthcare system, or the media predict intentions to get vaccinated against COVID-19.

Your vaccine attitude determines your altitude. What are the determinants of attitudes toward vaccination?

Attitudes toward vaccination are doubtless an important determinant of public health, and this became evident after the first year of the last COVID-19 pandemic. The issue, long-debated within European societies, especially with respect to occasional surges of diseases in given years, has become a crucial determinant of the wellbeing of a country since 2021. In this study, using microdata from a 2019 Eurobarometer survey, we frame and deepen our knowledge about the main determinants of vaccination attitudes as observed by the related literature. We argue that a positive attitude toward vaccination may be due to individualistic or altruistic reasons, or various incentives; our analysis aims to improve our knowledge about the determinants of such a complex decision. Our findings, obtained by means of a quantitative analysis that employs Ordered Probit, Ordered Logit and Generalized Ordered Logit estimations, provide complete support for some of the theories that have been debated in the literature, limited support for others because of mixed evidence, and no support for some.

Influenza Vaccination Assessment according to a Value-Based Health Care Approach

Background: Seasonal influenza has a considerable public health impact, and vaccination is the key to preventing its consequences. Our aim was to describe how the value of influenza vaccination is addressed in the scientific literature considering a new value framework based on four pillars (personal, allocative, technical, and societal value). Methods: A systematic review was conducted by querying three databases. The analysis was performed on international studies focused on influenza vaccination value, and the four value pillars were taken into consideration for their description. Results: Overall, 40 studies were considered. Most of them focused on influenza vaccination in the general population (27.5%), emphasizing its value for all age groups. Most studies addressed technical value (70.4%), especially in terms of economic models and cost drivers to be considered for the economic evaluations of influenza vaccines, and societal value (63%), whereas few dealt with personal (37%) and allocative values (22.2%). Conclusions: The whole value of influenza vaccination is still not completely recognized. Knowledge and communication of the whole value of influenza vaccination is essential to guide value-based health policies. To achieve this goal, it is necessary to implement initiatives that involve all relevant stakeholders.

Echo chambers and opinion dynamics explain the occurrence of vaccination hesitancy

Vaccination hesitancy is a major obstacle to achieving and maintaining herd immunity. Therefore, public health authorities need to understand the dynamics of an anti-vaccine opinion in the population. We introduce a spatially structured mathematical model of opinion dynamics with reinforcement. The model allows as an emergent property for the occurrence of echo chambers, i.e. opinion bubbles in which information that is incompatible with one's entrenched worldview, is probably disregarded. We scale the model both to a deterministic limit and to a weak-effects limit, and obtain bifurcations, phase transitions and the invariant measure. Fitting the model to measles and meningococci vaccination coverage across Germany, reveals that the emergence of echo chambers dynamics explains the occurrence and persistence of the anti-vaccination opinion in allowing anti-vaxxers to isolate and to ignore pro-vaccination facts. We predict and compare the effectiveness of different policies aimed at influencing opinion dynamics in order to increase vaccination uptake. According to our model, measures aiming at reducing the salience of partisan anti-vaccine information sources would have the largest effect on enhancing vaccination uptake. By contrast, measures aiming at reducing the reinforcement of vaccination deniers are predicted to have the smallest impact.

Psychometric properties and measurement invariance of the Vaccination Attitudes Examination Scale (VAX) in a Spanish sample

In these times of pandemic, the acceptance or rejection of vaccines has become increasingly clear, with a considerable rise in the anti-vaccine movement in Spain. It is important to understand the attitudes that lead a person to refuse vaccination in order to develop more effective public health campaigns. The objective of this study has been to study the psychometric properties and measurement invariance of the Vaccination Attitudes Examination (VAX) scale in a Spanish sample. Confirmatory factor analysis and structural equation modelling have been used to study the psychometric properties of the VAX. Likewise, the measurement invariance by gender and educational level has been studied. The structure of four related factors for VAX is confirmed, as well as its predictive value, since the factor “trust in the benefit of the vaccine” clearly predicts the choice to be vaccinated. The strong measurement invariance by gender and educational level is also confirmed. The comparison of latent means between groups indicates that there are no differences by gender in any factor. However, people with a high educational level present higher scores in factors “concern about unforeseen future effects”, “concern about commercial effects and speculation” and “preference for natural immunity”. The VAX is presented as a reliable and valid tool to assess four different factors related to attitudes towards vaccines in Spain. Future studies of its cross-cultural invariance may help to determine the main factors that lead people not to be vaccinated in order to develop more effective public health campaigns.

Availability and implementation of guidelines in European child primary health care: how can we improve?

BACKGROUND

Clinical guidelines are important for providing high-quality child primary health care. We aimed to assess the availability, use and achieved delivery of guidelines in the European Union (EU).

METHODS

We used a case study design to ascertain expert views on guidelines in six countries representing the EU. The experts completed an online questionnaire (response 49%), asking about their perception of guideline availability and implementation regarding three topics that represent prevention and care, i.e. vaccination, assessment of mental health and asthma care.

RESULTS

According to the respondents all countries had guidelines available for asthma care. For vaccination and mental health assessment respondents agreed to a lesser degree that guidelines were available. Implementation of guidelines for vaccination was mostly perceived as intended, but implementation of the guidelines for mental health assessment and asthma care was limited. Notable barriers were complexity of performance, and lack of training of professionals and of financial resources. Important facilitators for guideline implementation were the fit with routine practice, knowledge and skills of professionals and policy support. We found no clear relationship of guideline availability and implementation with type of child primary health care system of countries, but strong governance and sufficient financial resources seemed important for guideline availability.

CONCLUSIONS

Availability and implementation of clinical guidelines in child primary health care vary between EU countries. Implementation conditions can be strongly improved by adequate training of professionals, stronger governance and sufficient financial resources as facilitating factors. This can yield major gains in child health across Europe.

Willingness to get vaccinated with the first-generation vaccines against SARS-CoV-2

OBJECTIVE

To explore people's decision-making regarding whether or not to get vaccinated against COVID-19.

METHODS

A purposive sample of people over the age of 18 who had not yet been vaccinated against COVID-19 was studied. Data were gathered using semi-structured interviews in focus groups and personal in-depth interviews. All interviews were conducted on the Zoom^® platform and were recorded for subsequent verbatim transcription. Using a grounded theory approach, both open and axial coding of the narrative data were performed.

RESULTS

Information saturation was reached after eight focus group meetings and 14 in-depth interviews (n = 55). Six principal themes emerged, with the fear of possible adverse side-effects and the worries generated by the speed of the development and commercialization of the vaccine amongst the main expressed anxieties. Social pressure to get vaccinated was a recurrent subject, as was the desire for clear and understandable information from reliable sources.

CONCLUSIONS

The willingness to get vaccinated against COVID-19 is determined by a complex series of interconnected factors that define an explanatory model, which has evolved concurrently with the development of the vaccines and the progress of the vaccination campaigns. This model will be useful for deciding social scenarios aimed at tackling this or future pandemics and for designing formulas that will increase the initial acceptance of these vaccines.

COVID-19 Vaccines: Fear of Side Effects among German Health Care Workers

(1) Background: Health care workers (HCWs) play a key role in increasing anti-COVID vaccination rates. Fear of potential side effects is one of the main reasons for vaccine hesitancy. We investigated which side effects are of concern to HCWs and how these are associated with vaccine hesitancy. (2) Methods: Data were collected in an online survey in February 2021 among HCWs from across Germany with 4500 included participants. Free-text comments on previously experienced vaccination side effects, and fear of short- and long-term side effects of the COVID-19 vaccination were categorized and analyzed. (3) Results: Most feared short-term side effects were vaccination reactions, allergic reactions, and limitations in daily life. Most feared long-term side effects were (auto-) immune reactions, neurological side effects, and currently unknown long-term consequences. Concerns about serious vaccination side effects were associated with vaccination refusal. There was a clear association between refusal of COVID-19 vaccination in one's personal environment and fear of side effects. (4) Conclusions: Transparent information about vaccine side effects is needed, especially for HCW. Especially when the participants' acquaintances advised against vaccination, they were significantly more likely to fear side effects. Thus, further education of HCW is necessary to achieve good information transfer in clusters as well.

The COVID-19 Vaccine: Trust, doubt, and hope for a future beyond the pandemic in Germany

Public perceptions of COVID-19 vaccines are critical in reaching protective levels of herd immunity. Vaccine skepticism has always been relatively high in Germany, and surveys suggest that over the course of the pandemic, enthusiasm for the COVID-19 vaccine has dropped. Looking at the period just prior to the approval of the Pfizer/BioNTech and Moderna vaccines in Germany in the latter half of 2020, this paper aims to assess the reasons for and against COVID-19 vaccine uptake among residents of Germany, and to provide in-depth qualitative data to better understand and address concerns surrounding the safety and efficacy of a COVID-19 vaccine. Our findings indicate that there is widespread trust in German institutions and health experts to provide a safe vaccine for those who need it most. However, interviewees also point to the need for more information and the centrality of support from trusted medical authorities in making individual vaccination decisions. We also present the complexity of individual positions on vaccination, and suggest that vaccine hesitancy in relation to COVID-19 needs to be understood as a nuanced, and socially malleable, territory. This indicates that the goal of a vaccination campaign is not only achieving ‘herd immunity,’ but also a social endorsement of the collaborative effort that is required for a vaccine to be successful.

Perceptions, knowledge and attitudes about COVID-19 vaccine hesitancy in older Portuguese adults

BACKGROUND

Coronavirus 2019 (COVID-19) has become a public-health emergency of international concern. Most efforts to contain the spread and transmission of the virus rely on campaigns and interventions targeted to reduce Vaccine Hesitancy and Refusal (VHR).

OBJECTIVE

this study aims to assess the major factors associated with VHR in the older population in Portugal.

METHODS

a nation-wide cross-sectional study was conducted in the older Portuguese population (≥65 years old) through computer-assisted telephone interviewing. Logistic regression was used to determine the adjusted odds ratio (OR) of the independent variables (perceptions, knowledge and attitudes) and of the outcome (VHR).

RESULTS

the response rate was 60.1% (602/1,001). Perceptions, knowledge and attitudes were strongly associated with VHR probability. A 1-point Likert scale increase in concerns about the vaccines' efficacy and safety increased the risk of VHR by 1.96 (95% confidence interval [CI]: 1.40-6.28) and 3.13 (95%CI: 2.08-8.22), respectively. A reduction of VHR probability for 'reliability of the information released by social media' (OR = 0.34, 95%CI: 0.16-0.70) and for 'trust in national and international competent authorities' (OR = 0.34, 95%CI: 0.17-0.69) is also observed per 1-point increase.

CONCLUSIONS

as VHR seems to be strongly associated with perceptions, knowledge and attitudes, the design and promotion of vaccination campaigns/educational interventions specifically targeted at changing these potentially modifiable determinants may help to tackle COVID-19 VHR and achieve a wider vaccine coverage.

What have European countries done to prevent the spread of COVID-19? Lessons from the COVID-19 Health System Response Monitor

Although some European countries imposed measures that successfully slowed the transmission of Covid-19 during the first year of the pandemic, others struggled, either because they acted slowly or implemented measures ineffectively. In this paper we consider the European experience with public health measures designed to prevent transmission of COVID-19. Based on literature and country responses described in the COVID-19 Health System Response Monitor from March 2020 to December 2020, we consider some critical aspects of public health policy responses. These include the importance of public health capacity that can scale up surveillance and outbreak control, including effective testing and contract tracing, of clear messaging based on an understanding of human behaviour, policies that address the undesirable consequences of necessary measures, such as support for those isolating or unable to earn, and the ability to implement at pace and scale a major vaccine rollout. We conclude that for countries to be successful at preventing COVID-19 transmission, there is a need for a clear strategy with explicit goals and a whole systems approach to implementation.

Role of Information Sources in Vaccination Uptake: Insights From a Cross-Sectional Household Survey in Sierra Leone, 2019

Our findings suggest that health workers and faith leaders are important sources of information to deliver vaccination messages, given their strong association with vaccination confidence and uptake. In this context, vaccination promotion efforts that integrate faith leaders and health workers may help increase vaccination uptake.

Introduction:

There is limited understanding of the potential impact of information sources on vaccination attitudes and behaviors in low-income countries. We examined how exposure to immunization information sources may be associated with vaccination uptake in Sierra Leone.

Methods:

In 2019, a household survey was conducted using multistage cluster sampling to randomly select 621 caregivers of children aged 12–23 months in 4 districts in Sierra Leone. We measured exposure to various sources of immunization information and 2 outcomes: (1) vaccination confidence using an aggregate score (from 12 Likert items, informed by previously validated scale) that was dichotomized into a binary variable; (2) uptake of the third dose of diphtheria-pertussis-tetanus-hepatitis B-Haemophilus influenzae type-b-pentavalent vaccine (penta-3) based on card record or through caregiver recall when card was unavailable. Associations between information sources and the outcomes were examined using modified Poisson regression with robust variance estimator.

Results:

Weighted estimate for penta-3 uptake was 81% (75.2%–85.5%). The likelihood of uptake of penta-3 was significantly greater when caregiver received information from health facilities (adjusted prevalence ratio [aPR]=1.26, 95% confidence interval [CI]=1.1, 1.5), faith leaders (aPR=1.16, 95% CI=1.1, 1.3), and community health workers (aPR=1.13, 95% CI=1.003, 1.3). Exposure to greater number of information sources was associated with high penta-3 uptake (aPR=1.05, 95% CI=1.02, 1.1).

Discussion:

Immunization information received during health facility visits and through engagement with religious leaders may enhance vaccination uptake. Assessments to understand context-specific information dynamics should be prioritized in optimizing immunization outcomes.

Comparative Analysis of Mortality From Coronavirus Disease 2019 Across the European Union Countries and the Effects of Vaccine Coverage

Background

Mortality is a critical measure of disease impact. The European Union (EU) countries share the same regulatory framework but different implementation policies.

Methods

We extracted cumulative COVID-19 mortality data across the EU countries. We evaluated the 27 member states using the location quotient (LQ) to adjust for the expected mortality in the whole EU region, where an LQ <1 signifies a more and an LQ >1 a less favorable outcome. We categorized EU members into 3 distinct profiles based on their LQ estimates: favorable profile, LQ ≤0.9; unfavorable profile, LQ >1.10; and average profile, LQ between 0.9 and 1.10. We compared LQ estimates and profiles with the prevaccination era that ended in December 2020 with the COVID-19 vaccine rollout.

Results

Twelve member states had a favorable profile, 4 had an average profile, and 11 had an unfavorable profile. In quantitative analysis, an improvement (negative LQ difference) was noted across countries with higher vaccination coverage (median, 71% fully vaccinated vs 57% for countries with positive LQ differences). There was a significant negative association between the share of fully vaccinated and LQ changes (ρ = –0.62, P < .001) and a significant 4-month lag effect. After COVID-19 vaccines became available, 4 countries improved their profile and 5 moved to a worse profile.

Conclusions

There is significant variability in mortality and impact of COVID-19 between countries, even if they share the same regulatory framework. Extending immunization coverage may lead the transition to a more favorable profile, and alter the trajectory of COVID-19 mortality.

Recommendations to drive a value-based decision-making on vaccination

INTRODUCTION

Health systems worldwide need to pay attention to both sustainability and quality. The explosion of health technologies represents a challenge for health systems' sustainability, and evidence-based tools should support resources allocation to guarantee a continuous quality improvement. The value-based approach could disentangle the full benefit of a health technology, and this is of utmost importance in the vaccination field because of several obstacles still existing in reaching optimal vaccination uptake.

AREAS COVERED

The paper conveys the evidence on the full value of vaccine(s)/vaccination based on the framework suggested by the Expert Panel on Effective Ways of Investing in Health of the European Commission. Indeed, evidence on the personal, technical, allocative, and societal value of vaccine(s)/vaccination published in the last decade was described as foundation of a following consultation with international experts of the field. The result was the issuing of recommendations for research, decision-making, and public engagement that aimed to drive a value-based decision-making on vaccination.

EXPERT OPINION

The development of vaccination programs based on the recognition of the full value of vaccine(s)/vaccination is essential. To achieve this goal, it is necessary to launch intersectoral and multidisciplinary research and implementation initiatives involving all relevant stakeholders.

The Israeli Experience with the "Green Pass" Policy Highlights Issues to Be Considered by Policymakers in Other Countries

In the first half of 2021, Israel had been ahead of other countries concerning the speed of its rollout and coverage of COVID-19 vaccinations. During that time, Israel had implemented a vaccine certificate policy, the "Green Pass Policy" (GPP), to reduce virus spread and to allow the safe relaxation of COVID-19 restrictions in a time of great uncertainty. Based on an analysis of GPP regulations and public statements compiled from the Israeli Ministry of Health website, we describe the design and implementation of the GPP. We also look back and discuss lessons learned for countries that are considering a GPP policy, given the current upsurge of the Delta variant as of summer 2021. To reduce equity concerns when introducing a GPP, all population groups should be eligible for the vaccine (contingent on approval from the manufacturer) and have access to it. Alternatively, health authorities can grant temporary certificates based on a negative test. We also highlight the fact that in practice, there will be gaps between the GPP regulations and implementation. While some places might require a GPP without legal need, others will not implement it despite a legal obligation. The GPP regulations should have standardised epidemiological criteria, be implemented gradually, remain flexible, and change according to the epidemiological risks.

COVID-19 vaccine-taking hesitancy among Bangladeshi people: knowledge, perceptions and attitude perspective

Several novel efforts have been put forth to make a readily available vaccine against the global pandemic of COVID-19. However, there seems to appear vaccine-taking hesitancy among the general people. Against this backdrop, this current study sets to assess the vaccine-taking intention, ways to overcome the vaccine-taking reluctance among Bangladeshi people and explore their knowledge, perceptions, and attitude toward the COVID-19 vaccine. To this end, this study leveraged on a cross-sectional survey, which was consisted of 1377 respondents covering the eight divisions of Bangladesh. The descriptive statistical method and ordinal logistics regression were employed to explore and rationalize our study outlined objectives. Empirical findings revealed that approximately 71% of the respondents had adequate knowledge about the COVID-19 vaccine, whereas 46% of the respondents were willing to be vaccinated against COVID-19 while the rest of the respondents were hesitant to take the vaccine. However, concern about the potential side effects was one of the core reasons for vaccine-taking hesitancy. Assuring the common people about vaccine safety and efficacy, along with easing the registration procedure, can ameliorate people's confidence to get vaccinated. Meanwhile, about 60% of the respondents believed that a vaccine could help Bangladesh win the battle against COVID-19 and will allow back to normal life. Although the government has taken some pragmatic action steps to promote the vaccination rate, it is recommended that the mass vaccination program should be extended to the grassroots level with proper extension community support and easing the registration process.

Pediatric health care professionals' vaccine knowledge, awareness and attitude: a survey within the Italian Society of Pediatric Allergy and Immunology

Background

Physicians play a key role in driving vaccine acceptance and their recommendations are crucial to address vaccine hesitancy. The aim of the study was to assess knowledge, awareness and attitude of Italian Pediatric Health Care Professionals (pHCPs) on vaccinations.

Methods

An anonymous on-line questionnaire was developed within the Vaccine Committee of Italian Society of Pediatric Allergy and Immunology (SIAIP) and spontaneously completed by 231 Pediatricians and Pediatric Nurses (PN).

Results

An accurate vaccine education was reported by 70% of pediatricians and 13% of PN but 11% of pediatricians versus 26% of PN consult social media instead of scientific sources for their vaccine update. The investigation on the pHCPs attitudes to vaccination in a personal and family setting highlights poor adherence to vaccinations. Only 63% of pediatricians versus 16% of PN (p < 0.0001) annually received the Flu vaccine. In their family setting 93% of pediatricians versus 51% of PN recommended all vaccinations (p < 0.0001). Anti-flu, anti-rotavirus, anti-zoster and anti-pneumococcal vaccines were not regularly recommended by all pHCPs due to doubts of uselessness (55% of pediatricians versus 40% of PN) and preference for “natural immunity” (44% of pediatricians versus 40% of PN).

Conclusions

Our results indicate that pHCPs’ attitude and confidence in regards to vaccines remain suboptimal. Current COVID-19 pandemic and the rapid development of vaccines could increase vaccine hesitancy. Due to the documented pHCPs’ influence in the parental decision, educational interventions are needed to improve their level of knowledge and counselling skills in order to address parental vaccine hesitancy and to maintain continuity of immunization services.

A look into the future of the COVID-19 pandemic in Europe: an expert consultation

How will the coronavirus disease 2019 (COVID-19) pandemic develop in the coming months and years? Based on an expert survey, we examine key aspects that are likely to influence the COVID-19 pandemic in Europe. The challenges and developments will strongly depend on the progress of national and global vaccination programs, the emergence and spread of variants of concern (VOCs), and public responses to non-pharmaceutical interventions (NPIs). In the short term, many people remain unvaccinated, VOCs continue to emerge and spread, and mobility and population mixing are expected to increase. Therefore, lifting restrictions too much and too early risk another damaging wave. This challenge remains despite the reduced opportunities for transmission given vaccination progress and reduced indoor mixing in summer 2021. In autumn 2021, increased indoor activity might accelerate the spread again, whilst a necessary reintroduction of NPIs might be too slow. The incidence may strongly rise again, possibly filling intensive care units, if vaccination levels are not high enough. A moderate, adaptive level of NPIs will thus remain necessary. These epidemiological aspects combined with economic, social, and health-related consequences provide a more holistic perspective on the future of the COVID-19 pandemic.

Determinants of COVID-19 vaccine acceptance and hesitancy: a cross-sectional study in Saudi Arabia

Several COVID-19 vaccines have been developed in unprecedented time by research centers and pharmaceutical companies. This study aimed to determine COVID-19 vaccine acceptance and hesitancy rates and investigated the factors that influence vaccine acceptance and hesitancy. A cross-sectional research was conducted among adults in Saudi Arabia between January and March 2021 to determine willingness to receive a COVID-19 vaccine. A self-administered questionnaire was designed to explore the participants' COVID-19 vaccine acceptance and hesitancy. Categorical variables are described by frequency and percentage. A cross-tabulation analysis using the chi-squared test was performed to find associations between sociodemographic characteristics and vaccine acceptance and hesitancy. Logistic regression analysis was performed for variables that were found to be significant by the chi-squared test. A descriptive analysis of the 531 participants showed that 61.8% were willing to get the COVID-19 vaccine, while 38.2% were not. COVID-19 vaccine hesitancy was higher among women (44.9%), those 34-49 years of age (47.9%), those who were married (41.9%), employed (39.7%), had lower educational attainment (40%), and urban dwellers (40.8%). The main reason for COVID-19 vaccine acceptance was to protect oneself and others, while concerns about vaccine safety were the main reason for vaccine hesitancy. Statically significant associations were found between vaccine acceptance and age (p = .002) and gender (p = .03). Our study revealed a high prevalence of COVID-19 vaccine hesitancy (38.2%). Several sociodemographic characteristics were related to hesitancy, which may hinder the promotion of vaccine uptake. Public health campaigns is recommended to promote COVID-19 vaccine uptake.

COVID-19 vaccine hesitancy: A community-based research in Turkey

AIM

The frequency of vaccine refusal and hesitation, which is associated with many factors, is increasing worldwide. The purpose of this study is to estimate the frequency of vaccine refusal against COVID-19 vaccines and to identify the underlying factors for refusal or hesitation.

MATERIALS AND METHODS

This is a cross-sectional study carried out in a district of Istanbul from 25 to 30 December 2020. A sample of people from the ages of 20 to 85 in the district was selected, and a total of 384 people were enrolled. A questionnaire about the COVID-19 vaccine was administered to the participants by phone. The questionnaire consisted of questions about the sociodemographic characteristics of participants and their thoughts about possible COVID-19 vaccines.

RESULTS

45.3% of the participants were hesitant about getting the COVID-19 vaccine, which was declared appropriate by the Ministry of Health. The rate of those who think that the COVID-19 vaccine will be effective in preventing and controlling the disease was 51.6%. 89.6% of the participants were hesitant about getting their children vaccinated. Those who do not consider COVID-19 disease as a risk to their health were 22.9%, and 32.8% thought that they would be protected from the disease by natural and traditional ways. The median score of the participants' risk perception was 7 (IQR: 6-8; Mean: 6.8; SD: 1.7). The median value of risk perception score of those who accept the vaccine was 6 (IQR: 4-6), while the median value for those who did not accept the vaccine was 4 (IQR: 4-6) (P < .01). Factors affecting vaccine acceptance were determined as the perception of risk (OR: 1.26% 95CI 1.03-1.55) and age (OR: 0.94% 95CI: 0.91-0.98) in logistic regression analysis.

CONCLUSION

Half of the participants were hesitant about the COVID-19 vaccines. The success of COVID-19 vaccination programmes largely depends on the public willingness to accept the vaccine.

Nurse-Led Model of Care That Helps a Community Heal: Curbside Immunizations With Assistance in Social Determinants

The COVID-19 pandemic has overwhelmed communities. Physical, emotional, and financial struggles have heightened, especially with our vulnerable populations. People have been afraid to return to their provider's office. For children, there has been an interruption of well-visits and immunizations. As the nation saw a decline in immunization uptake, a pilot nurse-led program was designed to increase vaccinations and address the social determinant needs during a global pandemic. The purpose of this article is to describe the planning and implementation of a curbside immunization event. The Logic model was used as a framework to ensure an efficient and replicable process. Initial observations showed an overall increase in immunization uptake and 97% of participants current with recommended vaccinations. Most parents (93%) would attend again and recommend it to others. They also felt that infection control precautions helped make the care delivered safe and efficient. Social determinants of health were assessed and addressed. This method of vaccine delivery is a viable model going into the future. Others may replicate this model, and it may also serve as a platform regarding flu or COVID-19 vaccine distribution.

The UPTAKE study: a cross-sectional survey examining the insights and beliefs of the UK population on COVID-19 vaccine uptake and hesitancy

OBJECTIVE

A key challenge towards a successful COVID-19 vaccine uptake is vaccine hesitancy. We examine and provide novel insights on the key drivers and barriers towards COVID-19 vaccine uptake.

DESIGN

This study involved an anonymous cross-sectional online survey circulated across the UK in September 2020. The survey was designed to include several sections to collect demographic data and responses on (1) extent of agreement regarding various statements about COVID-19 and vaccinations, (2) previous vaccination habits (eg, if they had previously declined vaccination) and (3) interest in participation in vaccine trials. Multinominal logistic models examined demographic factors that may impact vaccine uptake. We used principle component analysis and text mining to explore perception related to vaccine uptake.

SETTING

The survey was circulated through various media, including posts on social media networks (Facebook, Twitter, LinkedIn and Instagram), national radio, news articles, Clinical Research Network website and newsletter, and through 150 West Midlands general practices via a text messaging service.

PARTICIPANTS

There were a total of 4884 respondents of which 9.44% were black, Asian and minority ethnic (BAME) group. The majority were women (n=3416, 69.9%) and of white ethnicity (n=4127, 84.5%).

RESULTS

Regarding respondents, overall, 3873 (79.3%) were interested in taking approved COVID-19 vaccines, while 677 (13.9%) were unsure, and 334 (6.8%) would not take a vaccine. Participants aged over 70 years old (OR=4.63) and the BAME community (OR=5.48) were more likely to take an approved vaccine. Smokers (OR=0.45) and respondents with no known illness (OR=0.70) were less likely to accept approved vaccines. The study identified 16 key reasons for not accepting approved vaccines, the most common (60%) being the possibility of the COVID-19 vaccine having side effects.

CONCLUSIONS

This study provides an insight into focusing on specific populations to reduce vaccine hesitancy. This proves crucial in managing the COVID-19 pandemic.

Simplified Mathematical Modelling of Uncertainty: Cost-Effectiveness of COVID-19 Vaccines in Spain

When exceptional situations, such as the COVID-19 pandemic, arise and reliable data is not available at decision-making times, estimation using mathematical models can provide a reasonable reckoning for health planning. We present a simplified model (static but with two-time references) for estimating the cost-effectiveness of the COVID-19 vaccine. A simplified model provides a quick assessment of the upper bound of cost-effectiveness, as we illustrate with data from Spain, and allows for easy comparisons between countries. It may also provide useful comparisons among different vaccines at the marketplace, from the perspective of the buyer. From the analysis of this information, key epidemiological figures, and costs of the disease for Spain have been estimated, based on mortality. The fatality rate is robust data that can alternatively be obtained from death registers, funeral homes, cemeteries, and crematoria. Our model estimates the incremental cost-effectiveness ratio (ICER) to be 5132 € (4926–5276) as of 17 February 2021, based on the following assumptions/inputs: An estimated cost of 30 euros per dose (plus transport, storing, and administration), two doses per person, efficacy of 70% and coverage of 70% of the population. Even considering the possibility of some bias, this simplified model provides confirmation that vaccination against COVID-19 is highly cost-effective.

What can we learn from Israel's rapid roll out of COVID 19 vaccination?

Israel has led the world in rolling out its COVID-19 vaccination program. This experience provides lessons that others can learn from. It is, however, necessary to consider some national specificities, including the small size of the country, its young population, and the political imperative to drive this program forward. Israel also has a number of other advantages, including a strong public health infrastructure. The lessons that can be learnt include the importance of coordinating delivery mechanisms with the inevitable prioritisation of groups within the population, timely deployment of a skilled cadre of health workers, a recognition that not everyone in the population shares in the benefits of digital connectedness, the need to reach out to disadvantaged groups, based on an understanding of the barriers that they face, and the importance of placing COVID-19 vaccination within a comprehensive response to the pandemic.

The 2017 Italian reform on mandatory childhood vaccinations: Analysis of the policy process and early implementation

BACKGROUND

The data on vaccination coverage for the year 2016 were a cause of concern for the Italian government. For some years, in fact, there has been a growing mistrust of vaccines in the Italy, and consequently vaccination coverage rates have been decreasing. The number of cases of measles has been particularly high.

AIM

The purpose of this article is to examine the content and the preliminary outcomes of the Lorenzin Decree, which was passed in 2017. This reform embodies a 'hard' approach to the issue of childhood vaccinations, based on their mandatory nature and on the intensification of the sanctions against non-compliant subjects.

RESULTS

The Lorenzin decree provides for an increase in mandatory infant vaccines from four to ten. Following the reform, unvaccinated children are denied access to nurseries and kindergartens. Parents who do not have their children vaccinated are liable to pay a financial penalty. Data on the preliminary outcomes of the reform show an increase in vaccination coverage.

CONCLUSION

The Italian experience provides some policy recommendations, and could be a source of inspiration for European countries that are tackling vaccine hesitancy and declining vaccination coverage rates. At least for the short term, the 'hard' approach adopted by the Italian government is, in fact, bearing fruit, having reversed the negative trend in vaccination coverage rates.

A Select Bibliography of Actions to Promote Vaccine Literacy: A Resource for Health Communication

In this bibliography, the researchers provide an introduction to the available evidence base of actions to promote vaccine literacy. The research team organized interventions to create a tool that can inform health communicators and practitioners seeking a resource focused on strategy and implementation design for actions that support vaccine literacy. This scoping bibliography is honed specifically to respond to the urgency of the current pandemic, when supporting and increasing vaccine literacy offers promise for achieving the critically needed high levels of vaccination. Over the course of the coming months and year, this bibliography will be a dynamic and "living" document hosted and maintained on vaccineliteracy.com.

Strengthening the Evidence-Based Approach to Guiding Effective Influenza Vaccination Policies

The availability of several effective and safe vaccines enables health systems to counteract annual influenza epidemics. However, the criteria of appropriateness and sustainability require that each citizen should receive the right vaccine. The value of each vaccine can be assessed within well-known frameworks, such as the Health Technology Assessment (HTA), a step that is fundamental to the process of allocating resources to vaccination strategies. The paper describes how HTA has been incorporated as an evidence-based tool to support the definition of Italian vaccination strategies, reports the results of the HTA report on the most recently available influenza vaccine in Italy (cell-based quadrivalent vaccine (QIVc)-Flucelvax® Tetra) and elaborates on current and future recommendations in the field of influenza vaccination. Recommendations issued by the Italian Ministry of Health foster the appropriate use of influenza vaccines from 2018-2019 onwards. Evidence of the value of newly available vaccines will hopefully support future decisions and promote the appropriate use of these vaccines on the basis of the characteristics of the target population. However, the success of influenza vaccination will also depend on citizens' empowerment and engagement in the decision-making process.