Vaccination uptake by vaccine-hesitant parents attending a specialist immunization clinic in Australia

Exploring mother-daughter communication and social media influence on HPV vaccine refusal for daughters aged 9-17 years in a cross-sectional survey of 11,728 mothers in China

This study investigated the influences of mother-daughter communication and social media on mothers' HPV vaccine refusal for their daughters aged 9-17. A cross-sectional online survey among 11,728 mothers of girls aged 9-17 in Shenzhen, China was implemented between July and October 2023. Multi-level logistic regression models were fitted. Among 11,728 participants, 43.2% refused to have their daughters receive an HPV vaccination. In multivariate analysis, more openness in the mother-daughter communication (AOR: 0.99, 95%CI: 0.98, 0.99), perceived more positive outcomes of mother-daughter communication (AOR: 0.77, 95%CI: 0.75, 0.79), higher frequency of exposure to testimonials about daughters' HPV vaccination (AOR: 0.81, 95%CI: 0.78, 0.85) and information encouraging parents to vaccinate their daughters against HPV on social media (AOR: 0.76, 95%CI: 0.73, 0.79), and thoughtful consideration of the veracity of the information specific to HPV vaccines (AOR: 0.80, 95%CI: 0.77, 0.83) were associated with lower vaccine refusal. Mothers who were not the main decision-makers of daughters' HPV vaccination (AOR: 1.28 to 1.46), negative outcome expectancies of mother-daughter communication (AOR: 1.06, 95%CI: 1.04, 1.08), and mothers' HPV vaccine refusal (AOR: 2.81, 95%CI: 2.58, 3.06) were associated with higher vaccine refusal for their daughters. The level of mothers' HPV vaccine refusal for their daughters was high in China. Openness and outcome expectancies of mother-daughter communication and information exposure on social media were considered key determinants of HPV vaccine refusal for daughters. Future HPV vaccination programs should consider these interpersonal factors.

High vaccine confidence and strong approval of the mandatory immunization schedule among Bulgarian general practitioners in 2022

In a context of recently decreasing childhood immunization coverage and low uptake of COVID-19 vaccines in Bulgaria, this study measures vaccine hesitancy among general practitioners (GPs) in the country, as they are central to forming patients' attitudes. In 2022, a face-to-face survey was conducted through a simple random sample from an exhaustive national database of Bulgarian GPs. This study measured attitudes on vaccine importance, safety, and effectiveness, and attitudes toward the Bulgarian immunization schedule. Information was collected on demographic and GP practice characteristics and possible predictors of vaccine confidence in order to test for associations with attitudes toward immunization. GP attitudes toward vaccines and the immunization schedule in Bulgaria were generally positive. Among 358 respondents, 351 (98%,95%CI96-99%) strongly agreed/agreed that vaccines are important, 352 (98%,95%CI96-99%) that vaccines are effective, and 341 (95%,95%CI93-97%) that vaccines are safe. 347 respondents (97%,95%CI95-98%) affirmed that "it's good that vaccines from the children's immunization schedule are mandatory", and 331 (92%,95%CI89-95%) agreed with the statement "Bulgaria's childhood immunization has my approval". Trust in information from official institutions was among the strongest predictors of vaccine confidence. Respondents' vaccine confidence levels are within the ranges reported by GPs in other European countries and above those reported within the general Bulgarian population. GPs' vaccine confidence is highly associated with trust in official institutions. It is important to maintain trust in official institutions and to support GPs in communicating vaccine knowledge with patients so that vaccine hesitancy in the general population is countered.

A systematic literature review to clarify the concept of vaccine hesitancy

Vaccine hesitancy (VH) is considered a top-10 global health threat. The concept of VH has been described and applied inconsistently. This systematic review aims to clarify VH by analysing how it is operationalized. We searched PubMed, Embase and PsycINFO databases on 14 January 2022. We selected 422 studies containing operationalizations of VH for inclusion. One limitation is that studies of lower quality were not excluded. Our qualitative analysis reveals that VH is conceptualized as involving (1) cognitions or affect, (2) behaviour and (3) decision making. A wide variety of methods have been used to measure VH. Our findings indicate the varied and confusing use of the term VH, leading to an impracticable concept. We propose that VH should be defined as a state of indecisiveness regarding a vaccination decision.

Childhood vaccination coverage in Australia: an equity perspective

BACKGROUND

This study describes trends in social inequities in first dose measles-mumps-rubella (MMR1) vaccination coverage in Western Australia (WA) and New South Wales (NSW). Using probabilistically-linked administrative data for 1.2 million children born between 2002 and 2011, we compared levels and trends in MMR1 vaccination coverage measured at age 24 months by maternal country of birth, Aboriginal status, maternal age at delivery, socio-economic status, and remoteness in two states.

RESULTS

Vaccination coverage was 3-4% points lower among children of mothers who gave birth before the age of 20 years, mothers born overseas, mothers with an Aboriginal background, and parents with a low socio-economic status compared to children that did not belong to these social groups. In both states, between 2007 and 2011 there was a decline of 2.1% points in MMR1 vaccination coverage for children whose mothers were born overseas. In 2011, WA had lower coverage among the Aboriginal population (89.5%) and children of young mothers (89.3%) compared to NSW (92.2 and 92.1% respectively).

CONCLUSION

Despite overall high coverage of MMR1 vaccination, coverage inequalities increased especially for children of mothers born overseas. Strategic immunisation plans and policy interventions are important for equitable vaccination levels. Future policy should target children of mothers born overseas and Aboriginal children.

Prevalence and predictors of vaccine hesitancy in an urbanized agglomeration of New Delhi, India

Background

The immunization program has been an important part of Indian public health policy for three decades; yet only 62% of children are being fully immunized. Vaccine hesitancy is a major contributor to the immunization gap that needs to be addressed.

Methods

A cross-sectional descriptive study of prevalence and predictors of vaccine hesitancy was conducted in 350 households having at least one child in the age group of 13–24 months. Statistical analysis was done using chi-square test and logistic regression.

Results

The prevalence of vaccine hesitancy was 28.9%. Fear of needles, concern about pain during vaccination, lack of family support, and apprehension regarding side effects were ascertained as reasons for vaccine hesitancy. The type of family, time taken to reach the health facility and antenatal care received by the mother were significant predictors of vaccine hesitancy.

Conclusion

The prevalence of vaccine hesitancy was found to be high. In 2019, the World Health Organization earmarked vaccine hesitancy as one of the major roadblocks to better global health. A better understanding of the subject can help public health agencies enhance vaccination coverage, not just in children but also as a tool to protect entire populations in this age of re-emerging epidemics.

Distrust, danger, and confidence: A content analysis of the Australian Vaccination-Risks Network Blog

The Australian Vaccination-risks Network is Australia's most active counter-vaccine lobby group. This study employs a content analysis of the organization's 2012-2019 blog posts, while further considering Australian-specific vaccine contexts. The goal is to identify the persuasion attributes of these counter-vaccine articles, and the ways that the group's media employs persuasive cues when communicating to Australian publics. The project gauges the occurrence rates of message variables associated with the Elaboration Likelihood Model of persuasion, including those labeled as the Scarcity Principle, Arousal of Fear, Asking Questions, Source Cues, the Contrast Principle and Negativity Effect, as well as Statistics and Technical Jargon. Three overarching themes collectively exhibited by these message variables are further identified and described as Distrust, Danger, and Confidence. In view of these findings, the study then considers how persuasive cue expression in Australian Vaccination-risks Network blog posts corresponds with Australian vaccine hesitancies and the country's No Jab No Pay/Play policies.

Delivery of a Mental Health First Aid training package and staff peer support service in secondary schools: a process evaluation of uptake and fidelity of the WISE intervention

BACKGROUND

Improving children and young people's provision for mental health is a current health priority in England. Secondary school teachers have worse mental health outcomes than the general working population, which the Wellbeing in Secondary Education (WISE) cluster randomised controlled trial aimed to improve. The WISE intervention comprised a Mental Health First Aid (MHFA) training package delivered to at least 16% of staff, a short mental health awareness session to all teachers and development of a staff peer support service. Twenty-five schools were randomised to intervention or control arms. This paper reports findings regarding the extent of uptake and fidelity of the intervention.

METHODS

Mixed methods data collection comprised researcher observations of training delivery, training participant evaluation forms, trainer and peer supporter interviews, peer supporter feedback meetings, logs of support provided, and teacher questionnaires. Quantitative data were summarised descriptively, while thematic analysis was applied to the qualitative data.

RESULTS

In the 12 schools assigned to the intervention arm, 113 (8.6%) staff completed the 2-day standard MHFA training course, and a further 146 (11.1%) staff completed the 1-day MHFA for schools and colleges training. In seven (58.3%) schools, the required 8% of staff completed the MHFA training packages. A 1-h mental health awareness-raising session was attended by 666 (54.5%) staff. Delivery of the MHFA training package was achieved with high levels of fidelity and quality across schools. All schools set up the peer support service following training, with a majority adhering to most of the operational guidelines developed from the pilot study at the outset. Teachers reported limited use of the peer support service during follow-up. At the 1-year follow-up, only three (25.0%) schools indicated they had re-advertised the service and there was evidence of a reduction in support from senior leadership.

CONCLUSION

The MHFA training package was delivered with reasonably high fidelity, and a staff peer support service was established with general, but not complete, adherence to guidelines. In some schools, insufficient staff received MHFA training and levels of delivery of the peer support service compromised intervention dose and reach.

TRIAL REGISTRATION

ISRCTN 95909211 . Registered on 15 January 2016.

Subcutaneous nodules following immunization in children; in Victoria, Australia from 2007 to 2016

BACKGROUND

Subcutaneous nodules are a rare adverse event following immunization (AEFI). We aimed to describe nodules at the injection site reported to SAEFVIC (Surveillance of Adverse Events Following Vaccination in the Community) using the Brighton Collaboration Case Definition (BCCD), management and recurrence following subsequent immunizations.

METHOD

We assessed 58 cases (<18 years of age) of 'nodule at injection site' reported to SAEFVIC, Melbourne, Australia, between May 2007 and June 2016. Case details were analyzed from records and phone interview follow-up. The Australian Immunization Registry was reviewed for immunization status.

RESULTS

71% (41/58 reported cases) were consistent with the BCCD for subcutaneous nodule, 14% (8 cases) were 'possible subcutaneous nodules', 10% (6 cases) were nodules associated with BCG immunization and 5% (3 cases) were attributable to an alternative diagnosis. The median age at immunization was 12 months, (range 1 month-12 years); 54% male (22/41 cases). 17% (7 cases) had multiple nodules. Nodules were associated with immunizations containing aluminum (74%, 36/49 nodules), no aluminum (8%, 4 nodules) and unknown (18%, 9 nodules). Most cases developed symptoms within 3 days post-immunization (59%, 24 cases) and in the thigh (59%, 29 nodules). Pruritus was associated in 41% (17 cases). Around 1/3 (34%) of nodules resolved 6 months post immunization, 2/3 (68%) by 12 months, however 1/4 (24%) remained persistent for >24 months. 5 cases had prior nodules and 1 case had recurrence with subsequent immunization. 83% (34 cases) were fully immunized for age at follow-up.

CONCLUSION

Subcutaneous nodules at the injection site may occur following a wide range of vaccines, including vaccines without aluminum. All cases require careful review and where possible, specialist management and to support subsequent immunizations.

The hepatitis B birth-dose immunisation: Exploring parental refusal

BACKGROUND

Hepatitis B virus (HBV) immunisation is the first vaccine of infant life and one of the most commonly refused immunisations on the Australian Immunisation Schedule.

AIMS

To quantify the frequency of declined HBV immunisation birth-doses, investigate reasons for refusal, and determine information sources used by parents.

MATERIALS AND METHODS

A cross-sectional study using a questionnaire was conducted on postnatal women who declined their newborn's HBV birth-dose immunisation during December 2016-July 2017 at an Australian tertiary referral hospital. Mothers who were non-English-speaking, unwell or medically unstable, or otherwise unavailable were excluded.

RESULTS

One hundred and thirty-seven of the 1574 (8.7%) eligible reviewed infants had HBV immunisation birth-doses documented as declined; 113 mothers consented to complete the questionnaire. The most common reasons for declining the dose were: 'baby too young' (55.8%); preference for two, four and six-month HBV immunisations only (56.6%); perceived low risk of contracting HBV (45.1%); and a fear of 'overloading' their baby's immune system (42.5%). General practitioners or nurses/midwives (43.3%) and the internet/media (33.6%) were the predominant information sources consulted, and 58.4% felt satisfied with the information they received antenatally. Eighty-eight of 113 mothers (77.9%) would still consider future immunisations for their infant.

CONCLUSIONS

The majority of postnatal women decline HBV birth-dose immunisation for their newborns citing age-related safety concerns and vaccine misconceptions. Informal information sources such as the internet and media are often consulted. Addressing the need for antenatal and health professional education toward the birth-dose may be instrumental in improving uptake.

Countering vaccine hesitancy through immunization information systems, a narrative review

Immunization is one of the most important public health interventions to contrast infectious disease; however, many people nowadays refuse vaccination. Vaccine hesitancy (VH) is due to several factors that influence the complex decision-making process. Information technology tools might play an important role in vaccination programs. In particular, immunization information systems (IISs) have the potential to improve performance of vaccination programs and to increase vaccine uptake. This review aimed to present IIS functionalities in order to counter VH. In detail, we analyzed the automatic reminder/recall system, the interoperability of the system, the decision support system, the web page interface and the possibility to record adverse events following immunization. IIS could concretely represent a valid instrument to increase vaccine confidence, especially trust in both health-care workers and decision makers. There are not enough trials aimed to evaluate the efficacy of IIS to counter VH. Further researches might focalize on this aspect.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Investigating Italian parents' vaccine hesitancy: A cross-sectional survey

This cross-sectional survey was designed to assess the prevalence of vaccine hesitancy and to identify factors associated among a randomly selected sample of parents. A questionnaire was self-administered from October to December 2017 to a sample of parents of children aged 2 to 6 years attending five randomly selected pre-schools in the geographic area of Naples, Italy. Out of the 727 selected parents, 437 returned the questionnaires for a response rate of 60.1%. The median of Parent Attitudes about Childhood Vaccines Survey (PACV) score among participants was 45.8 with a total of 141 parents (34.7%) scored a value ≥50 and were defined hesitant about the childhood vaccinations. Vaccine hesitancy was significantly more common among those who were concerned and among those were not sure that any one of the childhood shots might not be safe, among those who were concerned that their children might have a serious side effect from a shot, among those who were concerned that a shot might not prevent the disease, among those who delayed and refused at least a shot of vaccine for their children, and in those who are not sure and uncertain in the pediatrician. More than half of parents (53.8%) expressed a desire to receive additional information about the childhood vaccinations. Parents who were not sure and uncertain that to follow the recommended shot schedule is a good idea for their children and those who were parents of first-born children were more likely to need additional information. This study finds a high prevalence of vaccine hesitancy among parents suggesting that in the immunization program is necessary to achieve a higher quality of the relationship between pediatricians and the community.

Attitudes towards compulsory vaccination in Italy: Results from the NAVIDAD multicentre study

BACKGROUND

Vaccine hesitancy is a considerable issue in European countries and leads to low coverage rates. After a long debate, Italy has made vaccination mandatory for admission to its schools.

METHODS

In the NAVIDAD study (a cross-sectional multicentre study), a 63-item questionnaire was administered to 1820 pregnant women from 15 Italian cities. The questionnaire assessed the interviewee's opinion on mandatory vaccines, as well as their socioeconomic status, sources of information about vaccines, confidence in the Italian National Healthcare Service (NHS), and intention to vaccinate their newborn.

RESULTS

Information sources play a key role in determining the opinion on restoration of mandatory vaccines; in particular, women who obtained information from anti-vaccination movements are less likely to accept the vaccines (OR: 0.35, 95% CI: 0.21-0.58, p < 0.001). Women who had confidence in healthcare professional information agreed more on mandatory vaccination than did the other women (OR: 2.66, 95% CI: 1.62-4.36, p < 0.001); those who perceived that healthcare professionals have economic interest in child immunization and who declared that healthcare providers inform only on vaccinations benefits not on risks were less likely to agree on compulsory vaccination (OR: 0.66, CI 95%: 0.46-0.96, p = 0.03; OR: 0.66, CI 95%: 0.46-0.95, p = 0.03, respectively).

CONCLUSION

Information sources and confidence towards health professionals are the main determinants of acceptance of mandatory vaccine restoration. To increase the acceptability of the restoration and reduce vaccine hesitancy, these aspects need to be strengthened.

Exploring patients' awareness and healthcare professionals' knowledge and attitude to pertussis and influenza vaccination during the antenatal periods in Cavan Monaghan general hospital

Infection with Pertussis or with Influenza during the antenatal period usually results in complications leading to severe morbidity and mortality. Influenza virus outbreak usually occurs almost every year during the winter periods with profound burden on the entire healthcare system. Both disease conditions are preventable with adequate health education and vaccination. Healthcare professionals have a role to play in the communication and provision of this all important health programme.

OBJECTIVE

We aimed to assess patients' awareness of pertussis and influenza vaccination as well as healthcare professionals' knowledge and attitude to pertussis and influenza vaccination during the antenatal periods in Cavan Monaghan General Hospital.

DESIGN

We performed a prospective cohort study in the antenatal clinics among patients, Non- consultant hospital doctors (NCHDs) and midwives in the maternity unit.

SETTING

Our setting was a regional hospital in the North East of the Republic of Ireland with approximately 2000 deliveries per annum.

PARTICIPANTS

These were randomly recruited from those attending routine antenatal clinic during the study period and healthcare professional working in the maternity unit.

RESULTS

Of the 113 antenatal women who completed the questionnaire,. more than 75% have heard of both vaccinations in pregnancy. Interestingly, 51.3% of women heard of the vaccination from their General practitioner (GP) while 1.8% heard of it from their hospital doctor. Despite this awareness, 57.6% and 31.9% of women knew that influenza and pertussis vaccine respectively is safe in pregnancy. The uptake of both vaccines is quite low with 31% for pertussis and 42.5% for influenza vaccine respectively. Despite more than 95% of healthcare professionals being aware of the health service executive (HSE) guidelines on immunisation, more than 75% of healthcare professionals did not receive the influenza vaccinations themselves and had no plans to receive it. More so, only 18% of healthcare professionals always discuss immunisation with antenatal women during their consultations.

CONCLUSION

Our study identified low pertussis and influenza vaccine uptake among pregnant women and their HCPs. Inadequate knowledge of immunization guidelines among HCPs, lack of insight on the need to get the vaccines among HCPs and poor communication are the probable cause of the low uptake. Hence, the need for more health educational programs to improve health professionals' knowledge and vaccine confidence and also vaccine uptake by patients.

Loss of chance associated with sub-optimal HPV vaccination coverage rate in France

INTRODUCTION

Since 2007, HPV vaccination programs have been implemented in Europe. Significant real-life impact has already been reported in countries where the programs have been successfully implemented. In France, HPV vaccination coverage rate (VCR) is currently one of the lowest in Europe. This represents a missed opportunity for individuals who will not be protected. The study aimed to estimate the consequences of the sub-optimal VCR.

METHODS

A dynamic transmission model was calibrated to the French setting. Outcomes resulting from the vaccination of girls with quadrivalent HPV vaccine according to two theoretical VCR: 17% and 70%, reflecting the range of VCRs in Western Europe, were evaluated.

RESULTS

Over 100 years, with the current low VCR, an additional 85,000 cancers, 28,000 deaths and more than 5 million avertable disease events overall would occur compared with a 70% VCR. At steady state, the 17% VCR was estimated to be associated with an additional 1700 cancers, 600 deaths and 66,000 avertable disease events each year, compared with a 'standard' EU VCR.

CONCLUSION

The loss of chance associated with sub-optimal VCR is substantial for the French population and could amount to the occurrence of hundreds of avoidable deaths and thousands of disease events annually.

Attitudes, Knowledge and Factors Associated with Human Papillomavirus (HPV) Vaccine Uptake in Adolescent Girls and Young Women in Victoria, Australia

Background

Human papillomavirus (HPV) vaccination targets high-risk HPV16/18 that cause 70% of all cancers of the cervix. In Australia there is a fully-funded, school-based National HPV Vaccination Program which has achieved vaccine initiation rate of 82% among age-eligible females. Improving HPV vaccination rates is important in the prevention of morbidity and mortality associated with HPV-related disease. This study aimed to identify factors and barriers associated with uptake of the HPV vaccine in the Australian Program.

Methods

Between 2011 and 2014, females aged 18–25 years, living in Victoria, Australia who were offered HPV vaccination between 2007 and 2009 as part of the National HPV Vaccination Program, living in Victoria, Australia were recruited into a a young women’s study examining effectiveness of the Australian National HPV Vaccination Program. Overall, 668 participants completed the recruitment survey, which collected data of participants’ demographics and HPV knowledge. In 2015 these participants were invited to complete an additional supplementary survey on parental demographics and attitudes towards vaccinations.

Results

In 2015, 417 participants completed the supplementary survey (62% response rate). Overall, 19% of participants were unvaccinated. In multivariate analyses, HPV vaccination was significantly associated with their being born in Australia (p<0.001), having completed childhood vaccinations (p<0.001) and their parents being main decision-makers for participants’ HPV vaccination (p<0.001). The main reason reported for HPV non-vaccination was parental concern about vaccine safety (43%). Compared with HPV-vaccinated participants, those unvaccinated were significantly more likely to be opposed to all vaccines, including HPV vaccines (p<0.001) and were less likely to consider vaccinating their own children with all vaccines (p = 0.033), including HPV vaccines (p<0.001). Overall, 61% of unvaccinated participants reported that a recommendation from GPs would increase HPV vaccine acceptance.

Conclusions

Attitudes towards general health, vaccinations in general, as well as HPV vaccines are important in HPV vaccine uptake. Long-term monitoring of the knowledge, attitude and beliefs towards HPV vaccination in the community is critical to ensure a continued high uptake of the vaccine and success of the program.

Controversies and challenges of vaccination: an interview with Elizabeth Miller

Although strong evidence exists that the benefits of vaccination by far outweigh potential adverse events, controversy still exists. This has led opponents of vaccination to question its safety, efficacy and necessity. In an interview with Professor Elizabeth Miller, we discuss the continuum of beliefs held by vaccine refusers and hesitators, the resulting health consequences, and ways in which health professionals and industry regulators can help promote transparency to better convey the substantial health benefits of vaccination.