Experiences with provider and parental attitudes and practices regarding the administration of multiple injections during infant vaccination visits: lessons for vaccine introduction

Safety Analysis of Simultaneous Vaccination of Japanese Encephalitis Attenuated Live Vaccine and Measles, Mumps, and Rubella Combined Attenuated Live Vaccine from 2020 to 2023 in Guangzhou, China

OBJECTIVES

Our objectives were to evaluate the safety of the simultaneous vaccination of Japanese encephalitis attenuated live vaccine (JEV-L) and measles, mumps, and rubella combined attenuated live vaccine (MMR) in children and to provide a reference for the implementation of the strategy of simultaneous vaccination with the two vaccines.

METHODS

The data of adverse events following immunization (AEFI) and vaccination for JEV-L and MMR from 2020 to 2023 were extracted through the Guangdong Province Vaccine Distribution and Vaccination Management Information System and the Chinese National AEFI Information System (CNAEFIS). The inclusion criteria were that children were born after 1 October 2019, and received the first dose of JEV-L or MMR after 1 June 2020, in accordance with the starting age for vaccination (8 months). The study used the number of vaccine doses as the denominator to calculate and compare the reporting rates of cases and calculated the relative risk (RR) of adverse reactions and the 95% confidence interval (CI).

RESULTS

In Guangzhou, a total of 214,238 doses of JEV-L were administered to children. JEV-L and MMR were co-administered in 464,009 doses, and MMR was administered separately in 241,150 doses. The overall reporting incidence rates of AEFI (per 100,000 doses) for JEV-L, the simultaneous vaccination group, and MMR were 11.20, 53.02, and 60.96, respectively. Among children aged 8 months in Guangzhou, 57.98% (463,512/799,423) received the simultaneous administration of JEV-L and MMR. In the reported AEFI events, general reactions accounted for 87.50% in the JEV-L group, 88.21% in the simultaneous vaccination group, and 89.80% in the MMR separate group. The incidence rates of common adverse reactions were 9.80, 46.7, and 54.74, respectively. The incidence rates of rare adverse reactions were 0.93, 3.88, and 2.90, respectively. The reporting incidence rates of fever ≥38.6 °C after vaccination were 4.20, 16.16, and 17.83 for the JEV-L separate group, simultaneous vaccination group, and MMR separate group, respectively. There was a significant difference between the simultaneous vaccination group and the JEV-L separate group (RR = 3.848, 95% CI = 1.927, 7.683), while no significant difference was found compared with the MMR separate group (RR = 0.906, 95% CI = 0.623, 1.318). The simultaneous vaccination group showed no significant differences in the reporting incidence rates of local redness and induration compared with the two separate vaccination groups (RR = 1.385, 95% CI = 0.144, 13.315; RR = 0.390, 95% CI = 0.087, 1.743; RR = 0.520, 95% CI = 0.033, 8.314). No significant differences were found in the incidence rates of rare adverse reactions such as maculopapular rash, urticaria, and thrombocytopenic purpura.

CONCLUSIONS

The AEFI reporting incidence rate for the first dose of the simultaneous vaccination of JEV-L and MMR in 8-month-old children in Guangzhou is between the rates of the two separate groups. Compared with the MMR separate group, the simultaneous vaccination group does not increase the risk of adverse reactions.

Stakeholders Perspectives on the Introduction of an Additional Injectable Vaccine Under the Universal Immunization Programme in India

INTRODUCTION

In 2023, India's National Technical Advisory Group on Immunization (NTAGI) recommended the inclusion of typhoid conjugate vaccine (TCV) in the Universal Immunization Programme (UIP). However, introducing TCV, an additional injectable vaccine (AIV), will potentially increase the number of injections administered in a single visit to a maximum of five (if given at the 9 to 12 months touchpoint) or four (if given in the second year of life). In this context, the present study aimed to explore the perspectives of program managers, service providers, and caregivers regarding introduction of an AIV in a single visit under the UIP.

METHODS

A mixed-method study was undertaken wherein quantitative data was collected by telephonic surveys, and qualitative data by key informant interviews (KIIs) and focus group discussions (FGDs). Purposive sampling encompassed eight states, eight districts, eight planning units, and 32 session sites. The qualitative data were thematically analyzed manually using Excel, while the quantitative data was analyzed using STATA 17.

RESULTS

A total of 1140 telephonic surveys, 96 KIIs, and 16 FGDs were conducted. The study revealed that program managers mentioned maternal emotional reactions as a significant concern and backed AIV introduction at the 9-12 months touchpoint. Vaccinators and community mobilizers favored the 16-24 months window with combined presentations and mentioned single-dose vials as the preferred approach for vaccine delivery. Caregivers acknowledged the benefits of vaccination but expressed discomfort and fear regarding multiple injections to the child in a single visit. Caregivers expressed a preference for a combination vaccine. No preference was reported among caregivers for the introduction of AIV to the 9-12 or 16-24 months touchpoints.

CONCLUSION

Stakeholders' perspectives on introducing an additional injectable vaccine in a single visit under the UIP are diverse. These will be helpful in developing an effective strategy for the future introduction of AIV under UIP.

Longitudinal association between parents' reported vaccination program preferences and children's actual immunization patterns in Shanghai, China

BACKGROUND

As China expands its national immunization program, it is essential to understand parents' beliefs about pediatric vaccination programs and the translation into actual vaccination decision-making for their children. This study aims to characterize parents pediatric vaccination program preferences and assess the association between parents' reported vaccination preferences and their children's vaccination status.

METHODS

In a prospective cohort study in Shanghai, China, we linked parents' survey responses about their preferences for pediatric vaccine programs when the child was ≤ 3 months in 2017 to their children's immunization records in 2020. We classified parents by their vaccination program preferences through a latent class analysis (LCA). Logistic regression analysis was used to explore the association between immunization patterns and respondents' LCA results.

RESULTS

The 469 parents were split into four classes: governmental clinic advocates (20%), careful deciders (45%), convenience-focused (19%), and prefer less co-administration (16%). Among the children 66% received combination vaccines, 91% had received at least one imported vaccine, and the average number of office visits by the age of six months was 7.

CONCLUSIONS

There were no associations between parents' reported preference categories and children's vaccination patterns. The high acceptance of combination vaccines and tolerance of co-administration gives parents choices for vaccination and impart increased confidence in including new vaccines in the vaccination program.

Moments that matter: childhood pain treatment shapes pain for life-we can do better every time in every child

BACKGROUND

Needle procedures, such as vaccinations, blood draws, and intravenous cannulation, are the most frequent source of childhood pain, causing fear and reducing the uptake of medical procedures. Every child has the right to expect pain relief, and we have evidence-based tools to reduce needle procedure-related pain. Therefore, the lack of analgesic provision for needle pain is not justified. We argue that better informed and motivated healthcare professionals and families can advocate for appropriate pain relief in every child, every time.

OBSERVATIONS

Engaging communication campaigns are needed to educate our healthcare professionals. Evidence-based modalities such as topical anaesthesia, sucrose or breastfeeding, comfort positioning, and age-appropriate distractions should be available for every child during needle procedures. However, high-quality information is not enough to change behaviour-healthcare professionals need to be motivated, encouraged, and inspired. Parents and carers should be empowered to advocate for their children and be aware that their child has the right to receive pain relief during these procedures. CONCLUSIONS AND RELEVANCE: This is a call to action-we need collaboration between academics, healthcare professionals, industry and charities, to expedite behavioural change and parental advocacy through high-quality communication strategies. Effective pain management in infants and children can play a crucial role in promoting the uptake of vaccinations and medical procedures and can influence future attitudes to pain.

Changes in vaccine hesitancy among parents of children aged 6 months - 17 Years, National Immunization Surveys, 2019-2022

BACKGROUND

Vaccine hesitancy (VH) has been a major contributor to large outbreaks of vaccine-preventable diseases globally, including in the United States.

METHODS

Data from the 2019-2022 National Immunization Surveys were analyzed to assess parental hesitancy toward routine vaccination of their children aged 6 months -17 years. Joinpoint regression was employed to investigate trends in VH from 2019 to 2022 nationally overall and among socio-demographic subgroups. Using logistic regression, the difference between the prevalence of VH before and after the authorization of the COVID-19 vaccine for children aged 6 months-4 years, 5-11 years, and 12-17 years was computed. Both unadjusted and adjusted estimates were reported. VH was also compared within each socio-demographic subgroup with a reference level, at two-time points- before and after the authorization of the COVID-19 vaccine for each age group.

RESULTS

Overall, VH remained around 19.0 % from Q2 2019 to Q3 2022. Parents of non-Hispanic Black children had the largest average quarterly decrease in VH (β = -0.55; p < 0.05 by test for trend). After the authorization of the COVID-19 vaccine for children aged 6 months to 4 years, the adjusted percentage of children having parents that reported VH decreased by 2.2 (95 % CI: -3.9, -0.6) percentage points (pp) from 21.6 % to 19.4 %. Conversely, for children aged 5-11 years, VH increased by 1.2 (95 % CI: 0.2, 2.3) pp, from 19.8 % to 21.0 %. VH among parents of non-Hispanic Black children decreased after the authorization of the COVID-19 vaccine for adolescents aged 12-17 years but remained significantly higher compared to parents of non-Hispanic White children before and after authorization of the COVID-19 vaccine for all age groups.

DISCUSSION

About 1 in 5 children had parents reporting VH from 2019 to 2022. Parental VH increased after the authorization of the COVID-19 vaccine for children aged 5-11 years and declined for children aged 6 months-4 years.

Facilitating the development of urgently required combination vaccines

The essence of a vaccine lies in its ability to elicit a set of immune responses specifically directed at a particular pathogen. Accordingly, vaccines were historically designed, developed, registered, recommended, procured, and administered as monopathogen formulations. Nonetheless, the control and elimination of an astonishing number of diseases was realised only after several once-separate vaccines were provided as combinations. Unfortunately, the current superabundance of recommended and pipeline vaccines is now at odds with the number of acceptable vaccine administrations and feasible health-care visits for vaccine recipients and health-care providers. Yet, few new combinations are in development because, in addition to the scientific and manufacturing hurdles intrinsic to coformulation, developers face a gauntlet of regulatory, policy, and commercialisation obstacles in a milieu still largely designed for monopathogen vaccines. We argue here that national policy makers and public health agencies should prospectively identify and advocate for the development of new multipathogen combination vaccines, and suggest ways to accelerate the regulatory pathways to licensure of combinations and other concrete, innovative steps to mitigate current obstacles.

Impact of a research-action on vaccination indicators in the state of Minas Gerais, Brazil

OBJECTIVE

Analyze the impact of the state research-action project on immunization indicators (vaccination coverage - VC, homogeneity of vaccination coverage - HVC, dropout rate - DR, and risk rating) before and after the intervention in municipalities and priority Regional Health Administrations/Regional Health Superintendencies (RHA/RHS).

METHODS

The state research-action project was a before-after community clinical trial conducted in 212 municipalities belonging to eight RHA/RHS in the state of Minas Gerais, Brazil. The study sample comprised RHA/RHS with a decreasing trend for routine vaccination coverage in children under one year from 2015 to 2020. This study used secondary VC and DR data from 10 immunobiologicals recommended for children younger than two years from January to December 2021 (pre-intervention period, prior to the state research-action project) and from January to December 2022 (post-intervention period). The categorical variables were presented in proportions, and initially, a comparison was made between those of DR, HVC, and the risk rating for the transmission of vaccine-preventable diseases, according to the two periods (2021 and 2022), using the McNemar test.

RESULTS

All immunization indicators increased after conducting the research-action project. In 2021, 80.66% of the state's municipalities had a risk rating for the transmission of vaccine-preventable diseases as "high and very high." In 2022, the value reduced to 68.40%.

CONCLUSIONS

Risk rating for the transmission of vaccine-preventable diseases is an important mechanism to assist managers in defining priorities. The state research-action project used a method that enabled the construction and execution of unique action plans for each municipality, directing the improvement of immunization indicators in the state.

Pain management in infant immunisation: A cross-sectional survey of UK primary care nurses

BACKGROUND

Childhood immunisation is a critically important public health initiative. However, since most vaccines are administered by injection, it is associated with considerable pain and distress. Despite evidence demonstrating the efficacy of various pain management strategies, the frequency with which these are used during routine infant vaccinations in UK practice is unknown.

AIM

This study aimed to explore primary care practice nurses' (PNs) use of evidence-based pain management strategies during infant immunisation, as well as barriers to evidence-based practice.

METHODS

A questionnaire was developed and distributed to nurses throughout the UK via convenience sampling in paper and online formats. Questions assessed the frequency of pain management intervention use during infant immunisation and barriers to their use.

FINDINGS

A total of 255 questionnaire responses were received. Over 90% (n = 226) of respondents never used topical anaesthetics or sweet solutions during immunisations, while 41.9% advised breastfeeding occasionally (n = 103). Parent-/caregiver-led distraction was the most frequently used intervention, with most nurses using it occasionally (47.9%, n = 116) or often (30.6%, n = 74). Most practices had no immunisation pain management policy (81.1%, n = 184), and most PNs' previous training had not included pain management (86.9%, n = 186). Barriers to intervention use included lack of time, knowledge and resources. Excluding distraction, pain management strategies were infrequently or never used during infant immunisation. Key barriers to using evidence-based strategies were lack of time, knowledge and resources.

Exploring Shigella vaccine priorities and preferences: Results from a mixed-methods study in low- and middle-income settings

Background

Shigella is the leading bacterial cause of diarrheal mortality in children and can cause long-term effects on growth and development. No licensed Shigella vaccines currently exist but several promising candidates are in development and could be available in the next five years. Despite Shigella being a well-known public health target of the World Health Organization for decades, given current burden estimates and competing preventable disease priorities in low-income settings, whether the availability of an effective Shigella vaccine will lead to its prioritization and widespread introduction among countries at highest risk is unknown.

Methods

We conducted a mixed-methods study of national stakeholders and healthcare providers in five countries in Asia and Africa and regional stakeholders in the Pan American Health Organization to identify preferences and priorities for forthcoming Shigella vaccines.

Results

In our study of 89 individuals, diarrhea was the most frequently mentioned serious health concern for children under five years. Antimicrobial resistance (AMR) was more often considered very concerning than diarrhea or stunting. Shigella awareness was high but not considered a serious health concern by most stakeholders. Most participants were willing to consider adding a new vaccine to the routine immunization schedule but expressed reservations about a Shigella vaccine because of lower perceived burden relative to other preventable diseases and an already crowded schedule; interest was highest among national stakeholders in countries receiving more financial support for immunization. The priority of a Shigella vaccine rose when participants considered vaccine impacts on reducing stunting and AMR. Participants strongly preferred oral and combination vaccines compared to injectable and a single-antigen presentations, citing greater perceived community acceptability.

Conclusions

This study provides a critical opportunity to hear directly from country and regional stakeholders about health priorities and preferences around new vaccines. These findings should inform ongoing Shigella vaccine development efforts and eventual vaccine introduction and implementation planning.

Knowledge, Beliefs, and Behaviors of Turkish Parents about Childhood Vaccination

BACKGROUND AND OBJECTIVES

Vaccination is critical to the prevention and control of infectious disease outbreaks and is also one of the most important public health successes. When it comes to childhood vaccinations, parents' consent is very important. For this reason, childhood vaccination rates are directly related to the knowledge, beliefs, and behaviors of the parents. Therefore, this study aimed to evaluate the knowledge, beliefs, and behaviors of parents of children aged 0-5 regarding childhood vaccinations and how these beliefs affect their vaccination behaviors.

MATERIAL AND METHODS

This descriptive, cross-sectional study was conducted on 302 parents from February to June 2020. Data were collected using a questionnaire form with 26 questions. Sociodemographic characteristics were reported as frequencies, means, and percentages. Multiple regression analysis was utilized to evaluate vaccination behaviors and affective factors.

RESULTS

About 87.1% of the parents know that vaccines protect their children from infectious diseases, and 76.8% know that vaccines can have side effects. Although 97.7% of the parents had their children fully vaccinated according to the Extended Immunization Program, 2.3% did not vaccinate their children. Moreover, 98% of the parents trust the information given by healthcare professionals about vaccination. The parents' beliefs explain 53% (R2 = 0.53) of the parents' child vaccination behavior.

CONCLUSION

This study found that although the knowledge level of parents about vaccines is quite good, negative knowledge and beliefs that may affect vaccination also exist. Considered by parents as a reliable source of information, healthcare professionals should impart their knowledge, beliefs, and concerns regarding immunization.

A single-shot prophylactic tumor vaccine enabled by an injectable biomembrane hydrogel

Prophylactic tumor vaccines hold great promise against tumor occurrence. However, their clinical efficacy remains low due to inadequate activation of strong-sustainable immunity. Herein, a biomembrane hydrogel was designed as a powerful single-shot prophylactic tumor vaccine. Mannose-decorated hybrid biomembrane (MHCM) modified with oxidized sodium alginate (OSA) was designed as a gelator (O-MHCM), where the hybrid biomembrane (HCM) is a hybridization of bacterial outer membrane vesicles (OMV) and tumor cell membranes (TCM). The O-MHCM enables quick gelation subcutaneously where the cysteine protease inhibitor E64 is encapsulated in hydrogel micropores. After a single vaccination of E64@O-MHCM hydrogel, MHCM and E64 are released sustainably due to OSA moiety degradation. The MHCM enables active targeting to dendritic cells (DC) and effective DC maturation. Meanwhile, the E64 enables sufficient antigen availability for subsequent cross presentation. Ultimately, strong and sustainable T lymphocyte-mediated immunity was elicited, demonstrating a strong prophylactic effect against breast tumors. This study provides a long-lasting platform to prevent tumor occurrence, opening an innovative avenue for the design of a single-shot prophylactic tumor vaccine. STATEMENT OF SIGNIFICANCE: Developing a single-shot prophylactic tumor vaccine to elicit strong-sustainable immunity is of great interest clinically. Here, a prophylactic tumor vaccine was designed using an injectable biomembrane hydrogel for achieving strong-sustainable immunity. The mannose-tailored hybrid biomembrane was modified with oxidized sodium alginate to result in a gelator, which enabled the formation of the hydrogel after subcutaneous injection. Cysteine protease inhibitor E64 was incorporated into the micropores of the hydrogel. The hydrogel induced strong-sustainable immunity through the continuous release of active components. This was facilitated by the mannose moiety, which enabled active targeting, as well as the antigen and adjuvant function of biomembrane, and the E64-enabled suppression of antigen degradation. The biomembrane hydrogel demonstrated powerful prevention of 4T1 breast tumors. This study offers an attractive strategy for designing a single-shot prophylactic tumor vaccine.

Prevalence and factors associated with pentavalent vaccination: a cross-sectional study in Southern China

BACKGROUND

Immunization is one of the most far-reaching and cost-effective strategies for promoting good health and saving lives. A complex immunization schedule, however, may be burdensome to parents and lead to reduced vaccine compliance and completion. Thus, it is critical to develop combination vaccines to reduce the number of injections and simplify the immunization schedule. This study aimed to investigate the current status of the pentavalent diphtheria-tetanus-acellular pertussis inactivated poliomyelitis and Haemophilus influenzae type B conjugate (DTaP-IPV/Hib) vaccination in Southern China as well as explore the factors in the general population associated with uptake and the differences between urban and rural populations.

METHODS

A cross-sectional study was conducted with recently enrolled kindergarten students in Hainan Province between December 2022 and January 2023. The study employed a stratified multistage cluster random sampling method. Information regarding the demographic characteristics and factors that influence decisions were collected from the caregivers of children via an online questionnaire. Multivariate logistic regression was used to determine the factors associated with the status of DTap-IPV/Hib vaccinations.

RESULTS

Of the 4818 valid responses, 95.3% of children were aged 3-4 years, and 2856 (59.3%) held rural hukou. Coverage rates of the DTaP-IPV/Hib vaccine, from 1 to 4 doses, were 24.4%, 20.7%, 18.5%, and 16.0%, respectively. Caregivers who are concerned about vaccine efficacy [adjusted odds ratio (aOR) = 1.53, 95% confidence interval (CI): 1.30-1.79], the manufacturer (aOR = 2.05, 95% CI: 1.69-2.49), and a simple immunization schedule (aOR = 1.26, 95% CI: 1.04-1.54) are factors associated with a higher likelihood of vaccinating children against DTaP-IPV/Hib. In addition, caregivers in urban areas showed more concern about the vaccine price (P = 0.010) and immunization schedule (P = 0.022) in regard to vaccinating children.

CONCLUSIONS

The DTaP-IPV/Hib vaccine coverage rate in Hainan Province remains low. Factors such as lower socioeconomic status, cultural beliefs, concerns about vaccine safety, and cost may hinder caregivers from vaccinating their children. Further measures, such as health education campaigns to raise knowledge and awareness, and encouragement of domestic vaccine innovation, which would reduce out-of-pocket costs, could be implemented to improve the coverage of DTap-IPV/Hib vaccination.

Better adherence to childhood Haemophilus influenzae type b vaccination with combination vaccines compared to single-antigen vaccines: Evidence from China

Background

The coverage of Haemophilus influenzae type b (Hib) vaccination remains suboptimal in China, and this study aimed to investigate the influencing factors of caregivers' Hib-containing vaccine choices and the association between combination vaccine use and adherence to Hib immunisation schedule among Chinese children.

Methods

From August to October 2019, a cross-sectional survey was conducted in 148 community health care centres from ten provinces in China, which collected vaccination records from 5294 children aged 6-59 months. The children were categorised into three groups based on their Hib-containing vaccine receipt: unvaccinated group, monovalent vaccine group, and combination vaccine group. The outcome measures included: (1) receipt and choice of Hib-containing vaccines, and (2) completion of the three-dose schedule. Multinomial logistic regression was used to evaluate the influencing factors of Hib-containing vaccine receipt and choice, and logistic regression was adopted to investigate the associations between vaccine choice and schedule completion.

Results

Of the 5294 children, 19.53% received monovalent vaccines only, 22.59% received at least one dose of combination vaccines, and 57.88% were not vaccinated against Hib. The overall three-dose completion rate was 27.03%. The multinomial logistic (mlogit) regression findings indicated strong associations of socioeconomic status and Hib-containing vaccine supply with vaccination status. Multiple logistic regression among those who received at least one Hib-containing dose demonstrated a 3-fold increase in the likelihood of three-dose schedule completion by children who received any combination dose compared with those received single-antigen vaccines only (adjusted odds ratio (aOR) = 3.97 (95% CI = 3.14-5.03)).

Conclusions

Findings from the current study provide a more comprehensive understanding of the strong relationship between combination vaccine receipt and completion outcomes. Facing the suboptimal Hib vaccination rate in China, the use of combination vaccines could help increase vaccination compliance, and appropriate government actions to reduce out-of-pocket burden of immunisation are encouraged to address inequities in vaccine choices.

The association between vaccine hesitancy and pertussis: a systematic review and meta-analysis

BACKGROUND

Robust routine immunization schedules for pertussis-containing vaccines have been applied for years, but pertussis outbreaks remain a worldwide problem. This study aimed to investigate the association between vaccine hesitancy and pertussis in infants and children.

METHODS

We searched PubMed, Cochrane, Web of Science, Embase, and China National Knowledge Internet for studies published between January 2012 and June 2022. This study included case-control and cohort studies that assessed the association between childhood/maternal vaccine hesitancy and odds ratios (ORs), risk ratios (RRs), and vaccine effectiveness (VE) related to pertussis in infants and children [Formula: see text] 9 years old. ORs/VEs with a 95% confidence interval (CI) were calculated. Random-effects meta-analysis models were used for appropriate pooled estimates, and heterogeneity was assessed using [Formula: see text]. Cumulative meta-analysis and subgroup analyses stratified by study characteristics were performed.

RESULTS

Twenty-two studies were included, with a mean quality score of 7.0 (range 6.0-9.0). Infants and children with pertussis were associated with higher vaccine hesitancy to all doses (OR = 4.12 [95% CI: 3.09-5.50]). The highest OR was between children who were unvaccinated over four doses and children who were fully vaccinated (OR = 14.26 [95%CI: 7.62-26.70]); childhood vaccine delay was not statistically significantly associated with pertussis risk (OR = 1.18 [95% CI: 0.74-1.89]). Maternal vaccine hesitancy was associated with significantly higher pertussis risk in infants aged 2 and 3 months old, with higher pertussis ORs in infants [Formula: see text] 2 months old (OR = 6.02 [95%CI: 4.31-8.50], OR = 5.14 [95%CI: 1.95-13.52] for infants [Formula: see text] 2 and [Formula: see text] 3 months old, respectively). Maternal and childhood VEs were high in reducing pertussis infection in infants and children. The administration time of maternal vaccination had little effect on VE.

CONCLUSION

Vaccine hesitancy increased pertussis risks in infants and children. Ensuring that children receive up-to-date pertussis vaccines is essential; short delays in receiving childhood vaccinations may be unimportant. Maternal vaccinations for pertussis should be encouraged.

Liposome-based vaccines for minimally or noninvasive administration: an update on current advancements

INTRODUCTION

Vaccination requires innovation to provide effective protection. Traditional vaccines have several drawbacks, which can be overcome with advanced technologies and different administration routes. Over the past 10  years, a significant amount of research has focussed on the delivery of antigens into liposomes due to their dual role as antigen-carrying systems and vaccine adjuvants able to increase the immunogenicity of the carried antigen.

AREAS COVERED

This review encompasses the progress made over the last 10  years with liposome-based vaccines designed for minimally or noninvasive administration, filling the gaps in previous reviews and providing insights on composition, administration routes, results achieved, and Technology Readiness Level of the most recent formulations.

EXPERT OPINION

Liposome-based vaccines administered through minimally or noninvasive routes are expected to improve efficacy and complacency of vaccination programs. However, the translation from lab-scale production to large-scale production and collaborations with hospitals, research centers, and companies are needed to allow new products to enter the market and improve the vaccination programs in the future.

Immune response to co-administration of measles, mumps, and rubella (MMR), and yellow fever vaccines: a randomized non-inferiority trial among one-year-old children in Argentina

BACKGROUND

In yellow fever (YF) endemic areas, measles, mumps, and rubella (MMR), and YF vaccines are often co-administered in childhood vaccination schedules. Because these are live vaccines, we assessed potential immune interference that could result from co-administration.

METHODS

We conducted an open-label, randomized non-inferiority trial among healthy 1-year-olds in Misiones Province, Argentina. Children were randomized to one of three groups (1:1:1): Co-administration of MMR and YF vaccines (MMR1YF1), MMR followed by YF vaccine four weeks later (MMR1YF2), or YF followed by MMR vaccine four weeks later (YF1MMR2). Blood samples obtained pre-vaccination and 28 days post-vaccination were tested for immunoglobulin G antibodies against measles, mumps, and rubella, and for YF virus-specific neutralizing antibodies. Non-inferiority in seroconversion was assessed using a -5% non-inferiority margin. Antibody concentrations were compared with Kruskal-Wallis tests.

RESULTS

Of 851 randomized children, 738 were correctly vaccinated, had ≥ 1 follow-up sample, and were included in the intention-to-treat population. Non-inferior seroconversion was observed for all antigens (measles seroconversion: 97.9% in the MMR1YF1 group versus 96.3% in the MMR1YF2 group, a difference of 1.6% [90% CI -1.5, 4.7]; rubella: 97.9% MMR1YF1 versus 94.7% MMR1YF2, a difference of 3.3% [-0.1, 6.7]; mumps: 96.7% MMR1YF1 versus 97.9% MMR1YF2, a difference of -1.3% [-4.1, 1.5]; and YF: 96.3% MMR1YF1 versus 97.5% YF1MMR2, a difference of -1.2% [-4.2, 1.7]). Rubella antibody concentrations and YF titers were significantly lower following co-administration; measles and mumps concentrations were not impacted.

CONCLUSION

Effective seroconversion was achieved and was not impacted by the co-administration, although antibody levels for two antigens were lower. The impact of lower antibody levels needs to be weighed against missed opportunities for vaccination to determine optimal timing for MMR and YF vaccine administration.

TRIAL REGISTRATION

The study was retrospectively registered in ClinicalTrials.gov (NCT03368495) on 11/12/2017.

Meningococcal disease in North America: Updates from the Global Meningococcal Initiative

This review summarizes the recent Global Meningococcal Initiative (GMI) regional meeting, which explored meningococcal disease in North America. Invasive meningococcal disease (IMD) cases are documented through both passive and active surveillance networks. IMD appears to be decreasing in many areas, such as the Dominican Republic (2016: 18 cases; 2021: 2 cases) and Panama (2008: 1 case/100,000; 2021: <0.1 cases/100,000); however, there is notable regional and temporal variation. Outbreaks persist in at-risk subpopulations, such as people experiencing homelessness in the US and migrants in Mexico. The recent emergence of β-lactamase-positive and ciprofloxacin-resistant meningococci in the US is a major concern. While vaccination practices vary across North America, vaccine uptake remains relatively high. Monovalent and multivalent conjugate vaccines (which many countries in North America primarily use) can provide herd protection. However, there is no evidence that group B vaccines reduce meningococcal carriage. The coronavirus pandemic illustrates that following public health crises, enhanced surveillance of disease epidemiology and catch-up vaccine schedules is key. Whole genome sequencing is a key epidemiological tool for identifying IMD strain emergence and the evaluation of vaccine strain coverage. The Global Roadmap on Defeating Meningitis by 2030 remains a focus of the GMI.

The COVID-19 pandemic and vaccination abandonment in children: spatial heterogeneity maps

OBJECTIVE

to identify spatial clusters corresponding to abandonment of routine vaccines in children.

METHOD

an ecological study, according to data from the 853 municipalities of a Brazilian state. The records analyzed were those of the multidose pentavalent, pneumococcal 10-valent, inactivated poliomyelitis and oral human rotavirus vaccines of 781,489 children aged less than one year old. The spatial scan statistics was used to identify spatial clusters and assess the relative risk based on the vaccination abandonment indicator.

RESULTS

the spatial scan statistics detected the presence of statistically significant clusters for abandonment regarding the four vaccines in all the years analyzed. However, the highest number of clusters with high relative risk estimates was identified in 2020. The Vale do Aço and West, North and West, and Southwest regions stand out for the pentavalent, poliomyelitis and rotavirus vaccines, respectively.

CONCLUSION

in an attempt to mitigate the devastating impact of the COVID-19 pandemic, the immunization program experienced setbacks. The presence of clusters points to the need to implement integrated strategies that may involve different sectors for an active search for children and prevent outbreaks of vaccine-preventable diseases in the near future.

Population Attributable Fraction of Nonvaccination of Child and Adolescent Vaccines Attributed to Parental Vaccine Hesitancy, 2018-2019

Understanding the role of vaccine hesitancy in undervaccination or nonvaccination of childhood vaccines is important for increasing vaccine confidence and uptake. We used data from April to June interviews in the 2018 and 2019 National Immunization Survey-Flu (n = 78,725, United States), a nationally representative cross-sectional household cellular telephone survey. We determined the adjusted population attributable fraction (PAF) for each recommended childhood vaccine to assess the contribution of vaccine hesitancy to the observed nonvaccination level. Hesitancy is defined as being somewhat or very hesitant toward childhood vaccines. Furthermore, we assessed the PAF of nonvaccination for influenza according to sociodemographic characteristics, Department of Health and Human Services region, and state. The proportion of nonvaccination attributed to parental vaccine hesitancy was lowest for hepatitis B birth dose vaccine (6.5%) and highest for ≥3-dose diphtheria and tetanus toxoids and acellular pertussis vaccine (31.3%). The PAF of influenza nonvaccination was highest for non-Hispanic Black populations (15.4%), households with high educational (17.7%) and income (16.5%) levels, and urban areas (16.1%). Among states, PAF ranged from 25.4% (New Hampshire) to 7.5% (Louisiana). Implementing strategies to increase vaccination confidence and uptake are important, particularly during the coronavirus disease 2019 pandemic.

Parental knowledge about respiratory syncytial virus (RSV) and attitudes to infant immunization with monoclonal antibodies

BACKGROUND

Ninety percent of all children are infected with respiratory syncytial virus (RSV) within their first two years of life. RSV is the main cause behind hospitalization of infants with lower respiratory tract infections. A new monoclonal antibody (mAb) immunization may prevent RSV in all infants. This cross-national study aimed to examine parental knowledge about RSV and attitudes to such RSV immunization.

RESEARCH DESIGN AND METHODS

Based on a literature study, a questionnaire was designed and applied in a survey carried out in China, France, Germany, Italy, Japan, Spain, the UK, and the US. Eligible respondents were expecting their first baby or parents of children <24 months old who were open to vaccination.

RESULTS

Parental acceptance of immunizations relies on perceptions of the preventable disease. In 5627 parents, only 35% reported basic or good level of knowledge about RSV. Recommendation from health care professionals and inclusion in immunization programs were crucial to their acceptance of RSV immunization. If recommended and informed about its efficacy and safety, most parents would accept RSV mAb immunization for their infants.

CONCLUSIONS

Infant RSV infections are highly prevalent, yet parental awareness of RSV is poor. Country variations call for targeted communication about RSV and immunization.

Impact of combination MMRV vaccine on first-dose coverage for measles and varicella: a population-based study

Aim

Combination vaccines decrease the number of needles required, addressing a common concern of parents. However, some parents are hesitant about combination vaccines and/or want to opt out of certain vaccine components. This study assessed whether introduction of the combination MMRV vaccine influenced coverage levels for measles- and varicella-containing vaccines.

Study and methods

This was a population-based study of children born in Alberta, Canada between 2006 and 2012. We utilized administrative health data to evaluate coverage for the first dose of measles- and varicella-containing vaccines at the age of 24 months (i.e. between 2008 and 2014) before and after introduction of the combination MMRV vaccine in 2010. Among those who were vaccinated, we assessed whether any children continued to receive separate vaccines after the combination vaccine was introduced.

Results

Of 308,212 children, 272,345 (88.36%) were vaccinated with measles- and/or varicella-containing vaccines at the age of 24 months. Although coverage for measles-containing vaccines did not change overall between 2008 and 2014, coverage for varicella vaccine increased in the years following the introduction of MMRV. After the combination vaccine introduction, 96.55% of vaccinated children (n = 121,131) received MMRV vaccine.

Conclusion

Vaccine coverage for varicella increased after the introduction of the combination MMRV vaccine, and there was a narrowing in the gap between MMR and varicella coverage. Very few children received separate vaccines after the introduction of the combination MMRV vaccine. These findings suggest that combination vaccines are acceptable to most parents and increase coverage for varicella in our setting.

Parental Vaccine Hesitancy and Association With Childhood Diphtheria, Tetanus Toxoid, and Acellular Pertussis; Measles, Mumps, and Rubella; Rotavirus; and Combined 7-Series Vaccination

INTRODUCTION

Parental vaccine hesitancy can be a barrier to routine childhood immunization and contribute to greater risk for vaccine-preventable diseases. This study examines the impact of parental vaccine hesitancy on childhood vaccination rates.

METHODS

This study assessed the association of parental vaccine hesitancy on child vaccination coverage with ≥4 doses of diphtheria, tetanus toxoid, and acellular pertussis vaccine; ≥1 dose of measles, mumps, and rubella vaccine; up-to-date rotavirus vaccine; and combined 7-vaccine series coverage for a sample of children aged 19-35 months using data from the 2018 and 2019 National Immunization Survey-Child (N=7,645). Adjusted differences in multivariable analyses of vaccination coverage were estimated among vaccine hesitant and nonhesitant parents and population attributable risk fraction of hesitancy on undervaccination, defined as not being up to date for each vaccine.

RESULTS

Almost a quarter of parents reported being vaccine hesitant, with the highest proportion of vaccine hesitancy among parents of children who are non-Hispanic Black (37.0%) or Hispanic (30.1%), mothers with a high school education or less (31.9%), and households living below the poverty level (35.6%). Childhood vaccination coverage for all vaccines was lower for children of hesitant than nonhesitant parents, and the population attributable fraction of hesitancy on undervaccination ranged from 15% to 25%, with the highest percentage for ≥1 dose of measles, mumps, and rubella vaccine.

CONCLUSIONS

Parental vaccine hesitancy may contribute up to 25% of undervaccination among children aged 19-35 months. Implementation of strategies to address parental vaccine hesitancy is needed to improve vaccination coverage for children and minimize their risk of vaccine-preventable diseases.

Pandemia de COVID-19 y abandono de la vacunación en niños: mapas de heterogeneidad espacial

Resumen Objetivo: identificar grupos espaciales que abandonaron la vacunación de rutina de los niños. Método: estudio ecológico, basado en los datos de 853 municipios de un Estado brasileño. Se analizaron los registros de vacunas multidosis pentavalente, antineumocócica 10-valente y antipoliomielítica inactivada y vacuna oral contra el rotavirus humano de 781.489 niños menores de un año de edad. Se utilizó la estadística scan espacial para identificar agrupaciones espaciales y medir el riesgo relativo del indicador abandono de la vacunación. Resultados: la estadística scan espacial detectó la presencia de grupos estadísticamente significativos para el abandono de las cuatro vacunas en todos los años analizados. Sin embargo, el mayor número de grupos con estimaciones altas de riesgos relativos se identificó en 2020. Se destacan las macrorregiones del Vale do Aço y Oeste; Norte y Oeste; y Sudeste para las vacunas pentavalente, antipoliomielítica y contra el rotavirus, respectivamente. Conclusión: mientras se intentaba disminuir el impacto devastador de la pandemia de COVID-19, retrocedió el programa de inmunización. La presencia de grupos indica que es necesario implementar estrategias integradas que puedan involucrar a diferentes sectores para la búsqueda activa de niños y evitar brotes de enfermedades inmunoprevenibles en el futuro próximo.

Parent-level barriers to uptake of childhood vaccination: a global overview of systematic reviews

INTRODUCTION

Understanding barriers to childhood vaccination is crucial to inform effective interventions for maximising uptake. Published systematic reviews include different primary studies, producing varying lists of barriers. To make sense of this diverse body of literature, a comprehensive level of summary and synthesis is necessary. This overview of systematic reviews maps all potential parent-level barriers to childhood vaccination identified in systematic reviews. It synthesises these into a conceptual framework to inform development of a vaccine barriers assessment tool.

METHODS

We applied Joanna Briggs methodology, searching the Epistemonikos review database and reference lists of included reviews to June 2020. Systematic reviews of qualitative or quantitative data on parent-level barriers to routine vaccination in preschool-aged children were included. Reviews addressing influenza, reporting non-modifiable determinants or reporting barriers not relevant to parents were excluded. Where possible, we extracted review details, barrier descriptions and the number, setting and design of primary studies. Two authors independently screened search results and inductively coded barrier descriptions.

RESULTS

We screened 464 papers, identifying 30 relevant reviews with minimal overlap. Fourteen reviews included qualitative and quantitative primary studies, seven included quantitative and seven included qualitative studies only. Two did not report included study designs. Two-thirds of reviews (n=20; 67%) only included primary studies from high-income countries. We extracted 573 barrier descriptions and inductively coded these into 64 unique barriers in six overarching categories: (1) Access, (2) Clinic or Health System Barriers, (3) Concerns and Beliefs, (4) Health Perceptions and Experiences, (5) Knowledge and Information and (6) Social or Family Influence.

CONCLUSIONS

A global overview of systematic reviews of parent-level barriers to childhood vaccine uptake identified 64 barriers to inform development of a new comprehensive survey instrument. This instrument will assess both access and acceptance barriers to more accurately diagnose the reasons for under-vaccination in children in different settings.

Nonpharmacological Methods for Reducing Parental Concern for Infant Vaccine-Associated Pain

INTRODUCTION

Numerous studies demonstrate that parental concern for infant pain contributes to vaccine hesitancy. The purpose of this project was to alleviate parental concern for pain and facilitate infant immunization.

METHOD

Pediatric nurses at an urban ambulatory clinic implemented evidence-based nonpharmacological methods (breastfeeding or 24% sucrose solution) for managing vaccine pain in infants aged up to 6 months. A validated survey measured parental concern for vaccine-related pain before and after the implementation of pain relief interventions.

RESULTS

There was a statistically significant decrease in parental concern for vaccine pain from pre- to postintervention between both treatment groups (p = .035).

DISCUSSION

Nurses can effectively use nonpharmacological methods to alleviate the pain of infants undergoing routine vaccination while reducing the parental concern for vaccine-associated pain. Reducing infant pain and parental concern may increase vaccination rates.

Factors associated with the utilization of inactivated polio vaccine among children aged 12 to 23 months in Kalungu District, Uganda

Uganda officially introduced the inactivated polio vaccine (IPV) in May 2016 as part of the polio eradication strategy and integrated it into its routine immunization programme in addition to the oral polio vaccine. The current coverage stands at 60% as of July 2017. We therefore aimed to determine factors associated with the uptake of IPV among children in Kalungu District so as to inform the implementation of the vaccine policy. A community-based cross-sectional study was conducted among caregivers of 406 eligible children aged 12-23 months through multi-stage systematic sampling and a standardized semi-structured questionnaire. Nine key informant interviews were conducted through purposive selection of health care providers and members of Village Health Teams (VHTs) based on their expertize. Modified Poisson regression and thematic content analysis were used to determine factors significant to IPV uptake among children. 71% of sampled children aged 12-23 months had received IPV in Kalungu District. The survey found that being encouraged by health workers and VHTs was significant to children's uptake of IPV (Adjusted PR 1.24, 95% CI; 1.22-3.47). Distance to the immunization point (Adjusted PR 0.32,95% CI; 0.16-0.62) and caregiver's education level (Adjusted PR 1.16,95% CI; 1.05-2.22) were also associated with IPV uptake. Qualitative findings from health workers and VHT members further confirmed the perception that distance to the immunization post was important, and VHTs also stated that being encouraged by health workers was critical to IPV uptake. The current prevalence of IPV uptake among children aged 12-23 months in Kalungu is 71%, higher than the last reported national coverage (60%), though still below the recommended national coverage of 95%. Efforts should be focused on sensitization of caregivers through health workers and VHTs. Immunization outreach should be strengthened so as to bring services closer to patients.

Vaccine Hesitancy as a Challenge or Vaccine Confidence as an Opportunity for Childhood Immunisation in India

Vaccines have contributed substantially to decreasing the morbidity and mortality rates of many infectious diseases worldwide. Despite this achievement, an increasing number of parents have adopted hesitant behaviours towards vaccines, delaying or even refusing their administration to children. This has implications not only on individuals but also society in the form of outbreaks for e.g. measles, chicken pox, hepatitis A, etc. A review of the literature was conducted to identify the determinants of vaccine hesitancy (VH) as well as vaccine confidence and link them to challenges and opportunities associated with vaccination in India, safety concerns, doubts about the need for vaccines against uncommon diseases and suspicions towards new vaccines were identified as major vaccine-specific factors of VH. Lack of awareness and limited access to vaccination sites were often reported by hesitant parents. Lastly, socio-economic level, educational level and cultural specificities were contextual factors of VH in India. Controversies and rumours around some vaccines (e.g., human papillomavirus) have profoundly impacted the perception of the risks and benefits of vaccination. Challenges posed by traditions and cultural behaviours, geographical specificities, socio-demographic disparities, the healthcare system and vaccine-specific features are highlighted, and opportunities to improve confidence are identified. To overcome VH and promote vaccination, emphasis should be on improving communication, educating the new generation and creating awareness among the society. Tailoring immunisation programmes as per the needs of specific geographical areas or communities is also important to improve vaccine confidence. Fig. 1 Plain language summary.

Timeliness of routine vaccination among children and determinants associated with age-appropriate vaccination in Mongolia

INTRODUCTION

Routine vaccination at the recommended age is crucial to minimize the risk of acquiring vaccine preventable diseases. This study aimed to assess the proportion of children receiving routine immunization at the recommended age and determinants of timely (age-appropriate) vaccination in Mongolia.

MATERIAL AND METHOD

A total of 879 eligible children aged 12-23 months were included in this study. We investigated age-appropriate administration of Bacillus Calmette-Guerin vaccine (BCG); hepatitis B vaccine (Hep B); oral polio vaccine (OPV); pentavalent vaccine; and measles, mumps, and rubella vaccine (MMR) using Kaplan-Meier method. Multilevel logistic regression with random intercept at cluster level was used to assess the determinants of age-appropriate vaccination.

RESULTS

Overall, the crude vaccination coverage for routine vaccinations were above 90% for all vaccines except MMR1 which was 86.0% (95% CI, 83.6-88.2). While the first dose of almost all the vaccines given at birth; BCG, Hep B, and OPV0, were administered in a timely manner, a substantial proportion of second and third doses of these vaccines were not given in a timely manner with age-appropriate vaccination coverage ranging from 35.9% (32.8-39.1%) for MMR1 to 67.7% (64.5-70.7%) for OPV1 respectively. Factors associated with age-appropriate administration of the investigated vaccines included socio-economic status of household, religion of household heads, area of residence, owning mobile phone, and season of childbirth. For instance, children belonging to households from richer wealth quintile had higher possibilities of getting age-appropriate OPV1-OPV3, PE1-PE3 and MMR1 vaccines compared to those from the poorest household wealth quintile.

CONCLUSION

Our findings suggest that the commonly used indicator 'crude vaccination coverage' could be supplemented by 'age-appropriate vaccination' to help to identify gaps in timely vaccinations and stimulate interventions in Mongolia. Factors such as household wealth quintile, place of residence and religion associated with timely vaccination in our study could be considered to promote effective intervention aiming to improve adequate vaccination coverage.

Hepatitis B and pertussis antibodies in 4- to 5-year-old children previously vaccinated with different hexavalent vaccines

In randomized active-comparator controlled studies, DTaP5-HB-IPV-Hib showed comparable immunogenicity and safety to other licensed vaccines. This study assessed persistence of anti-hepatitis B surface antigen (HBs) and anti-pertussis antibodies, when children were 4 to 5 years of age, 3 to 4 years after initial infant/toddler hexavalent vaccination. This was an extension of 2 European studies in which infants/toddlers received either DTaP5-HB-IPV-Hib or DTaP3-HB-IPV/Hib on a 2 + 1 or 3 + 1 schedule. Primary endpoints included percentages with anti-HBs ≥10 mIU/mL, and anti-pertussis toxin (PT), anti-filamentous hemagglutinin (FHA), anti-pertactin (PRN), and anti-fimbriae types 2 & 3 (FIM) greater than or equal to the lower limit of quantitation (LLOQ). One month after 2 + 1 or 3 + 1 dosing, nearly all toddlers had anti-HBs ≥10 mIU/mL, and responded to the received pertussis antigens. Approximately 3 to 4 years later, 65.8%-70.2% in the DTaP5-HB-IPV-Hib and 82.0%-83.7% in the DTaP3-HB-IPV/Hib groups, respectively, had anti-HBs ≥10 mIU/mL. Percentages of children with pertussis antibodies above LLOQ after 2 + 1 dosing were 58.4% and 41.5% (anti-PT), 80.9% and 88.3% (anti-FHA), 66.1% and 72.6% (anti-PRN), and 94.4% and 3.3% (anti-FIM), in the DTaP5-HB-IPV-Hib and DTaP3-HB-IPV/Hib groups, respectively. This study demonstrated, as expected, waning of hepatitis B and pertussis antibodies during the 3 to 4 years after completion of a 3 + 1 or 2 + 1 hexavalent vaccination schedule. Nonetheless, anti-HBs levels ≥10 IU/mL and detectable antibodies against acellular pertussis antigens persisted in most study participants. The implications of these findings for the long-term prevention of hepatitis B and pertussis are further discussed.

Adherence to Timely Vaccinations in the United States

OBJECTIVES

To estimate (1) the proportion of children not adhering to the Advisory Committee on Immunization Practices (ACIP) recommended early childhood immunization schedule and (2) associations between schedule adherence, sociodemographic characteristics, and up-to-date immunization status by 19 to 35 months of age.

METHODS

We used 2014 National Immunization Survey provider-verified vaccination data to classify vaccination patterns as "recommended" (ie, in line with ACIP dose- and age-specific recommendations), "alternate" (ie, in line with either limiting the number of shots per visit or skipping at least 1 vaccine series), or "unknown or unclassifiable" (ie, not in line with ACIP recommendations or clearly limiting shots per visit or vaccine series). We evaluated the association between vaccination patterns and up-to-date status for all ACIP-recommended vaccinations (including rotavirus and hepatitis A vaccines) using Poisson regression.

RESULTS

The majority of children's patterns were classified as "recommended" (63%), with 23% and 14% following alternate or unknown or unclassifiable patterns, respectively; 58% of children were up-to-date with all ACIP-recommended immunizations by 19 to 35 months. Not being up-to-date was associated with alternate (prevalence ratio = 4.2, 95% confidence interval: 3.9-4.5) and unknown or unclassifiable (prevalence ratio = 2.4, 95% confidence interval: 2.2-2.7) patterns.

CONCLUSIONS

High vaccine coverage by 19 to 35 months of age may miss nonadherence to the recommended immunization schedule in the first 18 months of life, leaving children vulnerable to preventable diseases. With more than one-third of US children not following the ACIP schedule, targeted interventions are needed to minimize vaccine delays and disease susceptibility.

Preferences for vaccination program attributes among parents of young infants in Shanghai, China

Compared to many other countries, China offers fewer pediatric vaccines. Future attempts to add mandatory vaccines may run counter to parents' preferences for shot-limiting. The aim of this study was to assess Chinese parents' preferences and willingness-to-pay (WTP) for programmatic attributes of vaccination services. Parents of young infants ≤3 months of age presenting at immunization clinics in Shanghai, China, in 2017 completed a discrete choice experiment (DCE) on vaccination program attributes: waiting time at the clinic, number of shots before 7 months, number of injections per visit, cost per visit, and location of the shot. We estimated preference utilities and WTP using logistic regression. In total, 590 completed the DCE. Caregivers expressed greater utility for less waiting time, fewer office visits, lower cost of vaccines, and fewer injections co-administered. Over the course of their child's first 6 months, parents were willing to pay 113 RMB ($17) to avoid an additional 10 minutes of waiting at each appointment (95% confidence interval [CI]: 213, 929), 474 RMB ($70) to avoid an additional office visit (95% CI: 241, 707), and 703 RMB ($104) to avoid an additional injection at each appointment (95% CI: 337, 1068). As China expands its list of publicly funded vaccines, public health officials will have to counter Chinese parents' strong preferences for limiting the total number of office visits and the number of injections administered at each visit, potentially through the use of combination vaccines.

Measurement of coverage, compliance and determinants of uptake in a publicly funded rotavirus vaccination programme: a retrospective cohort study

OBJECTIVES

In June 2015, Alberta, Canada instituted a universal publicly funded rotavirus vaccination programme (Rotarix, RV1), with vaccine doses scheduled for 2 and 4 months of age. Vaccination was restricted so that infants were only allowed to receive first dose between 6 and 20 weeks of age, and second dose before eight calendar months of age. We assessed the coverage and schedule non-compliance of rotavirus vaccination for babies born between June 2015 and August 2016, that is, since the inception of the publicly funded rotavirus vaccination programme, and determined factors associated with rotavirus vaccine uptake.

DESIGN

Retrospective cohort study using linked administrative health data.

SETTING

Alberta, Canada.

PARTICIPANTS

Cohort of 66 689 children. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) First and second dose rotavirus vaccination coverage, (2) percent of children non-compliant with recommended vaccine schedule and (3) adjusted ORs for factors associated with vaccination status.

RESULTS

For the 66 689 children included in the study, coverage levels for one-dose and two-dose rotavirus vaccination were 87% and 83%, respectively. In comparison, two-dose diphtheria-tetanus-pertussis-polio-Haemophilus influenzae type b vaccine coverage was 92%, despite having the same dosing schedule. Schedule non-compliance during the publicly funded programme was very low. We observed socioeconomic disparities in the uptake of the vaccine, with income, location of residence and number of children in the household all contributing to the odds of a child being vaccinated with rotavirus.

CONCLUSIONS

Compliance to the recommended rotavirus schedule was very high, suggesting that even with the restrictive rotavirus vaccine schedule, the vaccine can be delivered on-time. However, rotavirus vaccine coverage remained lower than DTaP, a similarly scheduled childhood vaccination. We also observed socioeconomic disparities in vaccine uptake. These findings raise concerns about rotavirus protection in the groups at highest risk for gastrointestinal illness, including low-income and rural populations.

Home-based records and vaccination appointment stickers as parental reminders to reduce vaccination dropout in Indonesia: A cluster-randomized controlled trial

INTRODUCTION

Limited evidence is available about the effectiveness of strategies to remind caregivers when to bring children back for future vaccinations in low- and middle-income country settings. We evaluated the effectiveness of two reminder strategies based on home-based vaccination records (HBR) in Indonesia.

METHODS

In this cluster-randomized controlled trial involving 3616 children <1 year of age, 90 health facilities were randomly assigned to either a control group or one of two intervention groups: (1) HBR-only group, where healthcare workers provided an HBR to any child without an HBR during a vaccination visit and instructed the caregiver to keep it at home between visits, or (2) HBR + sticker group, where, in addition to HBR provision, healthcare workers placed vaccination appointment reminder stickers on the HBR. The primary outcome was receipt of the third dose of diphtheria-tetanus-pertussis-containing vaccine (DTPcv3) within 7 months and the secondary outcome was receipt of a timely DTPcv3 dose.

RESULTS

Control group DTPcv3 coverage was 81%. In intention-to-treat analysis, neither intervention group had significantly different DTPcv3 coverage compared with the control group (RR = 0.94, 95% confidence interval [CI] 0.87; 1.02 for HBR-only group; RR = 0.97, 95% CI 0.90; 1.04 for HBR + sticker group) by study end. However, children in the HBR + sticker group were 50% more likely to have received a DTPcv3 vaccination (RR = 1.46, 95% CI 1.02, 2.09) within 60 days of DTPcv1 vaccination, compared with children in the control group; children in the HBR-only group were not more likely to have done so (RR = 1.05, 95% CI 0.71, 1.55).

DISCUSSION

Reminder stickers had an immediate effect on coverage by improving the proportion of children who received a timely DTPcv3 dose but no effect on the proportion who received DTPcv3 after 7 months. Coupling reminder stickers with strategies to address other reasons why children do not return for vaccination visits should be further explored.

Accelerating Typhoid Conjugate Vaccine Introduction: What Can Be Learned From Prior New Vaccine Introduction Initiatives?

The health consequences of typhoid, including increasing prevalence of drug-resistant strains, can stress healthcare systems. While vaccination is one of the most successful and cost-effective health interventions, vaccine introduction can take years and require considerable effort. The Typhoid Vaccine Acceleration Consortium (TyVAC) employs an integrated, proactive approach to accelerate the introduction of a new typhoid conjugate vaccine to reduce the burden of typhoid in countries eligible for support from Gavi, the Vaccine Alliance. TyVAC and its partners are executing a plan, informed by prior successful vaccine introductions, and tailored to the nuances of typhoid disease and the typhoid conjugate vaccine. The iterative process detailed herein summarizes the strategy and experience gained from the first 2 years of the project.

Compliance with vaccination schedules

Childhood immunization is amongst the most cost-effective public health interventions for reducing children's morbidity and mortality. Vaccination coverage is commonly used to assess the vaccination status of a community. Adherence to schedule is critical for providing maximum effectiveness against vaccine-preventable diseases in the community. This is of paramount importance for diseases that are continuously circulating because they can cause large outbreaks. All stakeholders (public health administrators and vaccination providers) should work together in order to increase both vaccination coverage and adherence to schedule. They have to improve the infrastructure used for delivering vaccines, train the health care professionals and finally raise the awareness of the importance of vaccines among parents.

Introduction of inactivated poliovirus vaccine in the Philippines: Effect on health care provider and infant caregiver attitudes and practices

BACKGROUND

The introduction of inactivated poliovirus vaccine (IPV) to the Philippines' national immunization schedule meant the addition of a third injectable vaccine at a child's 14-week immunization visit. Although previous studies have shown that providing multiple vaccines at the same time affected neither the risk of severe adverse events nor vaccine efficacy, concerns were raised that providing three injections at a single visit, with two injections in one leg, might be unacceptable to health care providers (HCP) and infant caregivers.

METHODS

We conducted pre- and post-IPV introduction surveys on the acceptance and acceptability of the additional injectable vaccine in three of the Philippines' 17 administrative regions. Regions 3 and 6 were included in the pre-introduction phase and Regions 3, 6 and 10 were included in the post-introduction phase. Thirty public health centers (PHCs) were randomly sampled from each region. HCPs and infant caregivers were interviewed. In addition, vaccination records from a minimum of 20 eligible children pre-introduction and 10 children post-introduction per PHC were reviewed.

RESULTS AND DISCUSSION

We interviewed 89 HCPs and 286 infant caregivers during the pre-introduction phase and 137 HCPs and 455 caregivers during the post-introduction phase. Among 986 vaccination records reviewed post-introduction, 84% (n = 826) of children received all three recommended injections at one visit, with a range from 61% (209/342) in Region 10 to 100% (328/328) in Region 3. The proportion of HCPs reporting that they had administered three or more injectable vaccines and the proportion of caregivers that would be comfortable with their child receiving three or more injectable vaccines at one visit increased from pre- to post-introduction (p < 0.0001 for both). Eighty-seven percent of HCPs that had administered three or more injectable vaccines post-introduction reported being comfortable or very comfortable with the number of vaccines they had administered.

Implementing vaccine hesitancy screening for targeted education

BACKGROUND AND PURPOSE

Little research has been performed investigating the effect of using a vaccine hesitancy (VH) screening tool to address specific vaccination concerns. The purpose of this study was to determine whether using a VH screening tool in conjunction with provider discussions addressing parental concerns affected the parental intent to vaccinate (ITV).

METHODS

This study used a pretest/posttest design to measure and categorize VH and ITV.

CONCLUSIONS

The total sample size was 89. Differences between previsit and postvisit questionnaires showed mean responses for questions that measured specific VH categories had slight increases in the level of VH. A regression analysis was conducted to predict the postvisit ITV. Questions measuring parental trust in the provider, beliefs on vaccine efficacy, and beliefs about the prevalence of vaccine preventable disease (VPD) in the community predicted 72% of the postvisit ITV responses.

IMPLICATIONS FOR PRACTICE

The utilization of a VH screening tool used in conjunction with provider education in an educated and mildly VH population did not positively affect the level of VH or the parental ITV. Additional research should investigate the role of parental trust in the provider, beliefs on vaccine efficacy, and the prevalence of VPD in the community affect parental ITV.

The influence of education on the access to childhood immunization: the case of Spain

BACKGROUND

In order to enhance childhood vaccination uptake and the health consequences for the whole society, there is a need to study predictors that might help in understanding parents' behaviour in relation to childhood vaccination schemes. The aim of this paper is to assess whether parental education has an influence on their children's public health-care use in terms of visits for vaccinations, and thus evaluate whether more educated parents use public health resources more frequently in childhood immunization schedules.

METHODS

The setting was the region of Catalonia in the north-east of Spain. Three different databases, containing information about 11,415 individuals corresponding to 79,905 observations, were merged and linked: 1) observational and longitudinal administrative data for adults and children in Catalonia; 2) a database containing information on the vaccination of children in relation to the public health programme called the "Healthy Child Programme"; and 3) the governmental vaccination registration. The presence of an education gradient was explored using a logistic regression. Children's health-care use was modelled using a logistic procedure.

RESULTS

The greater the mothers' educational attainment level, the higher the probability of being vaccinated in this immunization programme. The presence of an age profile for vaccinations showed that less educated parents visit their GPs more frequently for immunizations when their children are below the age of six, but that pattern is completely the opposite after that age. Hence, for children aged between six and 16, more educated parents are more likely to ensure their children are immunized. Likewise, systematic vaccinations are more likely for those parents with a lower educational attainment level.

CONCLUSIONS

This paper evidenced the presence of an education gradient for specific preventive care through the public health system and visits to the GP without any particular disease or advice for specific vaccinations.

Impact of the addition of new vaccines in the early childhood schedule on vaccine coverage by 24 months of age from 2006 to 2016 in Quebec, Canada

CONTEXT

Between 2004 and 2016, in the province of Quebec (Canada), 4 new antigens were added in the early childhood vaccine schedule from birth to 18 months, increasing the number of injections or doses needed from 7 to 12. These additions may have decreased the proportion of children who had received all recommended vaccines.

OBJECTIVES

To assess the impact of the introduction of new vaccines to the childhood schedule on the 24-month vaccine coverage from 2006 to 2016 and identify factors associated with incomplete vaccination status by 24 months of age.

METHODS

We used the data from six cross-sectional vaccine coverage surveys conducted every two years which included a total of 3515 children aged 2 years old and randomly selected from the Quebec public health insurance database. Factors associated with an incomplete vaccine status by 24 months were identified with multivariable logistic regression.

RESULTS

Despite the addition of 4 new vaccine antigens since 2004, the vaccine coverage remained high from 2006 (82.4%) through 2016 (88.3%) for vaccines present in the schedule since 2006. In 2016, vaccine coverage was 78.2% for all vaccines included in the schedule. The vaccine coverage of new vaccines increases rapidly within 2 years of their introduction. For both new and older vaccines, incomplete vaccine status by 24 months of age is associated with a delay of 30 days or more in receiving the vaccines scheduled at 2 and 12 months of age.

CONCLUSIONS

Increasing to 12 the number of doses in the recommended schedule has slightly reduced the vaccine coverage by 24 months of age and the vaccine coverage of vaccines already in the schedule remained stable over the years. Future additions to the vaccine schedule may not be similarly accepted by the population and this will require continuing the monitoring of vaccine coverage.

Missed opportunities for HPV immunization among young adult women

BACKGROUND

Despite the availability of a safe and efficacious vaccine against human papillomavirus, uptake of the vaccine in the United States is low. Missed clinical opportunities to recommend and to administer human papillomavirus vaccine are considered one of the most important reasons for its low uptake in adolescents; however, little is known about the frequency or characteristics of missed opportunities in the young adult (18-26 years of age) population.

OBJECTIVE

The objective of the study was to assess both the rates of and the factors associated with missed opportunities for human papillomavirus immunization among young adult women who attended an urban obstetrics and gynecology clinic.

STUDY DESIGN

In this cross-sectional study, medical records were reviewed for all women 18-26 years of age who were underimmunized (<3 doses) and who sought care from Feb. 1, 2013, to January 31, 2014, at an urban, hospital-based obstetrics and gynecology clinic. A missed opportunity for human papillomavirus immunization was defined as a clinic visit at which the patient was eligible to receive the vaccine and a dose was due but not administered. Multivariable logistic regression was used to test associations between sociodemographic variables and missed opportunities.

RESULTS

There were 1670 vaccine-eligible visits by 1241 underimmunized women, with a mean of 1.3 missed opportunities/person. During the study period, 833 of the vaccine eligible women (67.1%) had at least 1 missed opportunity. Overall, the most common types of visits during which a missed opportunity occurred were postpartum visits (17%) or visits for either sexually transmitted disease screening (21%) or contraception (33%). Of the patients with a missed opportunity, 26.5% had a visit at which an injectable medication or a different vaccine was administered. Women who identified their race as black had higher adjusted odds of having a missed opportunity compared with white women (adjusted odds ratio, 1.61 [95% confidence interval, 1.08-2.41], P < .02). Women who reported a non-English- or non-Spanish-preferred language had lower adjusted odds of having a missed opportunity (adjusted odds ratio, 0.25 [95% confidence interval, 0.07-0.87], P = .03). No other patient characteristics assessed in this study were significantly associated with having a missed opportunity.

CONCLUSION

A majority of young-adult women in this study had missed opportunities for human papillomavirus immunization, and significant racial disparity was observed. The greatest frequency of missed opportunities occurred with visits for either contraception or for sexually transmitted disease screening.

Evaluation of potentially achievable vaccination coverage of the second dose of measles containing vaccine with simultaneous administration and risk factors for missed opportunities among children in Zhejiang province, east China

OBJECTIVES

This study aimed to evaluate the potential achievable coverage of the second dose of measles containing vaccine (MCV2) when the protocol of simultaneous administration of childhood vaccines was fully implemented. Risk factors for missed opportunity (MO) for simultaneous administration of MCV2 were also investigated.

METHODS

Children born from 1 January 2005 to 31 December 2014 and registered in Zhejiang provincial immunization information system were enrolled in this study. The MO of simultaneous administration of MCV2, the actual age-appropriate coverage (AAC) of MCV2 and the potentially achievable coverage (PAC) of MCV2 were evaluated and compared across different birth cohorts, by different socio-demographic variables. For the 2014 birth cohort, logistic regression model was used to detect the risk factors of MOs, from both socio-demographic and vaccination service providing aspects.

RESULTS

Compared to the AAC, the PAC of MCV2 increased significantly from 2005 birth cohort to 2014 birth cohort (p<0.001), with a median of 12.7 percentage points. Higher birth order of children, resident children, higher maternal education background, higher socio-economic development level of resident areas, less frequent vaccination service, and shorter vaccination service time were significant risk factors of MO for simultaneous administration of MCV2, with all p-value < 0.05.

CONCLUSION

The findings in this study suggest that fully utilization of all opportunities for simultaneous administration of all age-eligible vaccine doses at the same vaccination visit is critical for achieving the coverage target of 95% for MCV2. Future interventions focusing on the group with risk factors observed could substantially eliminate MOs for simultaneous administration of MCV2, further to improve the coverage of fully immunization of MCV, and finally achieve the goal of eliminating measles.

Perceptions of caregivers and providers regarding the potential introduction of the varicella vaccine to the childhood immunisation schedule in New Zealand: A qualitative exploratory study

AIM

The varicella vaccine has been proposed to be added to the childhood immunisation schedule in New Zealand as the fourth injectable at the 15-month event. We sought to understand the perceptions of caregivers and health-care providers regarding the potential introduction of routine varicella vaccination.

METHODS

A qualitative exploratory study was conducted using semi-structured interviews with caregivers and providers (N = 20) in Auckland. Key themes from the interviews were identified through thematic analysis using a combination of deductive and inductive coding.

RESULTS

All of the participants were aware of varicella but levels of awareness varied among caregivers regarding the varicella vaccine. Participants expressed positive support towards universal varicella vaccination and a high intention to vaccinate if available as a routine vaccine. However, many concerns were raised about multiple injections at a single immunisation visit, and participants suggested alternative scheduling options.

CONCLUSION

The results indicated a need to raise awareness among caregivers about the varicella vaccine, focusing on positive health beliefs about vaccination in terms of protecting the child's health and reducing the impact of a child getting varicella on the family. Health-care providers and government health authorities may play an important role in increasing positive health beliefs about the varicella vaccine. Should the varicella vaccine be introduced as proposed, our findings recommend an educational campaign to address both caregiver and provider concerns about multiple injections and how to manage alternative immunisation schedules. These insights may help inform national strategies for the proposed addition to increase acceptance of the varicella vaccination.

Parent Attitudes Toward Pain Management for Childhood Immunizations

OBJECTIVES

Evidence-based pain-limiting strategies for pediatric immunizations remain underutilized, with barriers identified to date mostly pertaining to health care providers and systems of care. The present study sought to quantify and investigate parent attitudes toward pain management as another potential barrier to the routine use of pain-mitigating strategies during immunizations.

MATERIALS AND METHODS

Questionnaires measuring parent attitudes, willingness to pay, and perceived barriers for using pain management for immunizations were completed by 259 parent/guardians of children ages 0 to 5 years attending appointments at an urban primary care clinic in the Midwestern United States.

RESULTS

Parent attitudes toward pain management for immunization were relatively normally distributed and varied from strongly positive to negative, with 33% of parents disagreeing that they were concerned about the pain their child may experience and 50% agreeing that there are no lasting negative effects from immunization pain. Negative parent attitudes were associated with willingness to spend less in money or time for pain management and with greater perceived significance of cost, time, and other barriers for using pain-mitigating strategies.

DISCUSSION

Some parents perceive limited value in trying to reduce pain during immunizations such that they may be hesitant to invest much time or effort in interventions. Greater success of translating evidence-based pain management into practice therefore may require accounting for differences in parent attitudes by tailoring educational efforts and pain management options accordingly.

Assessing Inactivated Polio Vaccine Introduction and Utilization in Kano State, Nigeria, April-November 2015

Background.

Kano State, Nigeria, introduced inactivated polio vaccine (IPV) into its routine immunization (RI) schedule in March 2015 and was the pilot site for an RI data module for the National Health Management Information System (NHMIS). We determined factors impacting IPV introduction and the value of the RI module on monitoring new vaccine introduction.

Methods.

Two assessment approaches were used: (1) analysis of IPV vaccinations reported in NHMIS, and (2) survey of 20 local government areas (LGAs) and 60 associated health facilities (HF).

Results.

By April 2015, 66% of LGAs had at least 20% of HFs administering IPV, by June all LGAs had HFs administering IPV and by July, 91% of the HFs in Kano reported administering IPV. Among surveyed staff, most rated training and implementation as successful. Among HFs, 97% had updated RI reporting tools, although only 50% had updated microplans. Challenges among HFs included: IPV shortages (20%), hesitancy to administer 2 injectable vaccines (28%), lack of knowledge on multi-dose vial policy (30%) and age of IPV administration (8%).

Conclusion.

The introduction of IPV was largely successful in Kano and the RI module was effective in monitoring progress, although certain gaps were noted, which should be used to inform plans for future vaccine introductions.

Acceptance of the Administration of Multiple Injectable Vaccines in a Single Immunization Visit in Albania

Background.

Albania introduced inactivated polio vaccine (IPV) into its immunization system in May 2014, increasing the maximum recommended number of injectable vaccines given in a single visit from 2 to 3.

Methods.

Health-care providers and caregivers were interviewed at 42 health facilities in Albania to assess knowledge, attitudes, and practices regarding injectable vaccine administration. Immunization register data were abstracted from December 2014 to July 2015 at the same facilities to explore the number of injectable vaccines children received during their 2- and 4-month visits.

Results.

The majority of children (87%) identified in the record review at either their 2- or 4-month immunization visit received all 3 injectable vaccines in a single visit. Almost all children who did not receive the vaccines in a single visit were subsequently fully immunized, most within a 2-week period. Over half of caregivers whose children got 3 or more injectable vaccines in a single visit reported being only comfortable with 1 or 2 injectable vaccines in a single visit.

Conclusions.

Despite most caregivers expressing hesitation regarding children receiving multiple injectable vaccines in a single visit, most children received vaccines according to the recommended schedule. Almost all children eventually received all recommended vaccines.

Experience With Inactivated Polio Vaccine Introduction and the "Switch" From Trivalent to Bivalent Oral Polio Vaccine in the World Health Organization's Western Pacific Region

The World Health Organization (WHO) Western Pacific Region (WPR) has maintained its polio-free status since 2000. The emergence of vaccine-derived polioviruses (VDPVs), however, remains a risk, as oral polio vaccine (OPV) is still used in many of the region's countries, and pockets of unimmunized or underimmunized children exist in some countries. From 2014 to 2016, the region participated in the globally coordinated efforts to introduce inactivated polio vaccine (IPV) into all countries that did not yet include it in their national immunization schedules, and to "switch" from trivalent OPV (tOPV) to bivalent OPV (bOPV) in all countries still using OPV in 2016.As of September 2016, 15 of 17 countries and areas that did not use IPV by the end of 2014 had introduced IPV. Introduction in the remaining 2 countries has been delayed because of the global shortage of IPV, making it unavailable to select lower-risk countries until the fourth quarter of 2017. All 16 countries using OPV as of 2016 successfully withdrew tOPV during the globally synchronized switch from April to May 2016, and 15 of 16 countries introduced bOPV at the same time, with the remaining country introducing it within 30 days. While countries were primarily responsible for self-funding these activities, additional support was provided.The main challenges encountered in the Western Pacific Region with both IPV introduction and the tOPV-bOPV switch were related to overcoming regulatory policies and challenges with vaccine procurement. As a result, substantial lead time was needed to resolve procurement and regulatory issues before the introductions of IPV and bOPV. As the global community prepares for the full removal of all OPV from immunization programs, this need for lead time and consideration of the impact on national policies should be considered.

Effect of combination vaccines on completion and compliance of childhood vaccinations in the United States

Vaccination at age-appropriate intervals increases protection against morbidity and mortality; however, compliance rates among children remain low partly due to a complicated vaccination schedule. Use of combination vaccines reduces the number of injections per visit; however, there is limited evidence quantifying the effect of combination vaccines on vaccination rates. To examine how combination vaccines impact childhood completion (receipt of recommended doses) and compliance (receipt of age-appropriate vaccinations) rates, this study analyzed vaccination data from the 2012 National Immunization Survey (NIS), a nationally representative cross-sectional survey of caregivers of children aged 24 to 35 months in the United States. Vaccines were categorized as combination or single antigen. Vaccine completion was measured at ages 8, 18, and 24 months. Vaccine compliance and time undervaccinated were measured at 24 months. Children who received at least 1 combination vaccine (86%) had a higher completion rate (69%) and compliance with the full vaccine series (4:3:1:3:3:1:4 series) at 24 months (24%) than those who received only single-antigen vaccines (50% and 13%, respectively). Receipt of combination vaccine was associated with an increased likelihood of completing all recommended vaccinations at 24 months (odds ratio [OR] = 2.5; P < 0.001), receiving all vaccinations at age-appropriate times (OR = 2.2; P < 0.001), and less than 7 months undervaccinated (OR = 2.4; P < 0.001). Combination vaccines were associated with improved completion and compliance and should be encouraged among children who are undervaccinated or who received single-antigen vaccines only.

Administering Multiple Injectable Vaccines During a Single Visit-Summary of Findings From the Accelerated Introduction of Inactivated Polio Vaccine Globally

Background.

In 2013, the World Health Organization’s (WHO’s) Strategic Advisory Group of Experts (SAGE) recommended that all 126 countries using only oral polio vaccine (OPV) introduce at least 1 dose of inactivated polio vaccine (IPV) into their routine immunization schedules by the end of 2015. In many countries, the addition of IPV would necessitate delivery of multiple injectable vaccines (hereafter, “multiple injections”) during a single visit, with infants receiving IPV alongside pentavalent vaccine (which covers diphtheria, tetanus, and whole-cell pertussis; hepatitis B; and Haemophilus influenzae type b) and pneumococcal vaccine. Unanticipated concerns emerged from countries over acceptability of multiple injections, sites of administration, and safety. We contextualized the issues surrounding multiple injections by documenting concerns associated with administration of ≥3 injections, existing evidence in the published literature, and findings of a systematic review on administration practices and techniques.

Methods.

Concerns associated with multiple-injection visits were documented from meetings and personal communications with immunization program managers. Published literature on the acceptability of multiple injections by providers and caregivers was summarized, and a systematic review of the literature on administration practices was completed on the following topics: spacing between injection sites (ie, vaccine spacing), site of injection, route of injection, and procedural preparedness. WHO and United Nations Children’s Fund data from 2013–2015 were used to assess multiple-injection visits included in national immunization schedules.

Results.

Healthcare provider and caregiver attitudes and practices indicated concerns about infant pain, potential adverse effects, and uncertainty about vaccine effectiveness with multiple-injection visits. Published literature reinforced the record of safety and acceptance of the recommended schedule of IPV by the SAGE, but the evidence was largely from developed countries. Parental acceptance of multiple injections was associated with a positive provider recommendation to the caregiver. Findings of the systematic review identified that the intramuscular route is preferred over the subcutaneous route for vaccine administration and that the vastus lateralis muscle is preferred over the deltoid muscle for intramuscular injections. Recommendations on vaccine spacing and procedural preparedness were based on practical necessities, but comparative evidence was not identified. During 2013–2015, 85 countries added IPV to their immunization schedules, 46 (55%) of which adopted a schedule resulting in 3 injectable vaccines being administered in a single visit.

Conclusion.

The multiple-injection experience identified gaps in guidance for future vaccine introductions. Global partner organizations quickly mobilized to assess, document, and communicate the existing global experience on multiple-injection visits. This evidence-based approach provided reassurance to opinion leaders, health workers, and professional societies, thus encouraging uptake of IPV as a second or third injection in an accelerated manner globally.