Perceptions of oral cholera vaccine and reasons for full, partial and non-acceptance during a humanitarian crisis in South Sudan

COVID-19 Vaccine Hesitancy and Associated Oral Cholera Vaccine Hesitancy in a Cholera-Endemic Country: A Community-Based Cross-Sectional Study in the Democratic Republic of Congo

COVID-19 vaccine hesitancy and its enablers shape community uptake of non-covid vaccines such as the oral cholera vaccine (OCV) in the post-COVID-19 era. This study assessed the impact of COVID-19 vaccine hesitancy and its drivers on OCV hesitancy in a cholera-endemic region of the Democratic Republic of Congo. We conducted a community-based survey in Bukavu. The survey included demographics, intention to take OCV and COVID-19 vaccines, reasons for COVID-19 hesitancy, and thoughts and feelings about COVID-19 vaccines. Poisson regression analyses were performed. Of the 1708 respondents, 84.66% and 77.57% were hesitant to OCV alone and to both OCV and COVID-19, respectively. Hesitancy to COVID-19 vaccines rose OCV hesitancy by 12% (crude prevalence ratio, [cPR] = 1.12, 95%CI [1.03-1.21]). Independent predictors of OCV hesitancy were living in a semi-urban area (adjusted prevalence ratio [aPR] = 1.10, 95%CI [1.03-1.12]), religious refusal of vaccines (aPR = 1.06, 95%CI [1.02-1.12]), concerns about vaccine safety (aPR = 1.05, 95%CI [1.01-1.11]) and adverse effects (aPR = 1.06, 95%CI [1.01-1.12]), as well as poor vaccine literacy (aPR = 1.07, 95%CI [1.01-1.14]). Interestingly, the belief in COVID-19 vaccine effectiveness reduced OCV hesitancy by 24% (aPR = 0.76, 95%CI [0.62-0.93]). COVID-19 vaccine hesitancy and its drivers exhibited a significant domino effect on OCV uptake. Addressing vaccine hesitancy through community-based health literacy and trust-building interventions would likely improve the introduction of novel non-COVID-19 vaccines in the post-COVID-19 era.

Health Problems of Increasing Man-Made and Climate-Related Disasters on Forcibly Displaced populations: A Scoping Review on Global Evidence

Forcibly displaced populations are among the most vulnerable groups in disasters. They experience poorer health conditions compared with nondisplaced individuals. However, a clear picture is lacking regarding the overall health problems encountered by disaster-induced mid- to long-term displaced people. This study investigated these disorders prevalence and identified their correlates among long-settled displaced populations worldwide. The current scoping review follows the PRISMA-ScR guidelines; a systematic search was conducted on PubMed, Web of Science, and CINAHL and included original peer-reviewed studies, commentary, reviews, and grey literature published in English between January 1990 to June 2022. In the thematic and content analysis, the authors applied the narrative review approach to identify themes and sub-themes. Forty-eight documents were identified as fully relevant to this study. The largest number of published papers were from Asia, followed by the Middle East, the United States, and Europe. IDPs in developed countries were the most researched populations. Human-made disasters were addressed by 89% of the included studies. The four main thematic categories included were "physical health," "mental health," "inadequate facilities," and "lack of healthy behaviour." The worsening of noncommunicable diseases had the highest prevalence, followed by communicable diseases. Due to their condition, forcibly displaced migrants face a triple burden of communicable diseases and noncommunicable diseases such as mental health issues. Health-related research and policy need to consider the links among disasters, health problems, and forced migration as a determinant of health in the new era of climate change-driven displacements.

Oral cholera vaccine coverage evaluation survey: Forcibly Displaced Myanmar Nationals and host community in Cox's Bazar, Bangladesh

Introduction

Cholera remains a significant public health concern in many parts of the world, particularly in areas with poor sanitation and hygiene. Bangladesh and other impoverished nations have been severely affected by cholera outbreaks, especially in areas with a high population density. In order to mitigate the spread of cholera, oral cholera vaccines (OCVs) are recommended as a prophylactic measure. In May 2018, 775,666 of the Forcibly Displaced Myanmar Nationals (FDMN) in the registered and makeshift camps and 103,605 of the residents in the host community received two doses of OCV Shanchol^TM in Cox's Bazar, Bangladesh, because the conditions in the area favored the transmission of cholera and other waterborne diseases. This study aimed to assess the coverage of OCV among the FDMN and the host community in Cox's Bazar.

Methods

In August 2018, we enrolled 4,240 respondents for this study following the "World Health Organization (WHO) Vaccination Coverage Cluster Surveys: Reference Manual (2018)." The coverage survey was conducted with three strata of the population: the host community from the Teknaf Upazila, the registered camp, and the makeshift camp from the Ukhia Upazila. We collected information regarding OCV coverage, demographic characteristics, and knowledge and behaviors of people toward the vaccine. The data were analyzed using descriptive statistics.

Results

According to our study, the overall OCV coverage was 85%, with 68% in the host community, 91% in the registered camp, and 98% in the makeshift camp. The lower coverage in the host community was due to residents unaware of the vaccination campaign, the unavailability of vaccines, and unaware where to go for vaccination.

Discussion

Our findings demonstrate that the OCV campaign in the FDMN camps was successful, reaching over 90% coverage, while coverage in the host community was much lower. In order to make sure that OCV vaccination efforts are reaching the target population and having the desired impact, our study emphasizes the need to inform the target population of when and where to get vaccinated.

A scoping review of facilitators and barriers influencing the implementation of surveillance and oral cholera vaccine interventions for cholera control in lower- and middle-income countries

BACKGROUND

Cholera still affects millions of people worldwide, especially in lower- and middle-income countries (LMICs). The Global Task Force on Cholera Control (GTFCC) has identified surveillance and oral cholera vaccines as two critical interventions to actualise the global roadmap goals-reduction of cholera-related deaths by 90% and decreasing the number of cholera endemic countries by half by 2030. Therefore, this study aimed to identify facilitators and barriers to implementing these two cholera interventions in LMIC settings.

METHODS

A scoping review using the methods presented by Arksey and O'Malley. The search strategy involved using key search terms (cholera, surveillance, epidemiology and vaccines) in three databases (PubMed, CINAHL and Web of Science) and reviewing the first ten pages of Google searches. The eligibility criteria of being conducted in LMICs, a timeline of 2011-2021 and documents only in English were applied. Thematic analysis was performed, and the findings were presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension.

RESULTS

Thirty-six documents met the predefined inclusion criteria, covering 2011 to 2021. There were two themes identified regarding the implementation of surveillance: timeliness and reporting (1); and resources and laboratory capabilities (2). As for oral cholera vaccines, there were four themes identified: information and awareness (1); community acceptance and trusted community leaders (2); planning and coordination (3); and resources and logistics (4). Additionally, adequate resources, good planning and coordination were identified to be operating at the interface between surveillance and oral cholera vaccines.

CONCLUSION

Findings suggest that adequate and sustainable resources are crucial for timely and accurate cholera surveillance and that oral cholera vaccine implementation would benefit from increased community awareness and engagement of community leaders.

Race, ethnicity and COVID-19 vaccination: a qualitative study of UK healthcare staff

OBJECTIVE

COVID-19-related inequities experienced by racial and ethnic minority groups including healthcare professionals mirror wider health inequities, which risk being perpetuated by lower uptake of vaccination. We aim to better understand lower uptake among racial and ethnic minority staff groups to inform initiatives to enhance uptake.

DESIGN

Twenty-five semi-structured interviews were conducted (October 2020-January 2021) with UK-based healthcare staff. Data were inductively and thematically analysed.

RESULTS

Vaccine decision-making processes were underpinned by an overarching theme, 'weighing up risks of harm against potential benefits to self and others'. Sub-themes included 'fear of harm', 'moral/ethical objections', 'potential benefits to self and others', 'information and misinformation', and 'institutional or workplace pressure'. We identified ways in which these were weighted more heavily towards vaccine hesitancy for racial and ethnic minority staff groups influenced by perceptions about institutional and structural discrimination. This included suspicions and fear around institutional pressure to be vaccinated, racial injustices in vaccine development and testing, religious or ethical concerns, and legitimacy and accessibility of vaccine messaging and communication.

CONCLUSIONS

Drawing on a critical race perspective, we conclude that acknowledging historical and contemporary abuses of power is essential to avoid perpetuating and aggravating mistrust by de-contextualising hesitancy from the social processes affecting hesitancy, undermining efforts to increase vaccine uptake.

Traumatic Events and Vaccination Decisions: A Systematic Review

Despite the apparent relationship between past experiences and subsequent vaccination decisions, the role of traumatic events has been overlooked when understanding vaccination intention and behaviour. We conducted a systematic review to synthesize what is known about the relationship between traumatic events and subsequent vaccination decisions. MEDLINE, PsycINFO and CINHAL electronic databases were searched, and 1551 articles were screened for eligibility. Of the 52 articles included in full-text assessment, five met the eligibility criteria. Findings suggest that the experience of trauma is associated with individual vaccination decisions. Social and practical factors related to both trauma and vaccination may mediate this relationship. As this is a relatively new field of inquiry, future research may help to clarify the nuances of the relationship. This review finds that the experience of psychological trauma is associated with vaccination intention and behaviour and points to the potential importance of a trauma-informed approach to vaccination interventions during the current global effort to achieve high COVID-19 vaccine coverage.

Trust, Care Avoidance, and Care Experiences among Kenyan Women Who Delivered during the COVID-19 Pandemic

We explore how the COVID-19 pandemic was associated with avoidance of, and challenges with, antenatal, childbirth and postpartum care among women in Kiambu and Nairobi counties, Kenya; and whether this was associated with a report of declined trust in the health system due to the pandemic. Women who delivered between March and November 2020 were invited to participate in a phone survey about their care experiences (n = 1122 respondents). We explored associations between reduced trust and care avoidance, delays and challenges with healthcare seeking, using logistic regression models adjusted for women's characteristics. Approximately half of respondents said their trust in the health care system had declined due to COVID-19 (52.7%, n = 591). Declined trust was associated with higher likelihood of reporting barriers accessing antenatal care (aOR 1.59 [95% CI 1.24, 2.05]), avoiding care for oneself (aOR 2.26 [95% CI 1.59, 3.22]) and for one's infant (aOR 1.77 [95% CI 1.11, 2.83]), and of feeling unsafe accessing care (aOR 1.52 [95% CI 1.19, 1.93]). Since March 2020, emergency services, routine care and immunizations were avoided most often. Primary reported reasons for avoiding care and challenges accessing care were financial barriers and problems accessing the facility. Declined trust in the health care system due to COVID-19 may have affected health care-seeking for women and their children in Kenya, which could have important implications for their health and well-being. Programs and policies should consider targeted special "catch-up" strategies that include trust-building messages and actions for women who deliver during emergencies like the COVID-19 pandemic.

Understanding the health needs of internally displaced persons: A scoping review

We seek to strengthen understanding of the health needs of internally displaced persons (IDPs) in contexts of conflict or violence. Based upon a scoping review, our paper identified limited evidence on IDP health, but nevertheless indicates that IDPs tend to experience worse health outcomes than other conflict-affected populations across a range of health issues; and this is due to the particularly vulnerable situation of IDPs relative to these other populations, including reduced access to health services. Further research is required to better understand these needs and the interventions that can most effectively address these needs.

Factors that influence parents' and informal caregivers' views and practices regarding routine childhood vaccination: a qualitative evidence synthesis

BACKGROUND

Childhood vaccination is one of the most effective ways to prevent serious illnesses and deaths in children. However, worldwide, many children do not receive all recommended vaccinations, for several potential reasons. Vaccines might be unavailable, or parents may experience difficulties in accessing vaccination services; for instance, because of poor quality health services, distance from a health facility, or lack of money. Some parents may not accept available vaccines and vaccination services. Our understanding of what influences parents' views and practices around childhood vaccination, and why some parents may not accept vaccines for their children, is still limited. This synthesis links to Cochrane Reviews of the effectiveness of interventions to improve coverage or uptake of childhood vaccination.

OBJECTIVES

- Explore parents' and informal caregivers' views and practices regarding routine childhood vaccination, and the factors influencing acceptance, hesitancy, or nonacceptance of routine childhood vaccination. - Develop a conceptual understanding of what and how different factors reduce parental acceptance of routine childhood vaccination. - Explore how the findings of this review can enhance our understanding of the related Cochrane Reviews of intervention effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, and three other databases for eligible studies from 1974 to June 2020.

SELECTION CRITERIA

We included studies that: utilised qualitative methods for data collection and analysis; focused on parents' or caregivers' views, practices, acceptance, hesitancy, or refusal of routine vaccination for children aged up to six years; and were from any setting globally where childhood vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a pre-specified sampling frame to sample from eligible studies, aiming to capture studies that were conceptually rich, relevant to the review's phenomenon of interest, from diverse geographical settings, and from a range of income-level settings. We extracted contextual and methodological data from each sampled study. We used a meta-ethnographic approach to analyse and synthesise the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane Reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We integrated the findings of this review with those from relevant Cochrane Reviews of intervention effectiveness. We did this by mapping whether the underlying theories or components of trial interventions included in those reviews related to or targeted the overarching factors influencing parental views and practices regarding routine childhood vaccination identified by this review.

MAIN RESULTS

We included 145 studies in the review and sampled 27 of these for our analysis. Six studies were conducted in Africa, seven in the Americas, four in South-East Asia, nine in Europe, and one in the Western Pacific. Studies included urban and rural settings, and high-, middle-, and low-income settings. Many complex factors were found to influence parents' vaccination views and practices, which we divided into four themes. Firstly, parents' vaccination ideas and practices may be influenced by their broader ideas and practices surrounding health and illness generally, and specifically with regards to their children, and their perceptions of the role of vaccination within this context. Secondly, many parents' vaccination ideas and practices were influenced by the vaccination ideas and practices of the people they mix with socially. At the same time, shared vaccination ideas and practices helped some parents establish social relationships, which in turn strengthened their views and practices around vaccination. Thirdly, parents' vaccination ideas and practices may be influenced by wider political issues and concerns, and particularly their trust (or distrust) in those associated with vaccination programmes. Finally, parents' vaccination ideas and practices may be influenced by their access to and experiences of vaccination services and their frontline healthcare workers. We developed two concepts for understanding possible pathways to reduced acceptance of childhood vaccination. The first concept, 'neoliberal logic', suggests that many parents, particularly from high-income countries, understood health and healthcare decisions as matters of individual risk, choice, and responsibility. Some parents experienced this understanding as in conflict with vaccination programmes, which emphasise generalised risk and population health. This perceived conflict led some parents to be less accepting of vaccination for their children. The second concept, 'social exclusion', suggests that some parents, particularly from low- and middle-income countries, were less accepting of childhood vaccination due to their experiences of social exclusion. Social exclusion may damage trustful relationships between government and the public, generate feelings of isolation and resentment, and give rise to demotivation in the face of public services that are poor quality and difficult to access. These factors in turn led some parents who were socially excluded to distrust vaccination, to refuse vaccination as a form of resistance or a way to bring about change, or to avoid vaccination due to the time, costs, and distress it creates. Many of the overarching factors our review identified as influencing parents' vaccination views and practices were underrepresented in the interventions tested in the four related Cochrane Reviews of intervention effectiveness.

AUTHORS' CONCLUSIONS

Our review has revealed that parents' views and practices regarding childhood vaccination are complex and dynamic social processes that reflect multiple webs of influence, meaning, and logic. We have provided a theorised understanding of the social processes contributing to vaccination acceptance (or not), thereby complementing but also extending more individualistic models of vaccination acceptance. Successful development of interventions to promote acceptance and uptake of childhood vaccination will require an understanding of, and then tailoring to, the specific factors influencing vaccination views and practices of the group(s) in the target setting. The themes and concepts developed through our review could serve as a basis for gaining this understanding, and subsequent development of interventions that are potentially more aligned with the norms, expectations, and concerns of target users.

Trust In Governments And Health Workers Low Globally, Influencing Attitudes Toward Health Information, Vaccines

Trust, particularly during emergencies, is essential for effective health care delivery and health policy implementation. We used data from the 2018 Wellcome Global Monitor survey (comprising nationally representative samples from 144 countries) to examine levels and correlates of trust in governments and health workers and attitudes toward vaccines. Only one-quarter of respondents globally expressed a lot of trust in their government (trust was more common among people with less schooling, those living in rural areas, those who were financially comfortable, and those who were older), and fewer than half of respondents globally said that they trust doctors and nurses a lot. People's trust in these institutions was correlated with trust in health or medical advice from them, and with more positive attitudes toward vaccines. Vaccine enthusiasm varied substantially across regions, with safety being the most common concern. Policy makers should understand that the public may have varying levels of trust in different institutions and actors. Although much attention is paid to crafting public health messages, it may be equally important, especially during a pandemic, to identify appropriate, trusted messengers to deliver those messages more effectively to different target populations.

Institutional mistrust and child vaccination coverage in Africa

INTRODUCTION

Despite considerable improvements in vaccination coverage over the last decade, half of the world's unvaccinated and undervaccinated children are located in Africa. The role of institutional trust in explaining vaccination gaps has been highlighted in several qualitative reports but so far has only been quantified in a small number of high-income countries.

METHODS

We matched information on child vaccination status from the Demographic Health Surveys with information on institutional trust from the Afrobarometer surveys at the subnational level. A total of 166 953 children from 41 surveys administered in 22 African countries covering 216 subnational regions were used. Based on a principal component analysis, we constructed an institutional mistrust index that combined the level of mistrust in the head of state, parliament, electoral system, courts and local government. Associations between institutional mistrust and child vaccination uptake were assessed with multivariable fixed effects logistic regressions that controlled for time-invariant subnational region characteristics and various child, caregiver, household and community characteristics.

RESULTS

A 1 SD increase in the institutional mistrust index was associated with a 10% (95% CI of ORs: 1.03 to 1.18) increase in the likelihood that a child had not received any of eight basic vaccines and with a 6% decrease in the likelihood a child had received all of the basic vaccines (95% CI: 0.92 to 0.97). Institutional mistrust was negatively associated with the likelihood that a child had received each of the eight basic vaccinations (p<0.05).

CONCLUSIONS

Child vaccination rates in Africa are considerably lower in areas in which the local population displays high levels of mistrust towards local authorities. Institutional mistrust is an important dimension of vaccine hesitancy, considered as one of the most important threats to global health. Empowering local authorities with resources and communication strategies to address institutional mistrust may be needed to close the remaining vaccination gaps in Africa.

Global oral cholera vaccine use, 2013-2018

Vaccination is a key intervention to prevent and control cholera in conjunction with water, sanitation and hygiene activities. An oral cholera vaccine (OCV) stockpile was established by the World Health Organization (WHO) in 2013. We reviewed its use from July 2013 to all of 2018 in order to assess its role in cholera control. We computed information related to OCV deployments and campaigns conducted including setting, target population, timelines, delivery strategy, reported adverse events, coverage achieved, and costs. In 2013-2018, a total of 83,509,941 OCV doses have been requested by 24 countries, of which 55,409,160 were approved and 36,066,010 eventually shipped in 83 deployments, resulting in 104 vaccination campaigns in 22 countries. OCVs had in general high uptake (mean administrative coverage 1st dose campaign at 90.3%; 2nd dose campaign at 88.2%; mean survey-estimated two-dose coverage at 69.9%, at least one dose at 84.6%) No serious adverse events were reported. Campaigns were organized quickly (five days median duration). In emergency settings, the longest delay was from the occurrence of the emergency to requesting OCV (median: 26 days). The mean cost of administering one dose of vaccine was 2.98 USD. The OCV stockpile is an important public health resource. OCVs were generally well accepted by the population and their use demonstrated to be safe and feasible in all settings. OCV was an inexpensive intervention, although timing was a limiting factor for emergency use. The dynamic created by the establishment of the OCV stockpile has played a role in the increased use of the vaccine by setting in motion a virtuous cycle by which better monitoring and evaluation leads to better campaign organization, better cholera control, and more requests being generated. Further work is needed to improve timeliness of response and contextualize strategies for OCV delivery in the various settings.

Essential healthcare services provided to conflict-affected internally displaced populations in low and middle-income countries: A systematic review

Background: Conflict and violent crises have resulted in over 40 million of internally displaced persons (IDPs). Most affected regions lack access to basic health resources and generally rely on humanitarian support. The objective of this review was to appraise primary health service interventions among conflict-induced internally displaced populations in low and middle income countries between 2000 and 2019. Methods: A systematic review of literature in the following databases: Embase, MEDLINE, PsyArticles, PsycINFO, Scopus, Web of Science, LILAC and CAB Articles, was performed to identify interventions implemented in conflict IDP settings. Results: Initial searches yielded 4578 papers and 30 studies met the inclusion criteria. Descriptivesynthesis analysis was used, and the final selections were assessed using a customized CriticalAppraisal Skills Programme (CASP) checklist. Included papers were from Sub-Saharan Africa, South Asia and the Middle East regions. Most studies were on prevention interventions, especially water treatment and maternal health. Treatment interventions mostly focused on onmalaria and mental health. Only one food and nutrition study with outcome data was identified, indicating limitations in IDP health-related intervention publications. Reported interventions were conducted between one week to five years, and the study qualities were moderate. The most effective interventions were integrated programmes and common challenges were weakstudy methodology and data reporting. Conclusion: Regardless of the intervention types and durations, the services offered were beneficial to the IDPs. More intervention evidence are, however required as shown in gaps around food and nutrition, health education and disease surveillance.

Post-vaccination campaign coverage evaluation of oral cholera vaccine, oral polio vaccine and measles-rubella vaccine among Forcibly Displaced Myanmar Nationals in Bangladesh

Background: The new influx of Forcibly Displaced Myanmar Nationals (FDMNs) into Bangladesh started in August 2017 through different entry points of Bangladesh. Considering the imminent threat of infectious diseases outbreaks, the Government of Bangladesh (GoB) decided to vaccinate children against three deadly diseases (measles, rubella and poliomyelitis) and oral cholera vaccine (OCV) for all except <1 year children. After completion of the campaigns, post-vaccination campaign evaluation was carried out to assess the coverage of OCV, OPV and MR vaccines during campaigns.Methods: Post-vaccination campaign evaluation was conducted after completion of the 2nd dose of oral cholera vaccine (OCV2) and oral polio vaccine (OPV2) through a cross-sectional survey. The evaluation was conducted in the Balukhali camps under Ukhiya upazilla. Precision-based sample size was calculated to estimate the vaccine coverage. Ninety-two trained interviewers were involved to collect data from the target of approximately 40000 FDMNs between 18 and 25 November 2017.Results: Data were collected from 39,438 FDMNs during the survey period. The highest coverage was observed for OCVs (94% for OCV1 and 92% for OCV2). On the other hand, lower coverage was observed for the other vaccines; the coverage for OPV1, OPV2 and MR were 75%, 88% and 38%, respectively. Unawareness (30.7% did not know about the campaign) was the most notable cause of lowering down MR vaccine coverage.Conclusion: The experience in Bangladesh demonstrates that vaccine campaigns can be successfully implemented as part of a comprehensive response toward disease outbreak among high-risk populations in humanitarian crisis.

"It depends how one understands it:" a qualitative study on differential uptake of oral cholera vaccine in three compounds in Lusaka, Zambia

Background

The Zambian Ministry of Health implemented a reactive one-dose Oral Cholera Vaccine (OCV) campaign in April 2016 in three Lusaka compounds, followed by a pre-emptive second-round in December. Understanding uptake of this first-ever two-dose OCV campaign is critical to design effective OCV campaigns and for delivery of oral vaccines in the country and the region.

Methods

We conducted 12 Focus Group Discussions (FGDs) with men and women who self-reported taking no OCV doses and six with those self-reporting taking both doses. Simple descriptive analysis was conducted on socio-demographic and cholera-related data collected using a short questionnaire. We analyzed transcribed FGDs using the framework of dose, gender and geographic location.

Results

No differences were found by gender and location. All participants thought cholera to be severe and the reactive OCV campaign as relevant if efficacious. Most reported not receiving information on OCV side-effects and duration of protection. Those who took both doses listed more risk factors (including ‘wind’) and felt personally susceptible to cholera and protected by OCV. Some described OCV side-effects, mostly diarrhoea, vomiting and dizziness, as the expulsion of causative agents. Those who did not take OCV felt protected by their good personal hygiene practices or, thought of themselves and OCV as powerless against the multiple causes of cholera including poor living conditions, water, wind, and curse. Most of those who did not take OCV feared side-effects reported by others. Some interpreted side-effects as ‘western’ malevolence. Though > 80% discussants reported not knowing duration of protection, some who did not vaccinate, suggested that rather than rely on OCV which could lose potency, collective action should be taken to change the physical and economic environment to prevent cholera.

Conclusions

Due to incomplete information, individual decision-making was complex, rooted in theories of disease causation, perceived susceptibility, circulating narratives, colonial past, and observable outcomes of vaccination. To increase coverage, future OCV campaigns may benefit from better communication on eligibility and susceptibility, expected side effects, mechanism of action, and duration of protection. Governmental improvements in the physical and economic environment may increase confidence in OCV and other public health interventions among residents in Lusaka compounds.

Vaccine non-receipt and refusal in Ethiopia: The expanded program on immunization coverage survey, 2012

INTRODUCTION

Rates of full childhood immunization in Ethiopia are well below the WHO global goal of 90% coverage by 2020. This study explores associations between sociodemographic characteristics and healthcare services utilization with experiences of not receiving a vaccine in Ethiopia.

METHODS

This analysis uses data from Ethiopia's 2012 Expanded Program on Immunization Coverage Survey. The relationships between explanatory variables, including sociodemographic and healthcare utilization factors, and various reasons a child was not vaccinated were assessed with Rao-Scott chi-square tests. Multivariable logistic regression analyses examined significant predictors of these experiences.

RESULTS

The sample includes the caregivers of 2,722 children. Experiences of not receiving a vaccine were characterized overall and by type of experience: whether a caregiver ever refused vaccination for their child (2.9%), ever decided to not take their child to a health center for vaccination (3.6%), and ever went to a health facility for vaccination but child was not vaccinated (12.0%). Region of residence, possession of a vaccination card, and the setting of the child's last routine vaccination were predictors of not receiving a vaccine. Caregivers reported negative perceptions of vaccines were among their reasons for refusing a vaccine or declining to take their child to a health facility for vaccination.

CONCLUSION

Prior experiences with health facilities, such as where a child received their last routine vaccine, play a key role in future vaccination. Vaccine receipt at an outreach event is associated with not bringing a child to a health facility for vaccination, which may indicate an unwillingness to visit or difficulty accessing health centers. Further, negative perceptions of vaccines may result in vaccine refusal or delay. Findings of this study provide public health officials with a better understanding of factors related to vaccination experiences and can inform development of interventions that will improve childhood vaccination rates in Ethiopia.

Rapid behavioral assessment of barriers and opportunities to improve vaccination coverage among displaced Rohingyas in Bangladesh, January 2018

BACKGROUND

In November 2017, the World Health Organization received initial reports of suspected diphtheria cases in camps established for displaced Rohingyas in Cox's Bazar district, Bangladesh. By January 11, 2018, over 4,000 suspected cases of diphtheria and 30 deaths were reported. The Bangladesh government and partners implemented a diphtheria vaccination campaign in December 2017. Outbreak response staff reported anecdotal evidence of vaccine hesitancy. Our assessment aimed to understand vaccination barriers and opportunities to enhance vaccine demand among displaced Rohingyas in Bangladesh.

METHODS

In January 2018, we conducted a qualitative assessment consisting of nine focus group discussions and 15 key informant interviews with displaced Rohingyas in three camps. Participants included mothers and fathers with under five-year-old children, community volunteers, majhis (camp leaders), Islamic religious leaders, traditional and spiritual healers, and teachers. We recruited participants using purposive sampling, and analyzed the data thematically.

RESULTS

Across focus groups and in-depth interviews, trusted information sources cited by participants included religious leaders, elders, village doctors, pharmacists, majhis, and mothers trained by non-governmental organizations to educate caregivers. Treatment of diphtheria and measles was usually sought from multiple sources including traditional and spiritual healers, village doctors, pharmacies, and health clinics. Major barriers to vaccination included: various beliefs about vaccination causing people to become Christian; concerns about multiple vaccines being received on the same day; worries about vaccination side effects; and, lack of sensitivity to cultural gender norms at the vaccination sites.

CONCLUSION

Although vaccination was understood as an important intervention to prevent childhood diseases, participants reported numerous barriers to vaccination. Strengthening vaccine demand and acceptance among displaced Rohingyas can be enhanced by improving vaccination delivery practices and engaging trusted leaders to address religious and cultural barriers using community-based channels.

Highly targeted cholera vaccination campaigns in urban setting are feasible: The experience in Kalemie, Democratic Republic of Congo

Introduction

Oral cholera vaccines are primarily recommended by the World Health Organization for cholera control in endemic countries. However, the number of cholera vaccines currently produced is very limited and examples of OCV use in endemic countries, and especially in urban settings, are scarce. A vaccination campaign was organized by Médecins Sans Frontières and the Ministry of Health in a highly endemic area in the Democratic Republic of Congo. This study aims to describe the vaccine coverage achieved with this highly targeted vaccination campaign and the acceptability among the vaccinated communities.

Methods and findings

We performed a cross-sectional survey using random spatial sampling. The study population included individuals one year old and above, eligible for vaccination, and residing in the areas targeted for vaccination in the city of Kalemie. Data sources were household interviews with verification by vaccination card. In total 2,488 people were included in the survey. Overall, 81.9% (95%CI: 77.9–85.3) of the target population received at least one dose of vaccine. The vaccine coverage with two doses was 67.2% (95%CI: 61.9–72.0) among the target population. The vaccine coverage was higher during the first round (74.0, 95%CI: 69.3–78.3) than during the second round of vaccination (69.1%, 95%CI: 63.9–74.0). Vaccination coverage was lower in male adults. The main reason for non-vaccination was to be absent during the campaign. No severe adverse events were notified during the interviews.

Conclusions

Cholera vaccination campaigns using highly targeted strategies are feasible in urban settings. High vaccination coverage can be obtained using door to door vaccination. However, alternative strategies should be considered to reach non-vaccinated populations like male adults and also in order to improve the efficiency of the interventions.

The oral cholera vaccine, Shanchol, has already been shown as an effective tool in controlling a cholera outbreak. The limited amount of doses, concurrently with the logistic constraints associated with a targeted vaccination campaign are serious difficulties to tackle in order to organize a vaccination campaign in an urban setting. Although the World Health Organization recommends its use for cholera control in endemic countries, the fact remains that the use of the oral cholera vaccine in endemic setting has scarcely been described, especially in an urban setting, until now. Médecins Sans Frontières and the Ministry of Health from Democratic Republic of Congo organized a vaccination campaign of a limited part of the urbanized and highly endemic city of Kalemie, in the Tanganyika Province using a door to door strategy. The vaccine coverage in the targeted zones was high and demonstrated the feasibility of cholera vaccination campaign in this setting but also the need for creative strategies in order to reach population remaining hard to vaccine.

International Travelers' Sociodemographic, Health, and Travel Characteristics: An Italian Study

BACKGROUND

Approximately the 8% of travelers requires medical care, with the diagnosis of a vaccine-preventable disease. The aim of our study was to analyze the socio-demographic, health and travel characteristics of the Italian international travelers.

METHODS

We conducted a cross sectional study from January 2015 to June 2016, at the Travel Medicine Clinic of Siena, asking the doctor to interview patients who attended the Clinic, recording socio-demographic and travel information, malaria prophylaxis, vaccinations. The data were organized in a database and processed by software Stata®.

RESULTS

We collected 419 questionnaires. Patients chose 71 countries for their travels; the favorite destinations were: India (6.31%), Thailand (6.31%), and Brazil (5.10%). The mean length of stay was 36.17 days. Italians, students, and freelancers tended to stay abroad for a longer time (mean: 36.4 days, 59.87 days and 64.16 days respectively). 33.17% of our sample used drugs for malaria chemoprophylaxis: 71.9% of them used Atovaquone/Proguanil (Malarone®), 26.6% used Mefloquine (Lariam®), 1.5% other drugs. The vaccinations that travelers mostly got in our study were to prevent hepatitis A (n = 264), the typhoid fever (n = 187), the Tetanus + Diphtheria + Pertussis (n = 165), the Yellow fever (n = 118) and the cholera (n = 78). Twenty-eight (6.68%) refused some recommended vaccinations. The vaccines mostly refused were for Typhoid fever (n = 20), hepatitis a (n = 9), and cholera (n = 9).

CONCLUSION

Our results demonstrated that Italian international travelers are at-risk because of their poor vaccinations adherence. This implies that pre-travel counseling is fundamental to increase the knowledge of the risks and the compliance of future travelers.

Building the nation's body: The contested role of abortion and family planning in post-war South Sudan

This paper offers an ethnographic analysis of public health policies and interventions targeting unwanted pregnancy (family planning and abortion) in contemporary South Sudan as part of wider 'nation-building' after war, understood as a process of collective identity formation which projects a meaningful future by redefining existing institutions and customs as national characteristics. The paper shows how the expansion of post-conflict family planning and abortion policy and services are particularly poignant sites for the enactment of reproductive identity negotiation, policing and conflict. In addition to customary norms, these processes are shaped by two powerful institutions - ethnic movements and global humanitarian actors - who tend to take opposing stances on reproductive health. Drawing on document review, observations of the media and policy environment and interviews conducted with 54 key informants between 2013 and 2015, the paper shows that during the civil war, the Sudan People's Liberation Army and Movement mobilised customary pro-natalist ideals for military gain by entreating women to amplify reproduction to replace those lost to war and rejecting family planning and abortion. International donors and the Ministry of Health have re-conceptualised such services as among other modern developments denied by war. The tensions between these competing discourses have given rise to a range of societal responses, including disagreements that erupt in legal battles, heated debate and even violence towards women and health workers. In United Nations camps established recently as parts of South Sudan have returned to war, social groups exert a form of reproductive surveillance, policing reproductive health practices and contributing to intra-communal violence when clandestine use of contraception or abortion is discovered. In a context where modern contraceptives and abortion services are largely unfamiliar, conflict around South Sudan's nation-building project is partially manifest through tensions and violence in the domain of reproduction.