Coverage and predictors of vaccination against 2012/13 seasonal influenza in Madrid, Spain: analysis of population-based computerized immunization registries and clinical records

Epidemiology of paediatric chronic heart failure in Germany-A population-based analysis

AIMS

Paediatric chronic heart failure (CHF) is associated with significant morbidity. The aim of this study was to describe paediatric CHF epidemiology in Germany.

METHODS AND RESULTS

This is a retrospective cross-sectional analysis of anonymized healthcare claims data in the InGef database. This database includes longitudinal data from a representative sample of the German population of approximately 4.8 million insured members. We included individuals <18 years from 2016 to 2021. CHF was defined by ≥2 diagnoses in different quarters of the year as inpatient or outpatient, using ICD-10-GM codes I50.- or P29.0. The number of eligible children in the database was 674 462 in 2016 and 660 692 in 2021. Prevalence of CHF per 100 000 children was 20.6 [95% confidence interval (CI), 17.3-24.3] in 2016 and 19.4 (95% CI, 16.2 to 23.0) in 2021. Incidence per 100 000 children was 9.6 (95% CI, 7.4 to 12.3) in 2016 and 7.6 (95% CI, 5.6 to 10.0) in 2021 for newly diagnosed CHF. All-cause hospitalizations occurred in 47.3% to 57.7% of children with CHF per year. Up to 6.3% of children with CHF were hospitalized, coded primarily for heart failure. Mortality of children with CHF was <5 death per year in the studied population. In 128 children with CHF in 2021, the most common ICD-coded comorbidities were congenital malformations of cardiac septa (57.8%), atrial septal defect (44.5%), congenital malformations of the great arteries (43.0%) and ventricular septal defect (32.0%). Coded treatment modalities for paediatric CHF in 2021 included angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers (18.8%), beta-blockers (17.2%), mineralocorticoid receptor antagonists (14.8%) and surgical procedures (13.3%).

CONCLUSIONS

This representative cohort study reveals a relatively high incidence proportion. Approximately half of the children with CHF are hospitalized annually while mortality is low.

Influenza Vaccination Coverage in Children: How Has COVID-19 Influenced It? A Review of Five Seasons (2018-2023) in Central Catalonia, Spain

Influenza vaccination is the main method of preventing influenza. Vaccination is recommended for certain individuals with diseases that could cause complications in the case of flu infection. The objective of this retrospective observational study was to examine influenza vaccination coverage in patients with risk factors, to describe the characteristics of those vaccinated and to study the influence of COVID-19. The study population was children under 14 years old with risk factors between 2018/19 and 2022/23 in Central Catalonia, sourced through the electronic database of the Catalan Institute of Health. The association of influenza vaccination data with sociodemographic data and risk factors was performed by bivariate and multivariate analysis. A total of 13,137 children were studied. Of those, 4623 had received the influenza vaccine in at least one season. The average influenza vaccination rate was 28.8%. The statistically significant factors associated with vaccination were age and having certain risk factors: asthma, diabetes, haemoglobinopathies and clotting disorders. In all seasons, the immigrant population was vaccinated more than the native population p < 0.05, except for the COVID-19 season (2020/21), where no differences were observed. Of those vaccinated, 7.1% had been vaccinated for 5 consecutive years. Influenza vaccination coverage in the paediatric age group was low. Vaccination promotion measures must be implemented. COVID-19 meant an increase in vaccination of the native population to the same level as that of the immigrant population.

Vaccination Rates and Influencing Factors in Patients with Axial Spondyloarthritis and Immunosuppressive Treatment-A Survey-Based Cross-Sectional Study

Patients with axial spondyloarthritis (axSpA) who receive immunosuppressive therapy are at risk of infection due to impaired immune function and immunosuppressive medication. Vaccination plays a crucial role in preventing infections in this population. However, vaccination rates and factors influencing vaccination uptake in axSpA patients still need to be adequately studied. This study was designed to determine the vaccination rates of vaccines covered by health insurance in this particular group in Turkey and attitudes towards vaccines and infections. This survey included 199 patients with axSpA who visited our outpatient clinic in June, July, and August 2023 and received biologic and targeted synthetic disease-modifying antirheumatic drugs. The mean age of the participants was 43.7 ± 0.7 years, and the majority were male (66.3%). The majority of the patients were vaccinated against COVID-19 (85.4%), followed by hepatitis B (41.2%), influenza (20.1%), and pneumococcal pneumonia (10.5%). While awareness of COVID-19 vaccination was widespread (100%), knowledge of other vaccines was lower (hepatitis B 80.9%, influenza 70.3%, pneumococcal 60.3%, respectively). Educational interventions targeting patients and healthcare professionals are needed to improve vaccination rates in this population. Our findings emphasize the need for strategies to increase vaccination rates in axSpA patients receiving immunosuppressive therapy. Removing barriers to vaccination and raising awareness of the importance of vaccination are critical to optimizing vaccination practices in this vulnerable population.

Influenza Vaccination in Children Younger than 5 Years in the Region of Murcia (Spain), a Comparative Analysis among Vaccinating and Non-Vaccinating Parents: Data from the FLUTETRA Study

The high burden of influenza in children has driven numerous countries towards universal vaccination of healthy children from 6 to 59 months of age. The Region of Murcia was one of the pioneer Spanish regions to conduct a universal vaccination campaign and to use live-attenuated intranasal vaccine (LAIV) if age appropriate. This study aims to evaluate the parents' likeliness to vaccinate their children and to compare the profile of vaccinating/non-vaccinating parents. This study was designed as a prospective, real-world, survey-based data collection in the 2022-2023 season campaign. This study's sample was selected from those children whose information was available in the local Public Health System databases PERSAN and VACUSAN. Children received LAIV or intramuscular vaccine (IIV) depending on their age as per standard practice. The parent self-vaccination/intention to vaccinate themselves in this campaign (OR = 4.75), the compliance with the official vaccination schedule (OR = 3.41), and the prescription of antibiotics more than twice in the previous year (OR = 2.24) were strongly associated with children's vaccination. Overall, vaccinating parents were very satisfied with the vaccine (IIV: 67.5% vs. LAIV: 68.8%, p = 0.320), and most parents would rather have their children vaccinated with LAIV for the next campaign (43.0%). The main reasons for vaccinating were to protect the child (LAIV: 85.9% vs. IIV: 89.4%), and the predominant reasons for not vaccinating were a lack of healthcare professional recommendation (30.9%), and lack of information about the vaccination campaign (21.5%) and the vaccine itself (21.0%). The clinical context of parents and children was determinant in decision making, which was also influenced by the presence or absence of recommendation by healthcare professionals. Parents were generally very satisfied with the vaccine and showed their preference towards LAIV for future campaigns.

Vaccination against influenza: Coverage and adherence in children under 15 years with high-risk medical conditions in the Community of Madrid

INTRODUCTION

Vaccination against influenza is indicated in children at risk of complications or severe disease. The objective of this study was to describe the percentage of children aged less than 15 years with risk conditions vaccinated against influenza in the Community of Madrid, and to analyze the factors associated with adherence to vaccination throughout 3 vaccination campaigns.

MATERIALS AND METHODS

Population-based cross-sectional observational study of children aged 6 months to 14 years with conditions that indicated influenza vaccination at the beginning of the 2018-2019 campaign. Electronic population registers were used. We described the percentage of children vaccinated in 3 consecutive campaigns, and assessed the association of adherence to vaccination with demographic and socioeconomic variables and risk conditions using bivariate and multivariate analysis.

RESULTS

The vaccination coverage was 15.6% in the 2018-2019 campaign. The adherence to vaccination was 65.9%. The variables associated with greater adherence were age greater than 2 years, especially in the 6-10 years group (aOR = 1.63; 95% CI, 1.43-1.85) and presenting more than one risk condition, especially 3 or more diseases (aOR = 1.80; 95% CI, 1.00-3.26). Diabetes mellitus was the disease associated most strongly with adherence (aOR = 2.15; 95% CI, 1.74-2.65). Adherence was lower in the immigrant population (aOR = 0.43; 95% CI, 0.36-0.51). We found no association between vaccination adherence and sex or socioeconomic status.

CONCLUSIONS

Vaccination coverage and adherence were suboptimal. Adherence to vaccination against influenza is associated with demographic and clinical conditions. Strategies need to be established to increase vaccination in children, with greater involvement of professionals and education of parents.

Differences and disparities in seasonal influenza vaccine, acceptance, adverse reactions, and coverage by age, sex, gender, and race

BACKGROUND

Influenza is a significant threat to public health worldwide. Despite the widespread availability of effective and generally safe vaccines, the acceptance and coverage of influenza vaccines are significantly lower than recommended. Sociodemographic variables are known to be potential predictors of differential influenza vaccine uptake and outcomes.

OBJECTIVES

This review aims to (1) identify how sociodemographic characteristics such as age, sex, gender, and race may influence seasonal influenza vaccine acceptance and coverage; and (2) evaluate the role of these sociodemographic characteristics in differential adverse reactions among vaccinated individuals.

METHODS

PubMed was used as the database to search for published literature in three thematic areas related to the seasonal influenza vaccine - vaccine acceptance, adverse reactions, and vaccine coverage.

RESULTS

A total of 3249 articles published between 2010 and 2020 were screened and reviewed, of which 39 studies were included in this literature review. By the three thematic areas, 17 studies assessed vaccine acceptance, 8 studies focused on adverse reactions, and 14 examined coverage of the seasonal influenza vaccine. There were also two studies that focused on more than one of the areas of interest.

CONCLUSION

Each of the four sociodemographic predictors - age, sex, race, and gender - were found to significantly influence vaccine acceptance, receipt and outcomes in this review.

Association Between Unmet Essential Social Needs and Influenza Vaccination in US Adults

BACKGROUND

Although social factors influence uptake of preventive services, the association between social needs and influenza vaccination has not been comprehensively evaluated for adults seeking primary care in the USA.

OBJECTIVE

To determine the association between unmet social needs and influenza vaccination.

DESIGN

Retrospective, cross-sectional, multivariable logistic regression.

PARTICIPANTS

Persons completing ambulatory visits in a primary care department at a midwestern, urban, multispecialty, academic medical center between July 2017 and July 2019 (N = 7955 individuals included).

MAIN MEASURES

Completion of influenza vaccination in the 2018-2019 influenza season (primary outcome) or any year (secondary outcome) against 11 essential social needs (childcare, companionship, food security, health literacy, home safety, neighborhood safety, housing, health care provider costs, prescription costs, transportation, and utilities). Demographics, diabetic status, COPD, smoking status, office visit frequency, and hierarchical condition category risk scores were included as covariates.

KEY RESULTS

Individuals with transportation vulnerability were less likely to be vaccinated against influenza (current-year aOR 0.65, 95% CI: 0.53-0.78, p < 0.001; any-year aOR 0.58, 95% CI: 0.47-0.71, p < 0.001). Poor health literacy promoted any-year, but not current-year, influenza vaccination (any-year aOR 1.30, 95% CI: 1.01-1.69, p = 0.043). Older age, female sex, diabetes, more comorbidities, and more frequent primary care visits were associated with greater influenza vaccination. Persons with Black or other/multiple race and current smokers were less frequently vaccinated.

CONCLUSIONS

Transportation vulnerability, health literacy, smoking, age, sex, race, comorbidity, and office visit frequency are associated with influenza vaccination. Primary care-led interventions should consider these factors when designing outreach interventions.

TRIAL REGISTRATION

Not applicable.

Pathophysiology and clinical presentation of paediatric heart failure related to congenital heart disease

Congenital heart disease (CHD) and cardiomyopathies represent the two most important causes of paediatric heart failure (HF) in developed countries. We made a review of the literature on pathophysiology and clinical presentation of paediatric HF in children with CHD. Two main pathophysiologic models can be identified: the 'over-circulation failure', characterised by signs and symptoms of congestion or hypoperfusion, due respectively to volume or pressure overload, and the 'pump failure'. CONCLUSIONS: The comprehension of the HF pathophysiology in paediatric patients with CHD is of paramount importance for the optimal management and for addressing the best therapeutic choices.

Zoster vaccination inequalities: A population based cohort study using linked data from the UK Clinical Practice Research Datalink

OBJECTIVE

To quantify inequalities in zoster vaccine uptake by determining its association with socio-demographic factors: age, gender, ethnicity, immigration status, deprivation (at Lower-layer Super Output Area-level), care home residence and living arrangements.

METHOD

This population-based cohort study utilised anonymised primary care electronic health records from England (Clinical Practice Research Datalink) linked to deprivation and hospitalisation data. Data from 35,333 individuals from 277 general practices in England and eligible for zoster vaccination during the two-year period (2013-2015) after vaccine introduction were analysed. Logistic regression was used to obtain adjusted odds ratios (aOR) for the association of socio-demographic factors with zoster vaccine uptake for adults aged 70 years (main target group) and adults aged 79 years (catch-up group).

RESULTS

Amongst those eligible for vaccination, 52.4% (n = 18,499) received the vaccine. Socio-demographic factors independently associated with lower zoster vaccine uptake in multivariable analyses were: being older (catch-up group: aged 79 years) aOR = 0.89 (95% confidence interval (CI):0.85-0.93), care home residence (aOR = 0.64 (95%CI: 0.57-0.73)) and living alone (aOR = 0.85 (95%CI: 0.81-0.90)). Uptake decreased with increasing levels of deprivation (p-value for trend<0.0001; aOR most deprived versus least deprived areas = 0.69 (95%CI: 0.64-0.75)). Uptake was also lower amongst those of non-White ethnicities (for example, Black versus White ethnicity: aOR = 0.61 (95%CI: 0.49-0.75)) but was not lower among immigrants after adjusting for ethnicity. Lower uptake was also seen amongst females compared to men in the catch-up group.

CONCLUSIONS

Inequalities in zoster vaccine uptake exist in England; with lower uptake among those of non-White ethnicities, and among those living alone, in a care home and in more deprived areas. Tailored interventions to increase uptake in these social groups should assist in realising the aim of mitigating vaccination inequalities. As care home residents are also at higher risk of zoster, improving the uptake of zoster vaccination in this group will also mitigate inequalities in zoster burden.

Coverage and predictors of influenza vaccination in patients with cystic fibrosis in a campaign with a mobile phone text messaging intervention

Annual influenza vaccination is considered the best protection against influenza infection. We analyzed the influenza vaccine coverage (IVC) in cystic fibrosis (CF) patients and evaluated the factors associated with the IVC, including the effect of text-message/SMS reminders.

We performed a cross-sectional study in the Community of Madrid (Spain) in 2015. The target population was people with CF older than 6 months of age at the beginning of the flu vaccination campaign. The IVC was calculated according to the study variables.

A total of 445 CF patients were analyzed. In 2015, IVC reached 67.9% and was higher in children and women. The main factor associated with flu vaccination was having been vaccinated in the previous campaign (aOR 14.36; IC95%: 8.48–24.32).

The probability of being vaccinated after receiving the SMS was more than twice than for those who did not receive it, although no statistical significance was reached.

In conclusion the IVC of patients with CF is high, but it still has room for improvement. SMS reminders sent to CF patients might improve influenza vaccine uptake.

Pulmonary Diseases in Refugees and Migrants in Europe

More than 2 million people fleeing conflict, persecution, and poverty applied for asylum between 2015 and 2016 in the European Union. Due to this, medical practitioners in recipient countries may be facing a broader spectrum of conditions and unusual presentations not previously encountered, including a wide range of infections with pulmonary involvement. Tuberculosis is known to be more common in migrants and has been covered broadly in other publications. The scope of this review was to provide an overview of exotic infections with pulmonary involvement that could be encountered in refugees and migrants and to briefly describe their epidemiology, diagnosis, and management. As refugees and migrants travel from numerous countries and continents, it is important to be aware of the various organisms that might cause disease according to the country of origin. Some of these diseases are very rare and geographically restricted to certain regions, while others have a more cosmopolitan distribution. Also, the spectrum of severity of these infections can vary from very benign to severe and even life-threatening. We will also describe infectious and noninfectious complications that can be associated with HIV infection as some migrants might originate from high HIV prevalence countries in sub-Saharan Africa. As the diagnosis and treatment of these diseases can be challenging in certain situations, patients with suspected infection might require referral to specialized centers with experience in their management. Additionally, a brief description of noncommunicable pulmonary diseases will be provided.

Systematic Literature Review on the Incidence and Prevalence of Heart Failure in Children and Adolescents

While the epidemiology of adult heart failure has been extensively researched, this systematic review addresses the less well characterized incidence and prevalence of pediatric HF. The search strategy used Cochrane methodology and identified 83 unique studies for inclusion. Studies were categorized according to whether the HF diagnosis was reported as primary (n = 10); associated with other cardiovascular diseases (CVDs) (n = 49); or associated with non-CVDs (n = 24). A narrative synthesis of the evidence is presented. For primary HF, the incidence ranged from 0.87/100,000 (UK and Ireland) to 7.4/100,000 (Taiwan). A prevalence of 83.3/100,000 was reported in one large population-based study from Spain. HF etiology varied across regions with lower respiratory tract infections and severe anemia predominating in lower income countries, and cardiomyopathies and congenital heart disease major causes in higher income countries. Key findings for the other categories included a prevalence of HF associated with cardiomyopathies ranging from 36.1% (Japan) to 79% (US); associated with congenital heart disease from 8% (Norway) to 82.2% (Nigeria); associated with rheumatic heart diseases from 1.5% (Turkey) to 74% (Zimbabwe); associated with renal disorders from 3.8% (India) to 24.1% (Nigeria); and associated with HIV from 1% (US) to 29.3% (Brazil). To our knowledge, this is the first systematic review of the topic and strengthens current knowledge of pediatric HF epidemiology. Although a large body of research was identified, heterogeneity in study design and diagnostic criteria limited the ability to compare regional data. Standardized definitions of pediatric HF are required to facilitate cross-regional comparisons of epidemiological data.

Migrant's access to preventive health services in five EU countries

Background

Preventive health services (PHSs) form part of primary healthcare with the aim of screening to prevent disease. Migrants show significant differences in lifestyle, health beliefs and risk factors compared with the native populations. This can have a significant impact on migrants’ access to health systems and participation in prevention programmes. Even in countries with widely accessible healthcare systems, migrants’ access to PHSs may be difficult. The aim of the study was to compare access to preventive health services between migrants and native populations in five European Union (EU) countries.

Methods

Information from Health Interview Surveys of Belgium, Italy, Malta, Portugal and Spain were used to analyse access to mammography, Pap smear tests, colorectal cancer screening and flu vaccination among migrants. The comparative risk of not accessing PHSs was calculated using a mixed-effects multilevel model, adjusting for potential confounding factors (sex, education and the presence of disability). Migrant status was defined according to citizenship, with a distinction made between EU and non-EU countries.

Results

Migrants, in particular those from non-EU countries, were found to have poorer access to PHSs. The overall risk of not reporting a screening test or a flu vaccination ranged from a minimum of 1.8 times (colorectal cancer screening), to a high of 4.4 times (flu vaccination) for migrants. The comparison among the five EU countries included in the study showed similarities, with particularly limited access recorded in Italy and in Belgium for non-EU migrants.

Conclusions

The findings of this study are in accordance with evidence from the scientific literature. Poor organization of health services, in Italy, and lack of targeted health policies in Belgium may explain these findings. PHSs should be responsive to patient diversity, probably more so than other health services. There is a need for diversity-oriented, migrant-sensitive prevention. Policies oriented to removing impediments to migrants’ access to preventive interventions are crucial, to encourage more positive action for those facing the risk of intersectional discrimination.

Translation of the UK Pediatric Influenza Vaccination Programme in Primary Schools to 13 European Countries Using a Dynamic Transmission Model

Objectives: To simulate the impact of a pediatric influenza vaccination programme using quadrivalent live attenuated influenza vaccine (QLAIV) in Europe by applying coverage rates achieved in the United Kingdom during the 2014-2015 season and to compare the model outcomes to the UK results. Methods: We used a deterministic, age-structured, dynamic transmission model adapted to the demography, contact patterns and influenza incidence of 13 European countries, with a 10-year horizon. The reference strategy was the unchanged country-specific coverage rate, using quadrivalent inactivated vaccine (assumed efficacy against infection from 45% in 1-year-old children to 60% in healthy adults). In the evaluated strategy, 56.8% of 5-10-year-old children were additionally vaccinated with QLAIV (assumed efficacy 80%), as was the case in 2014-2015 in the United Kingdom's primary school pilot areas. Symptomatic influenza cases and associated medical resources (primary care consultations [PCC], hospitalization, intensive care unit [ICU] admissions) were calculated. The evaluated versus reference strategies were compared using odds ratios (ORs) for PCC in the target (aged 5-10-years) and non-target adult (aged >17 years) populations as well as number needed to vaccinate (NNV) with QLAIV to avert one PCC, hospitalization or ICU admission. Model outcomes, averaged over 10 seasons, were compared with published real-life data from the United Kingdom for the 2014-2015 season. Results: Over 13 countries and 10 years, the evaluated strategy prevented 32.8 million of symptomatic influenza cases (172.3 vs 205.2 million). The resulting range of ORs for PCC was 0.18-0.48 among children aged 5-10-years, and the published OR in the United Kingdom was 0.06 (95% confidence interval [0.01; 0.62]). In adults, the range of ORs for PCC was 0.60-0.91 (UK OR=0.41 [0.19; 0.86]). NNV ranges were 6-19 per averted PCC (UK NNV=16), 530-1524 per averted hospitalization (UK NNV=317) and 5298-15 241 per averted ICU admission (UK NNV=2205). Conclusions: Across a range of European countries, our model shows the beneficial direct and indirect impact of a paediatric vaccination programme using QLAIV in primary school-aged children, consistent with what was observed during a single season in the United Kingdom. Recommendations for the implementation of pediatric vaccination programmes are, therefore, supported in Europe.

Direct and Indirect Protection with Pediatric Quadrivalent Live-Attenuated Influenza Vaccination in Europe Estimated by a Dynamic Transmission Model

Objectives: To estimate the public health impact of annual vaccination of children with a quadrivalent live-attenuated influenza vaccine (QLAIV) across Europe. Methods: A deterministic, age-structured, dynamic model was used to simulate influenza transmission across 14 European countries, comparing current vaccination coverage using a quadrivalent inactivated vaccine (QIV) to a scenario whereby vaccination coverage was extended to 50% of 2-17 year-old children, using QLAIV. Differential equations described demographic changes, exposure to infectious individuals, recovery and immunity dynamics. For each country, the basic reproduction number (R0) was calibrated to published influenza incidence statistics. Assumed vaccine efficacy for children was 80% (QLAIV) and 59% (QIV). Symptomatic cases cumulated over 10 years were calculated per 100 000 person-years. One-way sensitivity analyses were conducted on QLAIV efficacy in 7-17 year-olds (59% instead of 80%), durations of natural (±3 years; base case: 6, 12 years for influenza A, B respectively) and QLAIV vaccine-induced immunity (100% immunity loss after 1 season; base case: 30%), and R0 (+/-10% around all-year average value). Results: Across countries, annual QLAIV vaccination additionally prevents 1366-3604 symptomatic cases per 100 000 population (average 2495 /100 000, ie, a reduction of 47.6% of the cases which occur in the reference scenario with QIV vaccination only). Among children (2-17 years), QLAIV prevents 551-1555 cases per 100 000 population (average 990 /100 000, ie, 67.2% of current cases). Among adults, QLAIV indirectly prevents 726-2047 cases per 100 000 population (average 1466 /100 000, ie, 40.0% of current cases). The most impactful drivers of total protection were duration of natural immunity against influenza A, R0 and QLAIV immunity duration and efficacy. In all evaluated scenarios, there was a large direct and even larger indirect protection compared with the reference scenario. Conclusions: The model highlights direct and indirect protection benefits when vaccinating healthy children with QLAIV in Europe, across a range of demographic structures, contact patterns and vaccination coverage rates.

Barriers of Influenza Vaccination Intention and Behavior - A Systematic Review of Influenza Vaccine Hesitancy, 2005 - 2016

BACKGROUND

Influenza vaccine hesitancy is a significant threat to global efforts to reduce the burden of seasonal and pandemic influenza. Potential barriers of influenza vaccination need to be identified to inform interventions to raise awareness, influenza vaccine acceptance and uptake.

OBJECTIVE

This review aims to (1) identify relevant studies and extract individual barriers of seasonal and pandemic influenza vaccination for risk groups and the general public; and (2) map knowledge gaps in understanding influenza vaccine hesitancy to derive directions for further research and inform interventions in this area.

METHODS

Thirteen databases covering the areas of Medicine, Bioscience, Psychology, Sociology and Public Health were searched for peer-reviewed articles published between the years 2005 and 2016. Following the PRISMA approach, 470 articles were selected and analyzed for significant barriers to influenza vaccine uptake or intention. The barriers for different risk groups and flu types were clustered according to a conceptual framework based on the Theory of Planned Behavior and discussed using the 4C model of reasons for non-vaccination.

RESULTS

Most studies were conducted in the American and European region. Health care personnel (HCP) and the general public were the most studied populations, while parental decisions for children at high risk were under-represented. This study also identifies understudied concepts. A lack of confidence, inconvenience, calculation and complacency were identified to different extents as barriers to influenza vaccine uptake in risk groups.

CONCLUSION

Many different psychological, contextual, sociodemographic and physical barriers that are specific to certain risk groups were identified. While most sociodemographic and physical variables may be significantly related to influenza vaccine hesitancy, they cannot be used to explain its emergence or intensity. Psychological determinants were meaningfully related to uptake and should therefore be measured in a valid and comparable way. A compendium of measurements for future use is suggested as supporting information.

Differences in Influenza Vaccination Coverage between Adult Immigrants and Italian Citizens at Risk for Influenza-Related Complications: A Cross-Sectional Study

BACKGROUND

Due to their increased vulnerability, immigrants are considered a priority group for communicable disease prevention and control in Europe. This study aims to compare influenza vaccination coverage (IVC) between regular immigrants and Italian citizens at risk for its complications and evaluate factors affecting differences.

METHODS

Based on data collected by the National Institute of Statistics during a population-based cross-sectional survey conducted in Italy in 2012-2013, we analysed information on 42,048 adult residents (≥ 18 years) at risk for influenza-related complications and with free access to vaccination (elderly residents ≥ 65 years and residents with specific chronic diseases). We compared IVC between 885 regular immigrants and 41,163 Italian citizens using log-binomial models and stratifying immigrants by area of origin and length of stay in Italy (recent: < 10 years; long-term: ≥ 10 years).

RESULTS

IVC among all immigrants was 16.9% compared to 40.2% among Italian citizens (vaccination coverage ratio (VCR) = 0.42, 95% confidence interval (CI): 0.36-0.49). Adjusting for sex, age and area of residence, this difference was greatly reduced but remained statistically significant (VCR = 0.71, 95 CI: 0.61-0.81). Further adjustment for socio-economic factors (education, occupation, family composition and economic status) and a composite indicator of health-services utilization did not affect the difference (VCR = 0.78, 95% CI: 0.68-0.90). However, after adjustments, only long-term immigrants from Africa (VCR = 0.49, 95% CI: 0.28-0.85) and recent immigrants (VCR = 0.58, 95% CI: 0.43-0.78) showed a significantly different IVC compared to Italian citizens.

CONCLUSIONS

Differences in demographic characteristics, socio-economic conditions and health-services utilization explained the reduced IVC in most long-term immigrants compared to Italian citizens. By contrast, these differences did not explain the reduced IVC in long-term immigrants from Africa and recent immigrants. This suggests that IVC in these sub-groups is affected by other informal barriers (e.g., cultural and linguistic) that need to be investigated to promote effective immunization access strategies.

Correlates of influenza vaccine uptake among community-dwelling older adults in Brazil

This study aimed at assessing the factors associated with vaccine uptake in a representative sample of community-dwelling Brazilian older adults, specifically focusing on differences in socioeconomic factors among the country regions. We conducted a cross-sectional, population-based study, using a probabilistic household sample in 2013. Individuals aged 60 years or more answered a structured questionnaire informing on vaccination status and sociodemographic and behavioral covariates. Associations between variables were evaluated using prevalence ratios estimated by Poisson regression models. The overall vaccination coverage (72.6%) in older adults ranked lower than the goal of 80% stipulated by the Brazilian health authority; vaccine uptake differed significantly among the country regions. The prevalence of vaccination was lower in black individuals in Brazil than that in their white counterparts. The prevalence of vaccine uptake was significantly associated with covariates on current life style, use of health care, and socioeconomic determinants. Compared with individuals with 0-3 years of education, more schooled individuals had higher prevalence of vaccine uptake in the North, Northeast, and South regions of the country. This study showed that there is room for increasing vaccination coverage among the elderly in Brazil. The knowledge previously obtained on factors significantly associated with vaccine uptake has not prevented them to continue influencing this outcome. The socioeconomic inequality in vaccination in some Brazilian regions reinforces the need of targeting the intervention toward the most vulnerable groups.

Barriers to influenza vaccine uptake in obese people in Italy: Changes 2005-2013

BACKGROUND

Obesity is an independent risk factor for developing flu-related complications.

OBJECTIVE

The aim of this study was to analyze influenza vaccine uptake (VU) in the Italian obese, before and after the introduction of obesity among the national recommendations, and to evaluate factors associated to VU.

METHODS

The comparison of two editions of the national survey carried out in 2004-2005, before the inclusion of obese people among the specific high risk categories for flu complications, and in 2013, reaching a sample of 21,857 persons who declared to have a BMI>30. Multilevel logistic regression was used to evaluate potential independent predictors of influenza immunization.

RESULTS

Influenza vaccination coverage was 27.16% in 2013, versus 31.61% in 2005. A significant reduction of VU was registered after the introduction of obesity among the high risk conditions, for which flu VU was recommended. Regression modeling, both in adults and in older people, confirmed that barriers to VU in 2013 were younger age, medium level of education, absence of chronic disease, smoking habit, and reporting no contacts with GPs during the previous 12months. Among those aged 65 or more, the role of regional policies was associated to VU.

CONCLUSIONS

Immunization rates among young obese population are low, especially if not affected by comorbidities. Moreover, a reduction was registered in 2013 with respect to 2005. Flu vaccine uptake among the older population seems to be influenced by regional vaccination strategies. The development of novel strategy is warranted, especially among the young adults.

Long-Term Correlation between Influenza Vaccination Coverage and Incidence of Influenza-Like Illness in 14 European Countries

We aimed to examine the long-term correlation between influenza vaccination coverage and the incidence of influenza-like illness (ILI) in the total and elderly populations of European countries for which data was available on at least six consecutive influenza seasons. We graphically visualised vaccination coverage and ILI incidence trends and calculated Spearman rank correlation coefficients. Additionally, we fitted a negative binomial regression model to estimate the change in ILI incidence per percentage point change in vaccination coverage. We found significant negative correlations for the total population of the Netherlands (ρ = -0.60, p-value = 0.003) and for the elderly populations of England (ρ = -0.80, p-value < 0.001) and Germany (ρ = -0.57, p-value = 0.04). However, results were not consistent, and for some countries we observed significant positive correlations. Only for the elderly in England was there a significant decline in incidence rate per percentage point increase in vaccination coverage (incidence rate ratio = 0.93; 95% confidence interval 0.88–0.99). Based on this ecological study it is not possible to provide evidence for a negative correlation between influenza vaccination coverage and ILI incidence. For future, aetiological studies to assess impact of influenza vaccinations on the population, there is a need for high quality data over long periods of time, on proportion of ILI caused by influenza virus infection, on severe outcome measures such as hospitalisation for influenza, and on other factors that potentially affect influenza transmission.

Equity in disease prevention: Vaccines for the older adults - a national workshop, Australia 2014

On the 20th June, 2014 the National Health and Medical Research Council's Centre for Research Excellence in Population Health "Immunisation in under Studied and Special Risk Populations", in collaboration with the Public Health Association of Australia, hosted a workshop "Equity in disease prevention: vaccines for the older adults". The workshop featured international and national speakers on ageing and vaccinology. The workshop was attended by health service providers, stakeholders in immunisation, ageing, primary care, researchers, government and non-government organisations, community representatives, and advocacy groups. The aims of the workshop were to: provide an update on the latest evidence around immunisation for the older adults; address barriers for prevention of infection in the older adults; and identify immunisation needs of these groups and provide recommendations to inform policy. There is a gap in immunisation coverage of funded vaccines between adults and infants. The workshop reviewed provider misconceptions, lack of Randomised Control Trials (RCT) and cost-effectiveness data in the frail elderly, loss of autonomy, value judgements and ageism in health care and the need for an adult vaccination register. Workshop recommendations included recognising the right of elderly people to prevention, the need for promotion in the community and amongst healthcare workers of the high burden of vaccine preventable diseases and the need to achieve high levels of vaccination coverage, in older adults and in health workers involved in their care. Research into new vaccine strategies for older adults which address poor coverage, provider attitudes and immunosenescence is a priority. A well designed national register for tracking vaccinations in older adults is a vital and basic requirement for a successful adult immunisation program. Eliminating financial barriers, by addressing inequities in the mechanisms for funding and subsidising vaccines for the older adults compared to those for children, is important to improve equity of access and vaccination coverage. Vaccination coverage rates should be included in quality indicators of care in residential aged care for older adults. Vaccination is key to healthy ageing, and there is a need to focus on reducing the immunisation gap between adults and children.

Two-dose seasonal influenza vaccine coverage and timeliness among children aged 6 months through 3 years: An evidence from the 2010-11 to the 2014-15 seasons in Zhejiang province, east China

OBJECTIVE

To evaluate the coverage and timeliness of seasonal influenza vaccine vaccination (SIV) among children aged 6 months to 3 years from the 2010-11 through the 2014-15 seasons.

METHODS

Children registered in Zhejiang Provincial Immunization Information System (ZJIIS) and needed 2 seasonal influenza vaccine doses in a given season from 2010-11 to 2014-15 were enrolled. Socio-economic information and SIV records of target children were extracted from ZJIIS on 1 January 2016. Any (≥1 dose) and full (2 doses) vaccination coverage by December 1 and March 31 as well as interval between 2 doses were calculated. Trends of coverage over time and determinants on fully vaccination coverage and interval between 2 doses were assessed.

RESULTS

Full SIV overage by Mar 31 increased from the 2010-11 to the 2014-15 seasons (2.60% vs 2.92%). Less than 1% of children received 2 doses by December 1. The interval between 2 doses among fully vaccinated children decreased over time (2010-11: 68.32 days; 2014-15: 49.51 days; p < 0.05). Age, socio-economic development level of resident areas were inversely associated with full vaccination coverage and resident children had a significantly higher full vaccination coverage. Younger age, resident children, receiving vaccination from higher service frequency clinics and clinics with morning and afternoon sessions were positive determinants of a shorter interval between 2 doses.

CONCLUSION

Majority of children aged 6 months to 3 years remained at risk of incomplete and delayed SIV. The importance of the 2-dose SIV recommendation needs to be emphasized and effective interventions needs to be implemented to improve the completeness and the timeliness of SIV.

Uptake and Effectiveness of a Trivalent Inactivated Influenza Vaccine in Children in Urban and Rural Kenya, 2010 to 2012

BACKGROUND

In Africa, recent surveillance has demonstrated a high burden of influenza, but influenza vaccine is rarely used. In Kenya, a country with a tropical climate, influenza has been shown to circulate year-round, like in other tropical countries.

METHODS

During 3 months in 2010 and 2011 and 2 months in 2012, the Kenya Medical Research Institute/Centers for Disease Control and Prevention-Kenya offered free injectable trivalent inactivated influenza vaccine to children 6 months to 10 years old in 2 resource-poor communities in Kenya-Kibera and Lwak (total population ~50,000). We conducted a case-control study to evaluate vaccine effectiveness (VE) in preventing laboratory-confirmed influenza associated with influenza-like illness and acute lower respiratory illness.

RESULTS

Of the approximately 18,000 eligible children, 41%, 48% and 51% received at least 1 vaccine in 2010, 2011 and 2012, respectively; 30%, 36% and 38% were fully vaccinated. VE among fully vaccinated children was 57% [95% confidence interval (CI): 29% to 74%] during a 6-month follow-up period, 39% (95% CI: 17% to 56%) during a 9-month follow-up period and 48% (95% CI: 32% to 61%) during a 12-month follow-up period. For the 12-month follow-up period, VE was statistically significant in children <5 years and in children 5 to <10 years old (50% and 46%, respectively).

CONCLUSIONS

In Kenya, parents of nearly half of the eligible children <10 years old chose to get their children vaccinated with a free influenza vaccine. During a 12-month follow-up period, the vaccine was moderately effective in preventing medically attended influenza-associated respiratory illness.

Skewed risk perceptions in pregnant women: the case of influenza vaccination

Background

Pregnant women and their newborns have an increased risk of developing severe influenza and influenza-related complications. In Germany, seasonal influenza vaccination is recommended for pregnant women since 2010. However, little is known about pregnant women’s vaccination-related knowledge and attitudes, as well as their risk perceptions. This study therefore assessed pregnant women’s vaccination-related knowledge, risk perceptions related to influenza disease and influenza vaccination during pregnancy, and aimed to identify determinants of influenza vaccination uptake during pregnancy in Germany.

Methods

Between 2012 and 2014, a nationwide web-based prospective cohort study with follow-up interviews was conducted in initially pregnant women who gave birth over the study period. Control groups were set up in a cross-sectional fashion during the follow-up interviews. Women who participated in both, the baseline interview before giving birth and in the 1st interview after giving birth were included in the analysis. Univariate and multiple logistic regression were used to identify associations between influenza vaccination uptake and sociodemographic characteristics as well as items assessing attitude and knowledge.

Results

In total, 838 women were included in the analyses. Pregnant women had a positive attitude towards vaccination in general, but only modest vaccination knowledge. Overall, 10.9 % of women were vaccinated against seasonal influenza during pregnancy. While pregnant women perceived classical childhood diseases to be more risky than the respective vaccinations, this relation reversed for influenza: The risk of vaccination was perceived higher than the risk of the disease. These two types of risk perceptions independently determined influenza vaccination uptake—higher perception of disease risk and lower perceptions of vaccination-related risks increased uptake. Additionally, knowledge about the vaccination recommendation for pregnant women and a positive gynaecologist’s attitude towards vaccination during pregnancy influenced the uptake significantly.

Conclusions

Influenza vaccination uptake in pregnant women is low in Germany. Tailored communication strategies for pregnant women should focus especially on changing the perceptions of personal risks regarding influenza and influenza vaccination during pregnancy. Gynaecologists should be made aware about their crucial role in supporting vaccination decision-making of pregnant women and the need to provide relevant information to counteract misconceptions.

Why are older adults and individuals with underlying chronic diseases in Germany not vaccinated against flu? A population-based study

Background

Older adults and individuals with underlying chronic diseases are at increased risk of developing influenza-related complications and are target groups for seasonal influenza vaccination in many countries. In Germany, an annual national information campaign is conducted to increase influenza vaccination uptake in the target groups. However, data are lacking on knowledge and attitudes toward influenza vaccination among older adults and those with chronic diseases. The present study aimed to (i) estimate influenza vaccination uptake for the 2012/13 and 2013/14 seasons, (ii) assess knowledge and attitudes about influenza vaccination, and (iii) identify factors associated with vaccination uptake in two risk groups.

Methods

Between March and June 2014, we conducted a nationwide cross-sectional survey in adults (≥18 years) living in Germany using computer-assisted telephone interviewing. We calculated weighted vaccination coverage rates in two at-risk groups. Group 1 comprised participants aged 18–59 years with underlying chronic diseases. Group 2 comprised participants aged 60+, irrespective of underlying disease. We used univariate and multivariable logistic regression analyses to identify associations between influenza vaccination uptake and sociodemographic characteristics, and to evaluate attitudes and knowledge.

Results

In total, 1,519 interviews were conducted. Seasonal influenza vaccination uptake in people with underlying chronic diseases aged 18–59 years was 24 % in 2012/2013 and 23 % in 2013/2014. In older adults, uptake was 50 % and 49 % in 2012/13 and 2013/14 respectively. There were considerable vaccination-related knowledge gaps among respondents. For example, about half of the participants who aged ≥60 years and/or suffered from underlying chronic diseases believed that influenza vaccination could cause influenza. The most commonly stated reasons for not being immunized were mistrust of the vaccination (22 %) and the perception that influenza is not dangerous (21 %). For both groups, vaccination uptake was independently associated with sex, perceived severity of influenza, perceived vaccination effectiveness, and the perceived likelihood or severity of vaccination side effects. For older adults, additional factors influencing vaccination uptake were age, underlying chronic diseases, and recent advice through physician consultation.

Conclusions

Influenza vaccination coverage rates in Germany remain low. Individual perceptions regarding harms and benefits are crucial in the decision-making process. Communication strategies should focus on improving understanding and perception of personal risks arising from the disease and the vaccination.

Predictors of Adherence to Multiple Clinical Preventive Recommendations among Adults with Diabetes in Spain

OBJECTIVE

This study aims to describe adherence to seven clinical preventive services among Spanish adults with diabetes, to compare adherence with people without diabetes and to identify predictor of adherence to multiple practices among adults with diabetes.

DESIGN

Cross-sectional study based on data obtained from the European Health Survey for Spain 2009 and the Spanish National Health Survey 2011. We analyzed those aged 40-69 years (n= 20,948). Diabetes status was self-reported. The study variables included adherence to blood pressure (BP) checkup, cholesterol measurement, influenza vaccination, dental examination, fecal occult blood test (FOBT), mammography and cytology. Independent variables included socio-demographic characteristics, variables related to health status and lifestyle factors.

RESULTS

The study sample included 1,647 subjects with diabetes and 19,301 without. Over 90% had measured their BP and cholesterol in the last year, 44.4% received influenza immunization, 36.4% had a dental checkup within the year and only 8.1% underwent a FOBT. Among diabetic women 75.4% had received a mammography and 52.4% a cytology in the recommended periods. The adherence to BP and cholesterol measurements and influenza vaccination was significantly higher among those suffering diabetes and cytology and dental checkup were lower. Only 63.4% of people with diabetes had fulfilled half or more of the recommended practices. Female sex, higher educational level, being married or cohabiting, higher number of chronic conditions and number of physician visits increased the adherence to multiple preventive practices. For each unhealthy lifestyle reported the probability of having a higher adherence level decreased.

CONCLUSIONS

Acceptable adherence is found for BP and cholesterol checkups and mammography. Unacceptably low rates were found for influenza vaccine, dental care, cytology and FOBT. Moreover, preventive services are provided neither equitably nor efficiently so future research needs to identify individual and organizational factors that allow interventions to reach these subjects with diabetes.

Comparison of self-report influenza vaccination coverage with data from a population based computerized vaccination registry and factors associated with discordance

OBJECTIVES

We aim to compare influenza vaccination coverages obtained using two different methods; a population based computerized vaccination registry and self-reported influenza vaccination status as captured by a population survey.

METHODS

The study was conducted in the Autonomous Community of Madrid (ACM), Spain, and refers to the 2011/12 influenza vaccination campaign. Information on influenza vaccination status according to a computerized registry was extracted from the SISPAL database and crossed with the electronic clinical records in primary care (ECRPC). Self-reported vaccine uptake was obtained from subjects living in the ACM included in the 2011-12 Spanish National Health Survey (SNHS). Independent study variables included: age, sex, immigrant status and the presence of high risk chronic conditions. Vaccination coverages were calculated according to study variables. Crude and adjusted prevalence ratios were computed to assess concordance.

RESULTS

The study population included 5,245,238 adults living in the ACM in year 2011 with an individual ECRPC and 1449 adult living the ACM and interviewed in the SNHS from October 2011 to June 2012. The weighted vaccination coverage for the study population according to self-reported data was 19.77% and 15.04% from computerized registries resulting in a crude prevalence ratio (cPR) of 1.31 (95% CI 1.20-1.44) so self-reported data significantly overestimated 31% the registry coverage. Self-reported coverages are always higher than registry based coverages when the study population is stratified by the study variables. Self-reported overestimation was higher among men than women, younger age groups, immigrants and those without chronic conditions. Both methods provide the most concordant estimations for the target population of the influenza vaccine.

CONCLUSIONS

Self-report influenza vaccination uptake overestimates vaccination registries coverages. The validity of self-report seems to be negatively affected by socio-demographic variables and the absence of chronic conditions. Possible strategies must be considered and implemented to improve both coverage estimation methods.