Interventions to Improve Vaccination Uptake and Cost Effectiveness of Vaccination Strategies in Newly Arrived Migrants in the EU/EEA: A Systematic Review

Coverage of influenza, pneumococcal and zoster vaccination and determinants of influenza and pneumococcal vaccination among adults with cardiovascular diseases in community

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death and illness globally. Influenza, pneumococcal disease and herpes zoster infection may trigger acute cardiovascular events or cause complications among cardiac patients. Vaccination is recommended for adults with CVD. There is a gap in research evidence around determinants and uptake of influenza, pneumococcal and zoster vaccines in adults with CVD.

OBJECTIVE

The aim of this study is to examine the rate of the uptake of influenza, zoster and pneumococcal vaccines, factors associated with the uptake of influenza vaccine, and the perceptions of influenza and pneumococcal vaccination among people with CVD in the community.

METHOD

Cross-sectional survey data was analysed from three separate surveys carried out in Australia between October 2019 and September 2020 of 972 adults with CVD. We used descriptive statistics to describe data. Thematic analysis examined the reasons for taking influenza vaccine. Multivariable analysis was used to identify independent predictors of the influenza vaccine uptake and perceptions associated with the uptake of influenza and pneumococcal vaccines.

RESULTS

Out of 972 participants, a total of 661 (68 %) people said they had received influenza vaccine in the last 12 months; 361 (37 %) had ever received pneumococcal vaccine; 196 (20 %) had ever received zoster vaccine. Among 661 participants who said they received influenza vaccine within the 12 months prior to the study, 543 (82 %) participants received it from doctors or general practitioners (GPs) offices. Age 65 and older, being born in Australia, being employed or retired and having comorbidity were positive predictors of influenza vaccination. Doctors' recommendations to take the vaccine and awareness of free vaccines positively predicted influenza and pneumococcal vaccine uptake.

CONCLUSION

The uptake of recommended pneumococcal and zoster vaccines is low in people with CVD. Doctors' recommendations, targeted health promotion programs in general practice, and easy access to vaccination may optimise vaccination uptake in patients with CVD.

Seroprevalence status of vaccine-preventable diseases in migrants living in shelter centers in Barcelona, Spain

INTRODUCTION

Almost 281 million people were living in a foreign country in 2022, and more than 100 million were displaced because of war conflicts and human right violations. Vaccination coverage of infectious diseases in migrants from some disadvantaged settings could be lower than reception countries populations, consequently seroprevalence studies and better access to vaccination could contribute to reducing these differences.

METHODS

A descriptive retrospective cross-sectional study was conducted including migrants, living ≤5 years in the reception country and ≥16 years old, who requested a medical exam between January 1st, 2020 and January 31st, 2021. Seroprevalence assessment was performed, and vaccination was offered to those individuals without immunity to hepatitis B, hepatitis A, varicella, measles, mumps, and rubella.

RESULTS

A total of 315 migrants were attended during the study period. Immunity protection at arrival was 252/296 (85.1%) for measles, 274/295 (92.9%) for rubella, 257/296 (86.8%) for mumps, 264/295 (89.5%) for varicella, 267/313 (85.3%) for hepatitis A, and 104/300 (34.6%) for hepatitis B. The final immunity protection after full vaccination schedules was 278/296 (93.9%) for measles, 287/295 (97.3%) for rubella, 274/296 (92.6%) for mumps, 276/295 (93.6%) for varicella, 280/313 (89.5%) for hepatitis A, and 139/300 (46.3%) for hepatitis B.

CONCLUSIONS

The vaccination intervention has increased immunity rates for the studied diseases in the attended migrants in our center, however, such interventions should be maintained to reach local population immunization levels. Moreover, the collaboration between shelter and reference specialized health centers is fundamental to implement such vaccination programs.

Strengthening life-course immunisation in migrant populations: access, equity, and inclusion

Adult and adolescent migrants worldwide, and those arriving in Europe, are an under-immunised group for routine vaccinations due to missed childhood vaccines and doses in their countries of origin, and their subsequent marginalisation from health and vaccination systems. Declining population-level coverage for routine vaccines across Europe, which has accelerated post-pandemic, places these and other under-immunised populations at even greater risk of vaccine-preventable diseases. However, despite clear guidelines around the importance of delivering 'catch-up' vaccination throughout the life-course, migrants are rarely effectively incorporated into routine vaccination programmes on arrival to Europe. These populations have subsequently been involved in outbreaks, including measles and diphtheria, and are missing opportunities to receive more recently introduced vaccines such as HPV to align them with European vaccine schedules. WHO's new Immunization Agenda 2030 places a renewed emphasis on equitable access to vaccine systems and integrating catch-up vaccination for missed vaccines and doses throughout the life-course. In addition, lessons learned and innovations from the COVID-19 pandemic merit further consideration in the design and delivery of more inclusive vaccination programmes. We describe current gaps in policy and practice around life-course vaccination in migrant populations, key factors that drive low vaccine uptake and coverage, and explore the benefits of participatory approaches to designing and delivering interventions with impacted communities, to define new strategies to advance vaccine equity across the Region.

Determinants of uptake of influenza, zoster and pneumococcal vaccines in patients with cardiovascular diseases

BACKGROUND

Globally, cardiovascular disease (CVD) is the leading cause of death and illness. Vaccine-preventable infections may increase acute coronary vascular disease events and the risk of complications. Low vaccine coverage has been reported among adults at high risk of complications from vaccine-preventable infections. There is a gap in research evidence around determinants of uptake of vaccines among adults with CVD. This study examined the uptake of influenza, pneumococcal and zoster vaccines and the determinants of uptake of the vaccines among cardiac patients.

METHOD

A prospective cross-sectional study was carried out among hospitalised cardiac patients through an interviewer-administered questionnaire. Descriptive statistics were used to investigate self-reported uptake of influenza, pneumococcal and zoster vaccines. Univariate and multivariate analyses of participants' social demographic and clinical characteristics were conducted to identify factors for receiving influenza vaccine.

RESULTS

Low vaccination rates among 104 participants were found for influenza (45.2%), pneumococcal (13.5%) and zoster (5.8%) vaccines. The most common reason for not receiving influenza vaccine was concern about side effects. Lack of awareness about the pneumococcal and zoster vaccines was the main reason for the poor uptake of these vaccines. Australia-born participants were more likely to receive influenza vaccine than overseas-born participants. Working-age participants and, interestingly, people living with a current smoker were less likely to receive influenza vaccine.

CONCLUSION

Influenza, pneumococcal and zoster vaccine uptake among cardiac patients was low. Encouraging physician recommendations for vaccination for cardiac patients under 65 years of age and addressing vaccination challenges among people from culturally and linguistically diverse backgrounds and pharmacy, workplace, and hospital vaccination may help increase vaccination uptake among cardiac patients.

Knowledge and attitudes of healthcare personnel about vaccination of migrant and refugee children and adolescents

Background

The number of migrants to Greece has increased considerably the last decade. This study assessed the knowledge and attitudes of healthcare personnel (HCP) toward vaccination of newly-arrived children and adolescents in the Aegean islands, a major port of entry of migrants and refugees to Europe.

Methods

The study was conducted from September 2020 to January 2021. All (166) HCP employed in the public health sector of the Aegean islands were invited to participate. A structured questionnaire was used to collect demographic data and data about their knowledge and attitudes toward vaccinations for migrant and refugees.

Results

A total of 120 HCP participated (72 % response rate), including 54 (45 %) physicians, 43 nurses (35.8 %), and 23 health visitors (19.2 %). Sixty-seven (55.8 %) HCP were aware of the national vaccination guidelines. Health visitors had higher rates of knowledge about the national vaccination guidelines, compared with nurses and physicians (87% versus 44,2% and 51,9%; p-value-0.001). Overall, 73 (60.8 %) HCP were aware of vaccinations during the first examination upon arrival. Primary-healthcare physicians were more likely to be aware about the time of vaccine administration compared with hospital-based physicians (74 % versus 50 %; p-value = 0.006). Out of 120 HCP, 45 % knew that vaccination guidelines apply to all newly-arrived migrant and refugees and 65 % that vaccinations are free-of-charge. Overall, 67.5 % of participants supported no serology testing before vaccination, 21.8 % were against free-of-charge vaccinations, and 55 % recommended only priority vaccinations.

Conclusions

There is a need to increase HCP' awareness and knowledge through training programs and tailored protocols focusing on vaccinations for newly-arrived migrant and refugee children and adolescents in order to promote effective vaccination of this vulnerable population.

Co-designing a theory-informed, multicomponent intervention to increase vaccine uptake with Congolese migrants: A qualitative, community-based participatory research study (LISOLO MALAMU)

INTRODUCTION

Disparities in the uptake of routine and COVID-19 vaccinations have been observed in migrant populations, and attributed to issues of mistrust, access and low vaccine confidence. Participatory research approaches and behaviour change theory hold the potential for developing tailored vaccination interventions that address these complex barriers in partnership with communities and should be explored further.

METHODS

This study used a theory-informed, community-based participatory research approach to co-design a culturally tailored behaviour change intervention aimed at increasing COVID-19 vaccine uptake among Congolese migrants in London, United Kingdom (2021-2022). It was designed and led by a community-academic partnership in response to unmet needs in the Congolese community as the COVID-19 pandemic started. Barriers and facilitators to COVID-19 vaccination, information and communication preferences, and intervention suggestions were explored through qualitative in-depth interviews with Congolese migrants, thematically analysed, and mapped to the theoretical domains framework (TDF) and the capability, opportunity, motivation, behaviour model to identify target behaviours and strategies to include in interventions. Interventions were co-designed and tailored in workshops involving Congolese migrants.

RESULTS

Thirty-two Congolese adult migrants (24 (75%) women, mean 14.3 (SD: 7.5) years in the United Kingdom, mean age 52.6 (SD: 11.0) years) took part in in-depth interviews and 16 (same sample) took part in co-design workshops. Fourteen barriers and 10 facilitators to COVID-19 vaccination were identified; most barrier data related to four TDF domains (beliefs about consequences; emotion; social influences and environmental context and resources), and the behavioural diagnosis concluded interventions should target improving psychological capability, reflective and automatic motivations and social opportunities. Strategies included culturally tailored behaviour change techniques based on education, persuasion, modelling, enablement and environmental restructuring, which resulted in a co-designed intervention comprising community-led workshops, plays and posters. Findings and interventions were disseminated through a community celebration event.

CONCLUSIONS

Our study demonstrates how behavioural theory can be applied to co-designing tailored interventions with underserved migrant communities through a participatory research paradigm to address a range of health issues and inequalities. Future research should build on this empowering approach, with the goal of developing more sensitive vaccination services and interventions which respond to migrant communities' unique cultural needs and realities.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public involvement (PPI) were embedded in the participatory study design and approach, with community members co-producing all stages of the study and co-authoring this paper. An independent PPI board (St George's Migrant Health Research Group Patient and Public Involvement Advisory Board) comprising five adult migrants with lived experience of accessing healthcare in the United Kingdom were also consulted at significant points over the course of the study.

Faith-based organisations and their role in supporting vaccine confidence and uptake: a scoping review protocol

INTRODUCTION

Faith-based organisations (FBOs) and religious actors increase vaccine confidence and uptake among ethnoracially minoritised communities in low-income and middle-income countries. During the COVID-19 pandemic and the subsequent vaccine rollout, global organisations such as the WHO and UNICEF called for faith-based collaborations with public health agencies (PHAs). As PHA-FBO partnerships emerge to support vaccine uptake, the scoping review aims to: (1) outline intervention typologies and implementation frameworks guiding interventions; (2) describe the roles of PHAs and FBOs in the design, implementation and evaluation of strategies and (3) synthesise outcomes and evaluations of PHA-FBO vaccine uptake initiatives for ethnoracially minoritised communities.

METHODS AND ANALYSIS

We will perform six library database searches in PROQUEST-Public Health, OVID MEDLINE, Cochrane Library, CINAHL, SCOPUS- all, PROQUEST - Policy File index; three theses repositories, four website searches, five niche journals and 11 document repositories for public health. These databases will be searched for literature that describe partnerships for vaccine confidence and uptake for ethnoracially minoritised populations, involving at least one PHA and one FBO, published in English from January 2011 to October 2023. Two reviewers will pilot-test 20 articles to refine and finalise the inclusion/exclusion criteria and data extraction template. Four reviewers will independently screen and extract the included full-text articles. An implementation science process framework outlining the design, implementation and evaluation of the interventions will be used to capture the array of partnerships and effectiveness of PHA-FBO vaccine uptake initiatives.

ETHICS AND DISSEMINATION

This multiphase Canadian Institutes of Health Research (CIHR) project received ethics approval from the University of Toronto. Findings will be translated into a series of written materials for dissemination to CIHR, and collaborating knowledge users (ie, regional and provincial PHAs), and panel presentations at conferences to inform the development of a best-practices framework for increasing vaccine confidence and uptake.

Access to Vaccination for Newly Arrived Migrants: Developing a General Conceptual Framework for Understanding How to Improve Vaccination Coverage in European Countries

Objectives: Access to vaccination for newly arrived migrants (NAMs) is a relevant concern that requires urgent attention in EU/EEA countries. This study aimed to develop a General Conceptual Framework (GCF) for understanding how to improve vaccination coverage for NAMs, by characterizing and critically analyzing system barriers and possible strategies to increase vaccination. Methods: A theoretical conceptualization of the GCF was hypothesized based on conceptual hubs in the immunization process. Barriers and solutions were identified through a non-systematic desktop literature review and qualitative research. The GCF guided the activities and facilitated the integration of results, thereby enriching the GCF with content. Results: The study explores the vaccination of NAMs and proposes strategies to overcome barriers in their vaccination process. It introduces a framework called GCF, which consists of five interconnected steps: entitlement, reachability, adherence, achievement, and evaluation of vaccination. The study also presents barriers and solutions identified through literature review and qualitative research, along with strategies to enhance professionals' knowledge, improve reachability, promote adherence, achieve vaccination coverage, and evaluate interventions. The study concludes by recommending strategies such as proximity, provider training, a migrant-sensitive approach, and data collection to improve vaccination outcomes for NAMs. Conclusion: Ensuring equitable access to healthcare services, including vaccination, is crucial not only from a humanitarian perspective but also for the overall public health of these countries.

Experiences of American Health Departments, Health Systems, and Community Organizations in COVID-19 Vaccine Provision for Refugee, Immigrant, and Migrant Communities

Effective provision of COVID-19 vaccines could mitigate the disproportionate impact of the COVID-19 pandemic experienced by many immigrant communities. To describe organizational experiences in using COVID-19 vaccination programs, qualitative interviews were conducted from September 2020 to April 2021 with representatives from public health, health system, and community organizations responding to the COVID-19 pandemic among immigrant communities across the United States. Interviews followed a semistructured interview guide and were audio recorded, transcribed, and coded. A latent thematic analysis was facilitated by Dedoose software. Interviews representative of 18 public health departments, 20 healthcare systems, and 18 community organizations were included in the analysis. Five identified themes referenced the importance of 1) appreciating community and individual heterogeneity in health priorities and attitudes; 2) addressing vaccine fears with trustworthy messages; 3) ensuring equitable access to vaccine opportunities; 4) making substantive investments in community partnerships and outreach; and 5) adapting to meet new needs. It is essential that vaccine efforts consider community heterogeneity, communicate in a trustworthy and culturally and linguistically appropriate manner, strive for equitable provision of care, build partnerships, and learn from prior experiences.

Lowering COVID-19 vaccine hesitancy among immigrants in Norway: Opinions and suggestions by immigrants

Even though COVID-19 vaccine has been proved effective, vaccine uptake and coverage has been and still is a great concern across different immigrant groups. Vaccine hesitancy remains a barrier to accept the vaccine among immigrants across the globe-including Norway-despite higher rates of hospitalizations and deaths. This study aimed to explore the opinions and suggestions of immigrants on how to lower the COVID-19 vaccine hesitancy among immigrants in Norway. Qualitative interviews were conducted with 88 persons with different immigrant background. Data was analyzed using framework analysis, utilizing "3Cs model of vaccine hesitancy" as a theoretical framework. The analysis yielded five main themes related to factors that may lower the vaccine hesitancy among immigrants in Norway: (1) Effective cultural communication, (2) Vaccine advocacy through community engagement, (3) Motivating factors, (4) Collaborative efforts via government and healthcare, and (5) Incentives for vaccination. This study enhanced our understanding of factors that according to immigrants themselves may lower the vaccine hesitancy. The insights obtained in this study can contribute to a better understanding of the current status of vaccine uptake among immigrants and can further give directions on how to improve vaccine uptake in these groups in Norway.

"We don't routinely check vaccination background in adults": a national qualitative study of barriers and facilitators to vaccine delivery and uptake in adult migrants through UK primary care

OBJECTIVES

Explore primary care professionals' views around barriers/facilitators to catch-up vaccination in adult migrants (foreign-born; over 18 years of age) with incomplete/uncertain vaccination status and for routine vaccines to inform development of interventions to improve vaccine uptake and coverage.

DESIGN

Qualitative interview study with purposive sampling and thematic analysis.

SETTING

UK primary care.

PARTICIPANTS

64 primary care professionals (PCPs): 48 clinical-staff including general practitioners, practice nurses and healthcare assistants; 16 administrative-staff including practice managers and receptionists (mean age 45 years; 84.4% women; a range of ethnicities).

RESULTS

Participants highlighted direct and indirect barriers to catch-up vaccines in adult migrants who may have missed vaccines as children, missed boosters and not be aligned with the UK's vaccine schedule, from both personal and service-delivery levels, with themes including: lack of training and knowledge of guidance among staff; unclear or incomplete vaccine records; and lack of incentivisation (including financial) and dedicated time and care pathways. Adult migrants were reported as being excluded from many vaccination initiatives, most of which focus exclusively on children. Where delivery models existed, they were diverse and fragmented, but included a combination of opportunistic and proactive programmes. PCPs noted that migrants expressed to them a range of views around vaccines, from positivity to uncertainty, to refusal, with specific nationality groups reported as more hesitant about specific vaccines, including measles, mumps and rubella (MMR).

CONCLUSIONS

WHO's new Immunization Agenda 2030 calls for greater focus to be placed on delivering vaccination across the life course, targeting underimmunised groups for catch-up vaccination at any age, and UK primary care services therefore have a key role. Vaccine uptake in adult migrants could be improved through implementing new financial incentives or inclusion of adult migrant vaccination targets in Quality Outcomes Framework, strengthening care pathways and training and working directly with local community-groups to improve understanding around the benefits of vaccination at all ages.

COVID-19 Vaccination and Ukrainian Refugees in Poland during Russian-Ukrainian War-Narrative Review

The outbreak of the Russian–Ukrainian war contributed to the largest migration movement in the 21st century. As a result, over 3 million refugees, mainly women, children and the elderly, arrived in Poland in a short space of time. Despite the ongoing war, it is important to remember that the COVID-19 pandemic is still present in the world, and before the outbreak of the war, Ukraine was struggling with its fifth wave. Furthermore, Ukraine has one of the lowest vaccination rates in Europe, not exceeding 40%. It is, therefore, reasonable to suspect that the vast majority of migrants have not been vaccinated. This situation may pose a significant epidemiological risk. Therefore, it is necessary to implement appropriate steps to determine the vaccination status of refugees and to supplement the vaccination with both the core and booster doses. In response to these needs, the government of Poland, like many other countries, has made it possible to provide free COVID-19 vaccination to persons fleeing war. In the face of massive migration, the overriding priority should be to ensure adequate medical care for refugees, including free COVID-19 vaccinations. However, it seems that the lack of willingness to vaccinate among Ukrainians is also replicated on migration. It seems reasonable that appropriate steps should be taken to increase awareness and confidence in vaccination, which may ultimately translate into increased vaccination uptake. Analyzing previous experiences, it is advisable to consider that the first step should be to promote vaccination and remind refugees of the possibility of free COVID-19 vaccination. Additionally, refugees should be encouraged to be vaccinated during every contact with health care workers.

An undergraduate medical education framework for refugee and migrant health: Curriculum development and conceptual approaches

BACKGROUND

International migration, especially forced migration, highlights important medical training needs including cross-cultural communication, human rights, as well as global health competencies for physical and mental healthcare. This paper responds to the call for a 'trauma informed' refugee health curriculum framework from medical students and global health faculty.

METHODS

We used a mixed-methods approach to develop a guiding medical undergraduate refugee and migrant health curriculum framework. We conducted a scoping review, key informant interviews with global health faculty with follow-up e-surveys, and then, integrated our results into a competency-based curriculum framework with values and principles, learning objectives and curriculum delivery methods and evaluation.

RESULTS

The majority of our Canadian medical faculty respondents reported some refugee health learning objectives within their undergraduate medical curriculum. The most prevalent learning objective topics included access to care barriers, social determinants of health for refugees, cross-cultural communication skills, global health epidemiology, challenges and pitfalls of providing care and mental health. We proposed a curriculum framework that incorporates values and principles, competency-based learning objectives, curriculum delivery (i.e., community service learning), and evaluation methods.

CONCLUSIONS

The results of this study informed the development of a curriculum framework that integrates cross-cultural communication skills, exploration of barriers towards accessing care for newcomers, and system approaches to improve refugee and migrant healthcare. Programs should also consider social determinants of health, community service learning and the development of links to community resettlement and refugee organizations.

Immunization Catch-Up for Newly Arrived Migrants in France: A Cross-Sectional Study among French General Practitioners

Background: Migrants often undergo an incomplete vaccination program in regards to the French recommendations. The aim of this study was to evaluate the practices of French General Practitioners’ (GPs) in terms of catch-up vaccination. Methods: A cross-sectional study was carried-out in 2017–2018 in France. An online questionnaire was disseminated by email through scholarly societies to GPs involved in the care and the vaccination of migrants. Analyses included univariate and multivariate analysis with a logistic regression model. Results: A total of 216 GPs completed the survey. A majority identified themselves with an average level regarding the prevention of infectious diseases among migrant populations (56.7%) and confirmed this is part of their daily practice (83.3%). The majority of respondents do not perform more than two injections on the same day. When compared to GPs working in health centres, those with a private practice are more likely to report returning to a full primary vaccination schedule (adjusted OR = 2.90, 95% CI [1.29–6.53]). Aside from the serology for hepatitis B and to a lesser extent for measles, other pre-vaccination serologies were not frequently used by GPs. When a migrant declares to be up-to-date with his immunisations, only 56.5% of doctors consider this information reliable. Conclusions: This study clarified the vaccination practices of GPs receiving migrant patients in consultation and showed its heterogeneity. An important need for benchmarks has been identified and these results were used for the elaboration of the French guidelines on vaccines catch-up.

Seroprevalence of vaccine-preventable and non-vaccine-preventable infections in migrants in Spain

BACKGROUND

Updated seroprevalence studies of infections in migrants may aid the design of tailored vaccination and prevention programmes. The objective of this study was to describe the seroprevalence rates for potentially transmissible viral infections in migrants attended at a referral centre in a major European city.

METHODS

Descriptive analysis of seroprevalence of vaccine-preventable and non-vaccine-preventable infections in migrants attended at a centre in Madrid, Spain (2018-19). Recorded variables included age, gender, country of birth/continent of origin, time from arrival to Spain until first clinic visit, rubella, measles, mumps, varicella (VZV), hepatitis B virus (HBV), hepatitis A virus (HAV), hepatitis C virus (HCV) and HIV serology.

RESULTS

In total, 468 patients were included, 135 females (28.8%) and 333 males (71.2%), mean age 30.4 years. The majority of patients were from Africa (52.5%, of which 88.2% from sub-Saharan Africa), followed by Latin America (38.5%) and other areas (9%). Seroprevalence for tested migrants for rubella, measles and mumps was < 95% in the group overall (91% rubella, 88% measles, 83% mumps) and lower rates were observed in migrants >20 years (compared with those ≤ 20 years). Over 10% of females were potentially susceptible (negative/indeterminate serology) to rubella (11.4%), measles (12.7%) or mumps (10.3%). Lowest rates of rubella seropositivity were in Latin American migrants (over 12% potentially susceptible); measles and mumps seropositivity was lowest in migrants from areas other than Africa/Latin America (74% and 68%, respectively). Seroprevalence rates were 91% for VZV, 90% overall for HAV, ~6% for HBV chronic infection (~50% of migrants tested susceptible), 2% for HCV and 6% for HIV.

CONCLUSIONS

Differences in seroprevalence for vaccine-preventable and transmissible infections according to gender, age range and area of origin were observed. Tailored screening, vaccination and prevention strategies in potentially vulnerable migrant groups should be designed.

Newcomer knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination

BACKGROUND

Human Papillomavirus (HPV) is the most common sexually transmitted infection in Canada and around the world. Vaccination is an effective prevention strategy, but uptake is low, especially among newcomers to Canada. We sought to understand newcomers' knowledge, attitudes, and beliefs (KAB) on HPV and HPV vaccination and their role in HPV vaccine acceptance.

METHODS

Newcomers were defined as individuals born outside Canada, (i.e., individuals born in a different country, the majority of whom are immigrants or refugees, but also includes students and undocumented migrants). Eligible participants were newcomers, aged 16 or older and who could read or write in English, French or Arabic. Surveys were administered in two community health centres in Ottawa, Canada that primarily engage with newcomer populations. Follow-up interviews were conducted either at the community health centre or over the phone, depending on participants' preferences.

RESULTS

Fifty participants completed the survey, the majority of whom were women (74%) and spoke Arabic as their first language (54%). Seven participants completed supplemental interviews to complement their survey responses. The majority (70%) of participants had not previously heard of HPV. Less than half (46%) knew that the vaccine is effective in preventing certain types of cancer; nearly 40% incorrectly believed the vaccine could cure HPV. Qualitative interviews supported the survey findings.

CONCLUSIONS

Despite a lack of HPV knowledge due to cultural and language barriers, there is still a strong desire among newcomers to receive the vaccine, especially when accompanied by a physician recommendation. Cultural and language-appropriate resources are needed to help newcomers make informed vaccination decisions and promote HPV vaccine uptake.

Interventions to reduce the burden of vaccine-preventable diseases among migrants and refugees worldwide: A scoping review of published literature, 2006-2018

BACKGROUND

Disparities in vaccine-preventable disease (VPD) burden and immunisation coverage between migrants and refugees and their host populations have been described in numerous countries worldwide. Effective strategies are required to reduce the health disparities and immunisation inequities experienced by migrants and refugees.

METHODS

Using Arksey and O'Malley's framework, we conducted a scoping review to identify available literature on interventions aimed at reducing VPD burden among migrants and refugees worldwide. We searched for relevant empirical, peer-reviewed literature published in English between 2006 and 2018 using MEDLINE, Ovid EMBASE, CINAHL, Sociological Abstracts, and Web of Science databases. Relevant information from the studies, including intervention type, details and outcomes, were charted in Microsoft Excel and results were summarised using a descriptive analytical method.

RESULTS

Seventy studies met the inclusion criteria. The number of published studies increased over the years. The majority of studies were conducted in high-income countries. More studies were conducted among migrants (not including refugees) (n = 48, 66%) than specifically among refugees (n = 25, 34%). Interventions were implemented in a variety of settings, including health care (n = 31, 42%), community (n = 29, 39%), off-shore (n = 7, 9%), national (n = 4, 5%), school (n = 2, 3%), and workplace (n = 1, 1%). Studies reported interventions focused at the individual (to facilitate uptake of health services) (n = 4, 5%), community (to raise awareness) (n = 25, 34%), provider (to offer health services) (n = 12, 16%) and/or system (to increase compliance with recommendations) (n = 33, 45%) level. To be effective, interventions were designed to overcome commonly identified barriers to accessing services related to language, culture, distance and cost. Engagement with community members and organisations was an effective way to co-design interventions that address migrants' specific needs.

CONCLUSIONS

Studies emphasised the importance of interventions that address the heterogeneity within and between migrant and refugee populations. Considerable variation in practice remains, therefore more evaluation of interventions is needed to inform policy and programme decision-making.

Utility of the Tétanos Quick Stick® in the vaccine catch-up of adult migrants without proof of prior vaccination

BACKGROUND

Unknowing immunity status make migrants vaccine catch-up difficult. The interest of using a rapid tetanus immunotest as the Tétanos Quick Stick® (TQS®) to assess immunity status against tetanus has been evaluated in emergency rooms and it is now commonly used. The study aim was to evaluate TQS® as a tool for migrants' vaccine catch-up.

METHODS

From December 2018 to February 2019, a prospective study was performed and included consecutively migrants who attented to the primary medicine outconsultation of a health care centre in Paris. Migrants above 18, without any records of tetanus immunization were included and a TQS® was performed during a medical consultation. Adapted vaccine catch-up was then proposed. Immunity against tetanus among migrants, factors associated with positive TQS® and costs savings were evaluated.

RESULTS

TQS® test was positive for 32% of the 310 included patients. In the univariable analysis, factors associated to the presence of a positive TQS® test were a female gender (OR = 1.69 CI95% [1.02-2.80]) and an urban living in the country of origin (OR = 1.79 CI95% [1.07-3.02]). In the multivariable analysis, these factors were not significantly associated to a positive TQS®. Anamnesis was not correlated to the immunity status: only 26% of the migrants who reported vaccinations in childhood, adolescence and adulthood had a positive TQS® test. The use of TQS® test allowed savings of 6,522 US$ as compared to the immediate catch-up strategy for the 310 patients.

CONCLUSION

The TQS® test is an acceptable, simple, rapid and cost saving test that could find a place in the migrants' vaccine catch-up.

Meningococcal infections among refugees and immigrants: silent threats of past, present and future

Globally, there is an increasing number of international migrants. The majority are forced displaced refugees and children unaccompanied by a caregiver, and have limited access to essential public health interventions. Routine vaccination might be interrupted or be incomplete due to conflict areas with limited public health services or a long-unplanned journey. Refugees and migrants may bring infectious disease risks to their country of destination and may be exposed to new risk factors during transit or at their destination. There are lessons learned strategies among refugees and asylum seekers in different countries (vaccination campaign during outbreak, maintain vaccination systems for refugees and medical screening and/or vaccination on arrival) against vaccine-preventable diseases – other than meningococcal infections. Since the 1980s, invasive meningococcal disease (IMD) has been reported as a critical healthcare issue in places of humanitarian crisis such as Thailand and African’s meningitis belt. Refugees and migrants are at increased risk of IMD compared with the overall population due to sero-epidemiology in their country of origin, specific characteristics of the IMD, and a number of contacts during the journey. Recently, IMD cases due to serogroups X and W have been reported and are an emerging health threat for persons arriving from Africa to refugee camps in Italy. There have been sporadic case reports of IMD due to serogroup B in Turkey; however, there has not yet been increased disease activity in this population and no outbreaks have been observed. Outbreaks of IMD in refugee camps have been and could be successfully controlled through the implementation of timely and high-coverage vaccination campaigns, and individual cases of IMD can be treated with antibiotics. Research is needed to determine the prevalence of meningococcal carriage and serogroup distribution among refugees and migrants to inform vaccine recommendations. There is no official recommendation for meningococcal vaccination of refugees. Further strategies for prevention and treatment of human immunodeficiency virus, tuberculosis and antibiotic resistance among refugees are directly related to potential prevention methods for IMD. Meningococcal vaccines have been administered only to risk groups in most host countries Thus, further strategies for the definition of new/emerging risk factors for IMD would be helpful to guide vaccine implementation for refugees and immigrants.

Immunity status against tetanus in young migrants: a seroprevalence study

BACKGROUND AND AIM OF THE WORK

Thanks to the highly effective vaccine, tetanus became sporadic in high-income countries with well-established primary childhood immunization programs, but it is common in low-income countries. The migrants, leaving countries with poor immunization programs or where vaccinations have been interrupted, may represent a new risk group for tetanus in host countries. A seroprevalence study was conducted to estimate the immunological status against tetanus in young migrants without vaccination documentation.

METHODS

After a careful assessment by vaccination services of the Local Health Authority, all migrants recently arrived in Italy were included in the serosurvey. Titers of anti-tetanus toxoid were measured using a commercial ELISA kit. Subjects were stratified by age and by WHO region. Antibody titers <0.10 IU/ml were considered to be seronegative, between 0.10 and 1.00 IU/ml as intermediate protection, and >1.00 IU/ml high protection.

RESULTS

From January 2004 to December 2019, 2,326 blood samples were collected. Mean age was 13.9 years with no differences between WHO regions. The percentage of the subjects without protective antibodies was 22.3%, with an intermediate level was 45.2%, with high titer was 32.5%. Among migrant coming from African and Eastern Mediterranean WHO regions, the highest percentages of seronegative titers and, at the same time, the low percentages of high protective levels were found. Titers decreased with age.

CONCLUSIONS

The significant proportion of seronegative migrants and the decrease of protective titers increasing age, confirm the importance of the evaluation of the immunological status to employ the appropriate vaccination strategy.

Are refugees arriving in Denmark an under-immunised group for measles? A cross-sectional serology study

BACKGROUND

In 2018, Europe faced the highest number of Measles cases in a decade. In Denmark, the childhood vaccination programme has a coverage of approximately 90%. To eliminate the disease, vaccine coverage needs to be above the herd immunity threshold of 95%. This can be even more difficult to obtain, when vaccination programmes break down due to war, natural disasters etc. and concern has been raised, that unvaccinated refugees could facilitate spread of measles when migrating.

METHODS

In order to address this concern, we tested 513 newly arrived refugees and family reunified refugees aged between 0 and 70 years for measles IgG antibodies. The participants were tested as part of a general health assessment between May 2016 and October 2018. In the cohort, 50% were males and the majority came from Syria (55%).

RESULTS

We found that 85% of the total group of refugees had immunity against measles. The 15% lacking antibodies were evenly distributed between the various countries of origin. Moreover, we found immunity to increase with age, leaving young children most vulnerable to infection, 79.9% (<19 years) vs 89.1% (≥19 years). Interview questions on previous vaccinations did not correlate to serology.

CONCLUSION

Refugees have measles immunity slightly lower than the host population.

Infectious Diseases among Refugee Children

In recent years, there has been a substantial increase in refugee and asylum-seeking adults, adolescents and children to high-income countries. Infectious diseases remain the most frequently identified medical diagnosis among U.S.-bound refugee children. Medical screening and immunization are key strategies to reduce the risk of infectious diseases in refugee, internationally adopted, and immigrant children. Notable infectious diseases affecting refugee and other newly arriving migrants include latent or active tuberculosis, human immunodeficiency virus type 1 (HIV), hepatitis B, hepatitis C, vaccine-preventable diseases, malaria, and other parasitic infections. The U.S. Centers for Disease Control and Prevention and the American Academy of Pediatrics have published guidelines for health assessment of newly arriving immigrant, refugee, and internationally adopted children. Although, data on the health risks and needs of refugee exists in some high-income countries, there is an urgent need to develop robust evidence-informed guidance on screening for infectious diseases and vaccination strategies on a broader scale to inform national policies. Innovative approaches to reach migrant communities in the host nations, address health and other complex barriers to improve access to high-quality integrated health services, and strong advocacy to mobilize resources to improve health, safety, and wellbeing for refugee children and their families are urgent priorities.

The Global Vaccine Action Plan - insights into its utility, application, and ways to strengthen future plans

BACKGROUND

The pace of global progress must increase if the Global Vaccine Action Plan (GVAP) goals are to be achieved by 2020. We administered a two-phase survey to key immunization stakeholders to assess the utility and application of GVAP, including how it has impacted country immunization programs, and to find ways to strengthen the next 10-year plan.

METHODS

For the Phase I survey, an online questionnaire was sent to global immunization stakeholders in summer 2017. The Phase II survey was sent to regional and national immunization stakeholders in summer 2018, including WHO Regional Advisors on Immunization, Expanded Programme on Immunization managers, and WHO and UNICEF country representatives from 20 countries. Countries were selected based on improvements (10) versus decreases (10) in DTP3 coverage from 2010 to 2016.

RESULTS

Global immunization stakeholders (n = 38) cite global progress in improving vaccine delivery (88%) and engaging civil society organizations as advocates for vaccines (83%). Among regional and national immunization stakeholders (n = 58), 70% indicated reaching mobile and underserved populations with vaccination activities as a major challenge. The top ranked activities for helping country programs achieve progress toward GVAP goals include improved monitoring of vaccination coverage and upgrading disease surveillance systems. Most respondents (96%) indicated GVAP as useful for determining immunization priorities and 95% were supportive of a post-2020 GVAP strategy.

CONCLUSIONS

Immunization stakeholders see GVAP as a useful tool, and there is cause for excitement as the global immunization community looks toward the next decade of vaccines. The next 10-year plan should attempt to increase political will, align immunization activities with other health system agendas, and address important issues like reaching mobile/migrant populations and improving data reporting systems.

Immunisation of migrants in EU/EEA countries: Policies and practices

In recent years various EU/EEA countries have experienced an influx of migrants from low and middle-income countries. In 2018, the "Vaccine European New Integrated Collaboration Effort (VENICE)" survey group conducted a survey among 30 EU/EEA countries to investigate immunisation policies and practices targeting irregular migrants, refugees and asylum seekers (later called "migrants" in this report). Twenty-nine countries participated in the survey. Twenty-eight countries reported having national policies targeting children/adolescent and adult migrants, however vaccinations offered to adult migrants are limited to specific conditions in seven countries. All the vaccinations included in the National Immunisation Programme (NIP) are offered to children/adolescents in 27/28 countries and to adults in 13/28 countries. In the 15 countries offering only certain vaccinations to adults, priority is given to diphtheria-tetanus, measles-mumps-rubella and polio vaccinations. Information about the vaccines given to child/adolescent migrants is recorded in 22 countries and to adult migrants in 19 countries with a large variation in recording methods found across countries. Individual and aggregated data are reportedly not shared with other centres/institutions in 13 and 15 countries, respectively. Twenty countries reported not collecting data on vaccination uptake among migrants; only three countries have these data at the national level. Procedures to guarantee migrants' access to vaccinations at the community level are available in 13 countries. In conclusion, although diversified, strategies for migrant vaccination are in place in all countries except for one, and the strategies are generally in line with international recommendations. Efforts are needed to strengthen partnerships and implement initiatives across countries of origin, transit and destination to develop and better share documentation in order to guarantee a completion of vaccination series and to avoid unnecessary re-vaccination. Development of migrant-friendly strategies to facilitate migrants' access to vaccination and collection of vaccination uptake data among migrants is needed to meet existing gaps.

Infectious diseases at different stages of migration: an expert review

BACKGROUND

Human migration is increasing in magnitude and scope. The majority of migrants arriving in high-income countries originate from countries with a high prevalence of infectious diseases. The risk and burden of infectious diseases are not equally distributed among migrant groups and vary with migration stage.

METHODS

A broad literature review was conducted on the drivers for infectious diseases and associated health outcomes among migrants across different stages of migration. The aim was to provide practitioners with an overview of the key infectious disease risks at each stage to guide health promotion strategies.

RESULTS

A complex interaction of factors leads to infectious diseases and associated poor health outcomes among migrants. The most important drivers are the epidemiology of infectious diseases in their countries of origin, the circumstances and conditions of the migration journey and barriers accessing healthcare post-arrival. During the recent large waves of forced migration into Europe, the primary health concerns on arrival were psychological, traumatic and chronic non-communicable diseases. In the early settlement period, crowded and unhygienic living conditions in reception camps facilitated outbreaks of respiratory, gastrointestinal, skin infections and vaccine preventable diseases. After re-settlement, undetected and untreated latent infections due to tuberculosis, viral hepatitis, HIV, chronic helminthiasis and Chagas' disease led to poor health outcomes. Migrants are disproportionally affected by preventable travel-related diseases such as malaria, typhoid and hepatitis due to poor uptake of pre-travel prophylaxis and vaccination. Infectious diseases among migrants can be decreased at all migration stages with health promotion strategies adapted to their specific needs and delivered in a linguistically and culturally sensitive manner.

CONCLUSIONS

Tailored health promotion and screening approaches and accessible and responsive health systems, regardless of legal status, will be needed at all migration stages to limit the burden and transmission of infectious diseases in the migrant population.

National approaches to the vaccination of recently arrived migrants in Europe: A comparative policy analysis across 32 European countries

BACKGROUND

Migrants may be underimmunised and at higher risk of vaccine-preventable diseases, yet there has been no comprehensive examination of what policies are currently implemented across Europe targeting child and adult migrants. We analysed vaccination policies for migrants in 32 EU/EEA countries and Switzerland.

METHODS

Using framework analysis, we did a comparative analysis of national policies and guidelines pertaining to vaccination in recently arrived migrants through a systematic guideline and literature review and by approaching national experts.

RESULTS

Six (18.8%) of 32 countries had comprehensive policies specific to the vaccination of migrants (two focused only on child migrants, four on both adults and children). Nineteen (59.4%) countries applied their national vaccination schedule for migrant vaccinations, predominantly focusing on children; and five (15.6%) countries had circulated additional migrant-specific resources to relevant health-care providers. In six (18.8%) countries, policies on migrant vaccination focused on outbreak-specific vaccines only. In ten (31.3%) countries, policies focused on priority vaccinations, with polio being the vaccine most commonly administered and heterogeneity noted in vaccines recommended to adults, adolescents, and children. Eighteen (56.3%) countries recommended that an individual should be considered as unvaccinated where vaccination records were missing, and vaccines re-administered. Nine (28.1%) countries reported that specific vaccinations were mandatory.

CONCLUSION

There is considerable variation in policies across Europe regarding approaches to vaccination in adult and child migrants, and a lack of clarity on optimum ways forward, what vaccines to offer, with a need for robust research in this area. More emphasis must be placed on ensuring migrant-specific guidance is disseminated to front-line healthcare professionals to improve vaccine delivery and uptake in diverse migration populations across the region.

Divergent approaches in the vaccination of recently arrived migrants to Europe: a survey of national experts from 32 countries, 2017

BackgroundMigrants within the European Union and European Economic Area (EU/EEA) may be underimmunised and lack documentation on previous vaccinations. We investigated approaches to vaccination in recently arrived adult and child migrants, and guideline availability and implementation. Methods: Between March and May 2017, a national vaccination expert from every EU/EEA country and Switzerland completed an electronic questionnaire. We used descriptive analyses to calculate percentages, and framework analysis to synthesise free-text responses. Results: We approached 32 countries (response rate 100%). Although 28 experts reported vaccination guidance at national level, specific guidelines for recently arrived migrants were only available in six countries and not consistently implemented. Twenty-three countries administered vaccinations during on-arrival health checks. Most experts recommended multiple vaccination opportunities be made available: at point of entry (n = 13) or at holding level (reception centres, migrant camps, detention centres) (n = 21). In 30 countries, child migrants without evidence of previous vaccination were re-vaccinated according to the national schedule. Diphtheria-pertussis-tetanus and polio vaccinations were given to migrant children in all countries, measles-mumps-rubella (MMR) in 31 countries, hepatitis B vaccination in 25. Low levels of catch-up vaccination were reported in adult migrants, with only 13 countries offering MMR and 10 countries charging fees. Conclusion: Existing guidance is often not migrant-specific and may not be applied in practice; clarification is needed on which vaccines should be given. Strategies are needed specifically for catch-up vaccination in adult migrants. Vaccinations should be offered in multiple settings, free of charge, with sufficient guidance and training provided to front-line healthcare professionals.