A systematic review of strategies for reducing missed opportunities for vaccination

Addressing Missed Opportunities for Vaccination among Children in Hospitals: Leveraging the P-Process for Health Communication Strategies

Addressing missed opportunities for vaccination requires a nuanced and context-specific approach. The five-step P-Process provides a robust framework to develop a clearly defined strategy that addresses social and behavioral drivers, integrates into existing health delivery systems, and facilitates collaboration with local experts. This approach allows teams to design, implement, monitor, and evaluate strategies to address public health issues. However, its specific application in vaccination communication programs remains relatively underexplored and under-documented. Our team designed a multi-pronged communication intervention aimed at enhancing vaccine uptake among hospitalized children in two tertiary hospitals in India and Nigeria. In the Inquiry stage, we conducted in-depth interviews with caregivers of hospitalized children to assess barriers to vaccination in a hospital setting. In the Strategic Development stage, we developed a blueprint for activities, identifying target audiences and communication channels and developing implementation plans. During the Create and Test stage, we brought together a range of stakeholders to co-develop a communication intervention through human-centered design workshops, after which we piloted the materials in both hospitals. We then Mobilized and Monitored progress of the activities to identify potential gaps that our materials did not initially address. Lastly, in the Evaluate and Evolve stage, we conducted in-depth interviews with healthcare workers and caregivers to measure outcomes and assess the impact on caregivers' decisions to vaccinate their hospitalized children. By following the P-Process for the design, caregivers reported that many of their concerns about vaccines were alleviated, and HCWs reported that they were able to communicate with caregivers more effectively about vaccination. By harnessing the power of the P-Process, researchers can forge a context-specific path towards impactful vaccination communication interventions, one step at a time.

Effectiveness of patient reminders on influenza vaccination coverage among adults with chronic conditions: A feasibility study in Australian general practices

BACKGROUND

Influenza vaccination is recommended for Australians 18+ years old with medical risk factors, but coverage is suboptimal. We aimed to examine whether automatic, opportunistic patient reminders (SMS and/or printed) before appointments with a general practitioner increased influenza vaccination uptake.

METHODS

This clustered non-randomised feasibility study in Australian general practice included patients aged 18-64 years with at least one medical risk factor attending participating practices between May and September 2021. Software installed at intervention practices identified unvaccinated eligible patients when they booked an appointment, sent vaccination reminders (SMS on booking and 1 h before appointments), and printed automatic reminders on arrival. Control practices provided usual care. Clustered analyses adjusted for sociodemographic differences among practices were performed using logistic regression.

RESULTS

A total of 12,786 at-risk adults attended 16 intervention practices (received reminders = 4066; 'internal control' receiving usual care = 8720), and 5082 individuals attended eight control practices. Baseline influenza vaccination uptake (2020) was similar in intervention and control practices (∼34%). After the intervention, uptake was similar in all groups (control practices = 29.3%; internal control = 30.0%; intervention = 31.6% (p-value = 0.203). However, SMS 1 h before appointments increased vaccination coverage (39.3%, adjusted OR = 1.65; 95%CI 1.20;2.27; number necessary to treat = 13), especially when combined with other reminder forms. That effect was more evident among adults with chronic respiratory, rheumatologic, or inflammatory bowel disease.

CONCLUSION

These findings indicate that automated SMS reminders delivered at proximate times to appointments are a low-cost strategy to increase influenza vaccination among adults at higher risk of severe disease attending Australian general practices.

Epidemiology of community-acquired pneumonia caused by S treptococcus pneumoniae in older adults: a narrative review

PURPOSE OF REVIEW

This review covers updated perspectives on different aspects of pneumococcal community-acquired pneumonia (pCAP), including the epidemiology, clinical presentation, risk factors, antibiotic treatment, and existing preventive strategies in older adults.

RECENT FINDINGS

pCAP remains the most prevalent condition among lower respiratory tract infections in the older adults according to Global Burden of Diseases 2019. Older adults can display atypical symptoms such as confusion, general clinical deterioration, new onset of and exacerbation of underlying illness that might trigger clinical suspicion of pCAP. Older adults with pCAP often experience increased disease severity and a higher risk of pulmonary complications compared with younger individuals, owing to age-related changes in immunity and a higher prevalence of comorbidities. Vaccination stands fundamental for prevention, emphasizing the need for effective immunization strategies, specifically tailored for older adults. There is a pressing need to reinforce efforts aimed at boosting pneumococcal vaccination rates.

SUMMARY

Despite a high morbidity and mortality, the burden of pCAP, in particular hospital admission and occurrence of invasive infections, among the elderly population is not sufficiently documented. This review findings emphasize the substantial burden of pCAP in this vulnerable population, driven by factors such as advancing age and underlying comorbidities. The emergence of antibiotic-resistant pneumococcal strains further complicates treatment decisions and highlights the importance of tailored approaches for managing pCAP in older adults.

Determinants of vaccine adherence among non-dialysis chronic kidney disease patients in Qatar

INTRODUCTION

Chronic kidney disease (CKD) is a global health problem. Reduced innate and adaptive immunological responses predispose CKD patients to infections. Despite the clinical and epidemiological importance of CKD and the great value of vaccination as a prophylactic measure, the utilization of recommended vaccines in Qatar has not yet been evaluated.

METHODS

We conducted a cross-sectional study to estimate the level of influenza, pneumococcal, and hepatitis B vaccination and the predictors of adherence to these recommended vaccines among non-dialysis CKD patients receiving renal ambulatory care in Qatar from 1 September 2020 to 30 April 2021. Complete vaccination was defined as receiving the three vaccines, and partial vaccination was defined as receiving one or two vaccines. The full and partial vaccination predictors were assessed using multivariate logistic regression and reported as odds ratio (OR) with p<0.05 indicating statistical significance.

RESULTS

416 non-dialysis CKD patients were included in our analysis. 73% were males; the mean age was 56 ± 15 years. More than 50% of the patients were from the Middle East, followed by 36% from Asia. Most patients had concurrent hypertension, concurrent diabetes mellitus, and were stage V CKD. Only 12% of the patients were fully vaccinated, while 73% received partial vaccination. The predictors of vaccination included age, gender, Asian origin, employment, living conditions, concurrent medical conditions, CKD stage, allergy to medications, and use of injectable medications. Only stage V CKD positively predicted adherence to full and partial vaccinations in non-dialysis CKD patients.

CONCLUSION

There is very low adherence to the recommended vaccines in CKD patients, with a prevalence of complete vaccination of 12% only. Increased public awareness about the importance of vaccination in CKD may improve the adherence rates among these patients in Qatar.

Comparative estimates of crude coverage of the Mexican immunization program: Findings from a national survey

The purpose of the study is to provide estimates for immunization coverage, considering single-dose and schemes (three or five vaccines), by comparing self-report method to immunization cards, while also assessing the timeliness of immunization in Mexico, with reference to Mexican Immunization Program guidelines. Data on immunization was obtained from the Mexican Immunization Survey conducted in 2017 that aimed to assess crude (card-based) coverage at the regional level. Timely immunization was defined with reference to National Immunization Program guidelines, and immunization coverage was defined as a three or five vaccine scheme, based on previous national reports of immunization coverage. Immunization coverage estimates account for sample weights from the complex survey design. We used weighted immunization coverage estimates to assess the extent to which immunization cards and self-reporting concurred. It was found that most Mexican children are not receiving their full vaccine schedule in a timely manner. Concerning children under twelve months of age, the coverage targets for National Immunization of 95 % was not reached for either vaccine, and only 2.94 % (95 % CI 0.92-9.01) who had been receiving a three-vaccine scheme were considered as fully immunized in a timely manner. In contrast, coverage increased to 33.94 % (95 % CI 26.99-41.66), when untimely immunizations were taken into account, and the 95 % target was reached for five vaccines. Likewise, there is little correlation between self-report and immunization cards but rates show more concurrence, when only considering the proportion of true positives. In conclusion it was find that children at a local level are vaccinated in an incomplete and untimely manner. In order to improve immunization systems, a nominal registry of administered doses is thus of paramount importance. There is a need to address underlying health inequalities, as well as the factors associated with these, resulting in improved chances of a disease-free childhood and healthy life.

How to increase and maintain high immunization coverage: Vaccination Demand Resilience (VDR) framework

BACKGROUND

Resilience in vaccination demand is ever more critical as the COVID-19 pandemic has increased our understanding of the importance of vaccines on health and well-being. Yet timid demand for COVID-19 vaccines where available and reduced uptake of routine immunizations globally further raise the urgent need to build vaccination resilience. We demonstrate the complexity of vaccination demand and resilience in a framework where relevant dimensions are intertwined, fluid, and contextual.

METHODS

We developed the Vaccination Demand Resilience (VDR) framework based on a literature review on vaccination demand and expert consultation. The matrix framework builds on three main axes: 1) vaccination attitudes and beliefs; 2) vaccination seeking behavior; and 3) vaccination status. The matrix generated eight quadrants, which can help explain people's levels of vaccination demand and resilience. We selected four scenarios as examples to demonstrate different interventions that could move people across quadrants and build vaccination resilience.

RESULTS

Incongruence between individuals' attitudes and beliefs, vaccination behavior, and vaccination status can arise. For example, an individual can be vaccinated due to mandates but reject vaccination benefits and otherwise avoid seeking vaccination. Such incongruence could be altered by interventions to build resilience in vaccination demand. These interventions include information, education and communication to change individuals' vaccination attitudes and beliefs, incentive programs and reminder-recalls to facilitate vaccination seeking, or by strengthening healthcare provider communications to reduce missed opportunities.

CONCLUSIONS

Vaccination decision-making is complex. Individuals can be vaccinated without necessarily accepting the benefits of vaccination or seeking vaccination, threatening resilience in vaccination demand. The VDR framework can provide a useful lens for program managers and policy makers considering interventions and policies to improve vaccination resilience. This would help build and sustain confidence and demand for vaccinations, and help to continue to prevent disease, disability, and death from vaccine-preventable diseases.

Evaluation of behavioral economic strategies to raise influenza vaccination rates across a health system: Results from a randomized clinical trial

Influenza vaccination rates are low. Working with a large US health system, we evaluated three health system-wide interventions using the electronic health record's patient portal to improve influenza vaccination rates. We performed a two-arm RCT with a nested factorial design within the treatment arm, randomizing patients to usual-care control (no portal interventions) or to one or more portal interventions. We included all patients within this health system during the 2020-2021 influenza vaccination season, which overlapped with the COVID-19 pandemic. Through the patient portal, we simultaneously tested: pre-commitment messages (sent September 2020, asking patients to commit to a vaccination); monthly portal reminders (October - December 2020), direct appointment scheduling (patients could self-schedule influenza vaccination at multiple sites); and pre-appointment reminder messages (sent before scheduled primary care appointments, reminding patients about influenza vaccination). The main outcome measure was receipt of influenza vaccine (10/01/2020-03/31/2021). We randomized 213,773 patients (196,070 adults ≥18 years, 17,703 children). Influenza vaccination rates overall were low (39.0%). Vaccination rates for study arms did not differ: Control (38.9%), pre-commitment vs no pre-commitment (39.2%/38.9%), direct appointment scheduling yes/no (39.1%/39.1%), pre-appointment reminders yes/no (39.1%/39.1%); p > 0.017 for all comparisons (p value cut-off adjusted for multiple comparisons). After adjusting for age, gender, insurance, race, ethnicity, and prior influenza vaccination, none of the interventions increased vaccination rates. We conclude that patient portal interventions to remind patients to receive influenza vaccine during the COVID-19 pandemic did not raise influenza immunization rates. More intensive or tailored interventions are needed beyond portal innovations to increase influenza vaccination.

Optimizing Your Pediatric Office for Vaccine Confidence

Parents trust their pediatric clinicians for up-to-date information about vaccines. To reduce vaccine hesitancy, clinics must promote confidence by building trust, communicating clearly, using patient safety and infection control principles to reduce errors, and reducing missed opportunities by having a vaccination infrastructure that makes every visit a vaccine visit. Education and communication must be consistent among all staff and culturally competent to optimize vaccine confidence. Parents have a role in seeking reliable resources, raising concerns, and seeking trusted, evidence-based experts for vaccination conversations. Safe, effective vaccines are vital; however, vaccination, a complex operational process, prevents disease and saves lives.

Trends in vaccination schedules and up-to-date status of children 19-35 months, United States, 2015-2020

OBJECTIVES

To estimate trends in, and factors associated with, vaccination patterns and up-to-date immunization status of U.S. children by 19 to 35 months of age.

METHODS

Data from the 2015 to 2020 National Immunization Surveys were used to assess trends in vaccination patterns, up-to-date status, and zero vaccination status of U.S. children by 19-35 months. Vaccination patterns were categorized as: 1) recommended, 2) alternate, or 3) unknown or unclassifiable. Multivariable analyses were conducted to examine factors associated with each vaccination pattern and up-to-date status for all recommended vaccines.

RESULTS

From 2015 to 2020, the proportion of U.S. children completing the recommended schedule increased from 62.5% to 69.4%, alternative schedule decreased from 21.6% to 16.2%, and unknown or unclassifiable schedules decreased from 15.9% to 14.3%. In addition, being not up-to-date decreased from 39.7% to 35.6%. There was no change in the percentage of children receiving zero vaccinations from 2015 to 2020 (0.9% to 0.9%). Respondents with lower household income or who were uninsured were more likely to follow an alternate or unknown/unclassifiable schedule, or not be up-to-date with vaccines.

CONCLUSION

Following any schedule other than the recommended schedule was associated with not being up-to-date on immunizations. Increased efforts to catch up on recommended vaccines is important for protecting children's health. Further efforts should be made to improve timely adherence to recommended vaccination schedules, particularly among populations with the largest disparities in coverage through a tailored approach to increase confidence in and access to vaccines.

Structural violence in South African primary healthcare facilities: insights from discussions with adolescents and young people seeking sexual and reproductive health needs

Introduction. South Africa has an enabling legislative and policy framework that promotes the protection of adolescents and young people’s sexual and reproductive health and rights. Much of the literature in this field has identified discriminatory and hostile attitudes from healthcare workers as a major underlying factor to negative sexual and reproductive health outcomes for this age cohort. Not as well understood is the role of structural violence although this type of violence, through its structures of injustice and inequalities, is closely associated with stigma and discrimination. Data and sources. To contribute to closing this research gap, this paper draws on the findings of a larger qualitative study, specifically focus group discussions with young people aged 15–24 years. Results. The consequences of these attitudes within the structural violence framework are illuminated as are recommendations for enhancing access to sexual and reproductive health and services by adolescents and young people. Discussion and conclusion. Key among the latter is that young people’s sexual and reproductive health needs and wellbeing should be pursued through a multisectoral approach that encompasses stigma reduction interventions involving the young people, families, and communities collaborating with healthcare workers.

False Contraindications for Vaccinations Result in Sub-Optimal Vaccination Coverage in Quito, Ecuador: A Cross-Sectional Study

Vaccination coverage in Ecuador has decreased since 2013, falling short of the World Health Organization's vaccination goal. There are several causes for this deficiency in coverage, one of these are lost vaccination opportunities, which are caused when a patient without contraindications postpones, or for other reasons fails to receive a recommended immunization. The objective of this study was to determine the state of knowledge regarding vaccination contraindications among the Metropolitan District of Quito health personnel to assess missed vaccination opportunities. Through this cross-sectional descriptive study, health personnel were surveyed online and asked 18 clinical scenarios which were created to evaluate their knowledge of the true contraindications of vaccination, and measure missed opportunities. A total of 273 surveys were collected; 74% belonged to the public health system, and the rest represented by private practitioners. Of those surveyed, 98.2% of health personnel had improperly denied vaccination at least once. We specifically found vaccinations were incorrectly denied more frequently in cases where the hypothetical patient presented mild or moderate fever cases. The use of corticosteroids, autoimmune diseases, and egg allergy were also incorrectly denied (89%, 71.4%, 72.9%, and 58.6%, respectively). Among the health personnel surveyed, there is an apparent lack of knowledge of the true contraindications of vaccination and differences in knowledge about contraindications according to personnel in charge of administering immunization to children. Our preliminary results suggest that lack of education related to side effects could be biasing medical professionals' decisions, causing them to unnecessarily delay or deny vaccinations, which likely contributes to explaining low overall vaccination coverage in Quito, the capital city of Ecuador.

Measurement of provider fidelity to immunization guidelines: a mixed-methods study on the feasibility of documenting patient refusals of the human papillomavirus vaccine

BACKGROUND

Assessment and feedback is a common implementation strategy to improve healthcare provider fidelity to clinical guidelines. For immunization guidelines, fidelity is often measured with doses administered during eligible visits. Adding a patient refusal measure captures provider fidelity more completely (i.e., all instances of a provider recommending a vaccine, resulting in vaccination or refusal) and enables providers to track patient vaccine hesitancy patterns. However, many electronic health record (EHR) systems have no structured field to document multiple instances of refusals for specific vaccines, and existing billing codes for refusal are not vaccine specific. This study assessed the feasibility of a novel method for refusal documentation used in a study focused on human papillomavirus (HPV) vaccine.

METHODS

An observational, descriptive-comparative, mixed-methods study design was used to conduct secondary data analysis from an implementation-effectiveness trial. The parent trial compared coach-based versus web-based practice facilitation, including assessment and feedback, to increase HPV vaccination in 21 community-based private pediatric practices. Providers were instructed to document initial HPV vaccine refusals in the EHR's immunization forms and subsequent refusals using dummy procedure codes, for use in assessment and feedback reports. This analysis examined adoption and maintenance of the refusal documentation method during eligible well visits, identified barriers and facilitators to documentation and described demographic patterns in patient refusals.

RESULTS

Seven practices adopted the refusal documentation method. Among adopter practices, documented refusals started at 2.4% of eligible well visits at baseline, increased to 14.2% at the start of implementation, peaked at 24.0%, then declined to 18.8%. Barriers to refusal documentation included low prioritization, workflow integration and complication of the billing process. Facilitators included high motivation, documentation instructions and coach support. Among adopter practices, odds of refusing HPV vaccine were 25% higher for patients aged 15-17 years versus 11-12 years, and 18% lower for males versus females.

CONCLUSIONS

We demonstrated the value of patient refusal documentation for measuring HPV vaccination guideline fidelity and ways that it can be improved in future research. Creation of vaccine-specific refusal billing codes or EHR adaptations to enable documenting multiple instances of specific vaccine refusals would facilitate consistent refusal documentation. Trial Registration NCT03399396 Registered in ClinicalTrials.gov on 1/16/2018.

Missed opportunities for vaccination (MOV) in children up to 5 years old in 19 Médecins Sans Frontières-supported health facilities: a cross-sectional survey in six low-resource countries

OBJECTIVE

To describe missed opportunities for vaccination (MOV) among children visiting Médecins Sans Frontières (MSF)-supported facilities, their related factors, and to identify reasons for non-vaccination.

DESIGN

Cross-sectional surveys conducted between 2011 and 2015.

SETTING AND PARTICIPANTS

Children up to 59 months of age visiting 19 MSF-supported facilities (15 primary healthcare centres and four hospitals) in Afghanistan, Democratic Republic of the Congo, Mauritania, Niger, Pakistan and South Sudan. Only children whose caregivers presented their vaccination card were included.

OUTCOME MEASURES

We describe MOV prevalence and reasons for no vaccination. We also assess the association of MOV with age, type of facility and reason for visit.

RESULTS

Among 5055 children's caregivers interviewed, 2738 presented a vaccination card of whom 62.8% were eligible for vaccination, and of those, 64.6% had an MOV. Presence of MOV was more likely in children visiting a hospital or a health facility for a reason other than vaccination. MOV occurrence was significantly higher among children aged 12-23 months (84.4%) and 24-59 months (88.3%) compared with children below 12 months (56.2%, p≤0.001). Main reasons reported by caregivers for MOV were lack of vaccines (40.3%), reason unknown (31.2%) and not being informed (17.6%).

CONCLUSIONS

Avoiding MOV should remain a priority in low-resource settings, in line with the new 'Immunization Agenda 2030'. Children beyond their second year of life are particularly vulnerable for MOV. We strongly recommend assessment of eligibility for vaccination as routine healthcare practice regardless of the reason for the visit by screening vaccination card. Strengthening implementation of 'Second year of life' visits and catch-up activities are proposed strategies to reduce MOV.

Diagnosis of vaccination rooms in Brazilian primary health care centers taking part in the PlanificaSUS project, 2019

OBJECTIVE

To describe the diagnosis of vaccination rooms in primary healthcare centers in Brazil.

METHODS

This was a cross-sectional study with secondary data of convenience sampling comprised of 25 rooms. Results of a checklist adapted from the Vaccine Room Supervision Tool of the National Immunization Program in 2019 regarding the dimensions 'general organization', 'general aspects', 'technical procedures', 'cold chain', 'information system', 'adverse events following vaccination', 'special immunobiological agents', 'epidemiological surveillance' and 'health education', were used. Percentages of scores, both overall and by dimensions were described in median, interquartile range, minimum and maximum values.

RESULTS

The overall median was 77.1%, higher for 'health education' (100.0%) and 'cold chain' (86.7%), and lower for 'special immunobiological agents' (50.0%) and 'general organization' (58.3%).

CONCLUSION

Using the checklist enabled the diagnosis in different macro-regions, inter- and intra-regional differences were found in the dimensions, and positive results and opportunities for improvement in the general plan.

Pneumococcal and influenza vaccination coverage among at-risk adults: A 5-year French national observational study

INTRODUCTION

The risk of developing pneumococcal infections increases with certain chronic conditions and in immunocompromised patients. We aimed to monitor pneumococcal vaccination coverage in at-risk patients and to examine factors associated with pneumococcal vaccination in France.

MATERIAL AND METHODS

In this annual cross-sectional study, at-risk patients were extracted between 2014 and 2018 from the National Health Insurance's (NHI) General scheme's claims database with their vaccine reimbursements. Descriptive analyses and a logistic model were performed to assess the influence of healthcare use and medical and demographic factors on pneumococcal vaccination.

RESULTS AND DISCUSSION

In 2018, 4.5% of 4,045,021 at-risk adults were up to date with their pneumococcal vaccination. During the study period, the number of patients with chronic medical conditions (86% of 4,045,021) increased by 10.1%, but vaccination coverage decreased from 12.9% to 2.9%. The population with immunocompromised status (14% of 4,045,021) increased by 16.2% and vaccination coverage from 10.3% to 18.8%. Influenza vaccination coverage was much higher and stable (around 45.0%). Factors associated with pneumococcal vaccination were: immunocompromised status vs. having a chronic medical condition (odds ratio [OR] 4.72), influenza vaccination (OR 2.36-3.42), hepatitis B vaccination (OR 2.82), DTPolio vaccination (OR 1.52), ≥5 specialist physicians' visits (OR 1.17), and age above 74 (OR 1.12). Pneumococcal vaccine dispensing was extremely low (median of 9per GP,1per specialist over 9 years) despite frequent healthcare visits.

CONCLUSION

Pneumococcal and influenza vaccination coverage of adults at risk of pneumococcal disease fell well below public health expectations. Invitations for pneumococcal vaccination should be sent by the NHI to high-risk patients. Patient management protocols should include pneumococcal vaccination. Patients with multiple comorbidities are a high-priority population given the large potential health gains offered by pneumococcal vaccination. Commitment of both scientific societies and health authorities is urgently needed to increase vaccination coverage in at-risk populations.

Systematic review on reducing missed opportunities for vaccinations in Latin America

Objectives

To estimate the prevalence of missed opportunities for vaccination (MOV) in Latin America and the effect of interventions targeting health systems, health workers, patients, and communities on MOV.

Methods

Searches were conducted in MEDLINE, EMBASE, CINAHL, and LILACS electronic databases and relevant organizations were contacted, including the Pan American Health Organization (PAHO), to identify studies meeting eligibility criteria. A pair of reviewers identified 27 randomized and non-randomized studies quantifying the effectiveness of any intervention for reducing MOV and 5 studies assessing the rate of MOV in Latin America. Results are reported narratively when criteria to pool results were not met, and the certainty of this evidence was assessed using the GRADE approach.

Results

Evidence suggests the rate of MOV in Latin America ranged from 5% to 37% with a pooled estimate of 17% (95% CI [9, 32]) (low certainty) and that monetary incentives to healthcare teams, training for healthcare teams on how to communicate with patients, and educational interventions for caregivers probably reduce MOV (moderate to very low certainty).

Conclusions

There is insufficient evidence supporting the implementation of any intervention as policy based only on the potential reduction of MOV without considering several factors, including costs, feasibility, acceptability, and equity.

COVID-19 Vaccination and Ukrainian Refugees in Poland during Russian-Ukrainian War-Narrative Review

The outbreak of the Russian–Ukrainian war contributed to the largest migration movement in the 21st century. As a result, over 3 million refugees, mainly women, children and the elderly, arrived in Poland in a short space of time. Despite the ongoing war, it is important to remember that the COVID-19 pandemic is still present in the world, and before the outbreak of the war, Ukraine was struggling with its fifth wave. Furthermore, Ukraine has one of the lowest vaccination rates in Europe, not exceeding 40%. It is, therefore, reasonable to suspect that the vast majority of migrants have not been vaccinated. This situation may pose a significant epidemiological risk. Therefore, it is necessary to implement appropriate steps to determine the vaccination status of refugees and to supplement the vaccination with both the core and booster doses. In response to these needs, the government of Poland, like many other countries, has made it possible to provide free COVID-19 vaccination to persons fleeing war. In the face of massive migration, the overriding priority should be to ensure adequate medical care for refugees, including free COVID-19 vaccinations. However, it seems that the lack of willingness to vaccinate among Ukrainians is also replicated on migration. It seems reasonable that appropriate steps should be taken to increase awareness and confidence in vaccination, which may ultimately translate into increased vaccination uptake. Analyzing previous experiences, it is advisable to consider that the first step should be to promote vaccination and remind refugees of the possibility of free COVID-19 vaccination. Additionally, refugees should be encouraged to be vaccinated during every contact with health care workers.

[Trend in the availability of vaccines in Brazil: PMAQ-AB, 2012, 2014, and 2018]

The objective was to analyze the trend in the availability of vaccines in Brazil and its various regions and states from 2012 to 2018. This cross-sectional study used data from basic units assessed in cycles I (2012), II (2014), and III (2018) of the Brazilian National Program for Improvement of Access and Quality of Basic Care (PMAQ-AB). We assessed the availability of the dT, hepatitis B, meningococcal C, polio, pneumococcal 10-valent, MMR, DPT, tetravalent/pentavalent, and human rotavirus vaccines. Identification of trend was performed with weighted least squares regression to estimate annual percent changes. We also verified the relative and absolute differences in prevalence of vaccines. The sample consisted of 13,842 basic health units in Cycle I, 19,752 in Cycle II, and 25,152 in Cycle III. An upward trend was seen in the prevalence of availability of all vaccines investigated during the period, with an increase of 16 percentage points from 2012 to 2018, reaching nearly 70% in 2018. The regions with the largest upward trend were the North (2.9p.p.), Central-West (2.1p.p.), and Northeast (2.0p.p.). There was a visible downward trend in both the availability (-3.3p.p.) and absolute and relative difference (-20p.p.; 0.68) in Rio de Janeiro State. The prevalence of availability of vaccines was low in Brazil, with disparities between regions that become even more pronounced when assessing specific states.

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.

Reducing burden from respiratory infections in refugees and immigrants: a systematic review of interventions in OECD, EU, EEA and EU-applicant countries

BACKGROUND

Respiratory diseases are a major reason for refugees and other immigrants seeking health care in countries of arrival. The burden of respiratory diseases in refugees is exacerbated by sometimes poor living conditions characterised by crowding in mass accommodations and basic living portals. The lack of synthesised evidence and guideline-relevant information to reduce morbidity and mortality from respiratory infections endangers this population.

METHODS

A systematic review of all controlled and observational studies assessing interventions targeting the treatment, diagnosis and management of respiratory infections in refugees and immigrants in OECD, EU, EEA and EU-applicant countries published between 2000 and 2019 in MEDLINE, CINAHL, PSYNDEX and the Web of Science.

RESULTS

Nine of 5779 identified unique records met our eligibility criteria. Seven studies reported an increase in vaccine coverage from 2 to 52% after educational multilingual interventions for respiratory-related childhood diseases (4 studies) and for influenza (5 studies). There was limited evidence in one study that hand sanitiser reduced rates of upper respiratory infections and when provided together with face masks also the rates of influenza-like-illness in a hard to reach migrant neighbourhood. In outbreak situations of vaccine-preventable diseases, secondary cases and outbreak hazards were reduced by general vaccination strategies early after arrival but not by serological testing after exposure (1 study). We identified evidence gaps regarding interventions assessing housing standards, reducing burden of bacterial pneumonia and implementation of operational standards in refugee care and reception centres.

CONCLUSIONS

Multilingual health literacy interventions should be considered to increase uptake of vaccinations in refugees and immigrants. Immediate vaccinations upon arrival at refugee housings may reduce secondary infections and outbreaks. Well-designed controlled studies on housing and operational standards in refugee and immigrant populations early after arrival as well as adequate ways to gain informed consent for early vaccinations in mass housings is required to inform guidelines.

Missed opportunities for vaccination in Africa

The purpose of this review is to assess the extent of missed opportunities for vaccination (MOV) in Africa, determine the associated factors, and provide recommendations that countries could adopt in reducing MOV. Two databases were searched for multinational studies and systematic reviews reporting MOV and involving African countries. A total of 288 records were identified and 12 studies included for synthesis. The prevalence ranged from 47.0% to 62.1%, with a weighted mean of 27.3%. This review highlighted caregiver utilization, health service delivery, and healthcare worker' factors associated with MOV. Understanding the extent of MOV in Africa presents an opportunity for multiple approaches to resolve the differential factors that contribute to MOV, and to bridge the gap in vaccination coverage in the continent.

Can vaccination coverage be improved through reducing the missed opportunities for immunization? Results from the evaluation in Zhejiang province, east China

BACKGROUND

To evaluate the missed opportunities for vaccination (MOV) in Zhejiang province by using the global methodology from World Health Organization (WHO).

METHODS

Based on the WHO Planning Guide to Reduce Missed Opportunities for Vaccination (MOV) and Methodology for the Assessment of MOV, 33 health facilities from 11 cities in Zhejiang province were selected. For each health facility, exit investigations for 20 caregivers of children aged 0-23 months and knowledge, attitudes, and practices (KAP) surveys for 10 health workers was implemented. A MOV was determined based on the child's age on the date of investigation, eligibility for various vaccines. The prevalence of MOV was calculated and the risk factors of MOV were explored.

RESULTS

There were 660 completed exit investigations of caregivers of children aged 0-23 months and 330 health worker KAP investigations. Of the 658 children with documented vaccination records, 12.6% were still under-vaccinated. Among these under-vaccinated children, 54.2% still had a MOV. Children's age and their previous vaccination behavior, as well as caregivers' relationship to children and education level had a significant impact on the incidence of MOV.

CONCLUSION

The high proportions of visits with MOV in Zhejiang province suggested that interventions to reduce MOV in health service settings may be a potential quick win for improving coverage and equity. National immunization programs should explore the tailored efforts to improve health worker practices by making better use of existing health service contacts.

Incomplete Vaccination and Its Predictors among Children in Ethiopia: A Systematic Review and Meta-Analysis

Background. Vaccination is an effective public health intervention that has contributed to a substantial reduction in the burden of vaccine-preventable diseases. Abridged evidence on incomplete vaccination is not well established in Ethiopia. Therefore, this meta-analysis aimed to estimate the pooled prevalence of incomplete vaccination and its predictors among children aged 12 to 23 months. Methods. Primary studies conducted in Ethiopia were searched. The methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) checklist. The analysis was conducted using STATA 14 and RevMan. The presence of statistical heterogeneity was checked using the Cochran Q test, and its level was quantified using I2 statistics. Pooled prevalence and odds ratio (OR) were computed at a 95% confidence interval (CI). Results. The pooled prevalence of incomplete vaccination was 30% (95% CI: 25-35). Maternal illiteracy (OR = 1.96; 95% CI: 1.40, 2.74) and home delivery (OR = 2.78; 95% CI: 2.28, 3.38) were associated factors that increased incomplete vaccination. However, maternal autonomy (OR = 0.54; 95% CI: 0.33, 0.89), maternal knowledge (OR = 0.31; 95% CI: 0.20, 0.47), husband employment (OR = 0.49; 95% CI: 0.35, 0.67), urban residence (OR = 0.61; 95% CI: 0.43, 0.86), ANC visits (OR = 0.30; 95% CI: 0.23, 0.39), postnatal care (OR = 0.39; 95% CI: 0.30, 0.52), and tetanus toxoid vaccine (3+) (OR = 0.42; 95% CI: 0.26, 0.69) were factors that reduced incomplete vaccination. Conclusion. In Ethiopia, 3 out of 10 children have incomplete vaccination. Policies should focus on strengthening and improving women’s education, maternal health knowledge, empowering women, and the utilization of prenatal care can overcome some of the barriers.

A clinical update on vaccines: focus on determinants of under-immunization and special considerations for adolescents

PURPOSE OF REVIEW

The current article reviews recent literature related to pediatric and adolescent vaccination, specifically focusing on social determinants of under-immunization, expanding adolescent immunization rates, and new recommendations surrounding the meningococcal serotype B vaccine (MenB).

RECENT FINDINGS

Vaccine refusals and vaccine-preventable diseases have been rising in some parts of the world, and appear to be linked to household factors, such as a family's socioeconomic status. Adolescents have lower immunization rates than younger children. Newer vaccines targeted at adolescents, such as the MenB vaccine, have yet to be widely accepted by pediatric providers, parents, and patients.

SUMMARY

Pediatric healthcare providers should attempt to increase local immunization rates by vaccinating children at all eligible office visits and utilizing electronic health record decision-support tools. Although the number of families who choose not to vaccinate their children may be rising, providers can be innovative (e.g. incorporate digital vaccine reminder systems) and increase their familiarity with new vaccine recommendations to continue to prevent serious vaccine-preventable diseases.

Pharmacy-based interventions to increase vaccine uptake: report of a multidisciplinary stakeholders meeting

BACKGROUND

Despite the existence of efficacious vaccines, the burden of vaccine-preventable diseases remains high and the potential health benefits of paediatric, adolescent and adult vaccination are not being achieved due to suboptimal vaccine coverage rates. Based on emerging evidence that pharmacy-based vaccine interventions are feasible and effective, the European Interdisciplinary Council for Ageing (EICA) brought together stakeholders from the medical and pharmacy professions, the pharmaceutical industry, patient/ageing organisations and health authorities to consider the potential for pharmacy-based interventions to increase vaccine uptake. We report here the proceedings of this 3-day meeting held in March 2018 in San Servolo island, Venice, Italy, focussing firstly on examples from countries that have introduced pharmacy-based vaccination programmes, and secondly, listing the barriers and solutions proposed by the discussion groups.

CONCLUSIONS

A range of barriers to vaccine uptake have been identified, affecting all target groups, and in various countries and healthcare settings. Ease of accessibility is a potentially modifiable determinant in vaccine uptake, and thus, improving the diversity of settings where vaccines can be provided to adults, for example by enabling community pharmacists to vaccinate, may increase the number of available opportunities for vaccination.

Goad J. Using Community Pharmacy Immunization Screening Forms to Identify Potential Immunization Opportunities

Immunization screening forms are completed for each patient that is to be vaccinated in the pharmacy. Screening forms contain demographic and health questions, which are used to determine if a patient is contraindicated to receive a vaccine. The objective is to determine if patient responses to questions on these forms can be used to identify potential vaccine indications. De-identified data was retrospectively collected from 11 community pharmacies in California and Michigan that included basic demographics, answers to immunization screening questions, and vaccine(s) administered during that visit. The Advisory Committee on Immunization Practices (ACIP) recommendations were used to forecast vaccine needs using the limited demographic and health history available from the screening forms. Descriptive statistics are presented, characterizing patient demographics and health condition-based recommendations, and the percentage of patients in a pharmacy population that may have potential indications for additional vaccines. Data were collected from 8669 pharmacy vaccine screening forms. Using the patient’s date of birth on the screening form, 10% (n = 759) and 34.6% (n = 2615) of patients receiving vaccines at the pharmacy may be indicated for the zoster, or both the zoster and pneumococcal vaccines, respectively. Screening form questions that inquire about medical history are also able to identify 13.9% (n = 977) of patients with a potential need for pneumococcal vaccines. Our data indicate that pharmacists can identify potential immunization opportunities proactively by using their immunization screening form, not only to identify contraindications, but also indications.

Implementation and evaluation of a collaborative quality improvement program to improve immunization rate and reduce missed opportunities for vaccination in primary health-care facilities: a time series study in Kano, Nigeria

Background: The authors aimed to implement a quality improvement (QI) collaborative in primary health care (PHC) facilities in Nassarawa Local Government Area of Kano, Nigeria, to reduce missed opportunities for vaccination (MOV) among children aged 0-23 months. Research design and methods: Plausibility evaluation design was used in this study. Frontline health workers from five purposively selected PHC facilities used divergent-convergent thinking to select change ideas. Change ideas were implemented in two plan-do-study-act cycles that were 4 weeks apart. Statistical process control using P-chart was used to plot the outcomes over time. Upper and lower control limits were calculated for each p-chart. Results: In the facilities that implemented the QI program, the average percentage of MOV in the pre-implementation period was 31.7% with an upper control limit (UCL) of 44.5% and lower control limit (LCL) of 18.9%. After commencing QI implementation, data points stabilized as all points were within the control limits. Improvement was more evident in PHC 1 and 5. Conclusions: The findings from this study suggest that frontline health workers are capable of tailoring change ideas to their local context to generate context-specific change ideas. It also showed that QI can be used to attain process control in the occurrence of MOV.

O quotidiano na sala de vacinação: vivências de profissionais de enfermagem

Objetivo: compreender o quotidiano das salas de vacinação sob a ótica do profissional de Enfermagem. Materiais e Métodos: estudo de casos múltiplos holístico-qualitativo, fundamentado na sociologia compreensiva do quotidiano com 56 participantes de quatro microrregiões da Região Ampliada Oeste de Minas Gerais, Brasil.Resultados: a falta de vacina, a informatização, a comunicação e o horário de funcionamento da sala de vacinação interferem no quotidiano e na assistência prestada ao usuário. As ações realizadas na sala de vacinação implicam diretamente na confiança que os usuários têm no profissional. Surge a integralidade da atenção na sala de vacinação e esse espaço como um lugar para a construção do vínculo.Conclusões: aspectos inerentes ao profissional e à estrutura, organização, apoio e educação permanente influenciam o quotidiano do trabalho seguro na vacinação e nas coberturas vacinais. Faz-se necessário incorporar a supervisão sistematizada do enfermeiro nas salas de vacinação e a educação permanente dos profissionais.

Factors that influence parents' and informal caregivers' acceptance of routine childhood vaccination: a qualitative evidence synthesis

This is a protocol for a Cochrane Review (Qualitative). The objectives are as follows:

Identify, appraise and synthesise qualitative studies exploring: parents’ and informal caregivers’ views, experiences, or decision‐making regarding routine childhood vaccination; or the factors influencing acceptance of routine childhood vaccination arising from parents’ and informal caregivers’ accounts. Develop a conceptual understanding of what and how different factors influence parental acceptance of routine childhood vaccination. Explore how the findings of this review can enhance our understanding of the related intervention reviews (Saeterdal 2014 ; Oyo‐Ita 2016 ; Jacobson 2018 ; Kaufman 2018 ).

Vaccination in England: a review of why business as usual is not enough to maintain coverage

BACKGROUND

The vaccine system in England underwent radical changes in 2013 following the implementation of the Health and Social Care Act. There have since been multi-year decreases in coverage of many vaccines. Healthcare professionals have reported finding the new system fragmented and challenging. This study aims to produce a logic model of the new system and evaluate the available evidence for interventions to improve coverage.

METHODS

We undertook qualitative document analysis to develop the logic model using process evaluation methods. We performed a systematic review by searching 12 databases with a broad search strategy to identify interventions studied in England conducted between 2006 and 2016 and evaluated their effectiveness. We then compared the evidence base to the logic model.

RESULTS

We analysed 83 documents and developed a logic model describing the core inputs, processes, activities, outputs, outcomes and impacts of the new vaccination system alongside the programmatic assumptions for each stage. Of 9,615 unique articles, we screened 624 abstracts, 45 full-text articles, and included 16 studies: 8 randomised controlled trials and 8 quasi-experimental studies. Four studies suggest that modifications to the contracting and incentive systems can increase coverage, but changes to other programme inputs (e.g. human or capital resources) were not evaluated. Four multi-component intervention studies modified activities and outputs from within a GP practice to increase coverage, but were part of campaigns or projects. Thus, many potentially modifiable factors relating to routine programme implementation remain unexplored. Reminder/recall systems are under-studied in England; incentive payments to adolescents may be effective; and only two studies evaluated carer information.

CONCLUSIONS

The evidence base for interventions to increase immunisation coverage in the new system in England are limited by a small number of studies and by significant risk of bias. Several areas important to primary care remain unexplored as targets for interventions, especially modification to organisational management.

A process evaluation of how the routine vaccination programme is implemented at GP practices in England

BACKGROUND

In recent years, the incidence of several pathogens of public health importance (measles, mumps, pertussis and rubella) has increased in Europe, leading to outbreaks. This has included England, where GP practices implement the vaccination programme based on government guidance. However, there has been no study of how implementation takes place, which makes it difficult to identify organisational variation and thus limits the ability to recommend interventions to improve coverage. The aim of this study is to undertake a comparative process evaluation of the implementation of the routine vaccination programme at GP practices in England.

METHODS

We recruited a sample of geographically and demographically diverse GP practices through a national research network and collected quantitative and qualitative data as part of a Time-Driven Activity-Based Costing analysis between May 2017 and February 2018. We conducted semi-structured interviews with practice staff involved in vaccination, who then completed an activity log for 2 weeks. Interviews were transcribed and coded using a framework method.

RESULTS

Nine practices completed data collection from diverse geographic and socio-economic contexts, and 52 clinical and non-clinical staff participated in 26 interviews. Information relating to 372 vaccination appointments (233 childhood and 139 adult appointments) was captured using activity logs. We have defined a 14-stage care delivery value chain and detailed process map for vaccination. Areas of greatest variation include the method of reminder and recall activities, structure of vaccination appointments and task allocation between staff groups. For childhood vaccination, mean appointment length was 15.9 min (range 9.0-22.0 min) and 10.9 min for adults (range 6.8-14.1 min). Non-clinical administrative activities comprised 59.7% total activity (range 48.4-67.0%). Appointment length and total time were not related to coverage, whereas capacity in terms of appointments per eligible patient may improve coverage. Administrative tasks had lower fidelity of implementation.

CONCLUSIONS

There is variation in how GP practices in England implement the delivery of the routine vaccination programme. Further work is required to evaluate capacity factors in a wider range of practices, alongside other contextual factors, including the working culture within practices.

Evaluating Interventions to Increase Influenza Vaccination Rates among Pediatric Inpatients

Introduction:

Hospitalization provides an ideal opportunity for influenza vaccination, and strategies can enhance existing tools within the electronic medical record (EMR). The objectives of the study were to introduce and evaluate the effectiveness of provider and family-directed interventions to increase influenza vaccination ordering among inpatients.

Methods:

We conducted a quality improvement initiative for children aged older than 6 months on medical inpatient teams at a large pediatric tertiary care hospital from September 2014 to March 2015, comprising 2 intervention groups (provider reminders and family education) and 1 control group for comparison, using EMR prompts alone. The provider reminder interventions comprised weekly e-mails indicating inpatient immunization status; vaccination reports; and visual reminders. The family education group intervention consisted of handouts regarding the benefits and safety of influenza vaccination. We measured vaccine ordering rates for each group among eligible children and overall vaccination rates. Data were analyzed using Statistical Process Control Charts and Chi-square tests.

Results:

Among 2,552 patients aged older than 6 months hospitalized during the study period, 1,657 were unimmunized. During the intervention period, the provider group ordered 213/409 (52%) influenza vaccines, the family education group ordered 138/460 (30%) and the control group ordered 71/279 (25%) (P < 0.0001). The provider group had higher influenza immunization status than the control group (61% versus 53%; P = 0.0017). Exposure to the intervention did not impact the length of stay/discharge time.

Conclusions:

Provider reminders including e-mails, visual reminders, and vaccination reports are effective ways of increasing inpatient influenza vaccination rates and are more effective than family education, or EMR prompts alone.