The global effect of maternal education on complete childhood vaccination: a systematic review and meta-analysis

Introduction of the pneumococcal conjugate vaccine in humanitarian and fragile contexts: Perspectives from stakeholders in four African countries

Childhood pneumonia causes a significant burden of preventable child morbidity and mortality in Chad, Guinea, Somalia/Somaliland, and South Sudan. Leaders from these countries have committed to reducing this burden and are preparing to introduce the pneumococcal conjugate vaccine (PCV) into their immunization programs. To support long-term sustainability for expected PCV introductions in settings afflicted by prolonged humanitarian crises this research explores national stakeholders' perspectives on contextual factors that may influence optimal vaccine implementation. This qualitative study used purposive sampling to identify and interview stakeholders involved in vaccine decision-making. Interview transcripts were analyzed through the framework method, an approach involving charting data into pre-populated matrices. Findings from interviews with 16 key informants from government, partner organizations, and international health agencies fit within the following four overarching themes: (1) population-level vulnerabilities to pneumonia, exacerbated by climatic risks and low levels of maternal education; (2) disease burden and the interest in enhancing surveillance to monitor vaccine impact and integrate disease control efforts; (3) policy processes, including formalizing vaccine decision-making; and (4) vaccine implementation preparation, including the conduct of robust communication campaigns, training, and cold chain upgrades. This research explores perspectives from leaders in these countries which are at pivotal moments in their journeys toward introducing PCV. Widespread commitment among leaders, in addition to financial support, will facilitate vaccine introduction. Further, fostering a shared understanding among partners about context-specific determinants of program success will help build tailored implementation strategies for each country.

Decomposition Analysis of Socioeconomic Inequalities in Vaccination Dropout in Remote and Underserved Settings in Ethiopia

Despite increments in immunization coverage over the past decades, substantial inequality due to wealth status has persisted in Ethiopia. This study aimed to decompose the concentration index into the contributions of individual factors to socioeconomic inequalities of childhood vaccination dropout in remote and underserved settings in Ethiopia by using a decomposition approach. A wealth index was developed by reducing 41 variables related to women's household living standards into nine factors by using principal component analysis. The components were further totaled into a composite score and divided into five quintiles (poorest, poorer, middle, richer, and richest). Vaccination dropout was calculated as the proportion of children who did not get the pentavalent-3 vaccine among those who received the pentavalent-1 vaccine. The concentration index was used to estimate socioeconomic inequalities in childhood vaccination dropout, which was then decomposed to examine the factors contributing to socioeconomic inequalities in vaccination dropout. The overall concentration index was -0.179 (P <0.01), confirming the concentration of vaccination dropout among the lowest wealth strata. The decomposition analyses showed that wealth index significantly contributed to inequalities in vaccination dropout (49.7%). Place of residence also explained -16.2% of the inequality. Skilled birth attendance and availability of a health facility in the kebele (the lowest administrative government structure) also significantly contributed (33.6% and 12.6%, respectively) to inequalities in vaccination dropout. Wealth index, place of residence, skilled birth attendance, and availability of a health facility in the kebele largely contributed to the concentration of vaccination dropout among the lowest wealth strata. Policymakers should address vaccination inequality by designing more effective strategies.

Exploring Parental Attitudes and Perceptions Regarding Childhood Vaccinations in Greece: A Study Within the Framework of the National Health Examination Survey (EMENO)

AIM

Vaccinations have reduced illnesses and mortality rates globally, yet negative attitudes and uncertainty about them hinder their acceptability and efficacy. The study aims to document Greek parents' immunization perceptions and risk factors.

METHODS

Spanning 2014-2017, 447 parents (68% mothers) who participated in the Greek Health Examination Survey EMENO (National Survey of Morbidity and Risk Factors) completed an interview-delivered questionnaire. Attitudes were categorized into three groups: absolutely positive, positive, and negative. Absolutely positive attitudes included positive responses to all five statements in favor of vaccination and negative responses to the two statements against vaccination. Negative attitudes included positive responses to either one or both statements against vaccination and negative responses to all five statements in favor of vaccination.. All other participants were categorized as having a positive attitude. Skepticism towards vaccinations was classified into skeptical and non-skeptical groups based on responses to five statements implying uncertainty or skepticism. Participants were considered skeptical if they provided positive responses to at least three of these statements, and non-skeptical if they had none or up to two positive responses. The statistical analysis accounted for the study design whereas inverse probability weighting was used to adjust for non-response and multiple imputations were employed to impute missing values. The components of parental attitude and vaccine skepticism were identified using weighted multinomial logistic regression and logistic regression, respectively.

RESULTS

In total, 16.6% were classified as having absolutely positive attitudes towards vaccinations whereas 42.1% were skeptical of vaccines. Of all participants, 96.0% agreed that vaccinations are essential for their child's well-being and adhere to scientific recommendations. However, concerns were also mentioned, with 26.2% worrying about potential adverse effects, and 21.6% believing it is better to acquire immunity through illness rather than vaccination. Positive participants, compared to absolutely positive ones, were more likely to be of Greek origin (adjusted relative rate ratio (aRRR): 3.35; 95% CI: 1.53-7.30) and living in semi-urban areas (aRRR: 4.84; 95% CI: 1.77-13.29). Negative participants, in contrast, were more likely to have higher education (aRRR: 2.98; 95% CI: 1.05-8.44) but also to live in semi-urban areas (aRRR: 6.43; 95% CI: 1.69-24.56). Furthermore, parents of Greek origin had significantly higher odds of being skeptical towards vaccination (adjusted Odds Ratio (aOR): 2.86; 95% CI: 1.36-5.98), while married or cohabiting parents had lower odds of being skeptical compared to single parents (aOR: 0.60; 95% CI: 0.35-1.06).

CONCLUSIONS

While parents in this study recognize the importance of childhood immunizations, there is a widespread presence of negative attitudes and skepticism that can have a detrimental impact on vaccination rates.

Raising Epidemiological Awareness: Assessment of Measles/MMR Susceptibility in Highly Vaccinated Clusters within the Hungarian and Croatian Population-A Sero-Surveillance Analysis

Perceptions of the complete eradication of vaccine-preventable diseases such as measles, mumps, and rubella (MMR) may foster complacency and compromise vaccination efforts. Decreased measles vaccination rates during the COVID-19 pandemic have heightened the risk of outbreaks, even in adequately vaccinated populations. To address this, we have aligned with ECDC recommendations, leveraging previous cross-border sero-epidemiological assessments between Pécs, Hungary, and Osijek, Croatia, to identify latent risk groups and uncover potential parallels between our nations. Testing 2680 Hungarian and 1764 Croatian serum samples for anti-MMR IgG via ELISAs revealed anti-measles seropositivity ratios below expectations in Croatian cohorts aged ~20-30 (75.7%), ~30-40 (77.5%) and ~40-50 years (73.3%). Similarly, Hungarian samples also showed suboptimal seropositivity ratios in the ~30-40 (80.9%) and ~40-50 (87.3%) age groups. Considering mumps- and rubella-associated seropositivity trends, in both examined populations, individuals aged ~30-50 years exhibited the highest vulnerability. Additionally, we noted congruent seropositivity trends across both countries, despite distinct immunization and epidemiological contexts. Therefore, we propose expanding research to encompass the intricate dynamics of vaccination, including waning long-term immunity. This understanding could facilitate targeted interventions and bolster public awareness. Our findings underscore persistent challenges in attaining robust immunity against measles despite vaccination endeavors.

Post-campaign coverage evaluation of a measles and rubella supplementary immunization activity in five districts in India, 2019-2020

BACKGROUND

In alignment with the Measles and Rubella (MR) Strategic Elimination plan, India conducted a mass measles and rubella vaccination campaign across the country between 2017 and 2020 to provide a dose of MR containing vaccine to all children aged 9 months to 15 years. We estimated campaign vaccination coverage in five districts in India and assessed campaign awareness and factors associated with vaccination during the campaign to better understand reasons for not receiving the dose.

METHODS AND FINDINGS

Community-based cross-sectional serosurveys were conducted in five districts of India among children aged 9 months to 15 years after the vaccination campaign. Campaign coverage was estimated based on home-based immunization record or caregiver recall. Campaign coverage was stratified by child- and household-level risk factors and descriptive analyses were performed to assess reasons for not receiving the campaign dose. Three thousand three hundred and fifty-seven children aged 9 months to 15 years at the time of the campaign were enrolled. Campaign coverage among children aged 9 months to 5 years documented or by recall ranged from 74.2% in Kanpur Nagar District to 90.4% in Dibrugarh District, Assam. Similar coverage was observed for older children. Caregiver awareness of the campaign varied from 88.3% in Hoshiarpur District, Punjab to 97.6% in Dibrugarh District, Assam, although 8% of children whose caregivers were aware of the campaign were not vaccinated during the campaign. Failure to receive the campaign dose was associated with urban settings, low maternal education, and lack of school attendance although the associations varied by district.

CONCLUSION

Awareness of the MR vaccination campaign was high; however, campaign coverage varied by district and did not reach the elimination target of 95% coverage in any of the districts studied. Areas with lower coverage among younger children must be prioritized by strengthening the routine immunization programme and implementing strategies to identify and reach under-vaccinated children.

The effect of mHealth on childhood vaccination in Africa: A systematic review and meta-analysis

INTRODUCTION

Vaccine-preventable diseases are the public health problems in Africa, although vaccination is an available, safe, simple, and effective method prevention. Technologies such as mHealth may provide maternal access to health information and support decisions on childhood vaccination. Many studies on the role of mHealth in vaccination decisions have been conducted in Africa, but the evidence needs to provide conclusive information to support mHealth introduction. This study provides essential information to assist planning and policy decisions regarding the use of mHealth for childhood vaccination.

METHODS

We conducted a systematic review and meta-analysis for studies applying mHealth in Africa for vaccination decisions following the Preferred Reporting Items for Systematic and Meta-Analysis [PRISMA] guideline. Databases such as CINAHL, EMBASE, PubMed, PsycINFO, Scopus, Web of Science, Google Scholar, Global Health, HINARI, and Cochrane Library were included. We screened studies in Endnote X20 and performed the analysis using Revman 5.4.1.

RESULTS

The database search yielded 1,365 articles [14 RCTs and 4 quasi-experiments] with 21,070 participants satisfied all eligibility criteria. The meta-analysis showed that mHealth has an OR of 2.15 [95% CI: 1.70-2.72; P<0.001; I2 = 90%] on vaccination rates. The subgroup analysis showed that regional differences cause heterogeneity. Funnel plots and Harbord tests showed the absence of publication bias, while the GRADE scale showed a moderate-quality body of evidence.

CONCLUSION

Although heterogeneous, this systematic review and meta-analysis showed that the application of mHealth could potentially improve childhood vaccination in Africa. It increased childhood vaccination by more than double [2.15 times] among children whose mothers are motivated by mHealth services. MHealth is more effective in less developed regions and when an additional incentive party with the messaging system. However, it can be provided at a comparably low cost based on the development level of regions and can be established as a routine service in Africa.

REGISTRATION

PROSPERO: CRD42023415956.

Trends in childhood vaccination in Pakistan and associated factors; 2006-2018

INTRODUCTION

Pakistan still has ongoing transmission of wild type polio virus. This study aims to determine changes in full vaccination with recommended Expanded Program on Immunization vaccines, including polio, by several socio-economic and demographic factors.

METHODS

We used three waves of Pakistan's Demographic and Health Survey, a population-based cross-sectional study from 2006-07 (N = 1471), 2012-13 (N = 1706), and 2017-18 (N = 1549), analyzed by residence, wealth, and sociodemographic factors. Analysis was limited to children aged 12-23 months in Punjab, Sindh, Northwest Frontier Province/Khyber Pakhtunkhwa and Balochistan. Full vaccination was measured as receipt of one Bacillus Calmette-Guérin dose, one measles dose, 3 polio doses, and 3 Diphtheria-Tetanus-Pertussis doses. Odds ratios (ORs) and 95 % confidence intervals (CIs) from logistic regression were used to determine associations between undervaccination and demographic variables.

RESULTS

Full vaccination coverage was 50.6 % in 2006-07, 54.7 % in 2012-13, and 68.3 % in 2017-18. In 2006-07, the odds of undervaccination were significantly higher in Sindh (OR: 1.74, 95 % CI: 1.30, 2.31) than Punjab, and disparities across province changed over time (P < 0.0001); notably, undervaccination was significantly higher in Sindh, KPK, and Balochistan than Punjab in 2017. Compared to the middle wealth quintile, the poorest had significantly higher odds of undervaccination in 2006-07 (OR: 2.58, 95 % CI: 1.76, 3.78), and this did not significantly change over time (P = 0.2168). The proportion of those with a polio birth dose increased across waves from 56.3 % in 2006-07 to 83.7 % in 2017-18; receiving three or more polio vaccine doses remained unchanged.

CONCLUSION

This study showed that the proportion of fully vaccinated children in Pakistan increased across three waves. Full vaccination and administration of polio vaccine birth doses have increased recently in Pakistan. The association between undervaccination with province differed significantly across the waves, with vaccination disparities between provinces increasing. Those in the poorest wealth quintile had the greatest odds of undervaccination.

Socioeconomic inequalities in vaccine uptake: A global umbrella review

This global umbrella review aimed to synthesise evidence of socioeconomic inequalities in the uptake of routine vaccinations and identify the mechanisms that may contribute to the association. To our knowledge, no attempt has been made to synthesise the global body of systematic reviews across a variety of vaccines, geographical locations, and measures of SES. The inclusion criteria were as follows: studies assessing vaccination uptake according to education, income, occupation/employment, and/or area-level deprivation; any country or universally recommended routine vaccination (according to the WHO); qualitative or quantitative reviews, published 2011-present. The searches were performed in eight databases. The screening process followed PRISMA-E guidelines, each stage was performed by one reviewer, and a 10% sample checked by a second for consistency. Included reviews underwent data extraction, quality appraisal (AMSTAR-2), and narrative synthesis according to country-context. After deduplication, 9,163 reports underwent title and abstract screening, leaving 119 full texts to be assessed for eligibility. Overall, 26 studies were included in the umbrella review. Evidence for lower uptake amongst disadvantaged SES individuals was found in all 26 reviews. However, 17 reviews showed mixed results, as inverse associations were also identified (lower uptake for advantaged SES, and/or higher uptake for disadvantaged SES). Those that explored high-income countries had a greater prevalence of mixed findings than those focusing on low/middle-income countries. The two most frequently cited mechanisms were vaccination knowledge, and confidence in vaccination or vaccination providers. These mechanisms were often understood by review authors as varying by level of education. We find socioeconomic differences in routine vaccination uptake, but the association did not always follow a gradient. Whilst education may be associated with uptake globally, our study indicates that its role varies by country-context. A limitation is the overlap of some primary studies across the included systematic reviews.

Trends in Vaccine Completeness in Children Aged 0-23 Months in Cape Town, South Africa

BACKGROUND

We have previously determined that the occurrence of missed vaccination opportunities in children in Cape Town, South Africa, is shaped by both individual and contextual factors. These factors present valuable openings for enhancing quality and implementing broader strategies to enhance the delivery of routine Immunisation services.

METHODS

Here, we are further reporting regional-level data on the coverage and factors influencing vaccination completion within a similar study population, based on extensive data analysis from the 2016 South African Demographic and Health Survey.

RESULTS AND DISCUSSION

The study reveals commendable vaccination coverage for most vaccines within recommended schedules, with high rates of initial vaccinations at birth and during the primary vaccination schedule. However, there are notable areas for improvement, particularly in ensuring complete coverage for the second measles vaccine and the 18-month vaccine. Socio-demographic factors also play a role, with maternal education and caregiver awareness campaigns showing the potential to positively influence vaccination completeness. This study emphasises the importance of timely vaccinations during the early months of life and underscores the need for interventions to maintain coverage as children age. Specific sub-districts, such as Tygerberg, may require targeted efforts to enhance vaccination completeness. Additionally, assessing caregiver knowledge about child vaccination is deemed vital, as it can impact vaccination decisions and adherence.

CONCLUSIONS

The findings provide valuable insights for public health interventions in Cape Town, aimed at reducing the burden of vaccine-preventable diseases and ensuring the health of the region's youngest population.

Pervasive Parental Hesitancy and Resistance towards Measles Rubella Vaccination in Jordan

Measles remains a highly contagious and potentially severe infectious disease, necessitating high vaccine coverage. However, misinformation and measles vaccine hesitancy/resistance have posed significant challenges to achieving this goal. The COVID-19 pandemic further exacerbated these challenges, leading to a measles outbreak in Jordan in 2023. This study aimed to investigate the acceptance of the measles rubella (MR) vaccine among parents in Jordan and to identify its associated determinants. This cross-sectional questionnaire-based study was conducted using a previously Arabic-validated version of the Parental Attitudes towards Childhood Vaccines (PACV) survey instrument. Data collection took place in October 2023, and the final study sample comprised a total of 391 parents, with mothers representing 69.8% of the participants (n = 273). The majority of participating parents expressed either resistance (n = 169, 43.2%) or hesitancy (n = 168, 43.0%) towards MR vaccination, while only 54 participants (13.8%) expressed MR vaccine acceptance. Multivariate analysis revealed that trust in vaccine safety/efficacy, behavior, and having fewer offspring were significantly associated with MR vaccine acceptance. The current study revealed a concerning level of MR vaccine hesitancy/resistance among parents in Jordan, which could signal a public health alarm in the country. Urgent and targeted interventions are strongly recommended to address this issue, including mass campaigns aimed at building trust in the MR vaccine's safety/efficacy. Additionally, there is an urgent need for effective public health initiatives to ensure sufficient measles vaccine coverage to prevent future outbreaks of this serious disease.

Understanding multilevel barriers to childhood vaccination uptake among Internally Displaced Populations (IDPs) in Mogadishu, Somalia: a qualitative study

BACKGROUND

Disparities in vaccination coverage exist in Somalia with Internally Displaced Persons (IDPs) being among the groups with the lowest coverage. We implemented an adapted Participatory Learning and Action (PLA) intervention, which focused on routine vaccinations among displaced populations living in Mogadishu IDP camps. The intervention was successful in improving maternal knowledge and vaccination coverage but unsuccessful in improving timely vaccination. We conducted a qualitative study to understand this result and analyze the multi-level barriers to routine childhood immunization uptake.

METHOD

In this qualitative study we used observation data from 40 PLA group discussions with female caregivers and purposively sampled nine vaccination service providers and six policy makers for interview. We also reviewed national-level vaccine policy documents and assessed the quality of health facilities in the study area. We used the socioecological framework to structure our analysis and analyzed the data in NVivo.

RESULTS

The barriers to childhood vaccination among IDPs at the individual level were fear due to lack of knowledge, mistrust of vaccines, concerns about side effects and misinformation; opportunity costs; and costs of transportation. At the interpersonal level, family members played an important role as did the extent of decision-making autonomy. Community factors such as cultural practices, gender roles, and household evictions influenced vaccination. Organizational issues at health facilities such as waiting times, vaccine stock-outs, distance to the facility, language differences, and hesitancy of health workers to open multi-dose vials affected vaccination. At the policy level, confusion about the eligible age for routine vaccination and age restrictions for catch-up vaccination and certain antigens such as BCG were important barriers.

CONCLUSION

Complex and interrelated factors affect childhood vaccination uptake among IDPs in Somalia. Interventions that address multiple barriers simultaneously will have the greatest impact given the complex nature of vulnerabilities in this population. There is a need to strengthen the health system and connect it with existing community structures to increase demand for services. Our research highlights the importance of formative research before implementing interventions. Further research on the integration of health service strengthening with PLA to improve childhood vaccination among IDPs is recommended.

TRIAL REGISTRATION NUMBER

ISRCTN-83,172,390. Date of registration: 03/08/2021.

Determinants of COVID-19 vaccination worldwide: WORLDCOV, a retrospective observational study

Introduction

The COVID-19 pandemic has resulted in numerous deaths, great suffering, and significant changes in people's lives worldwide. The introduction of the vaccines was a light in the darkness, but after 18 months, a great disparity in vaccination coverage between countries has been observed. As disparities in vaccination coverage have become a global public health issue, this study aimed to analyze several variables to identify possible determinants of COVID-19 vaccination.

Methods

An ecological study was conducted using pooled secondary data sourced from institutional sites. A total of 205 countries and territories worldwide were included. A total of 16 variables from different fields were considered to establish possible determinants of COVID-19 vaccination: sociodemographic, cultural, infrastructural, economic and political variables, and health system performance indicators. The percentage of the population vaccinated with at least one dose and the total doses administered per 100 residents on 15 June 2022 were identified as indicators of vaccine coverage and outcomes. Raw and adjusted values for delivered vaccine doses in the multivariate GLM were determined using R. The tested hypothesis (i.e., variables as determinants of COVID-19 vaccination) was formulated before data collection. The study protocol was registered with the grant number NCT05471635.

Results

GDP per capita [odds = 1.401 (1.299-1.511) CI 95%], access to electricity [odds = 1.625 (1.559-1.694) CI 95%], political stability, absence of violence/terrorism [odds = 1.334 (1.284-1.387) CI 95%], and civil liberties [odds = 0.888 (0.863-0.914) CI 95%] were strong determinants of COVID-19 vaccination. Several other variables displayed a statistically significant association with outcomes, although the associations were stronger for total doses administered per 100 residents. There was a substantial overlap between raw outcomes and their adjusted counterparts.

Discussion

This pioneering study is the first to analyze the association between several different categories of indicators and COVID-19 vaccination coverage in a wide complex setting, identifying strong determinants of vaccination coverage. Political decision-makers should consider these findings when organizing mass vaccination campaigns in a pandemic context to reduce inequalities between nations and to achieve a common good from a public health perspective.

Childhood vaccination uptake among children born in Aotearoa New Zealand based on parental nationality

Migrants and refugees generally experience immunization inequities compared to their host populations. Childhood vaccination coverage rates are influenced by a complex set of interrelated factors, including child and parental nativity. Coverage rates for MMR, pertussis, and HPV vaccines were compared among children born in Aotearoa New Zealand (NZ) of overseas-born parents or NZ-born parents. A nationwide retrospective cohort study was conducted using linked, de-identified data. Logistic regression models examined the most influential factors contributing to differences in timely vaccine uptake. Of the total study population who had received all scheduled vaccines (N = 760,269), 32.9% were children of migrant parents. Children of migrant parents had higher rates of complete and timely uptake for MMR, pertussis, and HPV vaccinations compared to non-migrant children. NZ-born children of migrant parents were significantly more likely to receive MMR and pertussis-containing vaccines on-time compared to those of non-migrants. All included factors, except for the child's gender and parents' English ability, significantly influenced vaccine uptake. Among NZ-born children of migrant parents, additional logistic modeling found significant differences based on parental duration of residence, visa group, and region of nationality. Findings point to the importance of differentiating between parent versus child nativity when examining immunization coverage. While vaccination rates were higher for NZ-born children of migrant parents, compared to non-migrant parents, timely coverage rates across both groups were below national targets. Continued efforts are needed to improve timely immunization service delivery to address suboptimal and inequitable coverage.

Timely childhood vaccination in Israel: a national retrospective study of ethnic and socioeconomic disparities

A large proportion of children do not receive vaccines within the recommended timeframe. This study examined ethnic and socioeconomic differences in age-appropriate immunization of children in Israel, where immunization is freely available. Percent of children receiving MMR/V at 12-13 months, and four doses of DTP/IPV/Hib by 18 months were obtained from the National Programme for Quality Measures between 2015 and 2018. Ethnic group (Jewish vs Arab) (defined by proxy by the neighbourhood in which the clinic was located), neighbourhood socioeconomic status and peripherality were obtained. Rates of MMR vaccination were 61% in the Jewish and 82% in the Arab population; for DPT/IPV/Hib 75% in the Jewish, compared to 92% in the Arab population. These patterns were stable over time. Lowest rates occurred in the most peripheral areas for Arab children, and in urban areas for Jewish children. Differences between ethnic groups were significant at higher SES levels. Greater adherence to the vaccination schedule occurred in the Arab minority in contrast to studies showing lower vaccination in ethnic minorities elsewhere. Lower immunization rates among rural Arab children suggest a need for improved access to clinics. Efforts should be directed towards lower SES groups, while emphasizing the importance of timely vaccination in wealthier groups in order to achieve herd immunity.

Acceptability of COVID-19 vaccination in Chinese children aged 3-7 years with bronchopulmonary dysplasia

OBJECTIVES

To describe the status of coronavirus disease 2019 (COVID-19) vaccination with inactivated vaccines BBIBP-CorV and CoronaVac in Chinese children aged 3-7 years with bronchopulmonary dysplasia (BPD), and explore factors influencing vaccination and reasons for nonvaccination.

METHODS

This cross-sectional study involving parents of 397 BPD children aged 3-7 years was conducted through WeChat or follow-up telephone interviews using a standardized questionnaire form. Factors influencing COVID-19 vaccination were explored by using modified Poisson regression models.

RESULTS

The overall COVID-19 vaccination rate was 69.0% (95% confidence interval: 64.3%-73.4%). COVID-19 vaccination was less likely to be accepted in children whose mothers had a relatively high educational background (university and above), who lived in urban areas and had a low birth weight (<1 kg), a history of hospitalization for lung diseases in the past 12 months, and intellectual disability. Conversely, kindergarten students and children from families with an annual income of >300,000 CNY (≈ $\approx $ 41,400 USD) were more likely to accept vaccination. Adverse reactions occurred in 13/274 children (4.7%) within 10 days after vaccination. With respect to reasons of not accepting COVID-19 vaccination, 95 parents (77.2%) worried about the adverse reactions, and 17 parents (13.8%) refused vaccination on the excuse of not being convenient to go to the vaccination station or not knowing where to get the vaccines.

CONCLUSIONS

The COVID-19 vaccination rate in BPD children aged 3-7 years needs to be further improved in China. Continuous efforts are required to monitor postvaccination adverse reactions in BPD children, and make vaccination more convenient and accessible.

Health inequalities in infectious diseases: a systematic overview of reviews

OBJECTIVES

The aim of this systematic overview of reviews was to synthesise available evidence on inequalities in infectious disease based on three dimensions of inequalities; inclusion health groups, protected characteristics and socioeconomic inequalities.

METHODS

We searched MEDLINE, Embase, Web of Science and OpenGrey databases in November 2021. We included reviews published from the year 2000 which examined inequalities in the incidence, prevalence or consequences of infectious diseases based on the dimensions of interest. Our search focused on tuberculosis, HIV, sexually transmitted infections, hepatitis C, vaccination and antimicrobial resistance. However, we also included eligible reviews of any other infectious diseases. We appraised the quality of reviews using the Assessment of Multiple Systematic Reviews V.2 (AMSTAR2) checklist. We conducted a narrative data synthesis.

RESULTS

We included 108 reviews in our synthesis covering all the dimensions of inequalities for most of the infectious disease topics of interest, however the quality and volume of review evidence and consistency of their findings varied. The existing literature reviews provide strong evidence that people in inclusion health groups and lower socioeconomic status are consistently at higher risk of infectious diseases, antimicrobial resistance and incomplete/delayed vaccination. In the protected characteristics dimension, ethnicity, and sexual orientation are important factors contributing to inequalities across the various infectious disease topics included in this overview of reviews.

CONCLUSION

We identified many reviews that provide evidence of various types of health inequalities in different infectious diseases, vaccination, and antimicrobial resistance. We also highlight areas where reviews may be lacking. The commonalities in the associations and their directions suggest it might be worth targeting interventions for some high risk-groups that may have benefits across multiple infectious disease outcomes rather than operating purely in infectious disease siloes.

Socioeconomic and residence-based related inequality in childhood vaccination in Sub-Saharan Africa: Evidence from Benin

Background and Aims

Childhood vaccination remains a cost-effective strategy that has expedited the control and elimination of numerous diseases. Although coverage of new vaccines in low- and middle-income countries increased exponentially in the last two decades, progress on expanding routine vaccination services to reach all children remains low, and coverage levels in many countries remains inadequate. This study aimed to examine the pattern of wealth and residence-based related inequality in vaccination coverage through an equity lens.

Methods

We used data from the 2017-2018 Benin Demographic and Health Survey. Statistical and econometrics modeling were used to investigate factors associated with childhood vaccination. The Wagstaff decomposition analysis was used to disentangle the concentration index.

Results

A total of 1993 children were included, with 17% in the wealthiest quintile and 63% were living in rural areas. Findings showed that wealth is positively and significantly associated with vaccination coverage, particularly, for middle-wealth households. A secondary or higher education level of women and partners increased the odds of vaccination compared to no education (p < 0.05). Women with more antenatal care visits, with multiple births, attending postnatal care and delivery in a health facility had increased vaccination coverage (p < 0.01). Inequalities in vaccination coverage are more prominent in rural areas; and are explained by wealth, education, and antenatal care visits.

Conclusion

Inequality in child vaccination varies according to socioeconomic and sociodemographic characteristics and is of interest to health policy. To mitigate inequalities in child vaccination coverage, policymakers should strengthen the availability and accessibility of vaccination and implement educational programs dedicated to vulnerable groups in rural areas.

Awareness and Knowledge of Pneumococcal Vaccination in Cardiology Outpatient Clinics and the Impact of Physicians’ Recommendations on Vaccination Rates

Aim: We aimed to evaluate the awareness of pneumococcal vaccination (PCV13, PPSV23) in general cardiology outpatient clinics and impact of physicians’ recommendations on vaccination rates. Methods: This was a multicenter, observational, prospective cohort study. Patients over the age of 18 from 40 hospitals in different regions of Turkey who applied to the cardiology outpatient clinic between September 2022 and August 2021 participated. The vaccination rates were calculated within three months of follow-up from the admitting of the patient to cardiology clinics. Results: The 403 (18.2%) patients with previous pneumococcal vaccination were excluded from the study. The mean age of study population (n = 1808) was 61.9 ± 12.1 years and 55.4% were male. The 58.7% had coronary artery disease, hypertension (74.1%) was the most common risk factor, and 32.7% of the patients had never been vaccinated although they had information about vaccination before. The main differences between vaccinated and unvaccinated patients were related to education level and ejection fraction. The physicians’ recommendations were positively correlated with vaccination intention and behavior in our participants. Multivariate logistic regression analysis showed a significant correlation between vaccination and female sex [OR = 1.55 (95% CI = 1.25–1.92), p < 0.001], higher education level [OR = 1.49 (95% CI = 1.15–1.92), p = 0.002] patients’ knowledge [OR = 1.93 (95% CI = 1.56–2.40), p < 0.001], and their physician’s recommendation [OR = 5.12 (95% CI = 1.92–13.68), p = 0.001]. Conclusion: To increase adult immunization rates, especially among those with or at risk of cardiovascular disease (CVD), it is essential to understand each of these factors. Even if during COVID-19 pandemic, there is an increased awareness about vaccination, the vaccine acceptance level is not enough, still. Further studies and interventions are needed to improve public vaccination rates.

Differential coverage for vaccines in the expanded program on immunization (EPI) among children in rural Pakistan

BACKGROUND

Pakistan has a well-established Expanded Program on Immunization (EPI) however vaccine-preventable diseases still account for high infant and child mortality rates. This study describes the differential vaccine coverage and determinants of vaccine uptake in rural Pakistan.

METHODS

From October 2014 to September 2018, we enrolled children younger than 2 years of age from the Matiari Demographic Surveillance System in Sindh, Pakistan. Socio-demographic and vaccination history were collected from all participants. Vaccine coverage rates and timeliness were reported. Socio-demographic variables for missed and untimely vaccination were studied in multivariable logistic regression.

RESULTS

Of the 3140 enrolled children, 48.4 % received all EPI recommended vaccines. Only 21.2 % of these were age appropriate. Around 45.4 % of the children were partially vaccinated, and 6.2 % were unvaccinated. Highest coverage was seen for the first dose of pentavalent (72.8 %), 10-valent Pneumococcal Conjugate Vaccine (PCV10) (70.4 %) and Oral Polio Vaccine (OPV) (69.2 %) and the lowest coverage was for measles (29.3 %) and rotavirus (1.8 %) vaccines. Primary caretakers and wage earners with a higher level of education were protective against missed and untimely vaccination. Enrollment in the 2nd, 3rd and 4th study year was negatively associated with being unvaccinated whereas distance from a major road was positively associated with non-adherence to schedule.

CONCLUSION

Vaccine coverage was low among children in Matiari, Pakistan, and majority received delayed doses. Parents' education status and year of study enrollment was protective against vaccine dropout and delayed vaccination whereas geographical distance from a major road was a predictor. Vaccine promotion and outreach efforts may have had a beneficial impact on vaccine coverage and timeliness.

A Systematic Review of Factors That Influence Parents’ Views and Practices around Routine Childhood Vaccination in Africa: A Qualitative Evidence Synthesis

A Cochrane review which explored the factors that influence caregivers’ views and practices around routine childhood vaccines worldwide was conducted by Cooper and colleagues. After sampling 154 studies that met their inclusion criteria, the authors included 27 studies in their synthesis, of which 6 were from Africa. The aim of the current review was to synthesise all 27 studies conducted in Africa. We wanted to determine if the inclusion of additional African studies will change any of the themes, concepts or theory generated in the Cochrane review. Our review found that parents’ views and practices regarding childhood vaccination in Africa were influenced by various factors, which we categorised into five themes, namely, ideas and practices surrounding health and illness (Theme 1); social communities and networks (Theme 2); political events, relations, and processes (Theme 3); lack of information or knowledge (Theme 4); and access-supply-demand interactions (Theme 5). All of the themes identified in our review were also identified in the Cochrane review except for one theme, which was lack of information or knowledge. This finding will help to promote vaccine acceptance and uptake in Africa by developing and implementing interventions tailored to address lack of knowledge and information around vaccines.

Factors Associated with Anti-SARS-CoV-2 Vaccine Acceptance among Pregnant Women: Data from Outpatient Women Experiencing High-Risk Pregnancy

Pregnant women are at higher risk of severe Coronavirus disease 2019 (COVID-19) complications than non-pregnant women. The initial exclusion of pregnant women from anti-SARS-CoV-2 vaccines clinical trials has caused a lack of conclusive data about safety and efficacy for this vulnerable population. This cross-sectional study aims to define the factors related to vaccination adherence in a sample of women experiencing high-risk pregnancies. The recruited women completed a questionnaire based on the Health Belief Model. Data were analyzed to evaluate the associations between socio-demographic variables and vaccination acceptance through descriptive, univariate and multivariate logistic analyses. Among the 233 women enrolled, 65.2% (n = 152) declared that they would accept the anti-SARS-CoV-2 vaccine. Multivariate analysis showed that vaccination acceptance was associated with a high educational level (aOR = 4.52, p = 0.001), a low perception of barriers to vaccination (aOR = 1.58, p = 0.005) and the gynecologist's advice (aOR = 3.18, p = 0.01). About a third of pregnant women are still hesitant about the anti-SARS-CoV-2 vaccine, probably because of the conflicting information received from media, friends, acquaintances and health institutions. Determining factors linked to vaccine hesitancy among pregnant women is useful for creating vaccination strategies that increase vaccination uptake.

An Equity Analysis of Zero-Dose Children in India Using the National Family Health Survey Data: Status, Challenges, and Next Steps

Background While immunization programs across the world have made considerable progress, children and communities continue to be beyond the reach of healthcare services. Globally, they are now referred to as zero-dose (ZD) children (those who have not received a single dose of diphtheria, pertussis, and tetanus-containing vaccine). Pre-COVID-19 pandemic analyses suggest that nearly 50% of vaccine-preventable deaths occur among ZD children. Two-thirds of these children live in extremely poor households suffering from multiple deprivations including lack of access to reproductive health services, water, and sanitation. Hence, ZD children have now been prioritized as a key cohort for identification and integration with the health systems as we build back from the pandemic. Methodology Extracting data from the last two National Family Health Survey (NFHS) rounds (NFHS 4, 2015-2016 and NFHS 5, 2019-2021), this study aims to ascertain the status of ZD children aged 12-23 months in India, the challenges, and the necessary action agenda going forward. Data were analyzed for equity determinants such as gender, place of residence, religion, birth order, caste, and mother's schooling. Key determinants included the change in ZD prevalence at the national, state, and district levels; variations across equity parameters and states with maximum improvements; and disparity across these indicators. A correlation analysis was also conducted to understand the nature of the association between ZD prevalence and critical maternal and child health indicators. Results The overall ZD prevalence between the two rounds was reduced by 4.1% (10.5-6.4%). A total of 26 states in the country reported a ZD prevalence of <10% in NFHS 5 compared to 18 in NFHS 4. In total, 324 districts reported a ZD prevalence of <5%, and 145 districts reported a prevalence of >10%. The equity parameters reflected a slow-footed reduction among ZD for girl children, across urban geographies, firstborn children, mothers with 12 or more years of schooling, and children in families with the highest wealth quintiles. A negative correlation accentuated between the two NFHS rounds was established between first-trimester registration, four or more antenatal visits, institutional deliveries, and ZD prevalence. Conclusions The findings point toward sustained improvement across key equity parameters, however, challenges do exist. Moreover, the impact of the pandemic on immunization programs across the globe and in India is bound to halt and reverse the progress and potentiate further inequities. It is thus imperative that continued and augmented efforts are continued to identify, integrate, and immunize ZD children, families, and communities.

Who goes back to school after birth? Factors associated with postpartum school return among adolescent mothers in the Eastern Cape, South Africa

Early motherhood can negatively impact health, educational, and socio-economic outcomes for adolescent mothers and their children. Supporting adolescent mothers' educational attainment, and timely return to school, may be key to interrupting intergenerational cycles of adversity. Yet, there remains a paucity of evidence on the factors that are associated with mothers' postpartum return to school and the mediators of this process, particularly across sub-Saharan Africa where adolescent pregnancy rates remain high . This paper is based on interviews with 1,046 adolescent mothers from South Africa. Mothers who had returned to school after birth showed lower poverty, fewer repeated grades preceding the pregnancy, continued schooling during pregnancy, higher daycare/crèche use, more family childcare support, and lower engagement in exclusive breastfeeding within six months postpartum. Mediation analyses showed that lower poverty was directly associated with school return and via two indirect pathways: continued schooling during pregnancy and using daycare/crèche services. This study demonstrates that lacking childcare constitutes a major hurdle to mothers' school return which needs to be addressed in addition to socioeconomic and individual-level barriers. Policy makers and practitioners should consider supporting young mothers with combination interventions which include services supporting school retention during pregnancy and access to, and financial supplements for, daycare.

A systematic review and meta-analysis of the prevalence of caregiver acceptance of malaria vaccine for under-five children in low-income and middle-income countries (LMICs)

INTRODUCTION

Malaria is the second leading cause of death in children after diarrheal disease, with low- and middle-income countries (LMICs) accounting for over 9 in 10 incidence and deaths. Widespread acceptance and uptake of the RTS,S vaccine, recently approved by the world health organization (WHO), is projected to significantly reduce malaria incidence and deaths. Therefore, we conducted this systematic review and meta-analysis with the aim to determine the malaria vaccine acceptance rate and the factors associated with acceptance.

METHODS

We searched six databases including Google Scholar, PubMed, Cochrane, African Index Medicus, The Regional Office for Africa Library, and WHO Institutional Repository for Information Sharing (IRIS) to identify studies evaluating the malaria vaccine acceptance rate. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Studies were included if they were original articles published in the English language in peer-reviewed journals and assessed the prevalence of willingness to accept a free malaria vaccine, and not qualitative. The risk of publication bias was checked using both Beggar's funnel plot and Egger's test, while the I2 statistic was used to assess the heterogeneity of the included studies. Study quality was determined using the Newcastle-Ottawa scale. A meta-analysis was performed using a random effects model to evaluate the pooled prevalence of malaria vaccine acceptance. The protocol for this article was registered prospectively on the International Prospective Register for Systematic Reviews (PROSPERO), with ID number CRD42022334282).

RESULTS

Our analysis included 11 studies with a total sample size of 14, 666 participants. The aggregate malaria vaccine acceptance rate was 95.3% (95% CI:93.0%-97.2%). Among the general population, the acceptance rate was 96.3% (95% CI:92.0%-99.0%) and among mothers, it was 94.4% (95% CI:90.8%-97.2%). By country, Nigeria had the highest acceptance rate (97.6%, 95% CI:96.0%-98.8%), followed by Ghana (94.6%, 95% CI:93.8%-95.3%) and Tanzania (92.5%, 95% CI:84.4%-97.8%). Sociodemographic determinants of vaccine acceptance included place of residence, tribe, age, sex, occupation, and religion. Reasons for low acceptance included safety concerns, efficacy profile, vaccine's requirement for multiple injections, and poor level of awareness.

CONCLUSION

Future efforts should be focused on identifying factors that may improve the actual uptake of the RTS,S vaccine in malaria-endemic communities.

Measles seroprevalence in persons over one year of age in Chandigarh, India

Measles continues to result in focal outbreaks in India, despite over three decades of universal infant vaccination. The aims of this study were to examine measles immunity in the population of Chandigarh, India, and to compare immunity by vaccination vs. natural infection. In a cross-sectional study of individuals 1-60 years selected from 30 communities within Chandigarh during 2017-2018, measles immunity was assessed using serological surveys. Seropositivity was compared across demographic groups, and by prior history of vaccination and natural history of infection. Among those 1-20 years old, measles seropositivity, and histories of measles vaccination or prior measles diagnosis were separately assessed as outcomes in logistic regression models, with demographic factors as independent variables. Among 1690 participants, 94% were seropositive, and 6% had borderline or negative antibody levels. Of those positive, 30% had prior vaccination, 16% had a history of natural infection, and 54% had an unknown history. Over 50% of individuals among those >20 years old, had unknown history of immunity. In the multivariable regression models, vaccination was more common in younger ages (P < .0001), and in males compared to females (P = .0220), and in those with more education (P < .0001). The majority of the population was seropositive, and seropositivity increased with age. Older age groups were more likely to be protected because of previous natural infection, whereas younger age groups were protected by vaccination. There was inequity in vaccination coverage by gender, and maternal education status.

Subnational Gender Inequality and Childhood Immunization: An Ecological Analysis of the Subnational Gender Development Index and DTP Coverage Outcomes across 57 Countries

The role of gender inequality in childhood immunization is an emerging area of focus for global efforts to improve immunization coverage and equity. Recent studies have examined the relationship between gender inequality and childhood immunization at national as well as individual levels; we hypothesize that the demonstrated relationship between greater gender equality and higher immunization coverage will also be evident when examining subnational-level data. We thus conducted an ecological analysis examining the association between the Subnational Gender Development Index (SGDI) and two measures of immunization-zero-dose diphtheria-tetanus-pertussis (DTP) prevalence and 3-dose DTP coverage. Using data from 2010-2019 across 702 subnational regions within 57 countries, we assessed these relationships using fractional logistic regression models, as well as a series of analyses to account for the nested geographies of subnational regions within countries. Subnational regions were dichotomized to higher gender inequality (top quintile of SGDI) and lower gender inequality (lower four quintiles of SGDI). In adjusted models, we find that subnational regions with higher gender inequality (favoring men) are expected to have 5.8 percentage points greater zero-dose prevalence than regions with lower inequality [16.4% (95% confidence interval (CI) 14.5-18.4%) in higher-inequality regions versus 10.6% (95% CI 9.5-11.7%) in lower-inequality regions], and 8.2 percentage points lower DTP3 immunization coverage [71.0% (95% CI 68.3-73.7%) in higher-inequality regions versus 79.2% (95% CI 77.7-80.7%) in lower-inequality regions]. In models accounting for country-level clustering of gender inequality, the magnitude and strength of associations are reduced somewhat, but remain statistically significant in the hypothesized direction. In conjunction with published work demonstrating meaningful associations between greater gender equality and better childhood immunization outcomes in individual- and country-level analyses, these findings lend further strength to calls for efforts towards greater gender equality to improve childhood immunization and child health outcomes broadly.

Pilot study to determine effect of an altruism intervention focusing on herd immunity to enhance influenza vaccination rates

OBJECTIVE

A prospective, single-arm clinical trial was conducted to evaluate an altruism-tailored educational intervention to improve parental attitudes and vaccine uptake in vaccine-hesitant parents.

METHODS

Vaccine-hesitant parents at two primary care sites, spanning two influenza seasons from 2020 to 2021 were provided an intervention (spoken and written communication) which highlighted altruistic benefits of accepting the seasonal influenza vaccine to optimize herd immunity to help protect pediatric cancer patients. Eligible parents included those with children eligible for the seasonal influenza vaccine, those who were proficient in English, and those with scores on the adjusted Vaccine Hesitancy Scale (aVHS) suggesting vaccine hesitancy (score ≥ 3). Enrollees completed a demographic questionnaire, underwent the educational intervention, and repeated the aVHS. Vaccination status at that visit was assessed. The primary outcome was change in aVHS scores obtained pre- and post-intervention. Influenza vaccine acceptance, along with demographic information, were also analyzed.

RESULTS

We enrolled 510 parents of influenza vaccine eligible children and identified 73 vaccine-hesitant parents. There was an overall trend toward lower aVHS score, with a mean change in hesitancy score of -0.4 (P < 0.01). 43/73 (58.9 %) of the cohort experienced a positive effect toward a lower aVHS score, and 27/73 (37.0 %) of vaccine hesitant subjects became non-hesitant on the aVHS. Several demographic characteristics were associated with vaccine hesitancy in the screening population: educational level lower than bachelor's degree (p = 0.03), household income < 400 % of federal poverty level (p < 0.01), unmarried (p = 0.02), and identifying with a political affiliation other than Democrat (p < 0.01). However, no demographic characteristics were significantly associated with an individual becoming non-hesitant. Our altruism-tailored communication approach carried the largest positive impact on the altruism-specific question on the aVHS, decreasing the post-intervention response value by nearly 25 % (P < 0.01).

CONCLUSIONS

Our altruism-tailored communication approach significantly improved attitudes regarding childhood influenza vaccine among vaccine-hesitant parents.

CLINICALTRIALS

gov Identifier: NCT04568590.

Missed Opportunities: A Cross-Sectional Descriptive Study on Reasons for Nonadherence to the South African Expanded Program on Immunization

Objective Our objective was to identify factors which underline nonadherence to childhood immunizations provided by the Department of Health and outlined in the Expanded Program on Immunizations in South Africa.

Methods A cross-sectional descriptive study was conducted at Dora Nginza Hospital, a regional hospital in the Eastern Cape Province, which provides free health care in resource-limited settings. It included patients under the age of 5 years and their primary caregivers. A piloted questionnaire was used to collect data, and comparisons were made between children under the age of 5 years who missed one or more immunizations and those with complete immunizations. Data on maternal/caregiver and health system-related characteristics were also collected, and comparisons were made between the two groups.

Results Of the 200 participants enrolled in the study, 47 (23.5%) had incomplete immunizations. Prematurity (odds ratio [OR] = 0.33, p = 0.001), vaccine shortages (OR = 0.22, p < 0.005), and a low maternal/caregiver level of education (OR = 0.32, p = 0.002) were significantly associated with incomplete immunization status.

Conclusion Strategies to improve supply chain management of vaccines and to optimize follow-up care of high-risk children, specifically those born prematurely and those born to women of lower education level, need to be identified and implemented to reduce vaccine-preventable diseases.

Factors consistently associated with utilisation of essential maternal and child health services in Nigeria: analysis of the five Nigerian national household surveys (2003-2018)

OBJECTIVE

This study aims to identify the individual and contextual factors consistently associated with utilisation of essential maternal and child health services in Nigeria across time and household geolocation.

DESIGN, SETTING AND PARTICIPANTS

Secondary data from five nationally representative household surveys conducted in Nigeria from 2003 to 2018 were used in this study. The study participants are women and children depending on essential maternal and child health (MCH) services.

OUTCOME MEASURES

The outcome measures were indicators of whether participants used each of the following essential MCH services: antenatal care, facility-based delivery, modern contraceptive use, childhood immunisations (BCG, diphtheria, tetanus, pertussis/Pentavalent and measles) and treatments of childhood illnesses (fever, cough and diarrhoea).

METHODS

We estimated generalised additive models with logit links and smoothing terms for households' geolocation and survey years.

RESULTS

Higher maternal education and households' wealth were significantly associated with utilisation of all types of essential MCH services (p<0.05). On the other hand, households with more children under 5 years of age and in poor communities were significantly less likely to use essential MCH services (p<0.05). Except for childhood immunisations, greater access to transport was positively associated with utilisation (p<0.05). Households with longer travel times to the most accessible health facility were less likely to use all types of essential MCH services (p<0.05), except modern contraceptive use and treatment of childhood fever and/or cough.

CONCLUSION

This study adds to the evidence that maternal education and household wealth status are consistently associated with utilisation of essential MCH services across time and space. To increase utilisation of essential MCH services across different geolocations, interventions targeting poor communities and households with more children under 5 years of age should be appropriately designed. Moreover, additional interventions should prioritise to reduce inequities of essential MCH service utilisation between the wealth quantiles and between education status.

A Survey Exploring Reasons behind Immunization Refusal among the Parents and Caregivers of Children under Two Years Living in Urban Slums of Karachi, Pakistan

This study assesses the experiences of parents/caregivers regarding the refusal to childhood immunization. A cross-sectional study was conducted among the parents/caregivers of children under two years old from January 2019 to June 2019 who were residents of either Pathan Colony or Orangi Town, Karachi. In this study, the data collectors targeted parents/caregivers of 440 households who showed a refusal mark "R" in the Expanded Program of Immunization (EPI) H-chalking system. These households were approached using a 30 × 7 multistage-stratified-cluster random sampling technique and were interviewed using a structured questionnaire. The study sample produced two different types of refusals: true refusal (absence) and potential refusal (presence), based on the absence and presence of a vaccination card at the time of the survey. Multivariate logistic regression was used to analyze the data using Jamovi (V-1.6.13). A total of 230 households consented to participate in this study, of which 141 (61.3%) represented true refusals, while 89 (38.7%) represented potential refusals. More than half of the participants from both groups complained about fever and pain at the injection site following immunization. The use of alternative medicines and a history of adverse events following immunization (AEFI) were associated with increasing the odds of immunization refusals by four-to-five fold. However, advanced paternal age, a long distance to the clinic, a lack of trust in government, and the influence of community/religious leaders were associated with lower immunization refusal odds. Thus, an unawareness about self-limiting vaccine-related adverse events, the use of alternative medicines, and an increased concern about the safety and efficacy of vaccines were found to be barriers to immunization, which can be improved by increasing public awareness through media campaigns and policy reform.

Socioeconomic Inequalities and Vaccine Uptake: An Umbrella Review Protocol

The effectiveness of immunization is widely accepted: it can successfully improve health outcomes by reducing the morbidity and mortality associated with vaccine-preventable diseases. In the era of pandemics, there is a pressing need to identify and understand the factors associated with vaccine uptake amongst different socioeconomic groups. The knowledge generated from research in this area can be used to inform effective interventions aimed at increasing uptake. This umbrella systematic review aims to determine whether there is an association between socioeconomic inequalities and rate of vaccine uptake globally. Specifically, the study aims to determine whether an individual's socioeconomic status, level of education, occupation, (un)-employment, or place of residence affects the uptake rate of routine vaccines. The following databases will be searched from 2011 to the present day: Medline (Ovid), Embase (Ovid), CINAHL (EBSCO), Cochrane CENTRAL, Science Citation Index (Web of Science), DARE, SCOPUS (Elsevier), and ASSIA (ProQuest). Systematic reviews will be either included or excluded based on a priori established eligibility criteria. The relevant data will then be extracted, quality appraised, and narratively synthesised. The synthesis will be guided by the theoretical framework developed for this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Equity extension (PRISMA-E) guidance will be followed. This protocol has been registered on PROSPERO, ID: CRD42022334223.

Travel time to health facilities in Papua New Guinea: Implications for coverage and equity in child vaccinations

With infant and child mortality rates that are among the highest in the Pacific region, and basic vaccination coverage rates that are 39% among children 12-23 months, increased coverage of vaccines is a high priority investment for Papua New Guinea (PNG). Using recently gathered household survey data for PNG, this paper contributes to the evidence-base for enhancing investments in frontline facilities by examining the implications of travel time to health facilities for basic vaccination coverage among children in PNG. We find that vaccination coverage rates among children 12-23 months old in PNG are decreasing in distance to healthcare facilities; and this holds whether the outcome is receipt of basic vaccinations (BCG; 3 dose pentavalent; OPV3; Measles), or basic vaccinations-plus (basic vaccinations + Hepatitis B + PCV3). We also find that travel time to health facilities lowers vaccination rates among children 12-23 months old in poor households to a greater extent than for children from richer households. Thus, enhanced geographical access to and resourcing of frontline facilities is likely to expand not only immunization coverage, lower mortality and increase aggregate economic gains, but also improve the distribution of immunization coverage in PNG across socioeconomic groups.

Vaccination coverage at seven months of age in Limpopo Province, South Africa: A cross-sectional survey

Many low- and middle-income countries face challenges in attaining adequate levels of vaccination coverage, and the factors driving this under-coverage have not been completely elucidated. In this cross-sectional study, we investigated factors associated with vaccination coverage in Mopani District, Limpopo Province, South Africa. Between July and October 2017, we surveyed 317 caregivers (83% of whom were mothers) of seven-month-old infants in Mopani District about barriers faced when attaining vaccines and attitudes towards vaccination, and reviewed the infants' documented vaccination history. Caregiver and child demographic data were collected shortly after birth. We described the coverage for vaccines that should be received by age seven months, according to South Africa's Expanded Programme on Immunization schedule, and explored the relationship between coverage and caregiver characteristics, behavioral factors (e.g. attitudes towards vaccination), and structural factors (e.g. vaccination stock-outs at clinics). We found that caregivers reported positive attitudes towards vaccination, based on a seven-question survey of vaccination attitudes. Although coverage was high for most recommended vaccines, it was low for pneumococcal conjugate vaccine (PCV), with just 36% of children having received it by age seven months. This appears to have been due to PCV stock-outs at government clinics. For vaccines other than PCV, children were more likely to be up-to-date on vaccinations if a community health worker (CHW) had visited their home in the past month (adjusted odds ratio (OR) 1.24, confidence interval (CI) (1.10-1.41); p < 0.001) and if the caregiver had more years of schooling (adjusted OR 1.03 (CI 1.01-1.05); p = 0.012). We conclude that addressing PCV stock-outs at government clinics in Mopani District is necessary to ensure coverage reaches adequate levels. Additionally, supporting CHW programs may be a productive avenue for improving vaccination coverage.

The Association between Childhood Immunization and Gender Inequality: A Multi-Country Ecological Analysis of Zero-Dose DTP Prevalence and DTP3 Immunization Coverage

This study explores the association between childhood immunization and gender inequality at the national level. Data for the study include annual country-level estimates of immunization among children aged 12–23 months, indicators of gender inequality, and associated factors for up to 165 countries from 2010–2019. The study examined the association between gender inequality, as measured by the gender development index and the gender inequality index, and two key outcomes: prevalence of children who received no doses of the DTP vaccine (zero-dose children) and children who received the third dose of the DTP vaccine (DTP3 coverage). Unadjusted and adjusted fractional logit regression models were used to identify the association between immunization and gender inequality. Gender inequality, as measured by the Gender Development Index, was positively and significantly associated with the proportion of zero-dose children (high inequality AOR = 1.61, 95% CI: 1.13–2.30). Consistently, full DTP3 immunization was negatively and significantly associated with gender inequality (high inequality AOR = 0.63, 95% CI: 0.46–0.86). These associations were robust to the use of an alternative gender inequality measure (the Gender Inequality Index) and were consistent across a range of model specifications controlling for demographic, economic, education, and health-related factors. Gender inequality at the national level is predictive of childhood immunization coverage, highlighting that addressing gender barriers is imperative to achieve universal coverage in immunization and to ensure that no child is left behind in routine vaccination.

Gender-Related Inequality in Childhood Immunization Coverage: A Cross-Sectional Analysis of DTP3 Coverage and Zero-Dose DTP Prevalence in 52 Countries Using the SWPER Global Index

Gender-related barriers to immunization are key targets to improve immunization coverage and equity. We used individual-level demographic and health survey data from 52 low- and middle-income countries to examine the relationship between women’s social independence (measured by the Survey-based Women’s emPowERment (SWPER) Global Index) and childhood immunization. The primary outcome was receipt of three doses of the diphtheria-tetanus-pertussis vaccine (DTP3) among children aged 12–35 months; we secondarily examined failure to receive any doses of DTP-containing vaccines. We summarized immunization coverage indicators by social independence tertile and estimated crude and adjusted summary measures of absolute and relative inequality. We conducted all analyses at the country level using individual data; median results across the 52 examined countries are also presented. In crude comparisons, median DTP3 coverage was 12.3 (95% CI 7.9; 16.3) percentage points higher among children of women with the highest social independence compared with children of women with the lowest. Thirty countries (58%) had a difference in coverage between those with the highest and lowest social independence of at least 10 percentage points. In adjusted models, the median coverage was 7.4 (95% CI 5.0; 9.1) percentage points higher among children of women with the highest social independence. Most countries (41, 79%) had statistically significant relative inequality in DTP3 coverage by social independence. The findings suggest that greater social independence for women was associated with better childhood immunization outcomes, adding evidence in support of gender-transformative strategies to reduce childhood immunization inequities.

Pro-vaccination Groups Expressing Hesitant Attitudes: A Cross-Sectional Study About the Difference Between Attitudes and Actual Behavior in Israel

Background

Vaccines have contributed to the decline in mortality, morbidity, and even the eradication of various infectious diseases. Over time, the availability of information to the public and the request for public involvement in the health decision-making process have risen, and the confidence in vaccines has dropped. An increasing number of parents and individuals are choosing to delay or refuse vaccines.

Objectives

(1) Identifying hesitant attitudes among pro-vaccination parents; (2) testing the difference between the rate of hesitant attitudes and the rate of hesitancy in practice among pro-vaccination parents; and (3) examining the association of sociodemographic characteristics (gender, age, marital status education and religious affiliation) with the difference between hesitant attitudes and hesitancy in practice among pro-vaccination parents.

Methods

Descriptive cross-sectional survey using an online survey that measured vaccine hesitancy among pro-vaccination parents (n = 558) whose children were in kindergarten (3–5 years), according to a variety of sociodemographic characteristics.

Results

A significant difference was found between the rate of hesitant attitudes and the rate of hesitation in actual vaccination among pro-vaccination and hesitant parents, where despite that 26% of the parents had hesitant attitudes, only 19% hesitated in practice [P = 0.0003]. There was also a significant difference between the rate of hesitant attitudes and the rate of hesitancy in practice among women [P = 0.0056] and men [P = 0.0158], parents between 30 and 39 years of age [P = 0.0008], traditional parents [P = 0.0093], Non-academic parents [P = 0.0007] and parents with BA degree [P = 0.0474].

Conclusion

Pro-vaccination individuals may have hesitant attitudes regarding vaccines. Therefore, it is very important for health authorities to address the public's fears and concerns, including those who are classified as pro-vaccination.

Tetanus seroprotection among children in the Democratic Republic of the Congo, 2013-2014

BACKGROUND

Tetanus is a potentially fatal disease that is preventable through vaccination. While the Democratic Republic of the Congo (DRC) has continued to improve implementing routine vaccination activities throughout the country, they have struggled to maintain high childhood vaccine coverage. This study aims to examine the seroprevalence of tetanus in children 6 to 59 months to identify areas for intervention and improvement of vaccination coverage.

METHODS

In collaboration with the 2013-2014 Demographic and Health Survey, we assessed the seroprevalence of tetanus antibodies among children in the DRC. Dried blood spot samples collected from children 6-59 months of age were processed using a prototype DYNEX Multiplier® chemiluminescent automated immunoassay instrument with a multiplex measles, mumps, rubella, varicella and tetanus assay. Multivariable logistic regression was used to determine factors associated with tetanus vaccination and seroprotection.

RESULTS

Overall, 36.1% of children 6-59 months of age reported receiving at least 1 dose of tetanus vaccine while 28.7% reported receiving 3 doses; tetanus seroprotection was 40%. Increasing age in children was associated with decreased tetanus seroprotection, but increased number tetanus vaccinations received. Factors related to increased tetanus seroprotection included number of children in the household, wealth index of the family, urban residence compared to rural, level of maternal education, and province and geography.

CONCLUSIONS

Our findings in this nationally representative sample indicate that serology biomarkers may help identify children who are not fully immunized to tetanus more accurately than reported vaccination. While children may be captured for routine immunization activities, as children age, decreasing seroprevalence may indicate additional need to bolster routine vaccination activities and documentation of vaccination in school aged children. Additionally, the study highlights gaps in rural residential areas and vaccination coverage based on maternal education, indicating that policies targeting maternal education and awareness could improve the coverage and seroprevalence of tetanus antibodies in the DRC.

Association between Mother's Education and Infant and Young Child Feeding Practices in South Asia

The association between mother's education and the World Health Organization's (WHO's) eight Infant and Young Child Feeding (IYCF) core indicators has yet to be explored in South Asia (SA). This study aimed to explore the association between mother's education and the WHO's eight IYCF core indicators in SA. We analyzed data from the most recent nationally representative Demographic and Health Surveys of six South Asian Countries (SACs)-Afghanistan, Bangladesh, India, Maldives, Nepal, and Pakistan. We found significantly higher odds (adjusted odds ratio, AOR, 1.13 to 1.47) among mothers who completed secondary or higher education than among mothers with education levels below secondary for the following seven IYCF indicators: early initiation of breastfeeding (EIBF), exclusive breastfeeding under 6 months (EBF), the introduction of solid, semisolid or soft foods (ISSSF), minimum dietary diversity (MDD), minimum meal frequency (MMF), minimum acceptable diet (MAD), and consumption of iron-rich or iron-fortified foods (CIRF); the exception was for the indicator of continued breastfeeding at one year. Country-specific analyses revealed significantly higher odds in EIBF (AOR 1.14; 95% CI: 1.11, 1.18) and EBF (AOR 1.27; 95% CI: 1.19, 1.34) among mothers with secondary or higher education levels in India. In contrast, the odds were lower for EIBF in Bangladesh and for EBF in Pakistan among mothers with secondary or higher education levels. For country-specific analyses for complementary feeding indicators such as ISSSF, MDD, MMF, MAD, and CIRF, significantly higher odds (AOR, 1.15 to 2.34) were also observed among mothers with secondary or higher education levels. These findings demonstrate a strong positive association between mother's education and IYCF indicators. Strengthening national policies to educate women at least to the secondary level in SACs might be a cost-effective intervention for improving IYCF practices.

Parental preferences for a mandatory vaccination scheme in England: A discrete choice experiment

Background

Mandatory vaccination has been mooted to combat falling childhood vaccine uptake rates in England. This study investigated parental preferences for a mandatory vaccination scheme.

Methods

Discrete choice experiment. Six attributes were investigated: vaccine, child age group, incentive, penalty, ability to opt out, and compensation scheme. Mixed effects conditional logit regression models were used to investigate parental preferences and relative importance of attributes.

Findings

Participants were 1,001 parents of children aged 5 years and under in England (53% female; mean age=33·6 years, SD=7·1; 84% white). Parental preferences were mostly based on incentives (30·7% relative importance; 80·9% [95% confidence interval 76·3–85·0%] preference for parent and 74·8% [71·0–78·3%] for child incentive; reference: no incentive) and penalties (25·4% relative importance; 69·5% [65·7–73·1%] preference for schemes where unvaccinated children cannot attend school or day care and 67·6% [63·6–71·4%] for those withholding financial benefits for parents of unvaccinated children; reference: £450 fine). Parents also preferred schemes that: offered a compensation scheme (18·1% relative importance; 66·4% [62·7–69·8%] preference; reference: not offered), mandated vaccination in children aged 2 years (versus 5 years; 11·4% relative importance; 42·6% [39·4–45·9%] preference; reference: 2 years), mandated the 6-in-1 vaccine (10·5% relative importance; 58·2% [54·6–61·7%] preference; reference: MMR), and that offered only medical exemptions (versus medical and religious belief exemptions; 4·0% relative importance; 45·5% [41·1–50·0%] preference; reference: medical exemptions).

Interpretation

These findings can inform policymakers’ decisions about how best to implement a mandatory childhood vaccination scheme in England.

Funding

Data collection was funded by a British Academy/Leverhulme Small Research Grants (SRG1920\101118).

Children of more empowered women are less likely to be left without vaccination in low- and middle-income countries: A global analysis of 50 DHS surveys

Background

To help provide a global understanding of the role of gender-related barriers to vaccination, we have used a broad measure of women’s empowerment and explored its association with the prevalence of zero-dose children aged 12-23 months across many low- and middle-income countries, using data from standardized national household surveys.

Methods

We used data from Demographic and Health Surveys (DHS) of 50 countries with information on both women’s empowerment and child immunisation. Zero-dose was operationally defined as the proportion of children who failed to receive any doses of the diphtheria, pertussis, and tetanus containing vaccines (DPT). We measured women’s empowerment using the SWPER Global, an individual-level indicator estimated for women aged 15-49 years who are married or in union and with three domains: social independence, decision-making and attitude towards violence. We estimated two summary measures of inequality, the slope index of inequality (SII) and the concentration index (CIX). Results were presented for individual and pooled countries.

Results

In the country-level (ecological) analyses we found that the higher the proportion of women with high empowerment, the lower the zero-dose prevalence. In the individual level analyses, overall, children with highly-empowered mothers presented lower prevalence of zero-dose than those with less-empowered mothers. The social independence domain presented more consistent associations with zero-dose. In 42 countries, the lowest zero-dose prevalence was found in the high empowerment groups, with the slope index of inequality showing significant results in 28 countries. When we pooled all countries using a multilevel Poisson model, children from mothers in the low and medium levels of the social independence domain had respectively 3.3 (95% confidence interval (CI) = 2.3, 4.7) and 1.8 (95% CI = 1.5, 2.1) times higher prevalence of zero-dose compared to those in the high level.

Conclusions

Our country-level and individual-level analyses support the importance of women’s empowerment for child vaccination, especially in countries with weaker routine immunisation programs.

Role of Information Sources in Vaccination Uptake: Insights From a Cross-Sectional Household Survey in Sierra Leone, 2019

Our findings suggest that health workers and faith leaders are important sources of information to deliver vaccination messages, given their strong association with vaccination confidence and uptake. In this context, vaccination promotion efforts that integrate faith leaders and health workers may help increase vaccination uptake.

Introduction:

There is limited understanding of the potential impact of information sources on vaccination attitudes and behaviors in low-income countries. We examined how exposure to immunization information sources may be associated with vaccination uptake in Sierra Leone.

Methods:

In 2019, a household survey was conducted using multistage cluster sampling to randomly select 621 caregivers of children aged 12–23 months in 4 districts in Sierra Leone. We measured exposure to various sources of immunization information and 2 outcomes: (1) vaccination confidence using an aggregate score (from 12 Likert items, informed by previously validated scale) that was dichotomized into a binary variable; (2) uptake of the third dose of diphtheria-pertussis-tetanus-hepatitis B-Haemophilus influenzae type-b-pentavalent vaccine (penta-3) based on card record or through caregiver recall when card was unavailable. Associations between information sources and the outcomes were examined using modified Poisson regression with robust variance estimator.

Results:

Weighted estimate for penta-3 uptake was 81% (75.2%–85.5%). The likelihood of uptake of penta-3 was significantly greater when caregiver received information from health facilities (adjusted prevalence ratio [aPR]=1.26, 95% confidence interval [CI]=1.1, 1.5), faith leaders (aPR=1.16, 95% CI=1.1, 1.3), and community health workers (aPR=1.13, 95% CI=1.003, 1.3). Exposure to greater number of information sources was associated with high penta-3 uptake (aPR=1.05, 95% CI=1.02, 1.1).

Discussion:

Immunization information received during health facility visits and through engagement with religious leaders may enhance vaccination uptake. Assessments to understand context-specific information dynamics should be prioritized in optimizing immunization outcomes.

Trend of maternal education in Bangladesh from 2004–2018: Analysis of demographic surveillance data

Background

Maternal education is universally recognised as a major factor in positive societal indicators (health, wellbeing, overall education, etc.) and a country’s growth and economic sustainability, yet the underlying factors contributing to maternal education have not been widely investigated, especially in developing countries.

Objective

This study investigated the 15-year trend of maternal education in Bangladesh (2004–2018) to identify the factors contributing to maternal education.

Method

This study used publicly available cross-data from five consecutive Bangladesh Demographic and Health Surveys (2004, 2007, 2011, 2014 and 2018). Level of maternal education was grouped as ‘no education’, ‘incomplete primary’, ‘complete primary’, ‘incomplete secondary’, ‘complete secondary’ and ‘higher education’ (reference group). The differences in factors/exposure variables suspected to contribute to maternal education were measured for these groups for 2004–2018, and a survey multinomial logistic regression was performed to estimate the explanatory value of these factors.

Results

From 2004–2018, there was a 62% gross reduction of the no education group and a 61% gross increase in the higher education group. A gross increase was also observed for complete secondary (49%), incomplete secondary (39%) and complete primary education (14%). In multivariate analysis, in rural areas, in 2018, the probability of a woman being in the complete primary, incomplete primary or no education groups was increased (adjusted relative risk ratio: 1.21, 1.40 and 1.59), compared to 2004 (0.73, 1.09, 1.12), respectively. From 2004–2018, the factor of no television watching reduced the probability of maternal education levels. Having a husband/partner who had no education increased the probability of a woman’s education level. The probability of all maternal education levels decreased across all wealth index groups.

Conclusion

The data suggest that average maternal education level in Bangladesh increased from 2004–2018. However, an integrated effort is required to improve factors associated with maternal education to both increase maternal education and Bangladesh’s long-term sustainability.

Does social deprivation correlate with meningococcal MenACWY, Hib/MenC and 4CMenB/Meningococcal Group B vaccine uptake in Northern Ireland?

BACKGROUND

Several meningococcal vaccines have been recently introduced into the infant and adolescent vaccination schedules in Northern Ireland to promote immunity to Neisseria meningitidis, protecting against meningococcal septicaemia and meningococcal meningitis. Maintained vaccination uptake is vital in securing individual protection as well as herd immunity. Several social factors have been described in influencing vaccine uptake and therefore it was the aim of this study to examine possible correlations between meningococcal vaccine uptake rates and indicators of social deprivation in Northern Ireland.

METHODS

Vaccination data was retrieved from the Cover of Vaccination Evaluated Rapidly (COVER) database, for meningococcal vaccines (MenACWY, HiB/MenC & 4CMenB, as well as for MMR vaccine as a non-meningococcal control). Vaccine coverage data assessed included (i). Two doses of MenB by 12 months, (ii). All 3 doses of MenB by 24 months, (iii). HiB/MenC coverage, (iv). MenACWY (Year 12s, for NI) (v). First dose of MMR. Northern Ireland Multiple Deprivation Measures 2017 (NIMDM2017) were examined against 38 indicators in 7 domains. NI HSCT vaccine uptake dataset for each vaccine was correlated with each indicator in the HSCT NIMDM2017 dataset. Regression analysis was performed to determine the relationship between vaccine uptake and deprivation indicators and coefficient of variation (R²) was calculated for each of the indicators. R² values >0.7 were considered significant.

RESULTS

For 4CMenB (all 3 doses by 24 Months), HiB/MenC, MenACWY and for MMR, correlation of variation (R²) values > 0.7, were obtained for 17, 16, 0 and 17 social deprivation indicators, respectively. Significant deprivation indicators were (i) the proportion of 18-21 year olds, who have not enrolled in higher education courses at higher or further education establishments, (ii) the proportion of domestic dwellings that are unfit, (iii) the proportion of domestic dwellings with Local Area Problem Scores, (iv) rate of burglary, (v) rate of vehicle crime, (vi) rate of antisocial behaviour incidents (per 1,000 population), (vii) absenteeism at primary schools and (viii) the proportion of the population aged 65 and over living in households whose equivalised income is below 60% of the NI median.

CONCLUSIONS

Within the last two decades, incidence of meningococcal disease has been on the decline. The introduction of meningococcal vaccines has contributed to this decrease and uptake of such vaccines should remain a public health priority to maintain the decline in meningococcal disease. Identifying contributing factors to low vaccine uptake, such as, the association between local deprivation and uptake of meningococcal vaccines, should be of public health importance and acknowledged by local governments and policy makers in their efforts to enhance vaccine uptake, both infant and teenage vaccination. There is a clear correlation with educational deprivation measures such as absenteeism and poor educational attainment and reduced vaccine uptake, perhaps through lack of understanding and willingness to vaccinate. This is where the importance of a clear and coherent public health message surrounding meningococcal vaccination should be prioritised, particularly to establish innovative modalities in a multidisciplinary team approach, to reach out to and increase vaccine uptake rates in socially deprived communities in Northern Ireland.

National and State-Level Composite Completion of Recommended Vaccines Among Adolescents in the United States, 2015-2018

BACKGROUND

Routine adolescent vaccination recommendations in the United States include tetanus, diphtheria, and acellular pertussis, quadrivalent meningococcal conjugate vaccine, and human papillomavirus vaccines. Although coverage for these individual vaccines is known, limited data are available on composite completion for all three vaccines.

METHODS

This cross-sectional analysis of pooled 2015-2018 National Immunization Survey-Teen data used logistic regression to estimate model-adjusted composite vaccination completion nationally and by state among United States adolescents aged 17 years. National Immunization Survey-Teen data were combined with state-level data to estimate a multilevel model identifying factors associated with composite vaccination completion.

RESULTS

The pooled model-adjusted composite vaccination completion was 30.6% (95% confidence interval [CI], 30.13%-31.04%) nationally, varying from 11.3% in Idaho (6.91%-17.95%) to 56.4% (49.81%-62.82%) in Rhode Island. Individual-level factors with the greatest impact on composite completion were having a provider's recommendation for human papillomavirus vaccination (odds ratio, 3.24; 95% CI, 2.76-3.80) and a check-up visit at age 16-17 years (odds ratio, 2.35; 95% CI, 1.80-3.07), with other individual-level factors associated with completion including being Medicaid insured, female, Hispanic, or non-Hispanic black. State-level quadrivalent meningococcal conjugate vaccination mandates were also associated with an increased likelihood of composite vaccination completion (odds ratio, 1.64; 95% CI, 1.16-2.33).

CONCLUSIONS

Fewer than one-third of 17-year-old individuals have completed all three recommended vaccines, with rates varying by state. Although this study identified implementable strategies to improve composite completion, additional research is needed to further understand factors associated with adolescent vaccination completion.

Immunization status of children in Nepal and associated factors, 2016

BACKGROUND

Nepal has made substantial improvements in childhood immunization uptake. However, vaccination levels are still below the country-specific Sustainable Development Goal target of 94.8% coverage by 2025 for children aged 12-23 months who received all immunizations recommended in the national immunization schedule by their first birthday. A better understanding of the predictors of full immunization can inform successful programmatic interventions to improve coverage while also guiding resource allocation to ensure all children are fully vaccinated. This study estimates childhood immunization coverage in Nepal and characterizes the association between immunization status and various sociodemographic predictors.

METHODS

Data from the 2016 Nepal Demographic and Health Survey were used to examine the immunization status of children aged 12-23 months. Immunization status was categorized as fully immunized (receiving all recommended doses), under-immunized (receiving at least one, but not all, recommended doses), and un-immunized (not receiving any doses of any vaccine). Associations between full and under-immunization and potential sociodemographic predictors were assessed using logistic regression.

RESULTS

Among 976 children, 78.2% were fully immunized, 21% were under-immunized, and 0.8% were un-immunized. Retention of an immunization card was significantly associated with full immunization status. Mothers who had completed a formal education above secondary school and mothers who were working at time of interview had increased odds of full immunization. Birthing in an institutional setting was also associated with higher odds of full immunization.

CONCLUSIONS

Overall, immunization coverage in Nepal is relatively high, although it varies by dose and sociodemographic factors. Almost 25% of Nepalese children were not fully immunized, leaving them at increased risk for vaccine-preventable disease related morbidity and mortality. Nepal must continue focused efforts to reach every child and minimize the equity gap; programs may focus on advocating for the use of immunization cards, education and empowerment for girls, and delivery in institutional settings.

Academic activism on behalf of children during the COVID-19 pandemic in Israel; beyond public health advocacy

Among the challenges presented by the SARS-CoV2 pandemic are those related to balancing societal priorities with averting threats to population health. In this exceptional context a group of Israeli physicians and public health scholars (multidisciplinary academic group on children and coronavirus [MACC]) coalesced, examining the role of children in viral transmission and assessing the necessity and consequences of restricted in-class education. Combining critical appraisal and analytical skills with public health experience, MACC advocated for safe and monitored school re-opening, stressing the importance of education as a determinant of health, continuously weighing this stance against evolving COVID-19-risk data. MACC's activities included offering research-based advice to government agencies including Ministries of Health, Finance, and Education. In a setting where government bodies were faced with providing practical solutions to both decreasing disease transmission and maintaining society's vital activities, and various advisors presented decision-makers with disparate views, MACC contributed epidemiological, clinical and health policy expertise to the debate regarding school closure as a pandemic control measure, and adaptations required for safe re-opening. In this paper, we describe the evolution, activities, policy inputs and media profile of MACC, and discuss the role of academics in advocacy and activism in the midst of an unprecedented public health crisis. A general lesson learned is that academics, based on the rigor of their scientific work and their perceived objectivity, can and should be mobilized to pursue and promote policies based on shared societal values as well as empiric data, even when considerable uncertainty exists about the appropriate course of action. Mechanisms should be in place to open channels to multidisciplinary academic groups and bring their input to bear on decision-making.

The effect of community comprehensive nursing using scenario-based health education on the infant and young child immunization rates

OBJECTIVE

To investigate the effect of community comprehensive nursing using scenario-based health education on the infant and young child immunization rates.

METHODS

Ninety-eight infants and young children who were given immunizations in our hospital were divided into two groups, with 49 participants in each group. The control group was administered routine nursing, and the research group underwent community comprehensive nursing using scenario-based health education. The vaccination rates, the mastery of vaccination knowledge before and after the nursing, the adverse effects, the compliance, the satisfaction with the nursing, and the incidence of medical disputes were recorded and analyzed.

RESULTS

The delayed vaccination rate was significantly lower in the research group than it was in the control group, and the timely vaccination rate in the research group was significantly higher than it was in the control group (P<0.05). There was no statistically significant difference in the incidences of medical disputes between the two groups (P>0.05). The basic and total vaccination awareness rates were significantly higher in the research group compared with the control group (P<0.05). The incidence of adverse effects in the research group was significantly lower than it was in the control group (P<0.05). The full and total compliance rates in the research group were both significantly higher than they were in the control group (P<0.05). The proportions of very satisfied and completely satisfied were both significantly higher in the research group compared to the control group (P<0.05).

CONCLUSION

In the infant and young child immunization program, community comprehensive nursing using scenario-based health education can effectively increase the vaccination rate, increase the parents' knowledge, enhance their compliance, reduce the adverse effects, and improve the satisfaction with the nursing.

Determinants of Influenza Vaccine Uptake in Patients With Cardiovascular Disease and Strategies for Improvement

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Influenza infection is associated with an increased risk of cardiovascular events (myocardial infarction, stroke, and heart failure exacerbation) and mortality, and all‐cause mortality in patients with CVD. Infection with influenza leads to a systemic inflammatory and thrombogenic response in the host body, which further causes destabilization of atherosclerotic plaques. Influenza vaccination has been shown to be protective against cardiovascular and cerebrovascular events in several observational and prospective studies of at‐risk populations. Hence, many international guidelines recommend influenza vaccination for adults of all ages, especially for individuals with high‐risk conditions such as CVD. Despite these long‐standing recommendations, influenza vaccine uptake among US adults with CVD remains suboptimal. Specifically, vaccination uptake is strikingly low among patients aged <65 years, non‐Hispanic Black individuals, those without health insurance, and those with diminished access to healthcare services. Behavioral factors such as perceived vaccine efficacy, vaccine safety, and attitudes towards vaccination play an important role in vaccine acceptance at the individual and community levels. With the ongoing COVID‐19 pandemic, there is a potential threat of a concurrent epidemic with influenza. This would be devastating for vulnerable populations such as adults with CVD, further stressing the need for ensuring adequate influenza vaccination coverage. In this review, we describe a variety of strategies to improve the uptake of influenza vaccination in patients with CVD through improved understanding of key sociodemographic determinants and behaviors that are associated with vaccination, or the lack thereof. We further discuss the potential use of relevant strategies for COVID‐19 vaccine uptake among those with CVD.