Determinants of non-vaccination and incomplete vaccination in Canadian toddlers

Impact of maternal depression and anxiety on immunization status of children: a prospective cohort study

BACKGROUND

Maternal depression and anxiety can have a detrimental impact on birth outcomes and healthy child development; there is limited knowledge on its influence on immunization schedule adherence. Therefore, the objectives of this study were to determine the impact of maternal depression and anxiety in the perinatal period on prolonged vaccine delay of childhood vaccines.

METHODS

In this prospective cohort study, we analyzed linked survey and administrative data of 2,762 pregnant women in Calgary, Alberta, Canada. Data were collected at two time-points: prenatal (< 25 weeks of gestation) and postpartum (4 months postpartum). We used multivariable logistic regression to examine the association between depression and anxiety with prolonged immunization delay, adjusting for covariates.

RESULTS

In multivariable analysis, maternal depression at either time point was not associated with prolonged delay for DTaP-IPV-Hib (OR 1.16, 95% CI 0.74-1.82), MMR/MMRV (OR 1.03, 95% CI 0.72-1.48), or all routine childhood vaccines combined (OR 1.32, 95% CI 0.86-2.04). Maternal anxiety at either time point was also not associated with prolonged delayed for DTaP-IPV-Hib (OR 1.08, 95% CI 0.77-1.53), MMR/MMRV (OR 1.07, 95% CI 0.82-1.40), or all vaccines combined (OR 1.00, 95% CI 0.80-1.26). In both the depression and anxiety models, children of Canadian-born mothers had higher odds of prolonged delay, as did those with low-income mothers.

CONCLUSION

Health care providers can be reassured that maternal depression and anxiety do not appear to influence maternal commitment to routine immunization. Findings suggested that low income and household moves may influence adherence to vaccine schedules and health care providers may want to provide anticipatory guidance to these families.

The influence of demographic and socio-economic factors on non-vaccination, under-vaccination and missed opportunities for vaccination amongst children 0-23 months in Kenya for the period 2003-2014

Vaccination is crucial in reducing child mortality and the prevalence of Vaccine-Preventable-Diseases (VPD), especially in low-and-middle-income countries like Kenya. However, non-vaccination, under-vaccination, and missed opportunities for vaccination (MOV) pose significant challenges to these efforts. This study aimed to analyze the impact of demographic and socio-economic factors on non-vaccination, under-vaccination, and MOV among children aged 0-23 months in Kenya from 2003 to 2014. A secondary data analysis of data from the Kenya Demographic Health Surveys (KDHS) conducted during this period was conducted, with a total of 11,997 participants, using a two-stage, multi-stage, and stratified sampling technique. The study examined factors such as child's sex, residence, mother's age, marital status, religion, birth order, maternal education, wealth quintile, province, child's birth order, parity, number of children in the household, place of delivery, and mother's occupation. Binary logistic regression was employed to identify the determinants of non-vaccination, under-vaccination, and MOV, and multivariable logistic regression analysis to report odds ratios (OR) and their corresponding 95% confidence intervals (CI). In 2003, the likelihood of non-vaccination decreased with higher maternal education levels: mothers who did not complete primary education (AOR = 0.55, 95% CI = 0.37-0.81), completed primary education (AOR = 0.34, 95% CI = 0.21-0.56), and had secondary education or higher (AOR = 0.26, 95% CI = 0.14-0.50) exhibited decreasing probabilities. In 2008/09, divorced/separated/widowed mothers (AOR = 0.22, 95% CI = 0.07-0.65) and those with no religion (AOR = 0.37, 95% CI = 0.17-0.81) showed lower odds of non-vaccination, while lower wealth quintiles were associated with higher odds. In 2014, non-vaccination was higher among younger mothers aged 15-19 years (AOR = 12.53, 95% CI = 1.59-98.73), in North Eastern Province (AOR = 7.15, 95% CI = 2.02-25.30), in families with more than 5 children (AOR = 4.19, 95% CI = 1.09-16.18), and in children born at home (AOR = 4.47, 95% CI = 1.32-15.17). Similar patterns were observed for under-vaccination and MOV. This information can inform strategies for bridging the gaps in immunization coverage and promoting equitable vaccination practices in Kenya.

Turkish Adaptation, Reliability, and Validity Study of the Vaccine Acceptance Instrument

This research study aimed to assess the reliability and validity of the Turkish version of the Vaccine Acceptance Instrument (VAI). The VAI is a 20-item Likert-type scale, with responses ranging across seven points. A systematic approach was followed to translate the scale into Turkish, involving translation, expert panel evaluation, back-translation, and pilot testing. The Vaccine Acceptance Instrument and a sociodemographic data form were used for data collection. The reliability of the scale was tested by test-retest analysis, and its internal reliability was examined by Cronbach's alpha test. The factor structure was examined using Exploratory Factor Analysis (EFA). Confirmatory Factor Analysis (CFA) was employed to assess the scale's fit. Overall, 229 participants were included in the study. In test-retest reliability analysis, the intraclass correlation coefficient of the scale was 0.992 (95% CI: 0.987-0.996). The Cronbach's alpha value of the scale was 0.824. A four-factor structure was determined. The model had an acceptable fit [χ2/df = 380.04/164 (2,317) p < 0.001, CFI = 0.91, GFI = 0.90, AGFI = 0.906, NFI = 0.90, RMSEA = 0.076]. The mean total VAI score was 112.71 ± 17.02. The low education level of the mother, being a housewife, and parents not having the COVID-19 vaccine were statistically significantly associated with a low scale score and low vaccine acceptance (p < 0.05). The Turkish adaptation of the VAI demonstrated satisfactory levels of validity and reliability following rigorous testing.

Determinants of parental vaccine hesitancy in Canada: results from the 2017 Childhood National Immunization Coverage Survey

BACKGROUND

In 2019, the World Health Organization (WHO) designated vaccine hesitancy as one of the ten leading threats to global health. Vaccine hesitancy exists when vaccination services are available and accessible, but vaccine uptake is lower than anticipated. It is often attributed to lack of trust in vaccine safety and effectiveness, or low level of concern about the risk of many vaccine-preventable diseases. This study aimed to examine the sociodemographic factors associated with parental vaccine hesitancy and vaccine refusal in Canada using data from the 2017 Childhood National Immunization Coverage Survey (CNICS).

METHOD

The 2017 CNICS was a cross-sectional and nationally representative survey to estimate national vaccine uptake and to collect information about parents' Knowledge, Attitudes and Beliefs (KAB) regarding vaccination. Using the KAB questions, parental vaccine hesitancy (i.e., parental hesitation, delay or refusal of at least one recommended vaccination) and refusal (i.e., unvaccinated children) by sociodemographic factors was estimated using weighted prevalence proportions. A multinomial logistic regression model was fitted to examine associations between parental vaccine hesitancy or refusal and sociodemographic factors among parents of two-year-old children in Canada. Adjusted odds ratios (aOR) of being vaccine-hesitant or vaccine-refusing versus being non-vaccine-hesitant were generated.

RESULTS

Both unadjusted and adjusted logistic regressions models showed that parents with lower household income (aOR 1.7, 95% CI 1.2-2.5), and those with a higher number of children in the household (aOR 2.2, 95% CI 1.4-3.5) had higher vaccine hesitancy. Conversely, lower vaccine hesitancy was observed among non-immigrant parents (aOR 0.4, 95% CI 0.3-0.6). In addition, lower household income (aOR 4.0, 95% CI 1.3-12.9), and higher number of children in the household (aOR 6.9, 95% CI 2.1-22.9) were significantly associated with parental vaccine refusal. Regional variations were also observed.

CONCLUSION

Several sociodemographic determinants are associated with parental vaccine hesitancy and refusal. The findings of the study could help public health officials and policymakers to develop and implement targeted interventions to improve childhood vaccination programs.

Predictors and impact of trust on vaccine decisions in parents of 2-year-old children in Canada: findings from the 2017 Childhood National Immunization Coverage Survey (cNICS)

Trust is known to be an important factor in vaccine decisions for parents of young children, but there has been a lack of Canadian data measuring the determinants and impact of trust. Using data from the 2017 Canadian Childhood National Immunization Coverage Survey (cNICS), this study analyzed the relationships between sources that parents trust for vaccine information and demographics, parental knowledge, attitudes, and beliefs (KAB) and vaccine decisions (refusal, delay or reluctance) in parents of 2-year-old children who had accepted at least one vaccine for their child (n = 6125). The findings show that 83% of parents trust doctors for vaccine information; 70-80% trust pharmacists, PMH, nurses and HC/PHAC; 34% trust family and 23% trust friends and CAM HCPs. However, parents found to have poor or moderate KAB were less likely to trust doctors, nurses, pharmacists, PMH and HC/PHAC. Parents were also less likely to trust the PMH or HC/PHAC if they had high school education or less or trade/college education, or were widowed, separated, or divorced. Parents who had never been reluctant to vaccinate their 2-year-old child were over 2 times more likely to trust doctors, nurses, pharmacists, PMH and HC/PHAC while parents who trusted family and friends were less likely to delay or refuse vaccines. There was also significant regional variation within Canada, with parents from Quebec most likely to trust doctors, nurses, pharmacists, friends, PMH and HC/PHAC. Parents from the Territories were less likely to trust doctors, nurses and pharmacists, but more likely to trust family. Parents were less likely to trust doctors if they were from the Prairies, and pharmacists if they were from BC, and parents from the Prairies and BC were less likely to trust HC/PHAC. Parents from Ontario were less likely to trust family or friends, but more likely to trust the PMH. Tailored vaccine campaigns are needed to account for educational, marital, and regional differences across Canada to improve vaccine uptake.

Association between pertussis vaccination coverage and other sociodemographic factors and pertussis incidence using surveillance data

Routine vaccination with pertussis vaccines has been successful in driving down pertussis mortality and morbidity globally. Despite high vaccination coverage, countries such as Australia, USA, and UK have experienced increase in pertussis activity over the last few decades. This may be due to local pockets of low vaccination coverage that result in persistence of pertussis in the population and occasionally lead to large outbreaks. The objective of this study was to characterize the association between pertussis vaccination coverage and sociodemographic factors and pertussis incidence at the school district level in King County, Washington, USA. We used monthly pertussis incidence data for all ages reported to the Public Health Seattle and King County between January 1, 2010 and December 31, 2017 to obtain school district level pertussis incidence. We obtained immunization data from the Washington State Immunization Information System to estimate school-district level vaccination coverage as proportion of 19-35 month old children fully vaccinated with ≥4 doses of the Diphtheria-Tetanus-acellular-Pertussis (DTaP) vaccine in a school district. We used two methods to quantify the effects of vaccination coverage on pertussis incidence: an ecological vaccine model and an endemic-epidemic model. Even though the effect of vaccination is modeled differently in the two approaches, both models can be used to estimate the association between vaccination coverage and pertussis incidence. Using the ecological vaccine model, we estimated the vaccine effectiveness of 4 doses of Diphtheria-Tetanus-acellular-Pertussis vaccine to be 83% (95% credible interval: 63%, 95%). In the endemic-epidemic model, under-vaccination was statistically significantly associated with epidemic risk of pertussis (adjusted Relative Risk, aRR: 2.76; 95% confidence interval: 1.44, 16.6). Household size and median income were statistically significantly associated with endemic pertussis risk. The endemic-epidemic model suffers from ecological bias, whereas the ecological vaccine model provides less biased and more interpretable estimates of epidemiological parameters, such as DTaP vaccine effectiveness, for each school district.

Determinants of vaccine refusal, delay and reluctance in parents of 2-year-old children in Canada: Findings from the 2017 Childhood National Immunization Coverage Survey (cNICS)

Vaccine hesitancy is a barrier to improving childhood vaccination rates in Canada, but the scope of this problem is unclear due to inconsistent measurement of vaccine uptake indicators. Using 2017 data from a Canadian national vaccine coverage survey, this study analyzed the impact of demographics and parental knowledge, attitudes and beliefs (KAB) on vaccine decisions (refusal, delay and reluctance) in parents of 2-year-old children who had received at least one vaccine. The findings show that 16.8% had refused a vaccine, specifically influenza (73%), rotavirus (13%) and varicella (9%); female parents or those from Quebec or the Territories more likely to refuse. 12.8% were reluctant to accept a vaccine, usually influenza (34%), MMR (21%) and varicella (19%), but eventually accepted them upon advice from a health care provider. 13.1% had delayed a vaccine, usually because their child had health issues (54%) or was too young (18.6%) and was predicted by five or six person households. Recent immigration to Canada decreased likelihood of refusal, delay, or reluctance; however, after 10 years in Canada, these parents were as likely to refuse or be reluctant as parents born in Canada. Poor KAB increased likelihood of refusal and delay by 5 times, and reluctance by 15 times, while moderate KAB increased likelihood of refusal (OR 1.6), delay (OR 2.3) and reluctance (OR 3.6). Future research into vaccine decisions by female and/or single parents, and predictors of vaccine KAB would provide valuable information and help protect our children from vaccine preventable diseases.

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.

Determinants of incomplete vaccination in children at age two in France: results from the nationwide ELFE birth cohort

Incomplete vaccination in the pediatric population is a growing public health issue in high-income countries, but its determinants are poorly understood. Their identification is necessary to design target actions that can improve vaccination uptake. Our aim was to assess the determinants of incomplete vaccination in two-year-old children in France. Among the 18,329 children included in the 2011 ELFE French nationwide population-based birth cohort, we selected those for whom vaccination status was available at age two years. Incomplete vaccination was defined as ≥ 1 missing dose of recommended vaccines. Potential determinants of incomplete vaccination were identified by using logistic regression, taking into account attrition and missing data. Of the 5,740 (31.3%) children analyzed, 46.5% (95% confidence interval [CI] 44.7-48.0) were incompletely vaccinated. Factors independently associated with incomplete vaccination were having older siblings (adjusted odds ratio 1.18, 95% CI [1.03-1.34] and 1.28 [1.06-1.54] for one and ≥ 2 siblings, respectively, vs. 0), residing in an isolated area (1.92 [1.36-2.75] vs. an urban area), parents not following health recommendations or using alternative medicines (1.81 [1.41-2.34] and 1.23 [1.04-1.46], respectively, vs. parents confident in institutions and following heath recommendations), not being visited by a maternal and child protection service nurse during the child's first two months (1.19 [1.03-1.38] vs. ≥ 1 visit), and being followed by a general practitioner (2.87 [2.52-3.26] vs. a pediatrician).

CONCLUSIONS

Incomplete vaccination was highly prevalent in the studied pediatric population and was associated with several socio-demographic, parental, and healthcare service characteristics. These findings may help in designing targeted corrective actions.

WHAT IS KNOWN

• Incomplete vaccination in the pediatric population is a growing public health issue in high-income countries. • The partial understanding of the determinants of incomplete vaccination precludes the design of effective targeted corrective actions.

WHAT IS NEW

• High prevalence of incomplete vaccination at age two years in France. • Incomplete vaccination was independently associated with several socio-demographic, parental, and healthcare service characteristics.

Immunization status of children at kindergarten entry in Alberta, Canada

OBJECTIVES

Little is known about immunization coverage among kindergarten-aged children in jurisdictions that do not require children's immunization records to be provided at school entry. Thus, we assessed immunization coverage and associated characteristics of a 2008 birth cohort of Alberta children at kindergarten entry as compared with at the end of grade one.

METHODS

This retrospective cohort study used population-based administrative health data for childhood vaccines in Alberta, Canada. We categorized and compared immunization status of children as follows: (a) complete at kindergarten entry; (b) incomplete at kindergarten entry but complete at the end of grade one; and (c) still incomplete at the end of grade one. To assess factors associated with immunization status, we used multinomial logistic regression.

RESULTS

Immunization coverage for the complete vaccine series for children (N = 41,515) at kindergarten entry was suboptimal (44.5%, 95% CI 44.0-45.0) and substantially lower than for children at the end of grade one (74.8%, 95% CI 74.3-75.2). Young maternal age, not living with a partner, and having > 1 child in a household were associated with incomplete immunization status at kindergarten entry. Midwife-assisted hospital and home delivery was strongly associated with incomplete immunization status at the end of grade one.

CONCLUSION

Immunization coverage at kindergarten entry was strikingly low. Risk factors for incomplete immunization status were identified that require particular attention when addressing immunization coverage. The school-based catch-up immunization program in grade one seems to have substantially improved coverage among children, suggesting a potential benefit of shifting the catch-up program from grade one to kindergarten entry.

Population immunity to measles in Canada using Canadian Health Measures survey data - A Canadian Immunization Research Network (CIRN) study

We aimed to determine population immunity to measles in Canada, and to assess the risk of future outbreaks. We tested 11,176 sera from Cycles 2 (2009-2011) and 3 (2011-2013) cohorts from the biobank of Statistics Canada's Canadian Health Measures Survey (CHMS) using the BioPlex 2220 MMRV IgG assay. We then tested all BioPlex negative and equivocal samples using a more sensitive Plaque Reduction Neutralization Test (PRNT). We determined the weighted proportion of positive, equivocal, and negative samples by age, sex, region and whether individuals were born in Canada. We found that 90.0% (95% confidence interval (CI): 88.2, 91.9) of samples were positive, 4.5% (95% CI: 3.4, 5.5) were equivocal and 5.5% (95% CI: 4.3, 6.7) were negative. Individuals in the 12-19 year age band had the lowest proportion positive at 78.7% (95% CI: 74.2, 83.2) and the highest proportion of positive samples was found in those 60-79 years (99.6%, 95% CI: 99.3, 99.9). Seropositivity was consistently <90% across a broad range of pediatric and adult age bands (6-39 years). We found that a slightly higher proportion of females were positive (91.9%, 95% CI: 90.1, 93.6) compared to males (88.3%, 95% CI: 85.8, 90.7). When taking into account interaction between age and born in Canada status, we found individuals born in Canada aged 19 and under were less susceptible (OR = 0.6 (95% CI: 0.4, 0.95)) compared to those born outside Canada whereas, those aged 20 and over were more susceptible (OR = 1.7 (95% CI: 1.1, 2.8)). Our findings indicate that measles immunity in Canada is below the 95% immunity threshold required to sustain measles elimination, underscoring the importance of maintaining high vaccine coverage to prevent future measles outbreaks and sustain Canada's elimination status.

Association between a single mother family and childhood undervaccination, and mediating effect of household income: a nationwide, prospective birth cohort from the Japan Environment and Children's Study (JECS)

Background

Although childhood undervaccination among single mother families is a concern for child healthcare, their association is still under debate. This study aimed to investigate the association between maternal marital status and the risk of childhood undervaccination and determine the mediating effect of household income.

Methods

We utilised prospective birth cohort from the Japan Environment and Children’s Study (JECS). Of 104,062 foetal records (children) from 97,413 mothers, 82,462 that included mothers recruited between 2011 and 2014, were analysed. Childhood undervaccination was defined as not having been vaccinated with at least one routine vaccine. A log-binomial regression analysis was used to estimate the risk ratio (RR) for the association between maternal marital status and the risk of childhood undervaccination. A causal mediation analysis was further performed to investigate the proportion of the association mediated by household income.

Results

Among 82,462 children, 3188 and 79,274 had unmarried and married mothers, respectively. Childhood undervaccination was observed in 1053 (33.0%) and 16,901 (21.3%) children of unmarried and married mothers, respectively. Maternal marital status was associated with a higher risk of childhood undervaccination (adjusted risk ratio [aRR], 1.34; 95% confidence interval [CI], 1.27 to 1.41). Compared with married and older mothers, both unmarried and older (aRR, 1.54; 95% CI, 1.35 to 1.77) and unmarried and younger (aRR, 1.66; 95% CI, 1.54 to 1.79) mothers were associated with a higher risk of childhood undervaccination. The causal mediation analysis showed that the proportion mediated by household income was 10.5% (95% CI, 9.9 to 11.0%).

Conclusions

This nationwide, prospective, large-scale birth cohort study found that a household with a single mother was associated with an increased risk of childhood undervaccination, and 10% of this association was explained by household income. These findings underscore the importance of improving the social environment among single mother families, including not only poverty but also working conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12511-7.

An equity-based assessment of immunization-related responses in urban Alberta during the 2014 measles outbreak: a comparative analysis between Calgary and Edmonton

OBJECTIVES

This study investigates measles, mumps, and rubella (MMR) immunization rates during the measles outbreak in Calgary and Edmonton of 2014 stratified by four area-level socio-demographic indicators. This study also leverages this epidemiological data to assess the equity aspect of emergency measures instituted regarding immunization in those two cities.

METHODS

A mixed-methods comparative case study analysis methodology was employed to assess the neighbourhood-level immunization statuses before (2013), during (2014), and after (2015) an active measles outbreak in Calgary and Edmonton, Alberta, Canada. The epidemiological one-dose by age-2 MMR coverage data were stratified using four socio-demographic indicators: median household income, %-homeownership, %-Aboriginal population, and %-immigrant population. Document and content analysis was utilized to investigate the outbreak mitigation strategies deployed in each city.

RESULTS

The measles outbreak of 2013/2014 involved the entirety of Alberta and led to both provincial and city-specific interventions in which Calgary deployed three mass immunization clinics in 2014, where Edmonton did not. The Calgary coverage data showed an increase in coverage inequalities across all indicators and the Edmonton data showed mixed results in terms of equity gains/losses. Calgary's additive intervention of three mass immunization clinics in 2014 appears to have contributed to both the higher gross immunization rates in Calgary (90.77%) and an inequitable increase in coverage rates as compared with Edmonton (88.96%), in most cases.

CONCLUSION

Public health policy-makers must be cognizant that large-scale public health efforts must be optimized for accessibility across all socio-economic levels to ensure public and population health gains are realized equitably.

Hesitação e recusa vacinal em países com sistemas universais de saúde: uma revisão integrativa sobre seus efeitos

RESUMO O número de indivíduos que recusam ou hesitam a vacinação vem crescendo nos últimos anos em diversos países, e isso tem sido notado com a diminuição da cobertura vacinal. Diante desse cenário, faz-se necessário conhecer quais os efeitos que esses fenômenos têm trazido para os sistemas universais de saúde. O estudo objetivou revisar os efeitos da recusa/hesitação vacinal para a população de países com sistemas universais de saúde, na produção científica da área da saúde. Realizou-se uma revisão integrativa nas bases de dados Lilacs, SciELO, PubMed/Medline, Scopus e Embase. Identificou-se o total de 318 publicações, realizou-se revisão sistematizada e ordenada, permanecendo para leitura completa 12 artigos científicos. Verificaram-se sete categorias de abordagem do tema: 1) políticas públicas para imunização da população; 2) fatores da hesitação da vacinação contra gripe; 3) hesitação entre profissionais de saúde; 4) fatores importantes para a decisão dos pais de vacinarem; 5) segurança das vacinas; 6) determinantes sociais, demográficos e econômicos para hesitação/recusa; e 7) projeção de cobertura vacinal para o futuro e política de vacinação. Os artigos científicos estudados permitiram entender como se dá a recusa e a hesitação vacinal em diferentes cenários, os seus efeitos e como esses motivos estão interligados entre si.

Demographic, psychological, and experiential correlates of SARS-CoV-2 vaccination intentions in a sample of Canadian families

The COVID-19 pandemic has been ongoing for close to a year, with second waves occurring presently and many viewing vaccine uptake as the most likely way to curb successive waves and promote herd immunity. Reaching herd immunity status likely necessitates that children, as well as their parents, receive a vaccine targeting SARS-CoV-2. In this exploratory study, we investigated the demographic, experiential, and psychological factors associated with the anticipated likelihood and speed of having children receive a SARS-CoV-2 vaccine in a sample of 455 Canadian families (858 children; parents' mean age = 38.2 ± 6.82 years). Using linear mixed-effects and proportional odds logistic regression models, we demonstrated that older parental age, living in the Prairies (relative to Central Canada), more complete child vaccination history, and a greater tendency to prioritise the risks of the disease relative to the risks of side effects (i.e. lower omission bias) were associated with higher likelihoods of intention to vaccinate participants' children, with trend-level associations with lower perceived danger of the vaccine and higher psychological avoidance of the pandemic. Faster speed of intended vaccination was predicted by a similar constellation of variables with an additional predictor of a child in the family having a COVID-19 related health risk being associated with slower intended speed. Results are discussed concerning public health knowledge mobilisation and the unique Canadian health landscape.

Individual and community-level determinants of childhood vaccination in Ethiopia

BACKGROUND

Vaccines are one of our most important tools for preventing outbreaks and keeping the world safe. Most unvaccinated children live in the poorest countries including Ethiopia. Therefore, this study aimed to identify the determinants of vaccination coverage among children aged12-23 months in Ethiopia.

METHODS

A cross-sectional secondary data were obtained from the 2016 Ethiopian Demographic and Health Survey data (EDHS). A total of 1929 children were included. A Multilevel Proportional Odds Model was used to identify the individual and community-level factors associated with child vaccination.

RESULT

Among 1, 929 children, only 48.6% (95% CI: 46.3 to 50.8%) were fully vaccinated while 37.8% (95% CI: 35.7 to 40.1%) were partially vaccinated.. The multilevel ordinal logistic regression model reveled that housewife mother (AOR =1.522, 95%CI: 1.139, 2.034), institutional delivery (AOR =2.345, 95%CI: 1.766, 3.114),four or above antenatal care visits (AOR = 2.657; 95% CI: 1.906, 3.704), children of mothers with secondary or higher education (AOR = 2.008; 95% CI: 1.209, 3.334),Children whose fathers primary education (AOR = 1.596; 95% CI: 1.215, 2.096), from the rich households (AOR = 1.679; 95% CI: 1.233, 2.287) were significantly associated with childhood vaccination.

CONCLUSION

Child vaccination coverage in Ethiopia remains low. Therefore, there is a need to increase child vaccination coverage by promoting institutional delivery and prenatal care visits, as well as maternal tetanus immunization. Besides, public initiatives needed to improve child vaccination coverage, women's and husband's education, poor women, and further advancement of health care services for poor women, housewife women, women living in remote areas should be made to maintain further improvements in child vaccination. Furthermore, policies and programs aimed at addressing cluster variations in child vaccination need to be formulated and their implementation must be strongly pursued.

Navigating inequities: a roadmap out of the pandemic

The COVID-19 pandemic has exposed social inequities that rival biological inequities in disease exposure and severity. Merely identifying some inequities without understanding all of them can lead to harmful misrepresentations and deepening disparities. Applying an 'equity lens' to bring inequities into focus without a vision to extinguish them is short-sighted. Interventions to address inequities should be as diverse as the pluralistic populations experiencing them. We present the first validated equity framework applied to COVID-19 that sheds light on the full spectrum of health inequities, navigates their sources and intersections, and directs ethically just interventions. The Equity Matrix also provides a comprehensive map to guide surveillance and research in order to unveil epidemiological uncertainties of novel diseases like COVID-19, recognising that inequities may exist where evidence is currently insufficient. Successfully applied to vaccines in recent years, this tool has resulted in the development of clear, timely and transparent guidance with positive stakeholder feedback on its comprehensiveness, relevance and appropriateness. Informed by evidence and experience from other vaccine-preventable diseases, this Equity Matrix could be valuable to countries across the social gradient to slow the spread of SARS-CoV-2 by abating the spread of inequities. In the race to SARS-CoV-2 vaccines, this urgently needed roadmap can effectively and efficiently steer global leadership towards equitable allocation with diverse strategies for diverse inequities. Such a roadmap has been absent from discussions on managing the COVID-19 pandemic, and is critical for our passage out of it.

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

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

Vaccine hesitancy among parents of preschoolers in Canada: a systematic literature review

OBJECTIVES

The purpose was to synthesize the available literature on what factors influence vaccine hesitancy of parents of preschoolers in Canada.

METHODS

Databases (e.g., CINAHL, PubMed, OVID, Proquest) were searched for relevant research articles produced between January 2009 and October 2019. Articles were required to examine vaccine uptake in children aged 0-7, in the English language, and focused within a Canadian context. Articles were excluded if they focused on uptake of the influenza vaccine and if the study population was children with chronic health conditions. A total of 367 articles were reviewed and 12 met the criteria for inclusion in this review.

SYNTHESIS

This review found that between 50% and 70% of children are completely vaccinated at 2 years old, with up to 97% having received at least one vaccine, and 2-5% receiving no vaccines. This review found that trust and access to health care providers is significantly associated with vaccine uptake, likely more important than parents' vaccine knowledge, and may compensate for challenges related to socio-economic status and family dynamics.

CONCLUSION

Vaccine programs need to be created that are accessible to all families, with an awareness of the significant impact of trust on vaccine uptake. Future research should include consistent measures of vaccine uptake, and data from First Nation communities, and should examine how increased trust between health care providers and parents of preschool children would increase vaccine uptake in Canada.

Parents' Perspectives about Vaccine Hesitancies and Vaccine Rejection, in the West of Turkey

PURPOSE

The aim of this study was to evaluate Turkish parents' perspectives on childhood vaccines.

DESIGN AND METHODS

614 parents of the children between the ages of 0-14 years were included in the study for examining their perspectives about vaccine hesitation and rejection. Age, gender, educational level, number of children, and income levels of volunteer participants were recorded. In addition to the personal data, a questionnaire form with questions about vaccines and vaccination was prepared.

RESULTS

The mean age of the participants was found as 37.20 ± 6.84 years (range, 21 to 53). The rate of vaccine hesitancy was found to be statistically significantly and higher in men. A statistically higher number of women were affected by the opinions of the individuals around them related to vaccines. Moreover, the rate of hearing any negative information about vaccines increased as the level of education increased. The impact of an increase in the number of children and the income level of the participants on the survey parameters were evaluated and significant relationships were observed.

CONCLUSIONS

Vaccine rejection is a significant public health problem in the world and will continue to be the case in the world.

PRACTICE IMPLICATIONS

In our country, it has been determined that men's hesitation rates are higher and women are more affected by the environment. Necessary trainings should be planned in this regard. Also, as the level of education affects opinions of the vaccine, many plans are needed to increase the level of education.

Socioeconomic Determinants in Vaccine Hesitancy and Vaccine Refusal in Italy

Childhood vaccination has been a milestone in the control of infectious diseases. However, even in countries offering equal access to vaccination, a number of vaccine-preventable diseases have re-emerged. Suboptimal vaccination coverage has been called into question. The aim was to explore socioeconomic inequalities in vaccine hesitancy and outright refusal. Families with at least one child aged between 3 months and 7 years were involved through an online survey. Families were classified as provaccine, hesitant, or antivaccine. The association between socioeconomic determinants and hesitancy/refusal was investigated with a logistic-regression model. A total of 3865 questionnaires were collected: 64.0% of families were provaccine, 32.4% hesitant, and 3.6% antivaccine. Rising levels of perceived economic hardship were associated with hesitancy (adjusted odds ratio (AOR) from 1.34 to 1.59), and lower parental education was significantly associated with refusal (AOR from 1.89 to 3.39). Family economic hardship and parental education did not move in parallel. Economic hardship was a determinant of hesitancy. Lower education was a predictor of outright refusal without affecting hesitancy. These findings may serve as warnings, and further explanations of socioeconomic inequities are needed even in universal healthcare systems. Insight into these factors is necessary to improve convenience and remove potential access issues.

Neighbourhood-level marginalization and avoidable mortality in Ontario, Canada: a population-based study

OBJECTIVE

To examine the impact of neighbourhood marginalization on avoidable mortality (AM) from preventable and treatable causes of death.

METHODS

All premature deaths between 1993 and 2014 (N = 691,453) in Ontario, Canada, were assigned to quintiles of neighbourhood marginalization using the four dimensions of the Ontario Marginalization Index: dependency, ethnic concentration, material deprivation, and residential instability. We conducted two multivariate logistic regressions to examine the association between neighbourhood marginalization, first with AM compared with non-AM as the outcome, and second with AM from preventable causes compared with treatable causes as the outcome. All models were adjusted for decedent age, sex, urban/rural location, and level of comorbidity.

RESULTS

A total of 463,015 deaths were classified as AM and 228,438 deaths were classified as non-AM. Persons living in the most materially deprived (OR, 1.24; 95% CI, 1.22 to 1.27) and residentially unstable neighbourhoods (OR, 1.13; 95% CI, 1.11 to 1.15) had greater odds of AM, particularly from preventable causes. Those living in the most dependent (OR, 0.91; 95% CI, 0.89 to 0.93) and ethnically concentrated neighbourhoods (OR, 0.93; 95% CI, 0.91 to 0.93) had lower odds of AM, although when AM occurred, it was more likely to arise from treatable causes.

CONCLUSION

Different marginalization dimensions have unique associations with AM. By identifying how different aspects of neighbourhood marginalization influence AM, these results may have important implications for future public health efforts to reduce inequities in avoidable deaths.

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

OBJECTIVES

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

DESIGN

Retrospective cohort study using linked administrative health data.

SETTING

Alberta, Canada.

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Determinants of vaccine hesitancy in Quebec: a large population-based survey

Objectives: Vaccine hesitancy is a global phenomenon that needs to be measured and addressed. This study aimed to identify the determinants of vaccine hesitancy among a large regional population.Methods: A structured telephone survey was administered to a random digit sample in Quebec's Eastern Townships region. In addition to socioeconomic information, respondents were asked questions on several health topics such as knowledge and beliefs about immunization, medical consultations, health status, and life habits. Data were weighted according to age, sex, and territories. Statistically significant variables in the univariate analysis were introduced into a multivariate logistic regression model to determine independent factors for vaccine hesitancy (adjusted odds ratios [aOR] and 95% confidence intervals).Results: A total of 8,737 interviews were conducted (participation rate 48.3%). Among all respondents, 32.2% were vaccine-hesitant. Several beliefs were significantly associated with vaccine hesitancy: belief that children receive too many vaccines (aOR = 2.72; 2.32-3.18), belief that a healthy lifestyle can eliminate the need for vaccination (aOR = 2.48; 2.09-2.93), and belief that the use of alternative medicine practices can eliminate the need for vaccination (aOR = 1.39; 1.16-1.68). Other determinants associated with vaccine hesitancy were having consulted a massage therapist (aOR = 2.34; 1.46-3.75), not being vaccinated against influenza (aOR = 1.80; 1.49-2.16), having a low (<$30,000) (aOR = 1.58; 1.24-2.02) or moderate ($30,000-$79,000) (aOR = 1.37; 1.12-1.67) household income, distrust in public health authorities (aOR = 1.40; 1.21-1.63), perceived insufficient knowledge about immunization (aOR = 1.26; 1.04-1.51), and smoking (aOR = 1.22; 1.01-1.47).Conclusions: Many determinants are related to vaccine hesitancy. These determinants should be taken into account when health professionals engage with vaccine-hesitant individuals.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Delayed measles vaccination of toddlers in Canada: Associated socio-demographic factors and parental knowledge, attitudes and beliefs

Delaying vaccination increases the period of vulnerability of children against vaccine-preventable diseases. We used a nationally representative sample of Canadian two-year-old children to explore factors associated with delays in the uptake of the first dose of measles-containing vaccine, recommended in Canada for children at 12 months of age. Distribution of delays was determined using data from the 2013 Childhood National Immunization Coverage Survey. Logistic regression was used to examine sociodemographic factors and knowledge, attitudes and beliefs (KAB) associated with the two outcomes of interest: delays of one to six months (vaccination at 13 to 18 months of age) and delays of seven to 18 months (vaccination at 19 to 23 months of age). Overall, 69% (95% confidence interval [CI] 67–71) of children received their first valid dose on time. Twenty-nine percent (95% CI 27–31) and 11% (95% CI 9–12) of children were unvaccinated before turning 13 and 16 months of age, respectively. Factors associated with delays of one to six months were being a girl, being born outside Canada, and the jurisdiction of residence. Being from a single-parent family, being born outside Canada and the jurisdiction of residence were associated with delays of seven to 18 months, suggesting that potential barriers might be at play. Associations between KAB and vaccination delays indicate that vaccine hesitancy could contribute to measles vaccination delays in Canada. Barriers in accessing vaccination services and the role of vaccine hesitancy in timely vaccination must be better understood to reduce vaccination delays in toddlers in Canada.

Seroprevalence of rubella antibodies and determinants of susceptibility to rubella in a cohort of pregnant women in Canada, 2008-2011

Long term control of rubella and congenital rubella syndrome relies on high population-level immunity against rubella, particularly among women of childbearing age. In Canada, all pregnant women should be screened so that susceptible new mothers can be offered vaccination for rubella before discharge. This study was undertaken to estimate rubella susceptibility in a cohort of pregnant women in Canada and to identify associated socio-economic and demographic factors. Biobanked plasma samples were obtained from the Maternal-Infant Research on Environmental Chemicals (MIREC) study, in which pregnant women were recruited between 2008 and 2011. Socio-demographic characteristics and obstetric histories were collected. Second trimester plasma samples (n=1,752) were tested for rubella-specific IgG using an in-house enzyme-linked immunosorbent assay. The percentage of women with IgG titers <5IU/mL, 5-10IU/mL, and ≥10IU/mL were 2.3%, 10.1%, and 87.6%, respectively. Rates of seronegativity, defined as <5IU/mL, were 3.1% in women who had no previous live birth and 1.6% in women who had given birth previously. Among the latter group, seronegativity was higher in women with high school education or less (adjusted OR (aOR) 5.93, 95% CI 2.08-16.96) or with a college or trade school diploma (aOR 3.82, 95% CI 1.45-10.12), compared to university graduates, and those born outside Canada (aOR 2.60, 95% CI 1.07-6.31). In conclusion, a large majority of pregnant women were found to be immune to rubella. Further research is needed to understand inequalities in vaccine uptake or access, and more effort is needed to promote catch-up measles-mumps-rubella vaccination among socioeconomically disadvantaged and immigrant women of childbearing age.