Knowledge, attitudes, and intentions regarding COVID-19 vaccination in the general population and the effect of different framing messages for a brief video on intentions to get vaccinated among unvaccinated individuals in the United States during July 2021

OBJECTIVE

To identify knowledge, attitudes, and beliefs (KABs) associated with COVID-19 vaccination intentions and assess the impact of vaccine-promoting messages on vaccination intentions.

METHODS

Our nationally representative survey measured KABs of COVID-19 vaccination and incorporated a randomized experiment to assess the impact of different framing messages for a video encouraging vaccination intentions among unvaccinated adults in the US. Multivariable multinomial logistic regression models were fitted to investigate the relationships of KABs, trust in public health authorities (PHAs), and vaccine confidence with vaccination intentions. Difference-in-difference estimation was conducted to assess the impact of framing messages for a video on unvaccinated individuals' vaccination intentions.

RESULTS

We observed that people with increasingly favorable vaccine KABs, trust in PHAs, and vaccine confidence were more likely to be vaccinated or intend to get vaccinated against COVID-19. Difference-in-difference estimates indicated a positive impact of exposure to the video on vaccination intentions while framing messages in some cases appeared to lower vaccination intentions. Associations between the video and vaccination intentions were more pronounced among Black/African American and Hispanic/Latinx populations and Democrats; however, associations did not vary by trust in PHAs or vaccine confidence.

CONCLUSION

Videos that encourage people to get vaccinated may provide an efficient approach to nudge vaccine-hesitant individuals towards getting vaccinated. However, framing messages may negatively impact vaccination intentions and need to be developed carefully.

PRACTICE IMPLICATIONS

This study provides solid experimental evidence for the importance of tailoring message framing to the characteristics and experience of the audience, while cautioning potential negative impacts of framing that does not match its intended audience. Our findings are applicable to health communication strategies on the population level, such as mass media campaigns, and the use of framing for messages to encourage vaccination but may also be informative for healthcare professionals consulting hesitant individuals about COVID-19 vaccinations.

Changes in vaccine attitudes and recommendations among US Healthcare Personnel during the COVID-19 pandemic

A recommendation from healthcare personnel (HCP) is a strong predictor of vaccination. This study aimed to measure how HCP vaccine attitudes and recommendations changed during the COVID-19 pandemic. HCP were surveyed in January 2023 using a double opt-in network panel. Survey responses were summarized and stratified by HCP type and COVID-19 booster status. Multivariable logistic regression models were fitted. Comparisons were made to a September 2021 survey, with differences tested for significance (p < 0.05) using Pearson's χ2 Test. Nearly 82% of the 1207 HCP surveyed had received a COVID-19 booster, most commonly pediatricians (94%), followed by family medicine doctors (87%), pharmacists (74%), and nurses (73%) (p < 0.01). HCP with high trust in the Centers for Disease Control and Prevention (CDC) had nearly 6 times the odds (OR: 5.5; 95%CI: 3.9-7.7) of being boosted compared to HCP with low trust. From September 2021 to January 2023, the proportion of HCP recommending vaccines (COVID-19 and routine) to their patients decreased substantially for nearly all vaccines and patient populations specified. Trust in CDC also decreased (from 79 to 73%, p < 0.01), as did support for HCP COVID-19 vaccine mandates (from 65 to 46%, p < 0.01). HCP interest in additional online resources to improve their vaccine discussions with patients increased from 46 to 66% (p < 0.01). Additional regularly updated online resources from trusted medical sources that clarify progressing science and address dynamic public concerns are needed to improve vaccine confidence among HCP and help them support their patients' decision-making.

Attitudes toward COVID-19 and Other Vaccines: Comparing Parents to Other Adults, September 2022

Few analyses of COVID-19 vaccine attitudes also cover routine vaccines or focus on parents. In this cross-sectional study, we surveyed US adults in September 2022, immediately following the authorization of updated bivalent COVID-19 boosters for adults but before their authorization for children. The vaccine attitudes of parents were compared to other adults. Fewer parents were up-to-date on COVID-19 vaccines than other adults (54% vs. 67%), even after adjusting for age, education, and race/ethnicity (Adjusted Odds Ratio: 0.58; 95% Confidence Interval: 0.45-0.76). More parents had concerns about COVID-19 vaccines' safety in children (67% vs. 58%; aOR: 1.59; 95%CI: 1.23-2.06) and vaccine ingredients (52% vs. 45%; aOR: 1.41; 95%CI: 1.09-1.81), and more parents perceived COVID-19 in children to be no worse than a cold or the flu (51% vs. 38%; aOR: 1.56; 95%CI: 1.22-2.01). Fewer parents supported COVID-19 vaccine school requirements (52% vs. 57%; aOR: 0.75; 95%CI: 0.58-0.97) and perceived high vaccine coverage among their friends (51% vs. 61%; aOR: 0.60; 95%CI: 0.46-0.78). However, three-quarters of parents intended their child to receive all routinely recommended vaccines, whereas only half of adults intended to receive all routinely recommended vaccines themselves. To improve parental informed vaccine decision-making, public health must ensure pediatric providers have updated resources to support their discussions of vaccine risks and benefits with their patients' parents.

Corrigendum: LetsTalkShots: personalized vaccine risk communication

[This corrects the article DOI: 10.3389/fpubh.2023.1195751.].

How to increase and maintain high immunization coverage: Vaccination Demand Resilience (VDR) framework

BACKGROUND

Resilience in vaccination demand is ever more critical as the COVID-19 pandemic has increased our understanding of the importance of vaccines on health and well-being. Yet timid demand for COVID-19 vaccines where available and reduced uptake of routine immunizations globally further raise the urgent need to build vaccination resilience. We demonstrate the complexity of vaccination demand and resilience in a framework where relevant dimensions are intertwined, fluid, and contextual.

METHODS

We developed the Vaccination Demand Resilience (VDR) framework based on a literature review on vaccination demand and expert consultation. The matrix framework builds on three main axes: 1) vaccination attitudes and beliefs; 2) vaccination seeking behavior; and 3) vaccination status. The matrix generated eight quadrants, which can help explain people's levels of vaccination demand and resilience. We selected four scenarios as examples to demonstrate different interventions that could move people across quadrants and build vaccination resilience.

RESULTS

Incongruence between individuals' attitudes and beliefs, vaccination behavior, and vaccination status can arise. For example, an individual can be vaccinated due to mandates but reject vaccination benefits and otherwise avoid seeking vaccination. Such incongruence could be altered by interventions to build resilience in vaccination demand. These interventions include information, education and communication to change individuals' vaccination attitudes and beliefs, incentive programs and reminder-recalls to facilitate vaccination seeking, or by strengthening healthcare provider communications to reduce missed opportunities.

CONCLUSIONS

Vaccination decision-making is complex. Individuals can be vaccinated without necessarily accepting the benefits of vaccination or seeking vaccination, threatening resilience in vaccination demand. The VDR framework can provide a useful lens for program managers and policy makers considering interventions and policies to improve vaccination resilience. This would help build and sustain confidence and demand for vaccinations, and help to continue to prevent disease, disability, and death from vaccine-preventable diseases.

Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia

Background

Pulse oximeters are not routinely available in outpatient clinics in low- and middle-income countries. We derived clinical scores to identify hypoxemic child pneumonia.

Methods

This was a retrospective pooled analysis of two outpatient datasets of 3-35 month olds with World Health Organization (WHO)-defined pneumonia in Bangladesh and Malawi. We constructed, internally validated, and compared fit & discrimination of four models predicting SpO2 < 93% and <90%: (1) Integrated Management of Childhood Illness guidelines, (2) WHO-composite guidelines, (3) Independent variable least absolute shrinkage and selection operator (LASSO); (4) Composite variable LASSO.

Results

12,712 observations were included. The independent and composite LASSO models discriminated moderately (both C-statistic 0.77) between children with a SpO2 < 93% and ≥94%; model predictive capacities remained moderate after adjusting for potential overfitting (C-statistic 0.74 and 0.75). The IMCI and WHO-composite models had poorer discrimination (C-statistic 0.56 and 0.68) and identified 20.6% and 56.8% of SpO2 < 93% cases. The highest score stratum of the independent and composite LASSO models identified 46.7% and 49.0% of SpO2 < 93% cases. Both LASSO models had similar performance for a SpO2 < 90%.

Conclusions

In the absence of pulse oximeters, both LASSO models better identified outpatient hypoxemic pneumonia cases than the WHO guidelines. Score external validation and implementation are needed.

Risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh: a multifacility prospective cohort study

BACKGROUND

Hypoxaemic pneumonia mortality risk in low-income and middle-income countries is high in children who have been hospitalised, but unknown among outpatient children. We sought to establish the outpatient burden, mortality risk, and prognostic accuracy of death from hypoxaemia in children with suspected pneumonia in Bangladesh.

METHODS

We conducted a prospective community-based cohort study encompassing three upazila (subdistrict) health complex catchment areas in Sylhet, Bangladesh. Children aged 3-35 months participating in a community surveillance programme and presenting to one of three upazila health complex Integrated Management of Childhood Illness (IMCI) outpatient clinics with an acute illness and signs of difficult breathing (defined as suspected pneumonia) were enrolled in the study; because lower respiratory tract infection mortality mainly occurs in children younger than 1 year, the primary study population comprised children aged 3-11 months. Study physicians recorded WHO IMCI pneumonia guideline clinical signs and peripheral arterial oxyhaemoglobin saturations (SpO2) in room air. They treated children with pneumonia with antibiotics (oral amoxicillin [40 mg/kg per dose twice per day for 5-7 days, as per local practice]), and recommended oxygen, parenteral antibiotics, and hospitalisation for those with an SpO2 of less than 90%, WHO IMCI danger signs, or severe malnutrition. Community health workers documented the children's vital status and the date of any vital status changes during routine household surveillance (one visit to each household every 2 months). The primary outcome was death at 2 weeks after enrolment in children aged 3-11 months (primary study population) and 12-35 months (secondary study population). Primary analyses included estimating the outpatient prevalence, mortality risk, and prognostic accuracy of hypoxaemia for death in children aged 3-11 months with suspected pneumonia. Risk ratios were produced by fitting a multivariable model that regressed predefined SpO2 ranges (<90%, 90-93%, and 94-100%) on the primary 2-week mortality outcome (binary outcome) using Poisson models with robust variance estimation. We established the prognostic accuracy of WHO IMCI guidelines for death with and without varying SpO2 thresholds.

FINDINGS

Participants were recruited between Sept 1, 2015, to Aug 31, 2017. During the study period, a total of 7440 children aged 3-35 months with the first suspected pneumonia episode were enrolled, of whom 3848 (54·3%) with an attempted pulse oximeter measurement and 2-week outcome were included in our primary study population of children aged 3-11-months. Among children aged 3-11 months, an SpO2 of less than 90% occurred in 102 (2·7%) of 3848 children, an SpO2 of 90-93% occurred in 306 (8·0%) children, a failed SpO2 measurement occurred in 67 (1·7%) children, and 24 (0·6%) children with suspected pneumonia died. Compared with an SpO2 of 94-100% (3373 [87·7%] of 3848), the adjusted risk ratio for death was 10·3 (95% CI 3·2-32·3; p<0·001) for an SpO2 of less than 90%, 4·3 (1·5-11·8; p=0·005) for an SpO2 of 90-93%, and 11·4 (3·1-41·4; p<0·001) for a failed measurement. When not considering pulse oximetry, of the children who died, WHO IMCI guidelines identified only 25·0% (95% CI 9·7-46·7; six of 24 children) as eligible for referral to hospital. For identifying deaths, in children with an SpO2 of less than 90% WHO IMCI guidelines had a 41·7% sensitivity (95% CI 22·1-63·4) and 89·7% specificity (88·7-90·7); for children with an SpO2 of less than 90% or measurement failure the guidelines had a 54·2% sensitivity (32·8-74·4) and 88·3% specificity (87·2-89·3); and for children with an SpO2 of less than 94% or measurement failure the guidelines had a 62·5% sensitivity (40·6-81·2) and 81·3% specificity (80·0-82·5).

INTERPRETATION

These findings support pulse oximeter use during the outpatient care of young children with suspected pneumonia in Bangladesh as well as the re-evaluation of the WHO IMCI currently recommended threshold of an SpO2 less than 90% for hospital referral.

FUNDING

Fogarty International Center of the National Institutes of Health (K01TW009988), The Bill & Melinda Gates Foundation (OPP1084286 and OPP1117483), and GlaxoSmithKline (90063241).

Evaluation of online videos to engage viewers and support decision-making for COVID-19 vaccination: how narratives and race/ethnicity enhance viewer experiences

Background

Vaccine hesitancy has hampered the control of COVID-19 and other vaccine-preventable diseases.

Methods

We conducted a national internet-based, quasi-experimental study to evaluate COVID-19 vaccine informational videos. Participants received an informational animated video paired with the randomized assignment of (1) a credible source (differing race/ethnicity) and (2) sequencing of a personal narrative before or after the video addressing their primary vaccine concern. We examined viewing time and asked video evaluation questions to those who viewed the full video.

Results

Among 14,235 participants, 2,422 (17.0%) viewed the full video. Those who viewed a personal story first (concern video second) were 10 times more likely to view the full video (p < 0.01). Respondent-provider race/ethnicity congruence was associated with increased odds of viewing the full video (aOR: 1.89, p < 0.01). Most viewers rated the informational video(s) to be helpful, easy to understand, trustworthy, and likely to impact others' vaccine decisions, with differences by demographics and also vaccine intentions and concerns.

Conclusion

Using peer-delivered, personal narrative, and/or racially congruent credible sources to introduce and deliver vaccine safety information may improve the openness of vaccine message recipients to messages and engagement.

LetsTalkShots: personalized vaccine risk communication

Introduction

Vaccine hesitancy is a global health threat undermining control of many vaccine-preventable diseases. Patient-level education has largely been ineffective in reducing vaccine concerns and increasing vaccine uptake. We built and evaluated a personalized vaccine risk communication website called LetsTalkShots in English, Spanish and French (Canadian) for vaccines across the lifespan. LetsTalkShots tailors lived experiences, credible sources and informational animations to disseminate the right message from the right messenger to the right person, applying a broad range of behavioral theories.

Methods

We used mixed-methods research to test our animation and some aspects of credible sources and personal narratives. We conducted 67 discussion groups (n = 325 persons), stratified by race/ethnicity (African American, Hispanic, and White people) and population (e.g., parents, pregnant women, adolescents, younger adults, and older adults). Using a large Ipsos survey among English-speaking respondents (n = 2,272), we tested animations aligned with vaccine concerns and specific to population (e.g., parents of children, parents of adolescents, younger adults, older adults).

Results

Discussion groups provided robust feedback specific to each animation as well as areas for improvements across animations. Most respondents indicated that the information presented was interesting (85.5%), clear (96.0%), helpful (87.0%), and trustworthy (82.2%).

Discussion

Tailored vaccine risk communication can assist decision makers as they consider vaccination for themselves, their families, and their communities. LetsTalkShots presents a model for personalized communication in other areas of medicine and public health.

Attitudes and Values of US Adults Not Yet Up-to-Date on COVID-19 Vaccines in September 2022

(1) Background: Periodic resurgences in COVID-19 due to more contagious variants highlight the need to increase coverage of booster doses. (2) Methods: Our September 2022 nationally representative survey of US adults measured COVID-19 vaccination status, intentions, attitudes, values, and confidence in information sources. (3) Findings: Although 85% of the weighted sample reported receiving at least one dose of a COVID-19 vaccine, only 63% reported being up-to-date on COVID-19 vaccines (e.g., received a booster dose). Only 12% of those not yet up-to-date indicated they were likely to get up-to-date as soon as possible, whereas 42% were unlikely to ever get up-to-date, and 46% were still uncertain. Most of those not up-to-date on their COVID-19 vaccines were under 45 years of age (58%), without a bachelor's degree (76%), making under $75,000 annually (53%), and Republican or Independent (82%). Prevalent concerns about COVID-19 vaccines among those uncertain about getting up-to-date included: potential side effects that have not been figured out yet (88%), speed of development (77%), newness (75%), ingredients (69%), drug companies making money (67%), allergic reactions (65%), and experimenting on people (63%). (4) Conclusions: Nearly half of adults not yet up-to-date on COVID-19 vaccines were uncertain about doing so, indicating an opportunity to support their decision-making.

COVID-19 vaccination among different types of US Healthcare Personnel

BACKGROUND

Increasing vaccine coverage remains the best way to control the COVID-19 pandemic. Healthcare personnel (HCP) have long been the most credible and frequently used source of vaccine information for the public, and an HCP recommendation is a strong predictor of vaccination.

METHODS

A survey of HCP was conducted in September 2021 via a double opt-in network panel. Responses to survey items were summarized and stratified by HCP type and adjusted logistic regression models were fitted.

RESULTS

>94% of the 1074 HCP surveyed reported receiving at least one dose of COVID-19 vaccine or intending to soon, with vaccinating most common among pediatricians (98%), followed by family medicine doctors (96%), pharmacists (94%), and nurses/nurse practitioners/physician assistants (88%). HCP with high trust in the Centers for Disease Control and Prevention had 26 times the odds of vaccinating of HCP with low trust (95%CI: 9, 74). Nearly half of unvaccinated HCP (47%) were concerned about side effects, and one third of unvaccinated HCP (33%) were concerned the vaccine was developed too quickly. About three quarters of HCP reported strongly recommending the Pfizer-BioNTech (75%) and Moderna (70%) vaccines to their patients, compared to about one quarter (24%) strongly recommending Johnson & Johnson.

CONCLUSIONS

Although most HCP are vaccinated against COVID-19 and strongly recommend vaccination to their patients, some harbor similar concerns to the public. Additional resources - regularly updated to explain the progressing scientific landscape and address ever evolving public concerns - are needed to further improve vaccine coverage among HCP and aid them in supporting the decision-making of their patients.

Impact of vaccine pause due to Thrombosis with thrombocytopenia syndrome (TTS) following vaccination with the Ad26.COV2.S vaccine manufactured by Janssen/Johnson & Johnson on vaccine hesitancy and acceptance among the unvaccinated population

BACKGROUND

In response to reports of thrombosis with thrombocytopenia syndrome (TTS) post-vaccination, the Johnson & Johnson (J&J) vaccine was paused and then restarted in April 2021. Our objective was to assess whether this pause adversely impacted vaccine confidence.

METHODS

Two large internet-based surveys were conducted in the US among adults to measure knowledge, attitudes and perceptions of the J&J vaccine pause and rates of vaccine hesitancy among unvaccinated persons before, during and after the pause.

RESULTS

Among 66% of respondents aware of the pause, 44% identified blood clots as the reason for the pause without prompting. The impact of the pause on vaccine behavior among unvaccinated persons and perception of the vaccine safety system was mixed and modified by trust in the public health authorities. Those who were less willing to get vaccinated because of the pause were less inclined for all vaccines, not only the J&J product. Moreover, a notable proportion (22.1%) of the small number of persons (n = 30) vaccinated with the J&J vaccine after the pause reported not receiving information about the risk of TTS. The proportion of unvaccinated persons who were hesitant was increasing before and during the pause and then leveled off after the pause.

CONCLUSIONS

The J&J vaccine pause is unlikely to be a major barrier to vaccine uptake. Public attitudes about vaccines may be more resilient than appreciated, especially when safety issues are investigated with transparent communication. This paper has important implications for messaging and program administration with future vaccine-specific adverse events. Efforts may be warranted to ensure all persons being offered the J&J vaccine are made aware of the risk of TTS.

Defining hypoxaemia from pulse oximeter measurements of oxygen saturation in well children at low altitude in Bangladesh: an observational study

Background

WHO defines hypoxaemia, a low peripheral arterial oxyhaemoglobin saturation (SpO₂), as <90%. Although hypoxaemia is an important risk factor for mortality of children with respiratory infections, the optimal SpO₂ threshold for defining hypoxaemia is uncertain in low-income and middle-income countries (LMICs). We derived a SpO₂ threshold for hypoxaemia from well children in Bangladesh residing at low altitude.

Methods

We prospectively enrolled well, children aged 3–35 months participating in a pneumococcal vaccine evaluation in Sylhet district, Bangladesh between June and August 2017. Trained health workers conducting community surveillance measured the SpO₂ of children using a Masimo Rad-5 pulse oximeter with a wrap sensor. We used standard summary statistics to evaluate the SpO₂ distribution, including whether the distribution differed by age or sex. We considered the 2.5th, 5th and 10th percentiles of SpO₂ as possible lower thresholds for hypoxaemia.

Results

Our primary analytical sample included 1470 children (mean age 18.6±9.5 months). Median SpO₂ was 98% (IQR 96%–99%), and the 2.5th, 5th and 10th percentile SpO₂ was 91%, 92% and 94%. No child had a SpO₂ <90%. Children 3–11 months had a lower median SpO₂ (97%) than 12–23 months (98%) and 24–35 months (98%) (p=0.039). The SpO₂ distribution did not differ by sex (p=0.959).

Conclusion

A SpO₂ threshold for hypoxaemia derived from the 2.5th, 5th or 10th percentile of well children is higher than <90%. If a higher threshold than <90% is adopted into LMIC care algorithms then decision-making using SpO₂ must also consider the child’s clinical status to minimise misclassification of well children as hypoxaemic. Younger children in lower altitude LMICs may require a different threshold for hypoxaemia than older children. Evaluating the mortality risk of sick children using higher SpO₂ thresholds for hypoxaemia is a key next step.

Effectiveness of the 10-valent pneumococcal conjugate vaccine against radiographic pneumonia among children in rural Bangladesh: A case-control study

Background

Pneumococcal conjugate vaccine (PCV) effectiveness against radiographic pneumonia in South Asia is unknown. Bangladesh introduced PCV10 in 2015 using a three dose primary series (3 + 0). We sought to measure PCV10 effectiveness for two or more vaccine doses on radiographic pneumonia among vaccine-eligible children in rural Bangladesh.

Methods

We conducted a matched case-control study over two years from 2015 to 2017 using clinic and community controls in three subdistricts of Sylhet, Bangladesh. Cases were vaccine eligible 3–35 month olds at Upazila Health Complex outpatient clinics with World Health Organization-defined radiographic primary endpoint pneumonia (radiographic pneumonia). Clinic controls were matched to cases within a one week time window by age, sex, and clinic and had an illness unlikely to be Streptococcus pneumoniae; community controls were healthy and similarly matched within a one week time window by age and sex, and distance from the clinic. We estimated adjusted vaccine effectiveness (aVE) using conditional logistic regression.

Results

We matched 1262 cases with 2707 clinic and 2461 community controls. Overall, aVE using clinic controls was 21.4% (95% confidence interval, −0.2%, 38.4%) for ≥2 PCV10 doses and among 3–11 month olds was 47.3% (10.5%, 69.0%) for three doses. aVE increased with higher numbers of doses in clinic control sets (p = 0.007). In contrast, aVE using community controls was 7.6% (95% confidence interval, −22.2%, 30.0%) for ≥2 doses. We found vaccine introduction in the study area faster and less variable than expected with 75% coverage on average, which reduced power. Information bias may also have affected community controls.

Conclusions

Clinic control analyses show PCV10 prevented radiographic pneumonia in Bangladesh, especially among younger children receiving three doses. While both analyses were underpowered, community control enrollment – compared to clinic controls – was more difficult in a complex, pluralistic healthcare system. Future studies in comparable settings may consider alternative study designs.

Chest radiograph reading panel performance in a Bangladesh pneumococcal vaccine effectiveness study

Introduction

To evaluate WHO chest radiograph interpretation processes during a pneumococcal vaccine effectiveness study of children aged 3–35 months with suspected pneumonia in Sylhet, Bangladesh.

Methods

Eight physicians masked to all data were standardised to WHO methodology and interpreted chest radiographs between 2015 and 2017. Each radiograph was randomly assigned to two primary readers. If the primary readers were discordant for image interpretability or the presence or absence of primary endpoint pneumonia (PEP), then another randomly selected, masked reader adjudicated the image (arbitrator). If the arbitrator disagreed with both primary readers, or concluded no PEP, then a masked expert reader finalised the interpretation. The expert reader also conducted blinded quality control (QC) for 20% of randomly selected images. We evaluated agreement between primary readers and between the expert QC reading and the final panel interpretation using per cent agreement, unadjusted Cohen’s kappa, and a prevalence and bias-adjusted kappa.

Results

Among 9723 images, the panel classified 21.3% as PEP, 77.6% no PEP and 1.1% uninterpretable. Two primary readers agreed on interpretability for 98% of images (kappa, 0.25; prevalence and bias-adjusted kappa, 0.97). Among interpretable radiographs, primary readers agreed on the presence or absence of PEP in 79% of images (kappa, 0.35; adjusted kappa, 0.57). Expert QC readings agreed with final panel conclusions on the presence or absence of PEP for 92.9% of 1652 interpretable images (kappa, 0.75; adjusted kappa, 0.85).

Conclusion

Primary reader performance and QC results suggest the panel effectively applied the WHO chest radiograph criteria for pneumonia.

Pneumococcal Conjugate Vaccine impact assessment in Bangladesh

The study examines the impact of the introduction of 10-valent Pneumococcal Conjugate Vaccine (PCV10) into Bangladesh’s national vaccine program. PCV10 is administered to children under 1 year-old; the scheduled ages of administration are at 6, 10, and 18 weeks.

The study is conducted in ~770,000 population containing ~90,000 <5 children in Sylhet, Bangladesh and has five objectives: 1) To collect data on community-based pre-PCV incidence rates of invasive pneumococcal diseases (IPD) in 0-59 month-old children in Sylhet, Bangladesh; 2) To evaluate the effectiveness of PCV10 introduction on Vaccine Type (VT) IPD in 3-59 month-old children using an incident case-control study design. Secondary aims include measuring the effects of PCV10 introduction on all IPD in 3-59 month-old children using case-control study design, and quantifying the emergence of Non Vaccine Type IPD; 3) To evaluate the effectiveness of PCV10 introduction on chest radiograph-confirmed pneumonia in children 3-35 months old using incident case-control study design. We will estimate the incidence trend of clinical and radiologically-confirmed pneumonia in 3-35 month-old children in the study area before and after introduction of PCV10; 4) To determine the feasibility and utility of lung ultrasound for the diagnosis of pediatric pneumonia in a large sample of children in a resource-limited setting. We will also evaluate the effectiveness of PCV10 introduction on ultrasound-confirmed pneumonia in 3-35 month-old children using an incident case-control design and to examine the incidence trend of ultrasound-confirmed pneumonia in 3-35 month-old children in the study area before and after PCV10 introduction; and 5) To determine the direct and indirect effects of vaccination status on nasopharyngeal colonization on VT pneumococci among children with pneumonia . 

This paper presents the methodology. The study will allow us to conduct a comprehensive and robust assessment of the impact of national introduction of PCV10 on pneumococcal disease in Bangladesh.

Efforts to monitor Global progress on individual and community demand for immunization: Development of definitions and indicators for the Global Vaccine Action Plan Strategic Objective 2

The Second Strategic Objective of the Global Vaccine Action Plan, "individuals and communities understand the value of vaccines and demand immunization as both their right and responsibility", differs from the other five in that it does not focus on supply-side aspects of immunization programs but rather on public demand for vaccines and immunization services. This commentary summarizes the work (literature review, consultations with experts, and with potential users) and findings of the UNICEF/World Health Organization Strategic Objective 2 informal Working Group on Vaccine Demand, which developed a definition for demand and indicators related to Strategic Objective 2. Demand for vaccines and vaccination is a complex concept that is not external to supply systems but rather encompasses the interaction between human behaviors and system structure and dynamics.

Effectiveness of a pay-for-performance intervention to improve maternal and child health services in Afghanistan: a cluster-randomized trial

BACKGROUND

A cluster randomized trial of a pay-for-performance (P4P) scheme was implemented in Afghanistan to test whether P4P could improve maternal and child (MCH) services.

METHODS

All 442 primary care facilities in 11 provinces were matched by type of facility and outpatient volume, and randomly assigned to the P4P or comparison arm. P4P facilities were given bonus payments based on the MCH services provided. An endline household sample survey was conducted in 72 randomly selected matched pair catchment areas (3421 P4P households; 3427 comparison).The quality of services was assessed in 81 randomly sampled matched pairs of facilities. Data collectors and households were blinded to the intervention assignment. MCH outcomes were assessed at the cluster level.

RESULTS

There were no substantial differences in any of the five MCH coverage indicators (P4P vs comparison): modern contraception(10.7% vs 11.2% (P = 0.90); antenatal care: 56.2% vs 55.6% (P = 0.94); skilled birth attendance (33.9% vs 28.5%, P = 0.17); postnatal care (31.2% vs 30.3%, P = 0.98); and childhood pentavalent3 vaccination (49.6 vs 52.3%, P = 0.41), or in the equity measures. There were substantial increases in the quality of history and physical examinations index (P = 0.01); client counselling index (P = 0.01); and time spent with patients (P = 0.05). Health workers reported limited understanding about the bonuses.

CONCLUSIONS

The intervention had minimal effect, possibly due to difficulties communicating with health workers and inattention to demand-side factors. P4P interventions need to consider management and community demand issues.