Antenatal influenza vaccination in urban Pune, India: clinician and community stakeholders' awareness, priorities, and practices

Factors influencing vaccine acceptance in pregnancy during the COVID-19 pandemic: A multicenter study from West Bengal, India

Influenza, COVID-19, tetanus, pertussis and hepatitis B pose increased risk for pregnant women and infants and could be mitigated by maternal immunization. In India Tetanus-diphtheria (Td) and COVID-19 vaccines are recommended during pregnancy, while influenza and tetanus-acellular pertussis-diphtheria (Tdap) vaccines are not. We conducted a multicenter study from November 2021 to June 2022 among pregnant women (n = 172) attending antenatal clinics in three public hospitals in West Bengal, to understand the factors that influence women's decisions to get vaccinated during pregnancy. Questions assessed vaccination coverage, knowledge, intention and willingness to pay for influenza vaccine, and factors influencing decisions to get Td, influenza, and COVID-19 vaccines. 152/172 (88.4%) women were vaccinated with Td, 159/172 (93%) with COVID-19, 1/172 (0.6%) with influenza, and none with Tdap. 10/168 (6%) had received hepatitis B vaccine (HBV). Community health workers advice was crucial for Td uptake and, the belief of protection from COVID for COVID-19 vaccines. Most women were unaware about Tdap (96%), influenza (75%), and influenza severity during pregnancy and infancy (85%). None were advised for influenza vaccination by healthcare providers (HCP), albeit, 93% expressed willingness to take, and pay INR 100-300 (95% CI: ≤100 to 300-500) [$ 1.3-4.0 (95% CI: ≤1.3, 4-6.7)] for it. Vaccination on flexible dates and time, HCP's recommendation, proximity to vaccination center, and husband's support were most important for their vaccination decisions. Women were generally vaccine acceptors and had high uptake of vaccines included in the Universal Immunization Program (UIP). Inclusion of influenza, Tdap, and HBV into UIP may improve maternal vaccine uptake.

Acceptability of HPV vaccination for cervical cancer prevention amongst emerging adult women in rural Mysore, India: a mixed-methods study

BACKGROUND

India has the highest number of estimated deaths from cervical cancer globally, with most cases attributed to Human papillomavirus (HPV). The World Health Organization recommends primary HPV vaccination for girls ages 9-14, with catch-up vaccination for young women ≥ 15 if feasible. India authorized a new, inexpensive HPV vaccine in 2022; given anticipated vaccine expansion, we conducted a mixed-methods study exploring acceptability of HPV catch-up vaccination for young emerging adult women in rural Mysore, India.

METHODS

Between September 2022-April 2023, participants were recruited with assistance from community health workers. In the qualitative phase, gender-stratified, audio-recorded focus group discussions (FGDs) were conducted in Kannada with emerging adults ages 18-26. FGDs were transcribed, translated, and analyzed using rapid approach to identify key HPV vaccination attributes. In the quantitative phase, a conjoint analysis was conducted to assess the impact of seven vaccination attributes on likelihood to vaccinate (LTV). Women ages 18-26 ranked LTV in eight hypothetical vaccination scenarios, and the relative impact of each attribute on LTV was calculated. All participants received education about cervical cancer, HPV, and HPV vaccination.

RESULTS

Fifty-two young adults (female = 31, male = 21) participated in seven FGDs, and 101 women participated in the conjoint analysis. Average age of the 153 participants was 22.5 years, 66.7% had married, and all had completed high school. Only 17.9% had heard of cervical cancer, and 2.7% knew of the HPV vaccine. FGDs identified seven HPV vaccination attributes: cost, vaccination location, family support, peer influence, dose number, side effects, and risk of acquiring HPV. In the conjoint analysis, all attributes except dose number significantly impacted LTV. Family support (impact score = 19.37, p < 0.0001) and peer influence (impact score = 18.01, p < 0.0001) had the greatest influence, followed by cost (impact score = 16.64, p < 0.0001) and HPV risk (impact score = 12.31, p < 0.0001). Vaccination location (government centers preferred) and side effects were also significant.

CONCLUSION

Participants had poor knowledge of cervical cancer and HPV. Social attributes (family support, peer influence) had greatest impacts on LTV, and future studies should explore family-based interventions and peer education. Providing free vaccines at government centers through India's national immunization program would maximize catch-up HPV vaccination for rural young women.

Comparison of Physicians' Attitudes and Practice Regarding Vaccination during Pregnancy in Turkey

This study aimed to investigate the knowledge, attitudes, and behaviors of family physicians (FPs), pediatricians (PPs), and obstetricians and gynecologists (OGs) regarding vaccine administration during pregnancy in Turkey as factors that contribute to decision-making. The survey was distributed among FPs, OGs, and PPs, and participants were asked to rate their knowledge on specific topics using a five-point scale ranging from "Not Effective" to "Effective". The tetanus and diphtheria (Td) vaccine was highly recommended by 94.9% of physicians and considered very effective. Among the physicians surveyed, 80% of PPs and 66.0% of OGs were aware of the disease burden of pertussis. We also found that 74.5% of FPs and 77.2% of PPs believed they needed more information about vaccination during pregnancy. All physicians surveyed agreed or strongly agreed that explaining the disease risks and benefits of vaccination increases the vaccine acceptance rate. The results of this survey study indicate that the knowledge and awareness of physicians need to be improved to increase vaccination rates during pregnancy in Turkey, and it is essential to incorporate influenza and tetanus, diphtheria, and pertussis (TdaP) vaccines into the standard maternal immunization schedule for newborns.

Vaccine hesitancy in pregnant Women: A narrative review

Pregnant women are often at higher risk for morbidity and mortality due to contracting vaccine-preventable diseases that result in adverse pregnancy outcomes such as spontaneous abortion, preterm births, and congenital fetal defects. For example, health care provider recommendation is correlated with maternal acceptance of influenza vaccination, however, up to 33 % of pregnant women remain unvaccinated irrespective of provider recommendation. Vaccine hesitancy is a multifactorial problem that both the medical and public health systems need to address synergistically. Vaccine education should incorporate balanced perspectives to deliver vaccine education. This narrative review addresses four questions: 1) what are the primary concerns of pregnant women that lead them to be hesitant about receiving vaccinations; 2) to what extent does the source (e.g. provider, friend, family) of vaccine advice and information influence a pregnant person's decision to accept a vaccine; 3) how does the delivery method of vaccine education influence their decision; 4) how can categorizing patients into four distinct groups based on their opinions and behavior regarding vaccines be used to improve provider-patient communication and increase vaccine acceptance. Results from the literature show that the three most common reasons for vaccine hesitancy include: i.) fear of side effects or adverse events; ii.) lack of confidence in vaccine safety; iii.) low perception of being at high risk of infection during pregnancy and/or not having previously received the vaccination when not pregnant. We conclude that vaccine hesitancy is dynamic therefore people do not always hold a static level of vaccine hesitancy. People may move between a continuum of vaccine hesitancy for a multifactorial reasons. A framework, characterized by levels of vaccine hesitancy before and during pregnancy, was constructed to help providers find balance between promoting individual health and public health while providing vaccine education.

Health Systems Determinants of Delivery and Uptake of Maternal Vaccines in Low- and Middle-Income Countries: A Qualitative Systematic Review

Maternal vaccination is considered a key component of the antenatal care package for improving maternal and child health. Low- and middle-income countries (LMICs) fall short of global targets to prevent maternal and neonatal deaths, with a disproportionate burden of vaccine-preventable diseases. Strategies towards ending preventable maternal mortality necessitate a health systems approach to adequately respond to this burden. This review explores the health systems determinants of delivery and uptake of essential maternal vaccines in LMICs. We conducted a qualitative systematic review of articles on maternal vaccination in LMICs, published between 2009 and 2023 in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Thematic analysis was conducted to identify key themes in the literature, interpreted within a conceptual framing that explores the systems determinants influencing maternal vaccines. Our search yielded 1309 records, of which 54 were included, covering 34 LMICs. Most of the included studies were from South America (28/54) and included pregnant women as the primary study population (34/54). The studies explored influenza (25/54) and tetanus toxoid (20/54) vaccines predominantly. The findings suggest that systems hardware (lack of clear policy guidelines, ineffective cold-chain management, limited reporting and monitoring systems) are barriers to vaccine delivery. Systems software (healthcare provider recommendations, increased trust, higher levels of maternal education) are enablers to maternal vaccine uptake. Findings show that formulation, dissemination and communication of context-specific policies and guidelines on maternal vaccines should be a priority for decision-makers in LMICs.

The supply is there. So why can't pregnant and breastfeeding women in rural India get the COVID-19 vaccine?

Despite COVID-19 vaccines being available to pregnant women in India since summer 2021, little is known about vaccine uptake among this high need population. We conducted mixed methods research with pregnant and recently delivered rural women in northern India, consisting of 300 phone surveys and 15 in-depth interviews, in November 2021. Only about a third of respondents were vaccinated, however, about half of unvaccinated respondents reported that they would get vaccinated now if they could. Fears of harm to the unborn baby or young infant were common (22% of unvaccinated women). However, among unvaccinated women who wanted to get vaccinated, the most common barrier reported was that their health care provider refused to provide them the vaccine. Gender barriers and social norms also played a role, with family members restricting women's access. Trust in the health system was high, however, women were most often getting information about COVID-19 vaccines from sources that they did not trust, and they knew they were getting potentially poor-quality information. Qualitative data shed light on the barriers women faced from their family and health care providers but described how as more people got the vaccine that norms were changing. These findings highlight how pregnant women in India have lower vaccination rates than the general population, and while vaccine hesitancy does play a role, structural barriers from the health care system also limit access to vaccines. Interventions must be developed that target household decision-makers and health providers at the community level, and that take advantage of the trust that rural women already have in their health care providers and the government. It is essential to think beyond vaccine hesitancy and think at the system level when addressing this missed opportunity to vaccinate high risk pregnant women in this setting.

Expert opinion on the way forward for improving maternal influenza vaccination in India

INTRODUCTION

: Rates of maternal vaccination against influenza are extremely low in India. An expert panel of obstetric-gynecologists and pediatricians met to develop consensus-based recommendations for improving awareness of the benefits of influenza vaccination during pregnancy in India.

AREAS COVERED

: The group discussed experiences of influenza infection in pregnancy and infancy before focusing on maternal vaccination practices in India, including the degree of communication between obstetric-gynecologists and pediatricians and opinions on optimal timing for vaccination. The impact of inconsistent vaccine prescription practices by healthcare providers was discussed, as well as current clinical recommendations on maternal influenza vaccination.

EXPERT OPINION

: Although clinical evidence demonstrates the benefit of maternal influenza vaccination in any trimester, influenza vaccination is not widely accepted in India as an integral part of antenatal care. There is a lack of familiarity among obstetricians of clinical guidelines on maternal influenza vaccination. This can be addressed with an education campaign targeting obstetricians and other providers of maternal healthcare. With variable influenza seasons between regions in India, common vaccine stock shortages, and data suggesting influenza vaccination is feasible anytime in pregnancy, all opportunities to offer vaccination to this high-risk group for severe influenza disease should be considered.