Vaccinations in migrants and refugees: a challenge for European health systems. A systematic review of current scientific evidence

Predictors of COVID-19 vaccine acceptability among refugees and other migrant populations: A systematic scoping review

OBJECTIVE

This study aimed to map the existing literature to identify predictors of COVID-19 vaccine acceptability among refugees, immigrants, and other migrant populations.

METHODS

A systematic search of Medline, Embase, Scopus, APA PsycInfo and Cumulative Index of Nursing and Allied Health Literature (CINAHL) was conducted up to 31 January 2023 to identify the relevant English peer-reviewed observational studies. Two independent reviewers screened abstracts, selected studies, and extracted data.

RESULTS

We identified 34 cross-sectional studies, primarily conducted in high income countries (76%). Lower vaccine acceptance was associated with mistrust in the host countries' government and healthcare system, concerns about the safety and effectiveness of COVID-19 vaccines, limited knowledge of COVID-19 infection and vaccines, lower COVID-19 risk perception, and lower integration level in the host country. Female gender, younger age, lower education level, and being single were associated with lower vaccine acceptance in most studies. Additionally, sources of information about COVID-19 and vaccines and previous history of COVID-19 infection, also influence vaccine acceptance. Vaccine acceptability towards COVID-19 booster doses and various vaccine brands were not adequately studied.

CONCLUSIONS

Vaccine hesitancy and a lack of trust in COVID-19 vaccines have become significant public health concerns within migrant populations. These findings may help in providing information for current and future vaccine outreach strategies among migrant populations.

Seroprevalence status of vaccine-preventable diseases in migrants living in shelter centers in Barcelona, Spain

INTRODUCTION

Almost 281 million people were living in a foreign country in 2022, and more than 100 million were displaced because of war conflicts and human right violations. Vaccination coverage of infectious diseases in migrants from some disadvantaged settings could be lower than reception countries populations, consequently seroprevalence studies and better access to vaccination could contribute to reducing these differences.

METHODS

A descriptive retrospective cross-sectional study was conducted including migrants, living ≤5 years in the reception country and ≥16 years old, who requested a medical exam between January 1st, 2020 and January 31st, 2021. Seroprevalence assessment was performed, and vaccination was offered to those individuals without immunity to hepatitis B, hepatitis A, varicella, measles, mumps, and rubella.

RESULTS

A total of 315 migrants were attended during the study period. Immunity protection at arrival was 252/296 (85.1%) for measles, 274/295 (92.9%) for rubella, 257/296 (86.8%) for mumps, 264/295 (89.5%) for varicella, 267/313 (85.3%) for hepatitis A, and 104/300 (34.6%) for hepatitis B. The final immunity protection after full vaccination schedules was 278/296 (93.9%) for measles, 287/295 (97.3%) for rubella, 274/296 (92.6%) for mumps, 276/295 (93.6%) for varicella, 280/313 (89.5%) for hepatitis A, and 139/300 (46.3%) for hepatitis B.

CONCLUSIONS

The vaccination intervention has increased immunity rates for the studied diseases in the attended migrants in our center, however, such interventions should be maintained to reach local population immunization levels. Moreover, the collaboration between shelter and reference specialized health centers is fundamental to implement such vaccination programs.

Driving delivery and uptake of catch-up vaccination among adolescent and adult migrants in UK general practice: a mixed methods pilot study

BACKGROUND

Migrants in the UK and Europe face vulnerability to vaccine-preventable diseases (VPDs) due to missed childhood vaccines and doses and marginalisation from health systems. Ensuring migrants receive catch-up vaccinations, including MMR, Td/IPV, MenACWY, and HPV, is essential to align them with UK and European vaccination schedules and ultimately reduce morbidity and mortality. However, recent evidence highlights poor awareness and implementation of catch-up vaccination guidelines by UK primary care staff, requiring novel approaches to strengthen the primary care pathway.

METHODS

The 'Vacc on Track' study (May 2021-September 2022) aimed to measure under-vaccination rates among migrants in UK primary care and establish new referral pathways for catch-up vaccination. Participants included migrants aged 16 or older, born outside of Western Europe, North America, Australia, or New Zealand, in two London boroughs. Quantitative data on vaccination history, referral, uptake, and sociodemographic factors were collected, with practice nurses prompted to deliver catch-up vaccinations following UK guidelines. Focus group discussions and in-depth interviews with staff and migrants explored views on delivering catch-up vaccination, including barriers, facilitators, and opportunities. Data were analysed using STATA12 and NVivo 12.

RESULTS

Results from 57 migrants presenting to study sites from 18 countries (mean age 41 [SD 7.2] years; 62% female; mean 11.3 [SD 9.1] years in UK) over a minimum of 6 months of follow-up revealed significant catch-up vaccination needs, particularly for MMR (49 [86%] required catch-up vaccination) and Td/IPV (50 [88%]). Fifty-three (93%) participants were referred for any catch-up vaccination, but completion of courses was low (6 [12%] for Td/IPV and 33 [64%] for MMR), suggesting individual and systemic barriers. Qualitative in-depth interviews (n = 39) with adult migrants highlighted the lack of systems currently in place in the UK to offer catch-up vaccination to migrants on arrival and the need for health-care provider skills and knowledge of catch-up vaccination to be improved. Focus group discussions and interviews with practice staff (n = 32) identified limited appointment/follow-up time, staff knowledge gaps, inadequate engagement routes, and low incentivisation as challenges that will need to be addressed. However, they underscored the potential of staff champions, trust-building mechanisms, and community-based approaches to strengthen catch-up vaccination uptake among migrants.

CONCLUSIONS

Given the significant catch-up vaccination needs of migrants in our sample, and the current barriers to driving uptake identified, our findings suggest it will be important to explore this public health issue further, potentially through a larger study or trial. Strengthening existing pathways, staff capacity and knowledge in primary care, alongside implementing new strategies centred on cultural competence and building trust with migrant communities will be important focus areas.

Migration and infant immunization timeliness in New Zealand: Evidence from the Growing Up in New Zealand study

BACKGROUND

Migration has been recognized as an important determinant of child health outcomes including childhood vaccination status. This paper aims to examine the association between parental migration status and a less studied aspect of child immunization outcomes, namely timeliness, within the context of New Zealand (NZ), a country characterized by a substantial proportion of its resident population born overseas. Additionally, the study explored the impact of residential duration on children's immunization timeliness.

METHODS

The data was taken from a large, representative population-based cohort study in NZ (Growing Up in NZ study). A total of 6156 children and their parents, comprising 2241 foreign-born and 3915 NZ-born mothers and a sub-group of their partners were included in the analysis. The survey data was linked with the National Immunization Register dataset. Timely immunization was defined as receiving two vaccines at each scheduled vaccination point (at six-week, three-month, and five-month, totaling six doses of vaccines) within 30 days of their due date. We examined the associations between parental migration status, maternal residential duration, and child immunization timeliness while controlling for socio-economic variations. The results were presented as adjusted odds ratios (AORs) with 95 % confidence intervals (CIs).

RESULTS

The findings revealed that after adjustment for socioeconomic differences, children of foreign-born mothers exhibited higher odds of receiving all six studied vaccine doses on time compared to children of native-born mothers (AOR 1.51, 95 %CI:1.27-1.78). Similarly, having a foreign-born father was also significantly associated with timely completion of all six vaccine doses. Children of recent immigrants who had resided in the country for less than five years demonstrated higher odds of timely vaccination of all six vaccine doses compared to children of settled immigrants who had lived in the country for five or more years (AOR 1.65, 95 %CI: 1.25-2.19).

CONCLUSION

This study revealed a significant pattern in NZ where immigrants exhibited higher rates of timely immunization for their children compared to native-born parents. However, the findings also underscore the importance of providing support to settled immigrants, as their children experienced declines in timely vaccination rates compared to children of recent immigrants and even those born to NZ-born parents.

An exploration of COVID-19 vaccination models for newcomer refugees and immigrants in Calgary, Canada

BACKGROUND

The World Health Organization stresses the need for tailored COVID-19 models of vaccination to meet the needs of diverse populations and ultimately reach high rates of vaccination. However, little evidence exists on how COVID-19 models of vaccination operated in the novel context of the pandemic, how vulnerable populations, such as refugees, experience COVID-19 vaccination systems in high-income countries, and what lessons may be learned from vaccination efforts with vulnerable populations. To address this gap, this study explored COVID-19 vaccine delivery models available to newcomer refugees and immigrants, and refugee experiences across different COVID-19 vaccine delivery models in Calgary, Canada, and surrounding area in 2021 and 2022, to understand the barriers, strengths, and strategies of models to support access to COVID-19 vaccination for newcomer refugees and immigrants.

METHODS

Researchers conducted structured interviews with Government Assisted Refugees (n = 39), and semi-structured interviews with Privately Sponsored Refugees (n = 6), private refugee sponsors (n = 3), and stakeholders involved in vaccination systems (n = 13) in 2022. Thematic analysis was conducted to draw out themes related to barriers, strengths, and strategies of vaccine delivery models and the intersections with patient experiences.

RESULTS

Newcomer refugee and immigrant focused vaccination models and strategies were explored. They demonstrated how partnerships between organizations, multi-pronged approaches, and culturally responsive services were crucial to navigate ongoing and emergent factors, such as vaccine hesitancy, mandates, and other determinants of under-vaccination. Many vaccination models presented through interviews were not specific to refugees and included immigrants, temporary residents, ethnocultural community members, and other vulnerable populations in their design.

CONCLUSIONS

Increasing COVID-19 vaccine uptake for newcomer refugees and immigrants, is complex and requires trust, ongoing information provision, and local partnerships to address ongoing and emerging factors. Three key policy implications were drawn. First, findings demonstrated the need for flexible funding to offer outreach, translation, cultural interpretation, and to meet the basic needs of patients prior to engaging in vaccinations. Second, the research showed that embedding culturally responsive strategies within services ensures community needs are met. Finally, collaborating with partners that reflect the diverse needs of communities is crucial for the success of any health efforts serving newcomers.

The incidence of COVID-19-related hospitalisation in migrants in the UK: Findings from the Virus Watch prospective community cohort study

Background

Migrants in the United Kingdom (UK) may be at higher risk of SARS-CoV-2 exposure; however, little is known about their risk of COVID-19-related hospitalisation during waves 1-3 of the pandemic.

Methods

We analysed secondary care data linked to Virus Watch study data for adults and estimated COVID-19-related hospitalisation incidence rates by migration status. To estimate the total effect of migration status on COVID-19 hospitalisation rates, we ran mixed-effect Poisson regression for wave 1 (01/03/2020-31/08/2020; wildtype), and mixed-effect negative binomial regressions for waves 2 (01/09/2020-31/05/2021; Alpha) and 3 (01/06/2020-31/11/2021; Delta). Results of all models were then meta-analysed.

Results

Of 30,276 adults in the analyses, 26,492 (87.5 %) were UK-born and 3,784 (12.5 %) were migrants. COVID-19-related hospitalisation incidence rates for UK-born and migrant individuals across waves 1-3 were 2.7 [95 % CI 2.2-3.2], and 4.6 [3.1-6.7] per 1,000 person-years, respectively. Pooled incidence rate ratios across waves suggested increased rate of COVID-19-related hospitalisation in migrants compared to UK-born individuals in unadjusted 1.68 [1.08-2.60] and adjusted analyses 1.35 [0.71-2.60].

Conclusion

Our findings suggest migration populations in the UK have excess risk of COVID-19-related hospitalisations and underscore the need for more equitable interventions particularly aimed at COVID-19 vaccination uptake among migrants.

Risk of vaccine preventable diseases in UK migrants: A serosurvey and concordance analysis

Background

Vaccine preventable diseases (VPDs) such as measles and rubella cause significant morbidity and mortality globally every year. The World Health Organization (WHO), reported vaccine coverage for both measles and rubella to be 71 % in 2019, indicating an immunity gap. Migrants in the EU/EEA may be at high risk of VPDs due to under-immunisation and poor living conditions. However, there are limited data on VPD seroprotection rates amongst migrants living in the United Kingdom (UK).

Methods

We conducted an exploratory cross-sectional serosurvey amongst a sample of adult migrants living in Leicester, UK to: (a) determine seroprotection rates for measles, varicella zoster, and rubella in this group; (b) identify risk factors associated with seronegativity and, (c) understand if self-reported vaccine or diseases history is an effective measure of seroprotection. Participants gave a blood sample and completed a questionnaire asking basic demographic details and vaccine and disease history for the three VPDs. We summarised the data using median and interquartile range (IQR) for non-parametric continuous variables and count and percentage for categorical variables. We used logistic regression to establish predictors of seroprotection against these diseases. We examined the reliability of self-reported vaccination/disease history for prediction of seroprotection through a concordance analysis.

Results

149 migrants were included in the analysis. Seroprotection rates were: varicella zoster 98 %, rubella 92.6 % and measles 89.3 %. Increasing age was associated with seroprotection (OR 1.07 95 % CI 1.01-1.13 for each year increase in age). Migrants from Africa and the Middle East (aOR 15.16 95 % CI 1.31 - 175.06) and South/East Asia and Pacific regions (aOR 15.43 95 %CI 2.38 - 100.00) are significantly more likely to be seroprotected against measles as compared to migrants from Europe and Central Asia. The proportions of migrants unsure about their vaccination and disease history combined were 53.0 % for measles; 57.7 % for rubella; 43.0 % for varicella. There was no agreement between self-reported vaccination/disease history and serostatus.

Conclusion

Our findings suggest lower levels of seroprotection against measles in migrants living in Leicester, UK, with younger migrants and those from Europe and Central Asia more likely to lack seroprotection. A high proportion of surveyed migrants were unaware of their vaccination/disease history and self-reported vaccine/disease was a poor predictor of seroprotection against VPDs which is important for clinical decision-making regarding catch-up vaccination in this population. Our results, although derived from a small sample, suggest that there may be gaps in seroimmunity for certain VPDs in particular migrant populations. These findings should inform future qualitative studies investigating barriers to vaccine uptake in migrants and population-level seroprevalence studies aimed at determining individualised risk profiles based on demographic and migration factors.

COVID-19 Vaccinations, Trust, and Vaccination Decisions within the Refugee Community of Calgary, Canada

Refugee decisions to vaccinate for COVID-19 are a complex interplay of factors which include individual perceptions, access barriers, trust, and COVID-19 specific factors, which contribute to lower vaccine uptake. To address this, the WHO calls for localized solutions to increase COVID-19 vaccine uptake for refugees and evidence to inform future vaccination efforts. However, limited evidence engages directly with refugees about their experiences with COVID-19 vaccinations. To address this gap, researchers conducted qualitative interviews (N = 61) with refugees (n = 45), sponsors of refugees (n = 3), and key informants (n = 13) connected to local COVID-19 vaccination efforts for refugees in Calgary. Thematic analysis was conducted to synthesize themes related to vaccine perspectives, vaccination experiences, and patient intersections with policies and systems. Findings reveal that refugees benefit from ample services that are delivered at various stages, that are not solely related to vaccinations, and which create multiple positive touch points with health and immigration systems. This builds trust and vaccine confidence and promotes COVID-19 vaccine uptake. Despite multiple factors affecting vaccination decisions, a key reason for vaccination was timely and credible information delivered through trusted intermediaries and in an environment that addressed refugee needs and concerns. As refugees placed trust and relationships at the core of decision-making and vaccination, it is recommended that healthcare systems work through trust and relationships to reach refugees. This can be targeted through culturally responsive healthcare delivery that meets patients where they are, including barrier reduction measures such as translation and on-site vaccinations, and educational and outreach partnerships with private groups, community organizations and leaders.

COVID-19 vaccination coverage for half a million non-EU migrants and refugees in England

Despite evidence suggesting that some migrants are at risk of under-immunization and have experienced severe health inequities during the pandemic, data are limited on migrants' COVID-19 vaccine coverage globally. Here we linked data from non-European Union migrants and resettled refugees to the national COVID-19 vaccination dataset in England. We estimated patterns in second and third dose delays and overdue doses between 12 December 2020 and 20 April 2022 by age, visa type and ethnicity. Of the 465,470 linked records, 91.8% (427,073/465,470) of migrants received a second dose and 51.3% (238,721/465,470) received a third. Refugees had the highest risk of delayed second (adjusted odds ratio 1.66; 95% confidence interval 1.55-1.79) and third dose (1.55; 1.43-1.69). Black migrants were twice as likely to have a second dose delayed (2.37; 2.23-2.54) than white migrants, but this trend reversed for the third dose. Older migrants (>65 years) were four times less likely to have received their second or third dose compared with the general population in England aged >65 or older. Policymakers, researchers and practitioners should work to understand and address personal and structural barriers to vaccination for diverse migrant populations.

Exploring COVID-19 Vaccination Willingness in Italy: A Focus on Resident Foreigners and Italians Using Data from PASSI and PASSI d'Argento Surveillance Systems

(1) The COVID-19 pandemic exacerbated health disparities, both between foreign and autochthonous populations. Italy was one of the European countries that was the most affected by the COVID-19 pandemic; however, only limited data are available on vaccine willingness. This study aims to assess the propensity of foreign and autochthonous populations residing in Italy to be vaccinated and the relative associated factors. (2) Data were collected and analysed from the two Italian surveillance systems, PASSI and PASSI d'Argento, in the period of August 2020-December 2021. The data include those of the Italian resident adult population over 18 years old. A multinomial logistic regression model, stratified by citizenship, was used to assess the associations of sociodemographic, health, and COVID-19 experience variables with vaccination attitudes. (3) This study encompassed 19,681 eligible subjects. Considering the willingness to be vaccinated, foreign residents were significantly less certain to get vaccinated (49.4% vs. 60.7% among Italians). Sociodemographic characteristics, economic difficulties, and trust in local health units emerged as factors that were significantly associated with vaccine acceptance. Having received the seasonal flu vaccine was identified as a predictor of COVID-19 vaccine acceptance among foreign and Italian residents. (4) This study underscores the significance of tailoring interventions to address vaccine hesitancy based on the diverse characteristics of foreign and Italian residents. This research offers practical insights for public health strategies, highlighting the importance of tailored educational campaigns, improved communication, and nuanced interventions to enhance vaccine acceptance and uptake within both populations.

The impact of anthropogenic climate change on pediatric viral diseases

The adverse effects of climate change on human health are unfolding in real time. Environmental fragmentation is amplifying spillover of viruses from wildlife to humans. Increasing temperatures are expanding mosquito and tick habitats, introducing vector-borne viruses into immunologically susceptible populations. More frequent flooding is spreading water-borne viral pathogens, while prolonged droughts reduce regional capacity to prevent and respond to disease outbreaks with adequate water, sanitation, and hygiene resources. Worsening air quality and altered transmission seasons due to an increasingly volatile climate may exacerbate the impacts of respiratory viruses. Furthermore, both extreme weather events and long-term climate variation are causing the destruction of health systems and large-scale migrations, reshaping health care delivery in the face of an evolving global burden of viral disease. Because of their immunological immaturity, differences in physiology (e.g., size), dependence on caregivers, and behavioral traits, children are particularly vulnerable to climate change. This investigation into the unique pediatric viral threats posed by an increasingly inhospitable world elucidates potential avenues of targeted programming and uncovers future research questions to effect equitable, actionable change. IMPACT: A review of the effects of climate change on viral threats to pediatric health, including zoonotic, vector-borne, water-borne, and respiratory viruses, as well as distal threats related to climate-induced migration and health systems. A unique focus on viruses offers a more in-depth look at the effect of climate change on vector competence, viral particle survival, co-morbidities, and host behavior. An examination of children as a particularly vulnerable population provokes programming tailored to their unique set of vulnerabilities and encourages reflection on equitable climate adaptation frameworks.

Disparities in Coronavirus Disease 2019 Clinical Outcomes and Vaccination Coverage Among Migrants With Human Immunodeficiency Virus in the PISCIS Cohort: A Population-Based Propensity Score-Matched Analysis

Background

Coronavirus disease 2019 (COVID-19) disproportionately affects migrants and ethnic minorities, including those with human immunodeficiency virus (HIV). Comprehensive studies are needed to understand the impact and risk factors.

Methods

Using data from the PISCIS cohort of people with HIV (PWH) in Catalonia, Spain, we investigated COVID-19 outcomes and vaccination coverage. Among 10 640 PWH we compared migrants and non-migrants assessing rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing, diagnosis, and associated clinical outcomes through propensity score matching and multivariable Cox regression.

Results

The cohort (mean age, 43 years; 83.5% male) included 57.4% (3053) Latin American migrants. Migrants with HIV (MWH) had fewer SARS-CoV-2 tests (67.8% vs 72.1%, P < .0001) but similar COVID-19 diagnoses (29.2% vs 29.4%, P = .847) compared to Spanish natives. Migrants had lower complete vaccination (78.9% vs 85.1%, P < .0001) and booster doses (63.0% vs 65.5%, P = .027). COVID-19 hospitalizations (8.1% vs 5.1%, P < .0001) and intensive care unit (ICU) admissions (2.9% vs 1.2%, P < .0001) were higher among migrants, with similar hospitalization duration (5.5 vs 4.0 days, P = .098) and mortality (3 [0.2%] vs 6 [0.4%], P = .510). Age ≥40 years, CD4 counts <200 cells/μL, ≥2 comorbidities, and incomplete/nonreception of the SARS-CoV-2 vaccine increased the risk of severe COVID-19 among migrants.

Conclusions

MWH had lower rates of SARS-CoV-2 testing and vaccination coverage, although the rates of COVID-19 diagnosis were similar between migrants and non-migrants. Rates of COVID-19-associated hospitalizations and ICU admissions were higher among migrants in comparison with non-migrants, with similar hospitalization duration and mortality. These findings can inform policies to address disparities in future pandemic responses for MWH.

Community-based screening enhances hepatitis B virus linkage to care among West African migrants in Spain

BACKGROUND

Chronic infection with HBV is responsible for >50% of all hepatocellular cancer cases globally and disproportionately affects sub-Saharan African (sSA) countries. Migration from these countries to Europe has increased substantially in recent years, posing unique challenges to health systems. The aim of this study was to carry out a community-based intervention to increase HBV screening, vaccination, and linkage to care among sSA migrants in Catalonia, Spain.

METHODS

This was a prospective cohort study. Participants ≥18 years were offered community-based HBV screening between 20/11/20 and 21/01/22. Rapid HBV testing and blood sample collection utilizing plasma separation cards were carried out and linkage to care was offered to all participants. HBV vaccination and post-test counseling were performed at a second visit in the community. The main outcome was the odds of those with current HBV infection being successfully linked to hepatology. Rates of completing the care cascade of this model were analyzed.

RESULTS

In the present study, 444 people undergo screening, with 50.6% of participants showing evidence of past or current HBV infection, including an HBsAg prevalence of 9.2%. Migrants with current HBV infection exhibit 5.2 times higher odds of successful linkage to care compared to those in need of post-test counseling or vaccination. The study achieves a successful linkage to care rate of 72% for all participants, with specialist appointments arranged within 15.5 days.

CONCLUSIONS

This community-based HBV screening program provides evidence of a successful model for identifying and providing care, including vaccination, to west African migrants at high risk of HBV infection who may otherwise not engage in care.

Motivations for Adolescent COVID-19 Vaccination: A Comparative Study of Adolescent and Caregiver Perspectives in Germany

Given the crucial role of vaccination in halting the COVID-19 pandemic, it is imperative to understand the factors that motivate adolescents to get vaccinated. We surveyed adolescents and their accompanying guardians scheduled to receive a COVID-19 vaccination (Comirnaty) in an urban region in Germany in mid-2021 regarding their motivation for getting vaccinated and collected data on their sociodemographic characteristics, medical history, vaccination status, and any history of COVID-19 infection in the family. We also queried information strategies related to the SARS-CoV-2 pandemic. Motivations for getting vaccinated were similar among adolescents and their parents. The primary reasons for vaccination were protection against SARS-CoV-2-related illness and gaining access to leisure facilities. This was not influenced by gender, health status, migration background, or the presence of chronic or acute diseases. The percentage of parents who had received SARS-CoV-2 immunization and the proportion of parents with a high level of education were higher among study participants than in the general population. Adolescents were especially willing to be vaccinated if they came from a better educational environment and had a high vaccination rate in the family. Emphasizing the importance of vaccination among all segments of the population and removing barriers to vaccines may lead to an ameliorated acceptance of COVID-19 vaccines.

Perceived barriers of migrants and refugees to vaccinate their children against Measles and polio: a study in Iran

BACKGROUND

This study examined the perceived barriers of migrants and refugees to vaccinating their children against measles and polio in Iran.

METHODS

First, an instrument was developed and validated through several steps. Next, 1,067 parents who had not vaccinated their children against polio and measles or had delayed receiving any dose of these two vaccines until the age of 15 were selected from 16 provinces and completed the instrument. Finally, the data were analyzed.

RESULTS

The results of the explanatory factor analysis showed that the perceived barriers affecting vaccination against polio and measles vaccines were categorized into five factors: low knowledge, negative attitude, communication challenges, lack of participation in vaccination programs, and problems related to migration and refugees. Additionally, the results indicated a significant difference in the mean score of perceived barriers based on participants' level of education, economic status, and nationality.

CONCLUSION

The identified barriers may provide a perspective for developing effective efforts in this area. Interventions should focus on parents with low education and poor economic status.

Covid-19 vaccination among migrants in Rome, Italy

Migrants may be susceptible to vaccine barriers and hesitancy. We evaluated the association between migrant status, as measured by the citizenship from a High Migratory Pressure Country (HMPC), and COVID-19 vaccination uptake in the resident population in Rome, Italy. We also investigated sex differences. We followed participants for vaccination against COVID-19 in 2021. We calculated crude- and adjusted-vaccination rates and Cox hazard ratios of vaccination for migrants compared to Italians. Among migrants from HMPCs, we estimated HRs for females compared to males, stratifying by geographical area of origin. Models were adjusted for age and deprivation index and stratified by infection history. In 2021, among 1,731,832 18-64-year-olds, migrants were 55% less likely to uptake at least one COVID-19 vaccine dose than their Italian counterpart. Past SARS-CoV-2 infection reduced the difference between migrants and Italians to 27%. Among migrants from HMPCs, we observed a slight excess of vaccination uptake among females compared to males. Focusing on geographical areas, we observed that only females from central-western Asia were 9% less likely to uptake vaccination than males. Health communication strategies oriented to migrants and considering their different languages, cultures, and health literacy should be adopted for prevention before emergencies.

[Bacterial infections of the skin in the context of climate change and migration]

BACKGROUND

In the context of climate change and migration, both common and previously less common pathogens are gaining importance as cutaneous bacterial infections.

OBJECTIVE

To inform medical professionals about challenges to dermatology posed by climate change and migration.

MATERIALS AND METHODS

Review of the current literature on emerging antimicrobial resistance and emerging pathogens in general and on the epidemiological situation in Germany in particular.

RESULTS

Climate change has a direct impact on microbiological ecosystems in Germany's warming coastal waters leading to an increase of marine V. vulnificus counts and human infections. Secondary to global warming, transmitting vectors of, for example, Lyme disease, rickettsioses and tularemia are also increasing. In addition, infectious diseases like cutaneous diphtheria and mycobacteriosis have been diagnosed in migrants, mostly likely acquired before migration or on the migration route and first diagnosed in Germany. In this context, antimicrobial resistance (e.g. methicillin-resistant Staphylococcus aureus [MRSA] and multidrug-resistant gram-negative bacteria) is gaining importance.

CONCLUSION

Due to progressive changes in global climate and ongoing migration, the aforementioned pathogens of infectious skin diseases and changes in antimicrobial resistance patterns have to be expected. Physicians should be aware of these developments in order to offer appropriate diagnostics and treatment. Epidemiological and biogeographic monitoring will be indispensable for managing emerging changes.

The Endless Vulnerability of Migrant Children In-Transit across the Darién Gap

Many people from poverty-stricken countries are migrating across South and Central America to reach the México-United States border, a movement exacerbated by the COVID-19 pandemic. Migrant people who begin their northbound journey in South America must transit across a significant geographic bottleneck, the Darién Gap, a mountainous rainforest region between Colombia and Panama. Most migrant people crossing this region originate from Cuba, Haiti, and Venezuela. Other people reach the shores of South American countries from west and central Africa or central and southeastern Asia and continue to the Darién Gap. Poverty and violence drive families with children to flee their homes and endure incalculable risks in their path. Children traveling with their families or as unaccompanied minors across the Darién Gap are exposed to life-threatening situations and human rights violations, including abuse, exploitation, malnourishment, and limited access to medical care. In addition to experiencing untreated medical illnesses, children experience mental health disorders during migration and after they reach their destination as a result of victimization and adverse traumatic experiences. Therefore, providing migrants, especially children, with rapid medical screenings and mental health support when they arrive at their destination is critical to reduce health inequities. Furthermore, making these interventions available during their transit and ensuring their safety may prevent further human rights abuses in children and families. Latin American governments must address the ongoing humanitarian crisis endured by migrants throughout their migratory path by offering access to essential healthcare services and safeguarding the rights and security of children and vulnerable groups.

Scoping Review on Barriers and Challenges to Pediatric Immunization Uptake among Migrants: Health Inequalities in Italy, 2003 to Mid-2023

In the aftermath of the COVID-19 pandemic, asylum seekers, refugees, and foreign-born migrants are more likely to suffer from physical, mental, and socioeconomic consequences owing to their existing vulnerabilities and worsening conditions in refugee camps around the world. In this scenario, the education of migrants and newcomers about immunization is critical to achieving health equity worldwide. Globally, it is unclear whether government vaccination policies are prioritizing the health information needs of migrants. We searched for studies investigating the vaccination uptake of migrant children settled in Italy that were published between January 2003 and 25 June 2023. Following Arksey and O'Malley's five-stage method for scoping reviews, all potentially relevant literature published in English was retrieved from SciSearch, Medline, and Embase. This search resulted in 88 research articles, 25 of which met our inclusion criteria. Our findings indicate unequal access to vaccination due to a lack of available information in the native language of the immigrants' country of origin, vaccine safety concerns or lack of awareness, logistical difficulties, and fear of legal consequences. The findings strongly encourage further government and political discourse to ensure migrants have fair, equitable, ethical, and timely access to essential medicines.

Access to Vaccination for Newly Arrived Migrants: Developing a General Conceptual Framework for Understanding How to Improve Vaccination Coverage in European Countries

Objectives: Access to vaccination for newly arrived migrants (NAMs) is a relevant concern that requires urgent attention in EU/EEA countries. This study aimed to develop a General Conceptual Framework (GCF) for understanding how to improve vaccination coverage for NAMs, by characterizing and critically analyzing system barriers and possible strategies to increase vaccination. Methods: A theoretical conceptualization of the GCF was hypothesized based on conceptual hubs in the immunization process. Barriers and solutions were identified through a non-systematic desktop literature review and qualitative research. The GCF guided the activities and facilitated the integration of results, thereby enriching the GCF with content. Results: The study explores the vaccination of NAMs and proposes strategies to overcome barriers in their vaccination process. It introduces a framework called GCF, which consists of five interconnected steps: entitlement, reachability, adherence, achievement, and evaluation of vaccination. The study also presents barriers and solutions identified through literature review and qualitative research, along with strategies to enhance professionals' knowledge, improve reachability, promote adherence, achieve vaccination coverage, and evaluate interventions. The study concludes by recommending strategies such as proximity, provider training, a migrant-sensitive approach, and data collection to improve vaccination outcomes for NAMs. Conclusion: Ensuring equitable access to healthcare services, including vaccination, is crucial not only from a humanitarian perspective but also for the overall public health of these countries.

Prevalence of COVID-19 vaccine acceptance among migrant and refugee groups: A systematic review and meta-analysis

Objectives

Understanding COVID-19 vaccine hesitancy among migrant and refugee groups is critical for achieving vaccine equity. Therefore, we aimed to estimate the prevalence of COVID-19 vaccine acceptance among migrant and refugee populations.

Methods

A systematic review (PROSPERO: CRD42022333337) was conducted (December 2019-July 2022) using PubMed, Scopus, Web of Science, ProQuest and Google Scholar.

Results

Nineteen studies from 12 countries were included. The pooled estimated prevalence of COVID-19 vaccine willingness among migrant and refugee groups was 70% (19 studies, 95% CI: 62.3-77.4%, I2: 99.19%, τ2: 0.03). Female and male participants did not differ significantly with each other (p = 0.64). Although no individual variable contributed statistically significantly in multivariable meta-regression analysis, the multivariable model that considered methodological quality, mean age of participants, participant group and country of origin explained 67% of variance.

Discussion

Proportions of migrant/refugee groups receiving COVID-19 vaccinations approximated those observed among general populations. Additional studies are needed to examine factors relating to vaccine willingness to identify the most significant factors that may be targeted in interventions.

Access, acceptability, and uptake of the COVID-19 vaccine among global migrants: A rapid review

OBJECTIVE

To conduct a rapid review and determine the acceptability, access, and uptake of the COVID-19 vaccine among global migrants.

MATERIALS AND METHODS

A rapid review was conducted May 2022 capturing data collected from April 2020 to May 2022. Eight databases were searched: PubMed, Ovid Medline, EMBase, CINAHL, SCOPUS, Google Scholar, LILACS, and the Web of Science. The keywords "migrants" AND COVID-19" AND "vaccine" were matched with terms in MeSH. Peer-reviewed articles in English, French, Portuguese, or French were included if they focused on COVID-19 immunization acceptability, access, or uptake among global migrants. Two independent reviewers selected and extracted data. Extracted data was synthesized in a table of key characteristics and summarized using descriptive statistics.

RESULTS

The search returned 1,186 articles. Ten articles met inclusion criteria. All authors reported data on the acceptability of the COVID-19 vaccine, two on access, and one on uptake. Eight articles used quantitative designs and two studies were qualitative. Overall, global migrants had low acceptability and uptake, and faced challenges in accessing the COVID-19 vaccine, including technological issues.

CONCLUSIONS

This rapid review provides a global overview of the access, acceptability, and uptake of the COVID-19 vaccine among global migrants. Recommendations for practice, policy, and future research to increase access, acceptability, and uptake of vaccinations are discussed.

Health inequalities in infectious diseases: a systematic overview of reviews

OBJECTIVES

The aim of this systematic overview of reviews was to synthesise available evidence on inequalities in infectious disease based on three dimensions of inequalities; inclusion health groups, protected characteristics and socioeconomic inequalities.

METHODS

We searched MEDLINE, Embase, Web of Science and OpenGrey databases in November 2021. We included reviews published from the year 2000 which examined inequalities in the incidence, prevalence or consequences of infectious diseases based on the dimensions of interest. Our search focused on tuberculosis, HIV, sexually transmitted infections, hepatitis C, vaccination and antimicrobial resistance. However, we also included eligible reviews of any other infectious diseases. We appraised the quality of reviews using the Assessment of Multiple Systematic Reviews V.2 (AMSTAR2) checklist. We conducted a narrative data synthesis.

RESULTS

We included 108 reviews in our synthesis covering all the dimensions of inequalities for most of the infectious disease topics of interest, however the quality and volume of review evidence and consistency of their findings varied. The existing literature reviews provide strong evidence that people in inclusion health groups and lower socioeconomic status are consistently at higher risk of infectious diseases, antimicrobial resistance and incomplete/delayed vaccination. In the protected characteristics dimension, ethnicity, and sexual orientation are important factors contributing to inequalities across the various infectious disease topics included in this overview of reviews.

CONCLUSION

We identified many reviews that provide evidence of various types of health inequalities in different infectious diseases, vaccination, and antimicrobial resistance. We also highlight areas where reviews may be lacking. The commonalities in the associations and their directions suggest it might be worth targeting interventions for some high risk-groups that may have benefits across multiple infectious disease outcomes rather than operating purely in infectious disease siloes.

Determinants of Equity in Coverage of Measles-Containing Vaccines in Wales, UK, during the Elimination Era

In the context of the WHO’s measles and rubella elimination targets and European Immunization Agenda 2030, this large cross-sectional study aimed to identify inequalities in measles vaccination coverage in Wales, UK. The vaccination status of individuals aged 2 to 25 years of age, alive and resident in Wales as of 31 August 2021, was ascertained through linkage of the National Community Child Health Database and primary care data. A series of predictor variables were derived from five national datasets and all analysis was carried out in the Secure Anonymised Information Linkage Databank at Swansea University. In these 648,895 individuals, coverage of the first dose of measles-containing vaccine (due at 12–13 months of age) was 97.1%, and coverage of the second dose (due at 3 years and 4 months) in 4 to 25-year-olds was 93.8%. In multivariable analysis, excluding 0.7% with known refusal, the strongest association with being unvaccinated was birth order (families with six or more children) and being born outside of the UK. Living in a deprived area, being eligible for free school meals, a lower level of maternal education, and having a recorded language other than English or Welsh were also associated with lower coverage. Some of these factors may also be associated with refusal. This knowledge can be used to target future interventions and prioritise areas for catch up in a time of limited resource.

TURNING UP THE HEAT: A CONCEPTUAL MODEL FOR UNDERSTANDING THE MIGRATION AND HEALTH IN THE CONTEXT OF GLOBAL CLIMATE CHANGE

Background

The triangular relationship between climate change-related events, patterns of human migration and their implications for health is an important yet understudied issue. To improve understanding of this complex relationship, a comprehensive, interdisciplinary conceptual model will be useful. This paper investigates relationships between these factors and considers their impacts for affected populations globally.

Methods

A desk review of key literature was undertaken. An open-ended questionnaire consisting of 11 items was designed focusing on three themes: predicting population migration by understanding key variables, health implications, and suggestions on policy and research. After using purposive sampling we selected nine experts, reflecting diverse regional and professional backgrounds directly related to our research focus area. All responses were thematically analysed and key themes from the survey were synthesised to construct the conceptual model focusing on describing the relationship between global climate change, migration and health implications and a second model focusing on actionable suggestions for organisations working in the field, academia and policymakers.

Results

Key themes which constitute our conceptual model included: a description of migrant populations perceived to be at risk; health characteristics associated with different migratory patterns; health implications for both migrants and host populations; the responsibilities of global and local governance actors; and social and structural determinants of health. Less prominent themes were aspects related to slow-onset migratory patterns, voluntary stay, and voluntary migration. Actionable suggestions include an interdisciplinary and innovative approach to study the phenomenon for academicians, preparedness and globalized training and awareness for field organisations and migrant inclusive and climate sensitive approach for policymakers.

Conclusion

Contrary to common narratives, participants framed the impacts of climate change-related events on migration patterns and their health implications as non-linear and indirect, comprising many interrelated individual, social, cultural, demographic, geographical, structural, and political determinants. An understanding of these interactions in various contexts is essential for risk reduction and preventative measures. The way forward broadly includes inclusive and equity-based health services, improved and faster administrative systems, less restrictive (im)migration policies, globally trained staff, efficient and accessible research, and improved emergency response capabilities. The focus should be to increase preventative and adaptation measures in the face of any environmental changes and respond efficiently to different phases of migration to aim for better "health for all and promote universal well-being" (WHO) (World Health Organization 1999).

Suboptimal Serologic Immunity Against Poliomyelitis Among New Migrant Children in Greece Calls for Organized Action

BACKGROUND

Migration-flows pose the risk of poliovirus reintroduction from endemic countries to Greece. This study aims to evaluate serologic-immunity/vaccination against poliomyelitis in newly-arriving migrant children.

METHODS

Demographic-immunisation data and blood-serum were obtained from migrants 1-14years-old, referred to a hospital-clinic in Athens-Greece within three months from arrival. Immunity to polioviruses-1-3 was determined by serum-neutralizing-antibodies(WHO guidelines). Titers ≥ 1:8 were considered positive.

RESULTS

From 9/2010 to 9/2013, 274 children(150 refugees/124 immigrants), mean age 7.1years-old, were enrolled. Only 57(20.8%) of them presented with vaccination-records. Children originated mainly from Asia(n = 198), Eastern Europe(n = 28), Middle East(n = 24) and Africa(n = 24) with 160(58.4%) from polio-endemic-countries(Afghanistan-112(40.8%), Pakistan-24(8.8%) and India-24(8.8%)). Seropositivity against polio-1-2&3 was 84.3%, 86.1% and 74.5%, respectively. Immigrants, had higher seroprotective rates against polioviruses-1-2&3 than refugees(polio-1:p = 0.002;polio-2:p = 0.004,polio-3:p < 0.001). Seronegativity to 1PVs-2PVs and all three polio serotypes was found in 37(13.5%),12 (4.4%), and 30 children(10.9%) respectively. Increasing number of vaccine-doses, and younger-age, were positively-associated with seropositivity.

DISCUSSION

A remarkable fraction of newly-arrived migrant-children were seronegative to one or more polioviruses.

Codesigning an intervention to strengthen COVID-19 vaccine uptake in Congolese migrants in the UK (LISOLO MALAMU): a participatory qualitative study protocol

INTRODUCTION

Migrants positively contribute to host societies yet experience barriers to health and vaccination services and systems and are considered to be an underimmunised group in many European countries. The COVID-19 pandemic has highlighted stark inequities in vaccine uptake, with migrants facing access and informational barriers and lower vaccine confidence. A key challenge, therefore, is developing tailored vaccination interventions, services and systems which account for and respond to the unique drivers of vaccine uptake in different migrant populations. Participatory research approaches, which meaningfully involve communities in co-constructing knowledge and solutions, have generated considerable interest in recent years for those tasked with designing and delivering public health interventions. How such approaches can be used to strengthen initiatives for COVID-19 and routine vaccination merits greater consideration.

METHODS AND ANALYSIS

LISOLO MALAMU ('Good Talk') is a community-based participatory research study which uses qualitative and coproduction methodologies to involve adult Congolese migrants in developing a tailored intervention to increase COVID-19 vaccine uptake. Led by a community-academic coalition, the study will involve (1) semistructured in-depth interviews with adult Congolese migrants (born in Democratic Republic of Congo, >18 years), (2) interviews with professional stakeholders and (3) codesign workshops with adult Congolese migrants. Qualitative data will be analysed collaboratively using reflexive thematic analysis, and behaviour change theory will be used in parallel to support the coproduction of interventions and make recommendations across socioecological levels. The study will run from approximately November 2021 to November 2022.

ETHICS AND DISSEMINATION

Ethics approval was granted by the St George's University Research Ethics Committee (REC reference: 2021.0128). Study findings will be disseminated to a range of local, national and international audiences, and a community celebration event will be held to show impact and recognise contributions. Recommendations for implementation and evaluation of prototyped interventions will be made.

COVID-19 vaccines, mobility, and pandemic bureaucracies: Undocumented migrants' perspectives from Italy's Alpine border

While scholars have noted the deeply unequal effects of the pandemic containment, there has been limited attempt to map the socio-political lives of vaccination policies, particularly from the perspective of undocumented persons moving at state margins. This paper explores how undocumented migrants, who were predominantly male travellers attempting to cross Italy's Alpine borders, encountered Covid-19 vaccines and contemporary legislation. Based on ethnographic observations and qualitative interviews with migrants, doctors, and activists at safehouses both on the Italian and French sides of the Alpine border, we trace how mobility centred decisions to accept or reject vaccines were significantly shaped by exclusionary border regimes. We move beyond the exceptional focus of the Covid-19 pandemic to show how centring visions of health connected to viral risk diverted attention from migrants' wider struggles to move to obtain safety. Ultimately, we argue for a recognition of how health crises are not merely unequally experienced, but may result in the reconfiguration of violent governance practices at state borders.

Multi-method findings on COVID-19 vaccine acceptability among urban refugee adolescents and youth in Kampala, Uganda

ABSTRACTScant studies have explored COVID-19 vaccine acceptability among refugees. However, contexts of forced migration may elevate COVID-19 vulnerabilities, and suboptimal refugee immunisation rates are reported for other vaccine-preventable diseases. We conducted a multi-methods study to describe COVID-19 vaccine acceptability among urban refugee youth in Kampala, Uganda. This study uses cross-sectional survey data from a cohort study with refugees aged 16-24 in Kampala to examine socio-demographic factors associated with vaccine acceptability. A purposively sampled cohort subset (n = 24) participated in semi-structured in-depth individual interviews, as did key informants (n = 6), to explore COVID-19 vaccine acceptance. Among 326 survey participants (mean age: 19.9; standard deviation 2.4; 50.0% cisgender women), vaccine acceptance was low (18.1% reported they were very likely to accept an effective COVID-19 vaccine). In multivariable models, vaccine acceptance likelihood was significantly associated with age and country of origin. Qualitative findings highlighted COVID-19 vaccine acceptability barriers and facilitators spanning social-ecological levels, including fear of side effects and mistrust (individual level), misinformed healthcare, community and family attitudes (community level), tailored COVID-19 services for refugees (organisational and practice setting), and political support for vaccines (policy environment). These data signal the urgent need to address social-ecological factors shaping COVID-19 vaccine acceptability among Kampala's young urban refugees.Trial registration: ClinicalTrials.gov identifier: NCT04631367.

Vaccine hesitancy and its determinants among refugee parents resettled in Aotearoa New Zealand

Vaccine hesitancy is an important factor underpinning suboptimal vaccine uptake and evidence on marginalized subgroups, such as refugees, is limited. This cross-sectional survey was conducted in 2020/21 with former refugee parents who resettled in Aotearoa New Zealand (NZ). The Parent Attitudes about Childhood Vaccines (PACV) was offered in Somali, Oromo, Arabic, and English languages, and the reliability of the four versions were evaluated. The prevalence of parental vaccine hesitancy was explored and the association between vaccine hesitancy and sociodemographic factors was examined using logistic regression. One hundred and seventy-eight responses were included in the analysis. The Cronbach's alpha scores for Somali, Oromo, Arabic, and English PACV were 0.89, 0.64, 0.53, and 0.77, respectively. The rate of parental vaccine hesitancy was 16.3%, 95% CI (10.7, 21.3). Most caregivers were concerned about vaccine side effects (47%), safety (43%), and efficacy (40%). Less than a quarter (21%) of parents had delayed their child receiving a vaccine and 12% had refused to vaccinate their child for reasons other than medical exemptions. After adjusting for covariate/s, parents' primary source of information and education status were significantly associated with vaccine hesitancy. Media as a primary source of vaccine information and low education status were associated with higher vaccine hesitancy. Vaccine hesitancy is relatively low among former refugees and is influenced by modifiable factors, including educational level and primary source of vaccine information. Vaccine information tailored to former refugee parents' concerns are required to reduce vaccine hesitancy and improve vaccine uptake.

Access to Healthcare Services and Essential Medicines in GREEK Migrant Camps: an Online Cross-Sectional Study

During the last years, Greece has become the entry point of a high number of migrants and asylum seekers. The aim of this study was to assess the access to selected fields of primary healthcare, to emergency medical care, secondary healthcare and essential medicines among populations living in reception, temporary accommodation, and detention centres (migrant camps) in Greece. An online cross-sectional survey was conducted based on a self-administered questionnaire. Participants included indviduals working or volunteering in migrant camps in Greece. 64 individuals participated in this study. The most common health problem among people residing in migrant camps was mental health conditions. The access to each field of primary healthcare was assessed as minimum to non-existent by most of the participants. 47.2% assessed the access to emergency medical care as minimum/non-satisfactory, while 60.8% assessed the access to secondary healthcare as minimum to non-existent. Most participants assessed the access to all the medicines categories as minimum or moderate. Access to both primary and secondary health was given a lower grade in the East-Aegean islands compared to the mainland. Major health inequalities among populations residing in Greek migrant camps were highlighted in this study. A change in the current migration policies of Greece and the European Union is urgently needed.

"We don't routinely check vaccination background in adults": a national qualitative study of barriers and facilitators to vaccine delivery and uptake in adult migrants through UK primary care

OBJECTIVES

Explore primary care professionals' views around barriers/facilitators to catch-up vaccination in adult migrants (foreign-born; over 18 years of age) with incomplete/uncertain vaccination status and for routine vaccines to inform development of interventions to improve vaccine uptake and coverage.

DESIGN

Qualitative interview study with purposive sampling and thematic analysis.

SETTING

UK primary care.

PARTICIPANTS

64 primary care professionals (PCPs): 48 clinical-staff including general practitioners, practice nurses and healthcare assistants; 16 administrative-staff including practice managers and receptionists (mean age 45 years; 84.4% women; a range of ethnicities).

RESULTS

Participants highlighted direct and indirect barriers to catch-up vaccines in adult migrants who may have missed vaccines as children, missed boosters and not be aligned with the UK's vaccine schedule, from both personal and service-delivery levels, with themes including: lack of training and knowledge of guidance among staff; unclear or incomplete vaccine records; and lack of incentivisation (including financial) and dedicated time and care pathways. Adult migrants were reported as being excluded from many vaccination initiatives, most of which focus exclusively on children. Where delivery models existed, they were diverse and fragmented, but included a combination of opportunistic and proactive programmes. PCPs noted that migrants expressed to them a range of views around vaccines, from positivity to uncertainty, to refusal, with specific nationality groups reported as more hesitant about specific vaccines, including measles, mumps and rubella (MMR).

CONCLUSIONS

WHO's new Immunization Agenda 2030 calls for greater focus to be placed on delivering vaccination across the life course, targeting underimmunised groups for catch-up vaccination at any age, and UK primary care services therefore have a key role. Vaccine uptake in adult migrants could be improved through implementing new financial incentives or inclusion of adult migrant vaccination targets in Quality Outcomes Framework, strengthening care pathways and training and working directly with local community-groups to improve understanding around the benefits of vaccination at all ages.

Country immunization policies for refugees across 20 low-middle income and 20 high-income countries

In 2020, 26 million refugees resettled in a new country-fleeing their homes due to conflict and persecution. Due to low immunization coverage and underlying health conditions, refugees commonly face an increased risk of contracting vaccine-preventable diseases. We collected and analyzed existing routine immunization policies for refugees across 20 low- and middle-income countries (LMICs) and 20 high-income countries (HICs), each with the highest number of refugees per 1000 residents. Primary and secondary data sources were used to collect policy evidence. Across 20 LMICs, 13 countries specified standing nationwide routine immunization policies for refugees, while 14 out of the 20 HICs included refugees in their national routine immunization programs. LMICs and HICs should include refugees in their national routine immunization policies and provide accessible and affordable immunizations. Such efforts would reduce vaccine-preventable diseases and protect the health of refugee populations-especially during the COVID-19 pandemic.

Exploring the Mental, Social, and Lifestyle Effects of a Positive COVID-19 Infection on Syrian Refugees in Jordan: A Qualitative Study

Migrants and refugees are among the vulnerable populations that suffered disproportionately from the COVID-19 crisis. However, their experiences with COVID-19 positivity status have not been investigated. This study explored the physical, mental, and psychosocial impacts of a positive COVID-19 diagnosis on Syrian refugees living in Jordan. Using a qualitative approach, twenty phone interviews were conducted with ten adult Syrian refugees living within the camp and ten refugees living in non-camp (host community) settings in Jordan. Follow-up interviews with five health care providers at a refugee camp were conducted to explore the services and support provided to the refugees with COVID-19 infection. The findings were thematically analyzed and grouped into major themes, subthemes, and emerging themes. Refugees living within camp settings had better access to testing, healthcare, and disease management and did not experience fear of being deported. Refugees in both settings suffered mental and psychosocial health impacts, social isolation, fear of death, and disease complications. COVID-19 infection has negatively impacted refugees' well-being with noticeable disparities across the different living conditions. Refugees living within host community settings may need more support for managing their condition, accessibility to free testing, as well as treatment and healthcare services.

Experimental evidence on improving COVID-19 vaccine outreach among migrant communities on social media

Studies from several countries suggest that COVID-19 vaccination rates are lower among migrants compared to the general population. Urgent calls have been made to improve vaccine outreach to migrants, however, there is limited evidence on effective approaches, especially using social media. We assessed a targeted, low-cost, Facebook campaign disseminating COVID-19 vaccine information among Arabic, Turkish and Russian speakers in Germany (N = 888,994). As part of the campaign, we conducted two randomized, online experiments to assess the impact of the advertisement (1) language and (2) depicted messenger (government authority, religious leader, doctor or family). Key outcomes included reach, click-through rates, conversion rates and cost-effectiveness. Within 29 days, the campaign reached 890 thousand Facebook users. On average, 2.3 individuals accessed the advertised COVID-19 vaccination appointment tool for every euro spent on the campaign. Migrants were 2.4 (Arabic), 1.8 (Russian) and 1.2 (Turkish) times more likely to click on advertisements translated to their native language compared to German-language advertisements. Furthermore, findings showed that government representatives can be more successful in engaging migrants online compared to other messengers, despite common claims of lower trust in government institutions among migrants. This study highlights the potential of tailored, and translated, vaccination campaigns on social media for reaching migrants who may be left out by traditional media campaigns.

Defining the determinants of vaccine uptake and undervaccination in migrant populations in Europe to improve routine and COVID-19 vaccine uptake: a systematic review

Understanding why some migrants in Europe are at risk of underimmunisation and show lower vaccination uptake for routine and COVID-19 vaccines is critical if we are to address vaccination inequities and meet the goals of WHO's new Immunisation Agenda 2030. We did a systematic review (PROSPERO: CRD42020219214) exploring barriers and facilitators of vaccine uptake (categorised using the 5As taxonomy: access, awareness, affordability, acceptance, activation) and sociodemographic determinants of undervaccination among migrants in the EU and European Economic Area, the UK, and Switzerland. We searched MEDLINE, CINAHL, and PsycINFO from 2000 to 2021 for primary research, with no restrictions on language. 5259 data sources were screened, with 67 studies included from 16 countries, representing 366 529 migrants. We identified multiple access barriers-including language, literacy, and communication barriers, practical and legal barriers to accessing and delivering vaccination services, and service barriers such as lack of specific guidelines and knowledge of health-care professionals-for key vaccines including measles-mumps-rubella, diphtheria-pertussis-tetanus, human papillomavirus, influenza, polio, and COVID-19 vaccines. Acceptance barriers were mostly reported in eastern European and Muslim migrants for human papillomavirus, measles, and influenza vaccines. We identified 23 significant determinants of undervaccination in migrants (p<0·05), including African origin, recent migration, and being a refugee or asylum seeker. We did not identify a strong overall association with gender or age. Tailored vaccination messaging, community outreach, and behavioural nudges facilitated uptake. Migrants' barriers to accessing health care are already well documented, and this Review confirms their role in limiting vaccine uptake. These findings hold immediate relevance to strengthening vaccination programmes in high-income countries, including for COVID-19, and suggest that tailored, culturally sensitive, and evidence-informed strategies, unambiguous public health messaging, and health system strengthening are needed to address access and acceptance barriers to vaccination in migrants and create opportunities and pathways for offering catch-up vaccinations to migrants.

COVID-19 Vaccine Acceptance and Its Determinants among Migrants in Germany-Results of a Cross-Sectional Study

Vaccinations are a core element of infection control. Migrants have been reported to have low vaccination rates for many infectious diseases, including COVID-19. Still, determinants of migrants' uptake of COVID-19 vaccinations are not sufficiently clear. The present study addresses this gap and examines the respective influence of three potential determinants: barriers to access, attitude towards vaccinations in general, and towards COVID-19 vaccines. The study uses a cross-sectional online survey among migrants in Germany. The questionnaire assessed the aforementioned determinants using standardized tools. Information on 204 individuals was available. The vaccination rate in the sample was 80%. Vaccinated as compared to unvaccinated respondents reported more often the absence of financial barriers (71% (95%CI: 64-73%) vs. 45% (95%CI: 28-63%)), short waiting times (51% (95%CI: 43-59%) vs. 22% (95%CI: 5-38%)), and the presence of a vaccination center close-by (91.5% (95%CI: 87-96%) vs. 69.7% (95%CI: 54-85%)). Concerning COVID-19 vaccine acceptance, the majority of respondents (68%) agreed that the vaccine is important. Unvaccinated respondents more often feared side effects, were convinced that the vaccine is not safe, and assumed that COVID-19 is not dangerous. Correspondingly, acceptance of vaccinations in general was higher among vaccinated respondents. In line with findings from previous studies, our survey found that all three determinants seem to influence migrants' vaccination status while their overall vaccination rate was comparable to the general population. Hence, migration background per se does not sufficiently explain vaccine acceptance and further research is needed to identify subgroups of migrants that should be specifically addressed to increase their vaccination rate.

Access to Vaccination among Disadvantaged, Isolated and Difficult-to-Reach Communities in the WHO European Region: A Systematic Review

Vaccination has a significant impact on morbidity and mortality. High vaccination coverage rates are required to achieve herd protection against vaccine-preventable diseases. However, limited vaccine access and hesitancy among specific communities represent significant obstacles to this goal. This review provides an overview of critical factors associated with vaccination among disadvantaged groups in World Health Organisation European countries. Initial searches yielded 18,109 publications from four databases, and 104 studies from 19 out of 53 countries reporting 22 vaccine-preventable diseases were included. Nine groups representing the populations of interest were identified, and most of the studies focused on asylum seekers, refugees, migrants and deprived communities. Recall of previous vaccinations received was poor, and serology was conducted in some cases to confirm protection for those who received prior vaccinations. Vaccination coverage was lower among study populations compared to the general population or national average. Factors that influenced uptake, which presented differently at different population levels, included health service accessibility, language and vaccine literacy, including risk perception, disease severity and vaccination benefits. Strategies that could be implemented in vaccination policy and programs were also identified. Overall, interventions specific to target communities are vital to improving uptake. More innovative strategies need to be deployed to improve vaccination coverage among disadvantaged groups.

The Association between Childhood Immunization and Gender Inequality: A Multi-Country Ecological Analysis of Zero-Dose DTP Prevalence and DTP3 Immunization Coverage

This study explores the association between childhood immunization and gender inequality at the national level. Data for the study include annual country-level estimates of immunization among children aged 12–23 months, indicators of gender inequality, and associated factors for up to 165 countries from 2010–2019. The study examined the association between gender inequality, as measured by the gender development index and the gender inequality index, and two key outcomes: prevalence of children who received no doses of the DTP vaccine (zero-dose children) and children who received the third dose of the DTP vaccine (DTP3 coverage). Unadjusted and adjusted fractional logit regression models were used to identify the association between immunization and gender inequality. Gender inequality, as measured by the Gender Development Index, was positively and significantly associated with the proportion of zero-dose children (high inequality AOR = 1.61, 95% CI: 1.13–2.30). Consistently, full DTP3 immunization was negatively and significantly associated with gender inequality (high inequality AOR = 0.63, 95% CI: 0.46–0.86). These associations were robust to the use of an alternative gender inequality measure (the Gender Inequality Index) and were consistent across a range of model specifications controlling for demographic, economic, education, and health-related factors. Gender inequality at the national level is predictive of childhood immunization coverage, highlighting that addressing gender barriers is imperative to achieve universal coverage in immunization and to ensure that no child is left behind in routine vaccination.

The Global Impact of Hepatitis B Vaccination on Hepatocellular Carcinoma

Over 1.5 million preventable new hepatitis B infections continue to occur each year and there are an estimated 296 million people living with chronic hepatitis B infection worldwide, resulting in more than 820,000 deaths annually due to liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis B vaccination remains the cornerstone of public health policy to prevent HCC and a vital component of the global hepatitis B elimination response. The WHO has set a 90% vaccination target to achieve hepatitis B elimination by 2030; however, there is wide variability in reported birth dose coverage, with global coverage at only 42%. In this review, we outline the global trends in hepatitis B vaccination coverage and the impact of hepatitis B vaccination on HCC incidence and discuss the challenges and enabling factors for achieving WHO 2030 hepatitis B vaccination coverage targets.

Immunisation status of UK-bound refugees between January, 2018, and October, 2019: a retrospective, population-based cross-sectional study

Background

WHO's new Immunization Agenda 2030 places a focus on ensuring migrants and other marginalised groups are offered catch-up vaccinations across the life-course. Yet, it is not known to what extent specific groups, such as refugees, are immunised according to host country schedules, and the implications for policy and practice. We aimed to assess the immunisation coverage of UK-bound refugees undergoing International Organization for Migration (IOM) health assessments through UK resettlement schemes, and calculate risk factors for under-immunisation.

Methods

We undertook a retrospective cross-sectional study of all refugees (children <10 years, adolescents aged 10–19 years, and adults >19 years) in the UK resettlement programme who had at least one migration health assessment conducted by IOM between Jan 1, 2018 and Oct 31, 2019, across 18 countries. Individuals' recorded vaccine coverage was calculated and compared with the UK immunisation schedule and the UK Refugee Technical Instructions. We carried out multivariate logistic regression analyses to assess factors associated with varying immunisation coverage.

Findings

Our study included 12 526 refugees of 36 nationalities (median age 17 years [IQR 7–33]; 6147 [49·1%] female; 7955 [63·5%] Syrian nationals). 26 118 vaccine doses were administered by the IOM (most commonly measles, mumps, and rubella [8741 doses]). During the study, 6870 refugees departed for the UK, of whom 5556 (80·9%) had at least one recorded dose of measles-containing vaccine and 5798 (84·4%) had at least one dose of polio vaccine, as per the UK Refugee Technical Instructions, and 1315 (19·1%) had at least one recorded dose of diphtheria-containing vaccine or tetanus-containing vaccine. 764 (11·1%) of refugees were fully aligned with the UK schedule for polio, compared with 2338 (34·0%) for measles and 380 (5·5%) for diphtheria and tetanus. Adults were significantly less likely than children to be in line with the UK immunisation schedule for polio (odds ratio 0·0013, 95% CI 0·0001–0·0052) and measles (0·29, 0·25–0·32).

Interpretation

On arrival to the UK, refugees' recorded vaccination coverage is suboptimal and varies by age, nationality, country of health assessment, and by disease, with particularly low coverage reported for diphtheria and tetanus, and among adult refugees. These findings have important implications for the delivery of refugee pre-entry health assessments and catch-up vaccination policy and delivery targeting child, adolescent, and adults migrants in the UK, and other refugee-receiving countries. This research highlights the need for improved data sharing and clearer definition of where responsibilities lie between host countries and health assessment providers.

Funding

UK National Institute for Health Research (NIHR300072) and Medical Research Council (MR/N013638/1).

Vaccination coverage among migrants: A systematic review and meta-analysis

BACKGROUND

Migrants, a population vulnerable to communicable diseases, face multiple barriers in access to immunization programs. Individual studies suggest that they suffer immunization inequity compared to non-migrants, but the gap in vaccination has not been quantified. This systematic review assessed quantitatively the level of vaccination coverage among migrants, in comparison with non-migrants, collating the published literature.

METHODS

Review protocol was prospectively registered (PROSPERO CRD42021228061). A literature search without language restrictions was conducted in PubMed, Scopus and Web of Science, from database inception to February 2021. This review included observational studies that provided the vaccination rates among migrant and non-migrant groups. Study quality was assessed using Newcastle-Ottawa scale. Data were synthesized pooling data from individual studies to generate summary odds ratio (OR) with 95% confidence interval (CI) using random effects model, assessing heterogeneity with I² statistic and publication bias with funnel asymmetry analysis.

FINDINGS

There were 44 relevant studies (7,937,996 participants). Overall risk of bias was low in 13 (30%), moderate in 22 (50%) and high in 9 (20%) studies. Point estimates of individual ORs showed lower vaccination coverage among migrants in 36 of 39 meta-analyzable studies. Overall, the odds of vaccination coverage among migrants were lower compared to non-migrants (7,375,184 participants; summary OR 0.50; 95% CI 0.37-0.66; I² 99.9%). There was no funnel asymmetry.

INTERPRETATION

Migrants are half as often vaccinated compared to non-migrants. Public health prevention programs need to prioritize vaccination equity, not just to protect migrants but also to protect the host communities.

Durability of tetanus seroprotection in people living with HIV

OBJECTIVES

Estimate the durability of tetanus toxoid (TT) -specific seroprotection in a cohort of people living with HIV (PLWH).

DESIGN

Cross-sectional study.

METHODS

PLWH with a last date of TT booster available were identified. TT-specific IgG were detected using commercial ELISA kit. Durability of seroprotection was estimated using linear regression model and analyzed according to the country of birth. The impact of baseline parameters at the time of vaccination (CD4+ T cell count, viral load and ART) was also assessed.

RESULTS

One-hundred and three subjects were included. The median duration between last TT booster and sampling was 5.6 years (IQR 2.6-8.9). Using linear regression model, half-life of TT-specific antibody was estimated at 9.9 years (95% CI: 5.5-50) in the whole cohort. Half-life was reduced in subjects born outside Europe: 4.4 years (95% CI: 2.9-8.5). PLWH born outside Europe had lower CD4+ T cell count at the time of immunization and more frequently a CD4+ T cell count nadir<200 mm3 before vaccination.

CONCLUSIONS

PLWH born outside Europe have lower half-life of TT-specific antibody as compared to previous study performed in the general population. Possible causes include lower nadir or current CD4+ T cell count or under-immunization status in country of origin before migration. Longer interval of booster vaccination, as recommended in the general population, might not be appropriate in this subgroup of PLWH.

Evolving measles status and immunization policy development in six European countries

Developing and implementing new immunization policies in response to shifting epidemiology is a critical public health component. We adopted a mixed-methods approach (via narrative literature review [101 articles] and 9 semi-structured interviews) to evaluate policy development in response to shifting measles epidemiology in six European countries (Italy, Belgium, Germany, Romania, UK, and Ukraine); where policies and strategies have evolved in response to country-specific disease and vaccination patterns. Periodic outbreaks have occurred in all countries against a background of declining measles-containing-vaccine (MCV) uptake and increasing public vaccine hesitancy (with substantial regional or social differences in measles burden and vaccine uptake). Health-care worker (HCW) vaccine skepticism is also seen. While many outbreaks arise or involve specific susceptible populations (e.g., minority/migrant communities), the broader pattern is spread to the wider (and generally older) population; often among incompletely/non-vaccinated individuals as a legacy of previous low uptake. Immunization policy and strategic responses are influenced by political and social factors, where public mistrust contributes to vaccine hesitancy. A strong centralized immunization framework (allied with effective regional implementation and coherent political commitment) can effectively increase uptake. Mandatory vaccination has increased childhood MCV uptake in Italy, and similar benefits could be anticipated for other countries considering vaccine mandates. Although possible elsewhere, socio-political considerations render mandating impractical in other countries, where targeted immunization activities to bolster routine uptake are more important. Addressing HCW skepticism, knowledge gaps, improving access and increasing public/community engagement and education to address vaccine hesitancy/mistrust (especially in communities with specific unmet needs) is critical.

A sociotechnical approach to vaccine manufacturer selection as part of a global immunization strategy against epidemics and pandemics

These are unprecedented times while the world weathers the highly infectious respiratory pandemic caused by coronavirus disease-19 (COVID-19). Humanity has experienced other cataclysmic events, but something as novel as this pandemic cannot be easily described. A safe COVID-19 vaccine is often hailed as the only effective public health method to prevent the further spread of this virus. New vaccines' cost has increased even as policymakers struggle with limited resources and budget constraints. Thus, more decision-support tools are needed to facilitate the selection of vaccine manufacturers as part of a global immunization strategy against COVID-19 or other epidemics and pandemics. This study sought to address this issue by combining three well-established operational research methods (i.e., cognitive mapping, decision-making trial and evaluation laboratory, and the Choquet integral). Based on the insights provided by a panel of experts on vaccination and infectious diseases, a vaccine manufacturer selection mechanism was developed that incorporates the World Health Organization's guidelines. This approach facilitated the identification of multiple selection criteria regarding vaccine manufacturers, their allocation into six major clusters (i.e., soundness of scientific approach and technology used; speed of delivery; cost; liability and risk sharing; ability to supply sufficient quantities through production capacity development; and global solidarity), and subsequent analysis of the respective cause-and-effect relationships. The results of a real-life application of the proposed selection system were further consolidated by a member of Saint Francisco Xavier Hospital Infectious Diseases Unit in Lisbon, Portugal. The mechanism's advantages and limitations are also discussed.

International migration of unaccompanied minors: trends, health risks, and legal protection

The global population of unaccompanied minors-children and adolescents younger than 18 years who migrate without their legal guardians-is increasing. However, as data are not systematically collected in any region, if collected at all, little is known about this diverse group of young people. Compared with adult migrants, unaccompanied minors are at greater risk of harm to their health and integrity because they do not have the protection provided by a family, which can affect their short-term and long-term health. This Review summarises evidence regarding the international migration and health of unaccompanied minors. Unaccompanied minors are entitled to protection that should follow their best interests as a primary consideration; however, detention, sometimes under the guise of protection, is a widespread practice. If these minors are provided with appropriate forms of protection, including health and psychosocial care, they can thrive and have good long-term outcomes. Instead, hostile immigration practices persist, which are not in the best interests of the child.