The role of publics in the introduction of new vaccines

Public Preference and Priorities for Including Vaccines in China's National Immunization Program: Discrete Choice Experiment

Background

Several important vaccines, such as the Haemophilus influenzae type b vaccine, rotavirus vaccine, pneumococcal conjugate vaccine, and influenza vaccine, have not been included in China's National Immunization Program (NIP) due to a prolonged absence of updates and limited resources. Public engagement could identify concerns that require attention and foster trust to ensure continuous support for immunization.

Objective

This study aimed to identify public preferences for vaccine inclusion in the NIP and to determine the desired vaccine funding priorities in the Chinese population.

Methods

A dual-response discrete choice experiment was utilized to estimate the relative importance of 6 attributes, including incidence of vaccine-preventable diseases, mortality of vaccine-preventable diseases, vaccine effectiveness, vaccine cost, vaccinated group, and vaccine coverage. Participants were recruited through the Wenjuanxing platform using a census-based quota sample of the nationwide population aged 18 years and older. A mixed logit model was used to estimate the coefficient of attribute preferences and predict the selection probability. Subgroups and interaction effects were analyzed to examine the heterogeneity in preferences.

Results

In total, 1258 participants completed the survey, of which 880 were involved in the main analysis and 1166 in the sensitivity analysis. The relative importance and model estimates of 2 attributes, vaccine cost and vaccination group, varied between the unforced- and forced-choice settings. All 6 vaccine attributes significantly influenced the preferences for vaccine inclusion, with vaccine effectiveness and coverage as the most important factors, followed by the vaccinated group and mortality of vaccine-preventable diseases in the unforced-choice settings. The top vaccines recommended for China's NIP included the varicella vaccine, Haemophilus influenzae type b vaccine, enterovirus 71 vaccine, and influenza vaccine for preschoolers and school-aged children. The current analysis also revealed distinct preference patterns among different subgroups, such as gender, age, education, and income. The interaction analysis indicated that the region and health status of participants contribute to preference heterogeneity.

Conclusions

Public preferences for including vaccines in the NIP were primarily influenced by vaccine effectiveness and coverage. The varicella vaccine should be prioritized for inclusion in the NIP. The public preferences could provide valuable insights when incorporating new vaccines in the NIP.

COVID-19 vaccination for people with severe mental illness: why, what, and how?

Psychiatric disorders, and especially severe mental illness, are associated with an increased risk of severe acute respiratory syndrome coronavirus 2 infection and COVID-19-related morbidity and mortality. People with severe mental illness should therefore be prioritised in vaccine allocation strategies. Here, we discuss the risk for worse COVID-19 outcomes in this vulnerable group, the effect of severe mental illness and psychotropic medications on vaccination response, the attitudes of people with severe mental illness towards vaccination, and, the potential barriers to, and possible solutions for, an efficient vaccination programme in this population.

Vaccination hesitancy: fear, trust, and exposure expectancy of an Ebola outbreak

The purpose of this paper is to examine the relationship between vaccination hesitancy and fear, trust, and expectation of a potential imminent and proximate outbreak of Ebola. Our hypothesis is that people engage in self-protective behavior against an infectious disease when they are: fearful about things in general; trustful of government's ability to control the disease outbreak; and anticipating a direct threat to their health. The self-protective behavior we examine is the intention to accept a prospective anti-Ebola vaccination. We examine these relationships with basic demographic variables taken into account: gender, age, ethnicity, race and education. The data source is a national random sample of 1,018 United States adults interviewed early during the 2014 Ebola outbreak. We constructed a new three-item Exposure Expectancy Scale (alpha = 0. 635) to measure the degree of respondents' expectancy of a potential nearby Ebola outbreak. Our data analysis employs multiple logistic regressions. The findings support our hypothesis: willingness to take the Ebola vaccination is positively associated with a generalized sense of fear, trust in the government's ability to control an outbreak of the disease, and expectation of a potential Ebola outbreak that is imminent and proximate. The addition of the exposure expectancy variable in this analysis adds significantly to our understanding of contributors to vaccine hesitancy.

Religious and community leaders' acceptance of rotavirus vaccine introduction in Yogyakarta, Indonesia: a qualitative study

BACKGROUND

In Indonesia, oral rotavirus vaccines are available but not funded on the National Immunization Program (NIP). New immunization program introduction requires an assessment of community acceptance. For religiously observant Muslims in Indonesia, vaccine acceptance is further complicated by the use of porcine trypsin during manufacturing and the absence of halal labeling. In Indonesia, religious and community leaders and the Majelis Ulama Indonesia (MUI) are important resources for many religiously observant Muslims in decisions regarding the use of medicines, including vaccines. This study aimed to explore the views of religious and community leaders regarding the rotavirus vaccine to inform future communication strategies.

METHODS

Twenty semi-structured in-depth interviews were undertaken with religious leaders and community representatives from two districts of Yogyakarta Province, Indonesia. Thematic analysis was undertaken.

RESULTS

Although there was recognition childhood diarrhoea can be severe and a vaccine was needed, few were aware of the vaccine. Participants believed a halal label was required for community acceptance, and maintenance of trust in their government and leaders. Participants considered themselves to be key players in promoting the vaccine to the community post-labeling.

CONCLUSIONS

This study highlights the need for better stakeholder engagement prior to vaccine availability and the potentially important role of religious and community leaders in rotavirus vaccine acceptability in the majority Muslim community of Yogyakarta, Indonesia. These findings will assist with the development of strategies for new vaccine introduction in Indonesia.

Addressing vaccine hesitancy requires an ethically consistent health strategy

BACKGROUND

Vaccine hesitancy is a growing threat to public health. The reasons are complex but linked inextricably to a lack of trust in vaccines, expertise and traditional sources of authority. Efforts to increase immunization uptake in children in many countries that have seen a fall in vaccination rates are two-fold: addressing hesitancy by improving healthcare professional-parent exchange and information provision in the clinic; and, secondly, public health strategies that can override parental concerns and values with coercive measures such as mandatory and presumptive vaccination.

MAIN TEXT

It is argued that such conflicting, parallel approaches seriously risk undermining trust that is crucial for sustaining herd immunity. Although public health strategies can be ethically justified in limiting freedoms, a parent-centered approach seldom acknowledges how it is impacted by contemporaneous coercive measures. In addition, the clinical encounter is not well suited to helping parents consider the public dimensions of vaccination, despite these being important for trust formation and informed decision-making. Efforts to address vaccine hesitancy require more consistent engagement of parental and citizen views. Along with evidence-based information, debates need to be informed by ethical support that equips parents and professionals to respond to the private and public dimensions of vaccination in a more even-handed, transparent manner.

CONCLUSION

Efforts to address vaccine hesitancy need to avoid simple reliance on either parental values or coercive public policies. To do this effectively requires increasing citizen engagement on vaccination to help inform a parent-centered approach and legitimize public policy measures. In addition, cultivating a more ethically consistent strategy means moving beyond the current silos of health ethics - clinical and public health ethics.

How Are New Vaccines Prioritized in Low-Income Countries? A Case Study of Human Papilloma Virus Vaccine and Pneumococcal Conjugate Vaccine in Uganda

Background: To date, research on priority-setting for new vaccines has not adequately explored the influence of the global, national and sub-national levels of decision-making or contextual issues such as political pressure and stakeholder influence and power. Using Kapiriri and Martin’s conceptual framework, this paper evaluates priority setting for new vaccines in Uganda at national and sub-national levels, and considers how global priorities can influence country priorities. This study focuses on 2 specific vaccines, the human papilloma virus (HPV) vaccine and the pneumococcal conjugate vaccine (PCV).

Methods: This was a qualitative study that involved reviewing relevant Ugandan policy documents and media reports, as well as 54 key informant interviews at the global level and national and sub-national levels in Uganda. Kapiriri and Martin’s conceptual framework was used to evaluate the prioritization process.

Results: Priority setting for PCV and HPV was conducted by the Ministry of Health (MoH), which is considered to be a legitimate institution. While respondents described the priority setting process for PCV process as transparent, participatory, and guided by explicit relevant criteria and evidence, the prioritization of HPV was thought to have been less transparent and less participatory. Respondents reported that neither process was based on an explicit priority setting framework nor did it involve adequate representation from the districts (program implementers) or publicity. The priority setting process for both PCV and HPV was negatively affected by the larger political and economic context, which contributed to weak institutional capacity as well as power imbalances between development assistance partners and the MoH.

Conclusion: Priority setting in Uganda would be improved by strengthening institutional capacity and leadership and ensuring a transparent and participatory processes in which key stakeholders such as program implementers (the districts) and beneficiaries (the public) are involved. Kapiriri and Martin’s framework has the potential to guide priority setting evaluation efforts, however, evaluation should be built into the priority setting process a priori such that information on priority setting is gathered throughout the implementation cycle.

Community awareness, use and preference for pandemic influenza vaccines in Pune, India

Vaccination is a cornerstone of influenza prevention, but limited vaccine uptake was a problem worldwide during the 2009–2010 pandemic. Community acceptance of a vaccine is a critical determinant of its effectiveness, but studies have been confined to high-income countries. We conducted a cross-sectional, mixed-method study in urban and rural Pune, India in 2012–2013. Semi-structured explanatory model interviews were administered to community residents (n = 436) to study awareness, experience and preference between available vaccines for pandemic influenza. Focus group discussions and in-depth interviews complemented the survey. Awareness of pandemic influenza vaccines was low (25%). Some respondents did not consider vaccines relevant for adults, but nearly all (94.7%), when asked, believed that a vaccine would prevent swine flu. Reported vaccine uptake however was 8.3%. Main themes identified as reasons for uptake were having heard of a death from swine flu, health care provider recommendation or affiliation with the health system, influence of peers and information from media. Reasons for non-use were low perceived personal risk, problems with access and cost, inadequate information and a perceived lack of a government mandate endorsing influenza vaccines. A majority indicated a preference for injectable over nasal vaccines, especially in remote rural areas. Hesitancy from a lack of confidence in pandemic influenza vaccines appears to have been less of an issue than access, complacency and other sociocultural considerations. Recent influenza outbreaks in 2015 highlight a need to reconsider policy for routine influenza vaccination while paying attention to sociocultural factors and community preferences for effective vaccine action.

Sociocultural determinants of anticipated oral cholera vaccine acceptance in three African settings: a meta-analytic approach

BACKGROUND

Controlling cholera remains a significant challenge in Sub-Saharan Africa. In areas where access to safe water and sanitation are limited, oral cholera vaccine (OCV) can save lives. Establishment of a global stockpile for OCV reflects increasing priority for use of cholera vaccines in endemic settings. Community acceptance of vaccines, however, is critical and sociocultural features of acceptance require attention for effective implementation. This study identifies and compares sociocultural determinants of anticipated OCV acceptance across populations in Southeastern Democratic Republic of Congo, Western Kenya and Zanzibar.

METHODS

Cross-sectional studies were conducted using similar but locally-adapted semistructured interviews among 1095 respondents in three African settings. Logistic regression models identified sociocultural determinants of OCV acceptance from these studies in endemic areas of Southeastern Democratic Republic of Congo (SE-DRC), Western Kenya (W-Kenya) and Zanzibar. Meta-analytic techniques highlighted common and distinctive determinants in the three settings.

RESULTS

Anticipated OCV acceptance was high in all settings. More than 93% of community respondents overall indicated interest in a no-cost vaccine. Higher anticipated acceptance was observed in areas with less access to public health facilities. In all settings awareness of cholera prevention methods (safe food consumption and garbage disposal) and relating ingestion to cholera causation were associated with greater acceptance. Higher age, larger households, lack of education, social vulnerability and knowledge of oral rehydration solution for self-treatment were negatively associated with anticipated OCV acceptance. Setting-specific determinants of acceptance included reporting a reliable income (W-Kenya and Zanzibar, not SE-DRC). In SE-DRC, intention to purchase an OCV appeared unrelated to ability to pay. Rural residents were less likely than urban counterparts to accept an OCV in W-Kenya, but more likely in Zanzibar. Prayer as a form of self-treatment was associated with vaccine acceptance in SE-DRC and W-Kenya, but not in Zanzibar.

CONCLUSIONS

These cholera-endemic African communities are especially interested in no-cost OCVs. Health education and attention to local social and cultural features of cholera and vaccines would likely increase vaccine coverage. High demand and absence of insurmountable sociocultural barriers to vaccination with OCVs indicate potential for mass vaccination in planning for comprehensive control or elimination.

Knowledge and awareness of HPV vaccine and acceptability to vaccinate in sub-Saharan Africa: a systematic review

Objectives

We assessed the knowledge and awareness of cervical cancer, HPV and HPV vaccine, and willingness and acceptability to vaccinate in sub-Saharan African (SSA) countries. We further identified countries that fulfill the two GAVI Alliance eligibility criteria to support nationwide HPV vaccination.

Methods

We conducted a systematic review of peer-reviewed studies on the knowledge and awareness of cervical cancer, HPV and HPV vaccine, and willingness and acceptability to vaccinate. Trends in Diphtheria-tetanus-pertussis (DTP3) vaccine coverage in SSA countries from 1990–2011 were extracted from the World Health Organization database.

Findings

The review revealed high levels of willingness and acceptability of HPV vaccine but low levels of knowledge and awareness of cervical cancer, HPV or HPV vaccine. We identified only six countries to have met the two GAVI Alliance requirements for supporting introduction of HPV vaccine: 1) the ability to deliver multi-dose vaccines for no less than 50% of the target vaccination cohort in an average size district, and 2) achieving over 70% coverage of DTP3 vaccine nationally. From 2008 through 2011 all SSA countries, with the exception of Mauritania and Nigeria, have reached or maintained DTP3 coverage at 70% or above.

Conclusion

There is an urgent need for more education to inform the public about HPV, HPV vaccine, and cervical cancer, particularly to key demographics, (adolescents, parents and healthcare professionals), to leverage high levels of willingness and acceptability of HPV vaccine towards successful implementation of HPV vaccination programs. There is unpreparedness in most SSA countries to roll out national HPV vaccination as per the GAVI Alliance eligibility criteria for supporting introduction of the vaccine. In countries that have met 70% DTP3 coverage, pilot programs need to be rolled out to identify the best practice and strategies for delivering HPV vaccines to adolescents and also to qualify for GAVI Alliance support.