Vaccination barriers and drivers in Romania: a focused ethnographic study

BACKGROUND

In 2016-18, a large measles outbreak occurred in Romania identified by pockets of sub-optimally vaccinated population groups in the country. The aim of the current study was to gain insight into barriers and drivers from the experience of measles vaccination from the perspectives of caregivers and their providers.

METHODS

Data were collected by non-participant observation of vaccination consultations and individual interviews with health workers and caregivers in eight Romanian clinics with high or low measles vaccination uptake. Romanian stakeholders were involved in all steps of the study. The findings of this study were discussed during a workshop with key stakeholders.

RESULTS

Over 400 h of observation and 161 interviews were conducted. A clear difference was found between clinics with high and low measles vaccination uptake which indicates that being aware of and following recommended practices for both vaccination service delivery and conveying vaccine recommendations to caregivers may have an impact on vaccine uptake. Barriers identified were related to shortcomings in following recommended practices for vaccination consultations by health workers (e.g. correctly assessing contraindications or providing enough information to allow an informed decision). These observations were largely confirmed in interviews with caregivers and revealed significant knowledge gaps.

CONCLUSIONS

The identification of key barriers provided an opportunity to design specific interventions to improve vaccination service delivery (e.g. mobile vaccination clinics, use of an electronic vaccination registry system for scheduling of appointments) and build capacity among health workers (e.g. guidance and supporting materials and training programmes).

Confronting 21st-century monkeypox

The World Health Organization (WHO) hasn’t called the current monkeypox outbreak a Public Health Emergency of International Concern (PHEIC), but as a worldwide epidemic, it is clearly an emerging pandemic. More than 12,556 monkeypox cases and three deaths have been reported in 68 countries since early May, and these numbers will rise rapidly with improved surveillance, access to diagnostics, and continuing global spread of infection. Although many tools are needed to control this unfolding pandemic, it’s clear that limiting ongoing spread will require a comprehensive international vaccination strategy and adequate supplies.

Social media strategies to affect vaccine acceptance: a systematic literature review

Introduction: Vaccine hesitancy, defined as a delay in the acceptance or the refusal of vaccines despite their availability, is a growing global threat. More individuals are turning to social media for health information, including vaccine information. As such, there is an opportunity to leverage online platforms as a means to disseminate and persuade individuals toward vaccine acceptance. We sought to review literature focused on the influence of exposure to social media content on vaccine acceptance or hesitancy.Areas covered: This review focused on social networking sites (e.g. Facebook) and content communities (e.g. YouTube), to understand how exposure to vaccine information affected vaccine knowledge, attitudes, and intentions/behaviors. We searched PubMed, CINAHL, Scopus, and Inspec. We included English-language materials published from 2004 to 2020 and included interventional studies, observational studies, and impacts of policies. We excluded systematic reviews, protocols, editorials, letters, case reports, case studies, commentaries, opinion pieces, narrative reviews, and clinical guidelines.Expert opinion: Social media interventions to affect vaccine acceptance is a new but growing area of study. How a communication message is framed, who delivers the message, and network structure are critical for affecting the vaccine decision-making process. Social media should be leveraged to impact vaccine uptake.

The Coalition Against Typhoid: Mobilizing a Community for a Global Fight

Typhoid became a low priority on the global public health agenda when it was largely eliminated from developed countries in the 1940s. However, communities in South Asia and sub-Saharan Africa continue to bear the brunt of the disease burden. One strategy to increase attention and coordinate action is the creation of a coalition to act as a steward for typhoid. The Coalition against Typhoid (CaT) was created in 2010 with the mission of preventing typhoid among vulnerable populations through research, education, and advocacy. CaT successfully raised the profile of typhoid through convening the community with a biennial international conference that has experienced growing participation, disseminating data and news through a website and newsletter with increasing readership, and advocating through social media and a blog reaching a diverse audience. In 2017, CaT joined forces with the Typhoid Vaccine Acceleration Consortium to “Take on Typhoid,” combining advocacy and communications efforts to mobilize researchers, clinicians, and decision makers at the global, regional, and local levels to introduce the new typhoid conjugate vaccine. As a result, the knowledge base, political will, and momentum are increasingly in place to implement prevention and control interventions including the typhoid conjugate vaccine in the poor communities that have historically been left behind.

Informing vaccine decision-making: A strategic multi-attribute ranking tool for vaccines-SMART Vaccines 2.0

SMART Vaccines 2.0 software is being developed to support decision-making among multiple stakeholders in the process of prioritizing investments to optimize the outcomes of vaccine development and deployment. Vaccines and associated vaccination programs are one of the most successful and effective public health interventions to prevent communicable diseases and vaccine researchers are continually working towards expanding targets for communicable and non-communicable diseases through preventive and therapeutic modes. A growing body of evidence on emerging vaccine technologies, trends in disease burden, costs associated with vaccine development and deployment, and benefits derived from disease prevention through vaccination and a range of other factors can inform decision-making and investment in new and improved vaccines and targeted utilization of already existing vaccines. Recognizing that an array of inputs influences these decisions, the strategic multi-attribute ranking method for vaccines (SMART Vaccines 2.0) is in development as a web-based tool-modified from a U.S. Institute of Medicine Committee effort (IOM, 2015)-to highlight data needs and create transparency to facilitate dialogue and information-sharing among decision-makers and to optimize the investment of resources leading to improved health outcomes. Current development efforts of the SMART Vaccines 2.0 framework seek to generate a weighted recommendation on vaccine development or vaccination priorities based on population, disease, economic, and vaccine-specific data in combination with individual preference and weights of user-selected attributes incorporating valuations of health, economics, demographics, public concern, scientific and business, programmatic, and political considerations. Further development of the design and utility of the tool is being carried out by the National Vaccine Program Office of the Department of Health and Human Services and the Fogarty International Center of the National Institutes of Health. We aim to demonstrate the utility of SMART Vaccines 2.0 through the engagement of a community of relevant stakeholders and to identify a limited number of pilot projects to determine explicitly defined attribute preferences and the related data and model requirements that are responsive to user needs and able to improve the use of evidence for vaccine-related decision-making and consequential priorities of vaccination options.

Success of program linking data sources to monitor H1N1 vaccine safety points to potential for even broader safety surveillance

In response to the 2009 H1N1 pandemic and subsequent vaccination program, the Department of Health and Human Services and collaborators developed the Post-Licensure Rapid Immunization Safety Monitoring (PRISM) Program as a demonstration project to detect rare adverse events rapidly. The program monitored three million people who had received the H1N1 vaccine by linking data from large private health plans and from public immunization registries that had originally not been designed to share data, and on a larger scale than had been previously attempted. The program generated safety data in two weeks rather than three to six monty 10ths-the standard time frame achievable using health plan data. PRISM substantially contributed to the understanding of the safety of H1N1 vaccines. Its use in the case of H1N1 highlights the necessity of proactive planning, scalable infrastructure, and public-private partnerships in tracking adverse events after vaccination in epidemics. It also illustrates how data could be integrated to produce policy-relevant information for other medical products.

Association between Guillain-Barré syndrome and influenza A (H1N1) 2009 monovalent inactivated vaccines in the USA: a meta-analysis

BACKGROUND

The influenza A (H1N1) 2009 monovalent vaccination programme was the largest mass vaccination initiative in recent US history. Commensurate with the size and scope of the vaccination programme, a project to monitor vaccine adverse events was undertaken, the most comprehensive safety surveillance agenda in the USA to date. The adverse event monitoring project identified an increased risk of Guillain-Barré syndrome after vaccination; however, some individual variability in results was noted. Guillain-Barré syndrome is a rare but serious health disorder in which a person's own immune system damages their nerve cells, causing muscle weakness, sometimes paralysis, and infrequently death. We did a meta-analysis of data from the adverse event monitoring project to ascertain whether influenza A (H1N1) 2009 monovalent inactivated vaccines used in the USA increased the risk of Guillain-Barré syndrome.

METHODS

Data were obtained from six adverse event monitoring systems. About 23 million vaccinated people were included in the analysis. The primary analysis entailed calculation of incidence rate ratios and attributable risks of excess cases of Guillain-Barré syndrome per million vaccinations. We used a self-controlled risk-interval design.

FINDINGS

Influenza A (H1N1) 2009 monovalent inactivated vaccines were associated with a small increased risk of Guillain-Barré syndrome (incidence rate ratio 2·35, 95% CI 1·42-4·01, p=0·0003). This finding translated to about 1·6 excess cases of Guillain-Barré syndrome per million people vaccinated.

INTERPRETATION

The modest risk of Guillain-Barré syndrome attributed to vaccination is consistent with previous estimates of the disorder after seasonal influenza vaccination. A risk of this small magnitude would be difficult to capture during routine seasonal influenza vaccine programmes, which have extensive, but comparatively less, safety monitoring. In view of the morbidity and mortality caused by 2009 H1N1 influenza and the effectiveness of the vaccine, clinicians, policy makers, and those eligible for vaccination should be assured that the benefits of inactivated pandemic vaccines greatly outweigh the risks.

FUNDING

US Federal Government.

Immunization-safety monitoring systems for the 2009 H1N1 monovalent influenza vaccination program

The effort to vaccinate the US population against the 2009 H1N1 influenza virus hinged, in part, on public confidence in vaccine safety. Early in the vaccine program, >20% of parents reported that they would not vaccinate their children. Concerns about the safety of the vaccines were reported by many parents as a factor that contributed to their intention to forgo vaccination (see www.hsph.harvard.edu/news/press-releases/2009-releases/survey-40-adults-absolutely-certain-h1n1-vaccine.html and www.med.umich.edu/mott/npch/reports/h1n1.htm). The safety profiles of 2009 H1N1 monovalent influenza vaccines were anticipated to be (and have been) similar to those of seasonal influenza vaccines, for which an excellent safety profile has been demonstrated. Here we describe steps taken by the US government to (1) assess the key federal systems in place before 2009 for monitoring the safety of vaccines and (2) integrate and upgrade those systems for optimal vaccine-safety monitoring during the 2009 H1N1 monovalent influenza vaccination program. These efforts improved monitoring of 2009 H1N1 vaccine safety, hold promise for enhancing future national monitoring of vaccine safety, and may ultimately help improve public confidence in vaccines.

Strengthening the supply of routinely recommended vaccines in the United States: recommendations from the National Vaccine Advisory Committee

Between late 2000 and the spring of 2003, the United States experienced shortages of vaccines against 8 of 11 preventable diseases in children. In response, the Department of Health and Human Services requested that the National Vaccine Advisory Committee (NVAC) make recommendations on strengthening the supply of routinely recommended vaccines. The NVAC appointed a Working Group to identify potential causes of vaccine supply shortages, develop strategies to alleviate or prevent shortages, and enlist stakeholders to consider the applicability and feasibility of these strategies. The NVAC concluded that supply disruptions are likely to continue to occur. Strategies to be implemented in the immediate future include expansion of vaccine stockpiles, increased support for regulatory agencies, maintenance and strengthening of liability protections, improved communication among stakeholders, increased availability of public information, and a campaign to emphasize the benefits of vaccination. Strategies requiring further study include evaluation of appropriate financial incentives to manufacturers and streamlining the regulatory process without compromising safety or efficacy.

Control of epidemic group A meningococcal disease in Auckland

AIM

To study group A meningococcal vaccine delivery to infants less than 2 years of age in Auckland in 1987 to control epidemic disease.

METHODS

Mechanisms of vaccine delivery and its facilitation are described. A detailed audit of delivery of vaccine to children less than two years using signed consent forms determined delivery source. This was the age group at highest risk, and poorly covered by routine childhood vaccines. Primary health care source of children presenting with disease was determined by telephone.

RESULTS

The epidemic of group A meningococcal disease in the winters of 1985 and 1986 abated most likely due to the vaccination of high risk children (3 months-13 years) in 1987. 90% of the target population were vaccinated. In south Auckland the majority (92%) of vaccine doses for children less than two years of age was delivered by the Plunket Society with Department of Health backing aided by community health workers. By contrast delivery by, general practitioners was greater in north-west and central Auckland (approximately 25%, of dose 1), especially after the publicity over possible side effects (approximately 50% of dose 2). Coverage for dose 1 of children < 2 years was similar (89%) in south Auckland. Of children presenting with meningococcal disease 1 in 4 did not have an identifiable general practitioner.

CONCLUSIONS

Vaccines to prevent serious paediatric illness are known to be highly cost effective. The best method of delivery of vaccinations may vary from area to area. Major community involvement including community health workers for the Maori and Pacific Island communities may have facilitated the dissemination of information in this campaign.

Successful intervention in a group A meningococcal outbreak in Auckland, New Zealand

During two consecutive winter seasons (1985 and 1986) Auckland, New Zealand, experienced epidemic rates of Group A meningococcal disease, a pattern not previously recognized in New Zealand. The overall rate was 8.3/100,000/year. The highest annual rate (64.7) occurred in children 0 to 23 months of age. A city-wide vaccine campaign commencing in May, 1987, was conducted over 6 weeks among children 3 months to 13 years of age with special emphasis on reaching populations at highest risk (Maori and Pacific Island Polynesian children in certain geographic regions of Auckland). Children from 2 to 13 years of age received a single dose of monovalent Group A meningococcal vaccine. Children ages 3 to 23 months received two doses at least 1 month apart. Overall approximately 130,000 doses were delivered; coverage was approximately 90% in the single dose target group. Among the younger children approximately 89% received the primary dose. Only approximately 26% received the recommended "booster" dose. After 2 1/2 years of active surveillance (1987 to 1989) there were no cases of invasive Group A meningococcal disease in children appropriately vaccinated for age. In contrast to this 100% efficacy the efficacy of a single dose of monovalent Group A meningococcal vaccine to prevent illness in the youngest children during the 1987 epidemic period was 52% (95% confidence interval (-330%, 95%)) falling to 16% (95% confidence interval, (-538%, 90%)) after 1 year. Four cases that occurred in infants 3 to 7 weeks before the scheduled "booster" campaign supports limited true efficacy. However, the prescribed 1 to 3-month interval between the two doses in infants may be too long.(ABSTRACT TRUNCATED AT 250 WORDS)

The contribution of reinfection to gonorrhea incidence in Alaska, 1983 to 1987

Gonorrhea case reports to the Alaska Department of Health and Social Services were used to study the contribution of reinfection to rates of gonorrhea infection in Alaska. The case reports of 13,910 infections among 11,132 persons who had laboratory-proven gonorrhea between 1983 and 1987 were examined. Among 1,886 persons who had multiple infections, the average number of infections per person was 2.5 (range = 2-11). These persons accounted for 33.5% of all infections and 16.9% of all patients with gonorrhea from 1983 to 1987. Compared to persons with one infection, those having multiple infections were more likely to be Alaska Natives (relative risk = 1.8, 95% confidence interval = 1.6-1.9) and less than 21 years of age (relative risk = 1.3, 95% confidence interval = 1.2-1.4). There was no difference in risk between men and women. Two thirds of the reinfections occurred within 12 months of the initial infection. If gonorrhea incidence were calculated based on the number of people infected rather than as a "case rate," the mean annual rate (per 100,000) from 1983 to 1987 decreased from 1,644 to 1,228 (a 25.3% decrease) for Alaska Natives and from 316 to 267 (a 15.5% decrease) for non-Natives. Reporting gonorrhea incidence rates by number of persons infected rather than by total number of cases more accurately measures gonorrhea morbidity in a population and will allow prevention efforts to be directed to those persons who contribute the most to perpetuating the disease.