A survey of state and local practices encouraging pediatric COVID-19 vaccination of children ages 6 months through 11 years

OBJECTIVE

This report highlights state and local practices for optimizing the pediatric COVID-19 vaccination program for children ages 6 months through 11 years.

METHODS

State and local practices designed to optimize pediatric COVID-19 vaccine uptake were identified from a range of sources, including immunization program, CDC, and partner staff; and media stories or program descriptions identified via online searches.

RESULTS

A range of practices were identified across different categories: provider-focused practices, school-based practices, jurisdiction or health department-based activities, community-focused practices involving partners, use of vaccination incentives, and Medicaid-related practices.

CONCLUSIONS

Immunization programs and stakeholders implemented a variety of practices to meet the challenge of the pediatric COVID-19 vaccination program. The key findings may serve to inform not only the current pediatric COVID-19 vaccination program, but also future outbreak response work and routine immunization activities.

Accelerating into Immunization Agenda 2030 with momentum from China's successful COVID-19 vaccination campaign during dynamic COVID Zero

China's immunization programs conducted a unified, tightly coordinated COVID-19 vaccination campaign during the dynamic COVID Zero period that reached well over 90% of the population with vaccines having > 90% effectiveness against serious-to-fatal COVID-19. The campaign was eight times the size of the annual routine national immunization program, administering 3.4 billion doses of vaccines while monitoring vaccine coverage, acceptability, safety, and effectiveness. Every asset of the routine immunization program had to be strengthened and expanded to attain high coverage and reach hundreds of millions of adults who had not been vaccinated since childhood. Program strengthening and expansion were in directions aligned with the World Health Organization's Immunization Agenda 2030, which has a vision that "everyone, everywhere, at every age fully benefits from vaccines for good health and well-being" and requires reaching all children, adolescents, and adults with lifesaving vaccines. Momentum from this campaign should not be lost but should be invested into achieving what is possible with a properly resourced national immunization program that is now proven to be capable of reaching everyone in the world's largest country throughout the life course, and to do so with all vaccines recommended by the World Health Organization.

Vaccine events raising public concern and associated immunization program policy and practice changes, China, 2005-2021

INTRODUCTION

Several vaccine events causing public concern have occurred in China that were investigated and responded to by the central government. We describe causes, influences, and policy or practice changes associated with vaccine events that occurred between 2005 and 2021. We make recommendations to foster resilience in China's Expanded Program of Immunization (EPI) system and vaccination enterprises and to sustain vaccine and program confidence.

METHODS

Our study included all vaccine events since 2005 that were investigated and responded to by the central government of China. We verified mainstream and social media visibility of the events through Internet search. We extracted event times, causes, investigation processes, results, actions, and policy or practice regulation changes from official reports of government meetings and from official websites with media briefings.

RESULTS

Seven vaccine events were identified, each of which caused more than 100,000 mainstream or social media reports nationally or nationally and internationally. The events ranged in magnitude from 145 children receiving out-of-date oral poliovirus vaccine to a measles supplementary immunization activity involving 103 million children. Few, if any, children were directly harmed by vaccines in the events. Government responded to each event with program or policy changes, and in one case, with legislation. Responses affected the conduct of campaigns and supplementary immunization activities, use of schools as vaccination venues, financial incentives for vaccinating with non-program vaccines, vaccine procurement and distribution, and program policy making. The most fundamental response was enacting the country's first vaccine law, the 2019 Vaccine Administration Law, which guides virtually all aspects of vaccination work, from vaccine development through regulation, program implementation, and safety and impact monitoring.

CONCLUSIONS

All seven events generated substantial national and international mainstream and social media criticism and discussion, most commonly expressed through concerns of vaccine safety or vaccine effectiveness. Most had temporally associated temporary declines in vaccine confidence and coverage, jeopardizing decades of vaccination effort. The central government responded to each event by attempting to address root causes. Faithful implementation of the Vaccine Administration Law is fundamental to program strengthening and sustaining confidence of families, stakeholders, and government in vaccines and immunization in China.

Human papillomavirus (HPV) vaccine uptake among a community-recruited sample of gay, bisexual, and other men who have sex with men in the three largest cities in Canada from 2017 to 2019

INTRODUCTION

In 2015/2016, Canada's largest provinces implemented publicly-funded human papillomavirus (HPV) vaccination programs for gay, bisexual, and other men who have sex with men (GBM) ≤ 26 years old. We sought to describe HPV vaccine uptake among GBM and determine barriers and facilitators to vaccine initiation with a focus on healthcare access and utilization.

METHODS

Engage is a cohort study among GBM aged 16 + years in three Canadian cities recruited from 2017 to 2019 via respondent driven sampling (RDS). Men completed a comprehensive questionnaire at baseline. By publicly-funded vaccine eligibility (≤26 years old = eligible for vaccination, ≥27 years old = ineligible), we described HPV vaccine uptake (initiation = 1 + dose, completion = 3 doses) and explored factors associated with vaccine initiation using Poisson regression. All analyses were weighted with the RDS-II Volz-Heckathorn estimator.

RESULTS

Across the three cities, 26-35% and 14-21% of men ≤ 26 years and 7-26% and 2-9% of men ≥ 27 years initiated and completed HPV vaccination, respectively. Vaccine initiation was significantly associated with STI/HIV testing or visiting a HIV care specialist in the past six months (≤26: prevalence ratio[PR] = 2.15, 95% confidence interval[CI] 1.06-4.36; ≥27: PR = 2.73, 95%CI 1.14-6.51) and past hepatitis A or B vaccination (≤26: PR = 2.88, 95%CI 1.64-5.05; ≥27: PR = 2.03, 95%CI 1.07-3.86). Among men ≥ 27 years old, vaccine initiation was also positively associated with accessing PrEP, living in Vancouver or Toronto, but negatively associated with identifying as Latin American and increasing age. Vaccine initiation was twice as likely among men ≥ 27 years with private insurance versus no insurance.

CONCLUSIONS

Sixty-five to 74% of men eligible for publicly-funded vaccine across the three cities remained unvaccinated against HPV by 2019. High vaccine cost may partly explain even lower uptake among men ≥ 27 years old. Men seeking sexual health care were more likely to initiate vaccination; bundling vaccination with these services may help improve HPV vaccine uptake.

Changes and remaining challenges for the Japanese immunization program: Closing the vaccine gap

The Japanese immunization program has made considerable progress since 2009: several new vaccines have been introduced and most are included in the National Immunization Program (NIP). In October 2020, the Japanese law on immunization was revised, which resulted in a few laudable achievements. First, rotavirus vaccines were added to the NIP, 10 years after their introduction, and noteworthy studies of vaccine effectiveness and the incidence of intussusception in Japanese children were published. Second, rules on vaccine intervals-which had been a longstanding concern-were withdrawn. In addition to this revision of the law, the Japanese version of the Vaccine Information Statement (VIS) was released by the Japan Pediatric Society in 2018. The VIS provides useful caregiver information on general immunization concepts and individual vaccines. Further challenges for the Japanese immunization program include (1) administering a booster dose of pertussis-containing vaccine to preschool children or teenagers, (2) reestablishing the active recommendation for human papilloma virus vaccines, (3) adding the mumps and influenza vaccines to the NIP, and (4) ensuring optimal dosing of seasonal influenza vaccines. During the current coronavirus disease 2019 (COVID-19) pandemic, vaccination rates among children have been decreasing in many countries. In Japan, vaccination rates have been stable in infants, but declining among toddlers and school-aged children, despite public awareness of the need for timely administration of vaccines during the pandemic. Clearly, further action is needed if we are to adequately protect children living in Japan from vaccine-preventable diseases.

Ancillary benefits of seasonal influenza vaccination in middle-income countries

While seasonal influenza vaccines (SIV) remain the best method to prevent influenza-associated illnesses, implementing SIV programs may benefit countries beyond disease reduction, strengthening health systems and national immunization programs, or conversely, introduce new challenges. Few studies have examined perceived impacts of SIV introduction beyond disease reduction on health systems; understanding such impacts will be particularly salient in the context of COVID-19 vaccine introduction. We collected qualitative data from key informants-Partnership for Influenza Vaccine Introduction (PIVI) contacts in six middle-income PIVI vaccine recipient countries-to understand perceptions of ancillary benefits and challenges from SIV implementation. Respondents reported benefits associated with SIV introduction, including improved attitudes to SIV among risk groups (characterized by increased demand) and perceptions that SIV introduction improved relationships with other ministries and collaboration with mass media. Challenges included sustaining investment in SIV programs, as vaccine supply did not always meet coverage goals, and managing SIV campaigns.

Timeliness of childhood vaccinations in the Philippines

Timeliness of vaccinations is rarely part of monitoring in a routine immunization program. We reviewed infant immunization and conducted caregiver interviews in three regions in the Philippines from January to October 2016. We randomly selected thirty public health centers, one for each region. We defined timeliness of the receipt of antigen as within 4 weeks after the recommended age at vaccination. We assessed a total of 986 infants for timeliness of vaccination. The median age of receipt of vaccine was at 2.7 weeks (BCG), 10.1 weeks (Penta 1), and 21.7 weeks (Penta 3) compared to the recommended 0, 6, and 14 weeks of age, respectively. We found timely receipt only in 74.4% for BCG, 70.3% for Penta 1, and 39.1% for Penta 3 recipients. Thus, alongside declining immunization coverage, the infants in the Philippines had substantial delays in vaccine receipt.

How to recover lost vaccine acceptance? A multi-center survey on HPV vaccine acceptance in Japan

BACKGROUND

The plummeting acceptance rate of the HPV vaccine in Japan is one of the most disappointing vaccine-related events in recent times. Since 2013, the national HPV vaccine coverage rate fell from more than 70% to less than 1%. This survey investigated parental HPV vaccine acceptance and the factors that influence it.

METHODS

A multi-center survey was conducted in eight hospitals in Nara prefecture, Japan, from July 2019 to March 2020. Parents were asked to answer a series of questions in a survey that included information on the HPV vaccine.

RESULTS

Among the 1884 parents who answered the questionnaire, 21.8% indicated that they had accepted the HPV vaccine even before reading the information provided in the questionnaire. The overall acceptance rate after everyone had read the information increased to 50.2% (p < 0.001). Among those who still did not accept the vaccine after reading the information (N = 925), 26.7% indicated that they might change their mind if more vaccine safety reports were to appear in the mass media; other potentially influencing factors were direct communication from health care providers (35.1%), a recommendation by government (19.5%), and peer behavior (16.8%).

CONCLUSION

The study showed that providing appropriate medical information significantly improves HPV vaccine acceptance. To reverse the loss of HPV vaccine acceptance in Japan, a multi-discipline approach that includes the mass media, health care providers, the government and the general population will be needed.

What we know and don't know about the immunization program of Ethiopia: a scoping review of the literature

BACKGROUND

There has been significant recent prioritization and investment in the immunization program in Ethiopia. However, coverage rates have stagnated and remained low for many years, suggesting the presence of systemic barriers to implementation. Hence, there is a need to consolidate the existing knowledge, in order to address them and consequently improve program effectiveness.

METHODS

A thorough literature review and Delphi method were used. In this review, we searched Pubmed/Medline, WHO library, Science direct, Cochrane library, Google scholar and Google using different combinations of search strategies. Studies that applied any study design, data collection and analysis methods related to immunization program were included. In the Delphi method, a panel of 28 national and international experts were participated to identify current evidence gaps and set research priorities under the immunization program.

RESULTS

In this review, a total of 55 studies and national documents were included. The review showed that the vaccination coverage ranged from 20.6% in Afar to 91.7% in Amhara region with large inequities related to socio-economic, health service access and knowledge about vaccination across different settings. Only one study reported evidence on timeliness of immunization as 60%. The review revealed that 80% of health facilities provide immunization service nationally while service availability was only 2% in private health facilities. This review indicated that poor vaccine storage, vaccine shortage, service interruptions, poor defaulter tracing, low community engagement and poor documentation were the main barriers for the Expanded Program on Immunization with variations across different regions. Through expert panel of discussion using Delphi method, 10 priority research areas were identified across different domains of the immunization program at national level.

CONCLUSION

We found out that there is substantial knowledge on vaccination coverage, however, there is little evidence on timeliness of vaccination. The existing barriers that affect full immunization coverage also varied from context to context which indicates there is a need to design and implement evidence based locally tailored interventions. This review also indicated evidence gaps with more focus on health system related implementation barriers at lower level and identified further research priorities in the immunization program of Ethiopia.

Meningococcal disease surveillance in the Asia-Pacific region (2020): The global meningococcal initiative

The degree of surveillance data and control strategies for invasive meningococcal disease (IMD) varies across the Asia-Pacific region. IMD cases are often reported throughout the region, but the disease is not notifiable in some countries, including Myanmar, Bangladesh and Malaysia. Although there remains a paucity of data from many countries, specific nations have introduced additional surveillance measures. The incidence of IMD is low and similar across the represented countries (<0.2 cases per 100,000 persons per year), with the predominant serogroups of Neisseria meningitidis being B, W and Y, although serogroups A and X are present in some areas. Resistance to ciprofloxacin is also of concern, with the close monitoring of antibiotic-resistant clonal complexes (e.g., cc4821) being a priority. Meningococcal vaccination is only included in a few National Immunization Programs, but is recommended for high-risk groups, including travellers (such as pilgrims) and people with complement deficiencies or human immunodeficiency virus (HIV). Both polysaccharide and conjugate vaccines form part of recommendations. However, cost and misconceptions remain limiting factors in vaccine uptake, despite conjugate vaccines preventing the acquisition of carriage.

A human rights approach to understanding provider knowledge and attitudes toward the human papillomavirus vaccine in São Paulo, Brazil

Objective

To determine the extent to which human rights considerations influence the attitudes of healthcare providers in Brazil with regard to access to the human papillomavirus (HPV) vaccine for females over 13 and males of all ages.

Methods

From May to August 2015, we conducted a cross-sectional study among healthcare providers in eight public health clinics in the city of Mauá, Brazil. Frequency analysis was conducted across three subject areas: access, knowledge, and attitudes.

Results

A total of 154 surveys were analyzed. Providers reported their perception that Brazilians do not have equal access to health (80%) and the vaccine exclusions limit an individual's right to health (72%). Providers stated it is medically effective to vaccinate females over the age of 13 (77%), these females should be vaccinated (84%), and they would vaccinate them (82%). Similar responses were reported for males.

Conclusion

Cervical cancer is the 4th leading cause of cancer among females in Brazil. Most cervical cancer cases are caused by persistent HPV infection, preventable through HPV vaccination. Limiting access to the HPV vaccine when medically efficacious is a perceived infringement of an individual's right to health. Brazil has a constitutional responsibility to reduce these access barriers.

Prevention and control of meningococcal disease: Updates from the Global Meningococcal Initiative in Eastern Europe

The Global Meningococcal Initiative (GMI) aims to prevent invasive meningococcal disease (IMD) worldwide through education, research and cooperation. In March 2019, a GMI meeting was held with a multidisciplinary group of experts and representatives from countries within Eastern Europe. Across the countries represented, IMD surveillance is largely in place, with incidence declining in recent decades and now generally at <1 case per 100,000 persons per year. Predominating serogroups are B and C, followed by A, and cases attributable to serogroups W, X and Y are emerging. Available vaccines differ between countries, are generally not included in immunization programs and provided to high-risk groups only. Available vaccines include both conjugate and polysaccharide vaccines; however, current data and GMI recommendations advocate the use of conjugate vaccines, where possible, due to the ability to interrupt the acquisition of carriage. Ongoing carriage studies are expected to inform vaccine effectiveness and immunization schedules. Additionally, IMD prevention and control should be guided by monitoring outbreak progression and the emergence and international spread of strains and antibiotic resistance through use of genomic analyses and implementation of World Health Organization initiatives. Protection of high-risk groups (such as those with complement deficiencies, laboratory workers, migrants and refugees) is recommended.

[Strengthen the studies on vaccine safety surveillance and economic assessment in China: not a moment too soon]

Vaccination is among the most economic and effective intervention measures to combat infectious diseases. National immunization program is the best approach to achieve the major public health value of vaccines, and is an important sign of equity of medical service. The evidences accumulated by the studies on vaccine safety and economic assessment are the important basis for the decision making for immunization.

Questionnaire survey on maternal pertussis vaccination for pregnant women and mothers in Nara prefecture, Japan

Background: Infantile pertussis is a major concern and causes a significant health burden worldwide. Maternal adult tetanus, diphtheria, and acellular pertussis (Tdap) vaccination is very effective way of preventing infantile pertussis. However, Tdap has not been approved by the Japanese government or been included in Japan's national immunization program (NIP). We carried out a questionnaire survey to investigate whether Japanese women would accept the Tdap vaccination if they were provided with appropriate information.Methods: The questionnaire survey was administered to pregnant women who visited the Obstetrics and Gynecology Department and mothers who visited the Pediatrics Department of Nara Medical University, Kashihara City, Japan, between October 2018 and May 2019. The questionnaire included information about pertussis infection and maternal vaccination, followed by seven questions.Results: A total of 943 participants answered the questionnaire (481 pregnant women and 462 mothers). Before reading the information, just 4.6% of participants knew that infantile pertussis can be prevented by maternal vaccination. After reading the information, 93.0% and 92.6% of participants thought that the maternal Tdap vaccine should be approved by the Japanese government and be included in the NIP, respectively. Although only 67.6% of participants wished to have the maternal Tdap vaccine without government financial support after reading the information, 92.5% said they would have the vaccine with government support (P < .001).Conclusion: Most Japanese mothers and pregnant women would like the maternal Tdap vaccine to be approved by the government and included in the NIP, once they have been provided with appropriate information.

[Methodology of the 2nd seroprevalence study in Spain]

Seroprevalence studies are designed in population samples to assess the level and distribution of immunity induced by natural infection of certain infectious agents or by immunization against them. The purpose of the 2nd Seroprevalence Study in Spain is to assess the prevalence and distribution of immune status against vaccine-preventable diseases and generated by natural infection by other microorganisms. Pathologies specifically included in the study are: poliomyelitis, diphtheria, tetanus, pertussis, measles, rubella, mumps, varicella, invasive meningococcal disease by serogroup C, hepatitis A, hepatitis B, hepatitis E, hepatitis C and HIV. The study has a similar design of that conducted in 1996, as it is a descriptive cross-sectional study in resident population of 2 to 80 years of age in Spain. Two-stage conglomerate sampling was carried out on the population aged 2 to 80 years living in Spain, with an initial sample size of 10,000 people. The methodology of the study is described in this article.

Defining & assessing the quality, usability, and utilization of immunization data

Background

High quality data are needed for decision-making at all levels of the public health system, from guiding public health activities at the local level, to informing national policy development, to monitoring the impact of global initiatives. Although a number of approaches have been developed to evaluate the underlying quality of routinely collected vaccination administrative data, there remains a lack of consensus around how data quality is best defined or measured.

Discussion

We present a definitional framework that is intended to disentangle many of the elements that have confused discussions of vaccination data quality to date. The framework describes immunization data in terms of three key characteristics: data quality, data usability, and data utilization. The framework also offers concrete suggestions for a specific set of indicators that could be used to better understand immunization those key characteristics, including Trueness, Concurrence, Relevancy, Efficiency, Completeness, Timeliness, Integrity, Consistency, and Utilization.

Conclusion

Being deliberate about the choice of indicators; being clear on their definitions, limitations, and methods of measurement; and describing how those indicators work together to give a more comprehensive and practical understanding of immunization data quality, usability, and use, should yield more informed, and therefore better, programmatic decision-making.

Human rotavirus in Iran; molecular epidemiology, genetic diversity and recent updates on vaccine advances

Human rotavirus is the predominant pathogen causing gastroenteritis in infants and children younger than 5 years of age globally. Before introduction and implementation of rotavirus vaccine, more than frothy percent of all caused acute gastroenteritis hospitalization and nearly half a million deaths per year was occurred due to Rotavirus infection mostly in the low-income countries. Rotaviruses are divided in G and P genotypes, based on two genomic segments' nucleotide sequences VP7 and VP4, respectively. Currently, 27 G and 37 P types have been described; among them G1 to G4 and G9 and P[8], P[4], and P[6] genotypes are the most prevalent circulating rotavirus strains globally. Molecular epidemiological surveys revealed that G1P[8] is the predominant genotype in Iran, although other genotypes have also been reported. Rotavirus vaccine was recommended by the World Health Organization as a necessary part of national childhood immunization programs in 2009. Rotarix (monovalent) and RotaTeq (pantavalent) are two oral vaccines that have been available in more than one hundred countries around the world to control the viral infection and reduce the cases of diarrheal diseases. This article provides a review of frequency, molecular epidemiology and current situation of Rotavirus genetic diversity Iran. In addition, recent advances in rotavirus vaccine research are discussed.

Did two booster doses for schoolchildren change the epidemiology of pertussis in Israel?

Pertussis is the only vaccine-preventable disease that has re-emerged in Israel. In the last two decades, despite high primary immunization coverage, crude incidence increased over tenfold, with especially high morbidity among infants and adolescents and with 19 infant deaths. Two pertussis vaccine boosters were added, in 2005 for 7-year-olds and in 2011 for 13-year-olds. We reviewed age group incidence from 1999 to 2016, before and after the booster program introduction. We compared three groups of 13-15 year-olds with identical primary immunization but different booster immunization histories. Vaccine effectiveness was calculated before and after adjustment for specific incidence in those aged 65 and over. Two years after one booster, adjusted vaccine effectiveness was 74.5%. Two years after two boosters, adjusted vaccine effectiveness was 91.8%. However, crude morbidity rates were not reduced. The booster program has been effective only among recipient groups. The program will be continued. Israel is now encouraging pregnant women to be vaccinated against pertussis to improve protection of infants.

Progress and challenges for the Japanese immunization program: Beyond the "vaccine gap"

The Japanese immunization program has made considerable recent progress. The introduction of several new vaccines, especially foreign-produced vaccines, and the inclusion of important new vaccines in the National Immunization Program (NIP) are closing the "vaccine gap", i.e., the delay in the Japanese immunization program relative to programs in other developed countries. Major progress in the Japanese immunization program since 2014 includes (1) elimination of measles in March 2015, (2) introduction of a varicella vaccine as a routine immunization in the NIP in October 2015, and (3) introduction of hepatitis B virus vaccines as routine immunizations in the NIP in October 2016. Despite these promising developments, important issues remain. First, the government withdrew the active recommendation for human papilloma virus vaccines temporarily in 2013. The withdrawal has continued and unresolved despite new scientific evidence confirming the safety of these vaccines. Second, a few important voluntary vaccines, including vaccines for mumps and rotavirus, have not been included in the NIP since their introduction to Japan. Finally, there are concerns related to a shortage of mandatory domestic vaccines, which was caused by a natural disaster in the area where a vaccine-producing factory was located. Additionally, the manufacturer included unauthorized additives in some vaccine products with falsifying the production-process records. To avoid problems related to vaccine shortages, essential vaccines need to be stockpiled, and the future vaccine needs for children should to be discussed. New initiatives must continue to close the vaccine gap, as this will protect children living in Japan from vaccine-preventable diseases.

Proposal for cervical cancer screening in the era of HPV vaccination

Eradication of cervical cancer involves the expansion of human papillomavirus (HPV) vaccine coverage and the development of efficient screening guidelines that take vaccination into account. In Korea, the HPV National Immunization Program was launched in 2016 and is expected to shift the prevalence of HPV genotypes in the country, among other effects. The experiences of another countries that implement national immunization programs should be applied to Korea. If HPV vaccines spread nationwide with broader coverage, after a few decades, cervical intraepithelial lesions or invasive cancer should become a rare disease, leading to a predictable decrease in the positive predictive value of cervical screening cytology. HPV testing is the primary screening tool for cervical cancer and has replaced traditional cytology-based guidelines. The current screening strategy in Korea does not differentiate women who have received complete vaccination from those who are unvaccinated. However, in the post-vaccination era, newly revised policies will be needed. We also discuss on how to increase the vaccination rate in adolescence.

Meningococcal disease and control in China: Findings and updates from the Global Meningococcal Initiative (GMI)

The Global Meningococcal Initiative (GMI) is a global expert group, including scientists, clinicians and public health officials from a wide range of specialities. The goal of the GMI is to prevent meningococcal disease worldwide through education, research, and co-operation. The Chinese GMI roundtable meeting was held in June 2017. The GMI met with local experts to gain insight into the meningococcal disease burden in China and current prevention and vaccination strategies in place. China experienced five epidemics of serogroup A meningococcal disease (MenA) between 1938 and 1977, with peak incidence of 403/100,000 recorded in 1967. MenA incidence rates have significantly declined following the universal introduction of the MenA polysaccharide vaccine in China in the 1980s. Further, surveillance data indicates changing meningococcal epidemiology in China with the emergence of new clones of serogroup B from serogroup C clonal complex (cc) 4821 due to capsular switching, and the international spread of serogroup W cc11. The importance of carriage and herd protection for controlling meningococcal disease was highlighted with the view to introduce conjugate vaccines and serogroup B vaccines into the national immunization schedule. Improved disease surveillance and standardized laboratory techniques across and within provinces will ensure optimal epidemiological monitoring.

Integration of Neonatal and Child Health Interventions with Pediatric HIV Interventions in Global Health

BACKGROUND/OBJECTIVES

In the last decade, many strategies have called for integration of HIV and child survival platforms to reduce missed opportunities and improve child health outcomes. Countries with generalized HIV epidemics have been encouraged to optimize each clinical encounter to bend the HIV epidemic curve. This systematic review looks at integrated child health services and summarizes evidence on their health outcomes, service uptake, acceptability, and identified enablers and barriers.

METHODS

Databases were systematically searched for peer-reviewed studies. Interventions of interest were HIV services integrated with: neonatal/child services for children <5 years, hospital care of children <5 years, immunizations, and nutrition services. Outcomes of interest were: health outcomes of children <5 years, integrated services uptake, acceptability, and enablers and barriers. PROSPERO ID: CRD42017082444.

RESULTS

Twenty-eight articles were reviewed: 25 (89%) evaluated the integration of HIV services into child health platforms, while three articles (11%) investigated the integration of child health services into HIV platforms. Studies measured health outcomes of children (n=9); service uptake (n=18); acceptability of integrated services (n=8), and enablers and barriers to service integration (n=14). Service integration had positive effects on child health outcomes, HIV testing, and postnatal service uptake. Integrated services were generally acceptable, although confidentiality and stigma were concerns.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Each clinical "touch point" with infants and children is an opportunity to provide comprehensive health services. In the current era of flat funding levels, integration of HIV and child health services is an effective, acceptable way to achieve positive child health outcomes.

Static model simulation for routine mumps vaccination in Japan: with a result of mumps-related complications in a Japanese community hospital

Purpose

Mumps vaccine has not been included in the routine national immunization program in Japan, leading to low vaccine coverage rates and periodic epidemics approximately every 5 years. Our hospital (a secondary community hospital in Japan) experienced an increased number of mumps-related complications with a nationwide epidemic in 2016. Using previously reported data and mumps-related cases in our hospital, we estimated the cost-effectiveness of routine mumps vaccination in Japan with a static model using current epidemiologic data.

Materials and Methods

With a decision tree flowchart of mumps infection and adverse events, we estimated the burden of mumps-related complications in our hospital for 5 years, and calculated the current annual national burden. Finally, we compared the current burden and assumptive burden of the stable state after routine vaccination in Japan using a static model.

Results

The cost-benefit ratios with sensitivity analysis were 3.69 (1.08-9.52) and 6.84 (1.51-23.73) in independent inoculation and simultaneous inoculation, respectively, from a social perspective in addition to an annual gain of 9,487 (3,227-14,659) quality adjusted life years.

Conclusion

We contributed additional evidence in terms of cost-effectiveness that routine mumps vaccination should be introduced in Japan with simultaneous inoculation.

Exploring the acceptability of the available pneumococcal conjugate vaccines in Canadian health care professionals and immunization experts

BACKGROUND

In children, the 13 and 10-valent pneumoccocal conjugate vaccines (PCV13/10) are currently approved for the prevention of invasive pneumococcal disease (IPD). Acceptability is a key consideration in the implementation of a vaccine program and it is recognized that health professional's attitudes and opinions towards vaccines are independent predictors of the success of an immunization program. We aimed to survey the beliefs and attitudes for the two available PCVs in health care professionals and immunization experts.

FINDINGS

We interviewed 21 members of Canadian immunization committees and/or participants working in frontline healthcare delivery. Overall, participants predominantly preferred PCV-13 over PCV10. For most, AOM should not be taken into considerations in decisions for pneumococcal vaccination programs implementation. AOM was considered an important endpoint of the program but an ineffective measure of program success due to the lack of surveillance for the condition. Recent evidence pertaining to PCV10 cross-protection against 19A did not affect preference but had an impact on perceptions regarding pricing.

CONCLUSION

To consider implementing any changes to the current program, most participants would require more evidence regarding PCV10 cross-protection and effectiveness against OM. Decreasing vaccine price was cited as a positive outcome of funding both vaccines.

What vaccine product attributes do immunization program stakeholders value? Results from interviews in six low- and middle-income countries

This study attempts to capture the opinions of stakeholders working in immunization programs in low- and middle-income countries to understand how vaccine products could be improved to better meet their needs and to obtain feedback on specific vaccine product attributes including the number of doses per container and ease of preparing a dose for administration. We also reviewed how procurement decisions are made within immunization programs. Semi-structured interviews were undertaken with 158 immunization stakeholders in Brazil, China, India, Peru, the Philippines, and Tanzania. Interviewees included national decision-makers and advisors involved in vaccine-purchasing decisions (n=30), national Expanded Programme on Immunization managers (n=6), and health and logistics personnel at national, subnational, and health-facility levels (n=122). Immunization stakeholders at all levels of the supply chain valued vaccine product attributes that prevent heat damage, decrease vaccine wastage, and simplify delivery. Minimizing the time required to prepare a dose is especially valued by those closest to the work of actually administering vaccines. Respondents appreciated the benefits of lower-multidose presentations on reducing wastage but seemed to prefer single-dose vials even more. They also expressed concern about the need for training and the potential for confusion and vial contamination if opened vials of liquid preservative-free vaccines are not handled properly. Procurement decision-making processes varied widely between countries, though most relied heavily on international agencies and vaccine manufacturers for information.

Contributions and challenges for worldwide vaccine safety: The Global Advisory Committee on Vaccine Safety at 15 years

In 1999, the Global Advisory Committee on Vaccine Safety (GACVS) was established by the World Health Organization (WHO) to provide independent scientific advice on issues relating to the safety of vaccines and immunization. Fifteen years onward, we conducted a multi-faceted review to evaluate the impact, reach and challenges facing GACVS, including the role GACVS plays in informing global, regional and WHO member state vaccine policy. The methods included measures of organizational structure, citation impact, themes approached, and a discussion by previous and current members to evaluate past, present and future challenges. Given the increasing range of data sources and the deployment of many new vaccines, the Committee is facing the complex task of identifying the best available evidence for recommendations on vaccine safety. To help meet the increased demand for public transparency in decision making, GACVS-structured methodology for evidence-based decisions is evolving. GACVS also promotes best practices and capacity building for timely and accurate risk assessment; risk communications; outreach to help countries maintain and, if needed, rebuild public trust in vaccines; and advocacy for bridging the major gaps in vaccine safety capacity globally.

Evidence-based decision-making for vaccine introductions: Overview of the ProVac International Working Group's experience

INTRODUCTION

Pan American Health Organization's (PAHO) ProVac Initiative aims to strengthen countries' technical capacity to make evidence-based immunization policy. With financial support from the Bill and Melinda Gates Foundation, PAHO established the ProVac International Working Group (IWG), a platform created for two years to transfer the ProVac Initiative's tools and methods to support decisions in non-PAHO regions.

METHODS

In 2011, WHO Regional Offices and partner agencies established the IWG to transfer the ProVac framework for new vaccine decision support, including tools and trainings to other regions of the world. During the two year period, PAHO served as the coordinating secretariat and partner agencies played implementing or advisory roles.

RESULTS

Fifty nine national professionals from 17 countries received training on the use of economic evaluations to aid vaccine policy making through regional workshops. The IWG provided direct technical support to nine countries to develop cost-effectiveness analyses to inform decisions. All nine countries introduced the new vaccine evaluated or their NITAGs have made a recommendation to the Ministry of Health to introduce the new vaccine.

DISCUSSION

Developing countries around the world are increasingly interested in weighing the potential health impact due to new vaccine introduction against the investments required. During the two years, the ProVac approach proved valuable and timely to aid the national decision making processes, even despite the different challenges and idiosyncrasies encountered in each region. The results of this work suggest that: (1) there is great need and demand for technical support and for capacity building around economic evaluations; and (2) the ProVac method of supporting country-owned analyses is as effective in other regions as it has been in the PAHO region.

CONCLUSION

Decision support for new vaccine introduction in low- and middle-income countries is critical to guiding the efficient use of resources and prioritizing high impact vaccination programs.

Assessment of the hepatitis B birth dose vaccination program, Papua New Guinea, 2014

INTRODUCTION

Papua New Guinea (PNG) implemented hepatitis B birth dose (BD) vaccination in 2005 yet since that time coverage has remained low, allowing mother-to-child transmission to occur. We conducted a field assessment of the BD vaccination program to develop strategies for improving the BD coverage.

METHODS

We selected five provinces with higher hepatitis B prevalence and five with lower prevalence based on the results of a 2013 hepatitis B serological survey. Within each province, we interviewed district and provincial health officers, health workers, village volunteers, and caregivers from ten randomly selected health facilities. Data were collected on knowledge, practice, vaccine management and data recording/reporting. To identify enabling factors and barriers, we compared health facilities with higher BD coverage with those with lower coverage, and compared caregivers whose children received BD with those whose children did not.

RESULTS

Overall timely BD coverage was 31% and BD vaccination was taking place in 81% of sampled health facilities. Lack of cold chain and vaccine were the major reasons for not providing the BD. Insufficiencies in supervision, vaccine management, community outreach, and data management were identified as obstacles to achieving high timely hepatitis B BD coverage. Good supervision, knowledge of hepatitis B and hepatitis B vaccination, antenatal care including information about the hepatitis B BD, provision of vaccine refrigerators in maternity wards, and outreach vaccination for home deliveries were associated with higher timely BD coverage.

DISCUSSION

Several steps will likely be effective in improving BD coverage: strengthening training and supervision among health workers and officers, educating caregivers on the benefits of the BD and delivery in health facilities, improving vaccine management, and improving data quality. Considerable effort and leadership will be needed to achieve these steps.

Pneumococcal disease and use of pneumococcal vaccines in Taiwan

The use of pneumococcal vaccine plays an important role for prevention of invasive pneumococcal disease (IPD). However, introducing the pneumococcal vaccine into the national immunization program (NIP) is complex and costly. The strategy of progressively integrating the pneumococcal conjugate vaccine (PCV) into the NIP in Taiwan provides valuable experience for policy makers. The 7-valent PCV (PCV7) was first available in Taiwan in late 2005. PCV7 was first provided free to children with underlying diseases, those in vulnerable socioeconomic status, and those with inadequate health care resources. The catch-up immunization program with the 13-valent PCV was launched in 2013 and the national pneumococcal immunization program was implemented in 2015. Children aged 2-5 years had the highest incidence of IPD among pediatric population in Taiwan. Although the incidence of IPD caused by PCV7 serotypes has declined, the overall incidence of IPD remained high in the context of PCV7 use in the private sector. A surge of IPD caused by serotype 19A occurred, accounting for 53.6% of IPD cases among children aged ≤ 5 years in 2011-2012. After the implementation of the national pneumococcal immunization program, serogroup 15 has become the leading serogroup for IPD in children. Continued surveillance is necessary to monitor the serotype epidemiology in Taiwan.

Streptococcus pneumoniae Serotypes Identified in Mexican Children with Invasive Disease Before and After the Introduction of PCV7 (1993-2012)

BACKGROUND AND AIMS

Streptococcus pneumoniae is the leading cause of acute otitis media, pneumonia, meningitis, and sepsis. The heptavalent pneumococcal conjugate vaccine (PCV7) was incorporated into the national immunization program in Mexico in 2008. The aim of the study was to analyze the frequency of S. pneumoniae serotypes isolated from children ≤5 years of age with invasive diseases before and after the introduction of PCV7.

METHODS

Isolates from sterile fluids, tissues and other body fluids were obtained from 1993 to 2012. Isolates collected in hospitals for the surveillance network were sent to the Instituto Nacional de Salud Publica. Serotyping was done using the Quellung reaction. The pre-vaccination period was considered from 1993-2007.

RESULTS

A total of 1346 isolates were collected during 1993-2012. In the pre-vaccination era, serotypes included in PCV7 accounted for 59.7% of the strains, whereas in 2012 they represented only 21% of cases. There was a significant decrease in all PCV7-included serotypes. A gradual increase of the 19A serotype was detected during the vaccination period from 7% in 2008 to 39% of the isolates in 2012. In this year, 29% of the serotypes causing invasive disease were not included in any of the pneumococcal conjugate vaccines.

CONCLUSION

The emergence of PCV7 non-included serotypes after vaccination demands increased surveillance. Currently in Mexico, the 13-valent conjugate vaccine (PCV13) offers better coverage than the 10-valent pneumococcal conjugate vaccine (PCV10).

Recent progress and concerns regarding the Japanese immunization program: addressing the "vaccine gap"

Recent progress in the Japanese immunization program has partially closed the "vaccine gap," i.e., the deficiencies in that program relative to immunization programs in other developed countries. During the last several years, seven new vaccines (12 new products, excluding influenza vaccines) have been introduced in Japan. Five of these new vaccines are produced outside Japan and four are now included as routine vaccines in the National Immunization Program, which is a new development in the licensing and financial support of imported vaccines. However, along with this progress, important concerns have arisen regarding the Japanese immunization program. A rubella epidemic among adults, in 2012-2013, resulted in more than 40 cases of congenital rubella syndrome as of March 2014. In addition, the temporary withdrawal of the active governmental recommendation for human papilloma virus vaccines, in 2013-2014, highlighted challenges in the current Japanese immunization system. Furthermore, some important vaccines - including vaccines for hepatitis B virus, mumps, varicella, and rotavirus - are still not included in the National Immunization Program and have been categorized as voluntary vaccines since their introduction. The possibility of their inclusion in the National Immunization Program remains a matter for discussion. We hope that future initiatives will further address the vaccine gap and protect Japanese children from vaccine-preventable diseases.

Impact of 2+1 pneumococcal conjugate vaccine program in the province of Quebec, Canada

BACKGROUND

Quebec was the first jurisdiction in the world to recommend a 3-dose (2+1) pneumococcal conjugate vaccine (PCV) schedule. The program was implemented in December 2004 with a catch-up for children <5 years. PCV-7 was first used and replaced, respectively, by PCV-10 in 2009 and by PCV-13 in 2011.

METHODS

Cases of invasive pneumococcal disease (IPD) notified to public health authorities and isolates submitted to the provincial reference laboratory during the period 2000-2011 were analyzed.

RESULTS

IPD incidence in children <5 years was 67/100,000 in 2001-2004, and decreased to 32/100,000 in 2007-2009 following PCV-7 implementation (p<0.01). A further decrease to 24/100,000 was observed in 2010-2011 following PCV-10 introduction (p<0.01). PCV-7 serotypes represented 82% of the total IPD cases in 2000-2004 and elimination was achieved in 2011. Main emerging serotypes were 19A and 7F. Children exposed to the PCV-10 experienced lower IPD rates and all serotypes contributed to the decline, mainly 7F and 19A. In adults, a decrease of low magnitude was observed in 2005-2006 but rates in 2007-2009 were higher than in the prevaccination period.

CONCLUSIONS

A 3-dose PCV schedule with high uptake is highly effective and should be recommended worldwide. Serotype replacement eroded benefits especially in adults. PCV-10 introduction had an effect and the impact of PCV-13 use remains to be evaluated.

Antenatal Care Seeking Behaviour among Slum Mothers: A Study of Rajshahi City Corporation, Bangladesh

OBJECTIVES

The study aimed to identify the important effects of some selected variables in antenatal care (ANC) seeking behaviour among slum mothers.

METHODS

The data for the study were collected in 2006 from 700 mothers in the slum areas of Rajshahi City Corporation (RCC), Bangladesh.

RESULTS

The results indicate that tetanus toxoid (TT) is relatively widespread in slum areas of RCC. Serious health implications were observed for the mothers and their children who lived in the study areas because more than half of the respondents (56.1%) were not assisted at their last childbirth by any health professional. The respondents were too poor to buy iron tablets/syrup and vitamin tablets/syrup during their last pregnancy. The application of a logistic regression model suggested that demographic and socio-economic factors were associated with ANC seeking behaviour among slum mothers.

CONCLUSION

Respondents' education, place of treatment, husband's occupation, family's income, and exposure to mass media had highly significant effects on mothers seeking medical checkups during their last pregnancy.