Inequality in measles vaccination coverage in the "big six" countries of the WHO South-East Asia region

Mitigating Vaccine Hesitancy and Building Trust to Prevent Future Measles Outbreaks in England

Measles, a highly infectious respiratory viral infection associated with severe morbidity and mortality, is preventable when coverage with the highly effective measles, mumps and rubella vaccine (MMR) is ≥95%. Vaccine hesitancy is responsible for measles outbreaks in countries where measles had previously been eliminated, including in England, and is one of the ten threats to global public health identified by the World Health Organization (WHO). Official administrative 2012-2021 data on measles incidence and MMR coverage in England were reviewed alongside a scoping literature review on factors associated with MMR uptake in England. Whilst measles incidence has reduced significantly since 2012, sporadic measles outbreaks in England have occurred with geographic disparities and variations in MMR coverage. Over the last decade, MMR uptake has fallen across all regions with no area currently reaching the WHO target of 95% coverage of both doses of MMR necessary for herd immunity. Factors associated with MMR coverage overlap with the 3C (convenience, complacency and confidence) model of vaccine hesitancy. The COVID-19 pandemic has reinforced pre-existing vaccine hesitancy. Increasing MMR uptake by reducing vaccine hesitancy requires allocated funding for area-based and targeted domiciliary and community-specific immunisation services and interventions, public health catch-up campaigns and web-based decision aid tools.

Who is protected? Determinants of hepatitis B infant vaccination completion among a prospective cohort of migrant workers in Thailand during the COVID-19 pandemic

BACKGROUND

Hepatitis B causes significant disease and death globally, despite the availability of effective vaccination. Migration likewise affects hundreds of millions of people annually, many of whom are women and children, and increases risks for poor vaccine completion and mother to child transmission of hepatitis B. In the neighbouring countries of Thailand and Myanmar, vaccine campaigns have made progress but little is known about the reach of these programs into migrant worker communities from Myanmar living in Thailand.

METHODS

A cohort of 253 postpartum women (53 urban migrants in Chiang Mai and 200 rural migrants in Tak Province) were surveyed about their Hepatitis B knowledge and willingness to vaccinate their children between September 10, 2019 and March 30, 2019. They were subsequently followed to determine vaccine completion. When records of vaccination were unavailable at the birth facility, or visits were late, families were contacted and interviewed about vaccination elsewhere, and reasons for late or missed vaccines.

RESULTS

Though women in Tak province displayed better knowledge of Hepatitis B and equal intention to vaccinate, they were 14 times less likely to complete Hepatitis B vaccination for their children compared to migrants in Chiang Mai. Tak women were largely undocumented, had private (non-profit) insurance and had more transient residence. In Chiang Mai migrant women were mostly documented and had full access to the Thai national health services. Though minor individual and facility-level differences may have contributed, the major driver of the disparity seems to be the place of migrants within local socio-political-economic systems. The COVID-19 pandemic further disproportionately affected Tak province migrants who faced severe travel restrictions hampering vaccination. Sixty percent of families who were lost to vaccine follow-up in Tak province could not be contacted by phone or home visit. Chiang Mai migrants, with 86.8% vaccine completion, nearly reached the target of 90%.

CONCLUSIONS

Achievement of high levels of hepatitis B vaccination in migrant communities is important and feasible, and requires inclusive policies that integrate migrants into national health and social services. This is more urgent than ever during the COVID-19 era.

Communication lessons learned from the 2017 measles–rubella campaign in India: perspectives from vaccine decision-makers

In 2017, to reduce the burden of measles and rubella, a nation-wide measles–rubella campaign was launched in India. Despite detailed planning efforts that involved many stakeholders, vaccine refusal arose in several communities during the campaign. As strategic health communication and promotion is critical in any vaccine campaign, we sought to document lessons learned from the 2017 MR campaign from a strategic health communication and promotion perspective to capture lessons learned. To inform future campaigns, we conducted in-depth interviews through a perspective that is not usually captured, that of government and civil society stakeholders that had experience in vaccine campaign implementation (n = 21). We interviewed stakeholders at the national level and within three states that had diverse experiences with the campaign. Three key themes related to strategic health communication and promotion emerged: the importance of sensitizing communities at all levels through relevant and timely information about the vaccine and the vaccine campaign, leveraging key influencers to deliver tailored messaging about the importance of vaccines and mitigating vaccine misinformation rapidly. Our study findings have important implications for health communication and promotion research related to vaccine campaigns. The field must continue to enhance vaccine campaign efforts by identifying important health communication and promotion factors, including the importance of sensitization, trusted messengers that use tailored messaging and mitigating misinformation, as vaccine campaigns are crucial in improving vaccine acceptance.

Vaccine equity in low and middle income countries: a systematic review and meta-analysis

BACKGROUND

Evidence to date has shown that inequality in health, and vaccination coverage in particular, can have ramifications to wider society. However, whilst individual studies have sought to characterise these heterogeneities in immunisation coverage at national level, few have taken a broad and quantitative view of the contributing factors to heterogeneity in immunisation coverage and impact, i.e. the number of cases, deaths, and disability-adjusted life years averted. This systematic review aims to highlight these geographic, demographic, and sociodemographic characteristics through a qualitative and quantitative approach, vital to prioritise and optimise vaccination policies.

METHODS

A systematic review of two databases (PubMed and Web of Science) was undertaken using search terms and keywords to identify studies examining factors on immunisation inequality and heterogeneity in vaccination coverage. Inclusion criteria were applied independently by two researchers. Studies including data on key characteristics of interest were further analysed through a meta-analysis to produce a pooled estimate of the risk ratio using a random effects model for that characteristic.

RESULTS

One hundred and eight studies were included in this review. We found that inequalities in wealth, education, and geographic access can affect vaccine impact and vaccination dropout. We estimated those living in rural areas were not significantly different in terms of full vaccination status compared to urban areas but noted considerable heterogeneity between countries. We found that females were 3% (95%CI[1%, 5%]) less likely to be fully vaccinated than males. Additionally, we estimated that children whose mothers had no formal education were 28% (95%CI[18%,47%]) less likely to be fully vaccinated than those whose mother had primary level, or above, education. Finally, we found that individuals in the poorest wealth quintile were 27% (95%CI [16%,37%]) less likely to be fully vaccinated than those in the richest.

CONCLUSIONS

We found a nuanced picture of inequality in vaccination coverage and access with wealth disparity dominating, and likely driving, other disparities. This review highlights the complex landscape of inequity and further need to design vaccination strategies targeting missed subgroups to improve and recover vaccination coverage following the COVID-19 pandemic.

TRIAL REGISTRATION

Prospero, CRD42021261927.

Sex and age as determinants of the seroprevalence of anti-measles IgG among European healthcare workers: A systematic review and meta-analysis

INTRODUCTION

The international literature shows good evidence of a significant rate of measles susceptibility among healthcare workers (HCWs). As such, they are an important public health issue.

METHODS

We conducted a systematic review and meta-analysis to estimate the prevalence of susceptible HCWs in EU/EEA countries and in the UK and to explore the characteristics (sex and age differences) and management of those found to be susceptible.

RESULTS

Nineteen studies were included in the meta-analysis. The prevalence of measles-susceptible HCWs was 13.3% (95 %CI: 10.0-17.0%). In a comparison of serosusceptible female vs. male HCWs, the RR was 0.92 (95 %CI = 0.83-1.03), and in a comparison of age classes (born after vs. before 1980) the RR was 2.78 (95 %CI = 2.20-3.50). The most recent studies proposed the mandatory vaccination of HCWs.

DISCUSSION

According to our meta-analysis, the prevalence of serosusceptible European HCWs is 13%; HCWs born in the post-vaccination era seem to be at higher risk. Healthcare professionals susceptible to measles are a serious epidemiological concern. Greater efforts should therefore be made to identify those who have yet to be vaccinated and actively encourage their vaccination.

Can early measles vaccination control both measles and respiratory syncytial virus infections?

Measles virus and respiratory syncytial virus (RSV) are two important global health pathogens causing substantial morbidity and mortality worldwide. The current measles vaccination schedule has the first dose given at 9–12 months of age and the second dose given at 15–18 months of age. Measles outbreaks have been associated with an increase in severe RSV infections in children younger than 6 months, probably as a result of measles-induced immunosuppression. A resurgence in measles cases was already occurring before the COVID-19 pandemic, which has affected global immunisation programmes, resulting in millions of children, mostly in low-income and middle-income countries (LMICs), missing out on their measles vaccine. This will leave many children living in the most vulnerable of circumstances highly susceptible to measles and RSV infections when current COVID-19 public health control measures are lifted. This Viewpoint discusses these issues and highlights the need for urgent action to address this looming crisis. The use of early measles vaccination at 4 months of age could be an effective strategy to prevent severe morbidity and death from both measles and RSV infections in many LMICs.

Development and validation of the knowledge and attitude regarding childhood vaccination (KACV) questionnaire among healthcare workers: the Malay version

Health care workers play an important role in supporting childhood vaccination as they are the most trusted source of vaccine-related information for parents. However, there is limited validated tools to measure their knowledge and attitude on childhood vaccination. This study aims to develop and validate knowledge and attitude regarding childhood vaccination (KACV) questionnaire among healthcare workers. The questionnaire was developed based on literature reviews and underwent a sequential validation process, including content, face validity and exploratory factor analysis. However, the attitude section is unidimensional and has undergone reliability analysis only. The preliminary knowledge questionnaire contains 33 items and the attitude questionnaire consists of 17 items. The preliminary KACV showed a high item Content Validity Index and Face Validity Index. The final questionnaire consists of 10 items for knowledge and 15 items for attitude. The Cronbach alpha for the knowledge and attitude section were 0.896 and 0.861, respectively. KACV is a valid and reliable tool to measure healthcare workers' knowledge and attitude on childhood vaccination.

Evaluation of measles vaccination coverage in Lincang City, Yunnan Province, China

Background: Lincang City in Yunnan Province on the China-Myanmar border, has reached the World Health Organization recommended coverage (95%) for measles-containing vaccine (MCV), but measles outbreaks still occur. We conducted a survey in Lincang City to determine the measles vaccination status of children on the China-Myanmar border.Methods: We used multistage sampling among children aged 8-83 months. Information on measles vaccination status was obtained from the child's vaccination certificate, and serum samples were tested using commercially available ELISA kits.Results: A total of 938 children were surveyed. The vaccination coverage rate was 98.9% (95% CI: 98.2-99.6%) for measles-containing vaccine dose 1 (MCV1), and 95.8% (95% CI:94.9-96.7%) for measles-containing vaccine dose 2 (MCV2). The timely vaccination coverage rate was 52.0% (95% CI:48.8-55.2%) for MCV1, and 74.1% (95% CI: 82.9-89.0%) for MCV2. The timely-and-complete vaccination coverage rate was 41.0% (95% CI: 36.7-45.3%). The median delay period was 33 (95% CI: 27-39) days for MCV1, and 196 (95% CI: 146-246) days for MCV2. The seropositivity rate in children aged less than 7 years was 94.0% (95% CI: 92.5-95.5%) with a geometric mean titer of 1210.1 mIU/mL.Conclusions: The MCV coverage was high, but timely and timely-and-complete vaccination coverage were low and insufficient to prevent measles outbreaks. It is necessary to add the timely and timely-and-complete vaccination coverage as indicators of vaccination to provide a more complete picture of measles immunization status.