Comparing role of religion in perception of the COVID-19 vaccines in Africa and Asia Pacific.

BACKGROUND: In the midst of the global COVID-19 vaccine distribution challenge, religion stands out as a key determinant of vaccine hesitancy and health choices. Notably, the multifaceted religious environments of Africa and the Asia Pacific remain under-researched in this context. METHODS: Utilizing data from two survey waves conducted between 2021 and 2022, this cross-sectional study investigated the effects of religious beliefs on perceptions of compatibility between religion and vaccines and COVID-19 vaccine acceptance in Africa and Asia Pacific. Logistic regression models were employed, with interaction terms between socio-economic factors incorporated to account for variations among diverse subpopulations. RESULTS: Among the eight religious groups identified, Atheists and Buddhists in the Asia Pacific exhibit the lowest agreement, with fewer than 60% acknowledging the religious compatibility of vaccines. Willingness to accept vaccines, however, is consistently higher in Asia Pacific by at least four percentage points compared to Africa, with the disparity widening further in the second wave. Impacts of education on vaccine perceptions vary across religious groups, while acknowledging vaccine compatibility with religion positively contributed to vaccine acceptance. Dynamics between region, religion, and other socio-demographic factors have changed substantially over time. All but Atheists and Muslims exhibit a higher propensity to endorse vaccines during Survey Wave 2. CONCLUSIONS: Our study reveals complex, context-dependent connections between vaccine attitudes and religion and the heterogeneous effects of time and education among different religious affiliations. Understanding the underlying drivers of these temporal variations helps inform tailored approaches aimed at addressing vaccine hesitancy, promoting vaccine uptake, and improving the well-being of each religious group.

This study examined the effects of religious beliefs on thoughts about agreement between religion and vaccines, and COVID-19 vaccine acceptance in Africa and Asia Pacific. Data came from surveys of individuals across many regions during the COVID-19 pandemic in 2021 and 2022. We found lower agreement to compatibility between vaccine and religious belief among Atheists and Buddhists in the Asia Pacific, while Africans were generally less likely to accept the COVID-19 vaccines. In addition, education influenced vaccine views differently across religious groups, and those who felt vaccination was compatible with their religion were more likely to accept a vaccine. These findings show we should monitor vaccine confidence and tailor efforts to reduce vaccine hesitancy among different subgroups of people.

Social Vulnerability and Compliance With World Health Organization Advice on Protective Behaviors Against COVID-19 in African and Asia Pacific Countries: Factor Analysis to Develop a Social Vulnerability Index.

BACKGROUND: COVID-19 protective behaviors are key interventions advised by the World Health Organization (WHO) to prevent COVID-19 transmission. However, achieving compliance with this advice is often challenging, particularly among socially vulnerable groups. OBJECTIVE: We developed a social vulnerability index (SVI) to predict individuals' propensity to adhere to the WHO advice on protective behaviors against COVID-19 and identify changes in social vulnerability as Omicron evolved in African countries between January 2022 and August 2022 and Asia Pacific countries between August 2021 and June 2022. METHODS: In African countries, baseline data were collected from 14 countries (n=15,375) during the first Omicron wave, and follow-up data were collected from 7 countries (n=7179) after the wave. In Asia Pacific countries, baseline data were collected from 14 countries (n=12,866) before the first Omicron wave, and follow-up data were collected from 9 countries (n=8737) after the wave. Countries' socioeconomic and health profiles were retrieved from relevant databases. To construct the SVI for each of the 4 data sets, variables associated with COVID-19 protective behaviors were included in a factor analysis using polychoric correlation with varimax rotation. Influential factors were adjusted for cardinality, summed, and min-max normalized from 0 to 1 (most to least vulnerable). Scores for compliance with the WHO advice were calculated using individuals' self-reported protective behaviors against COVID-19. Multiple linear regression analyses were used to assess the associations between the SVI and scores for compliance to WHO advice to validate the index. RESULTS: In Africa, factors contributing to social vulnerability included literacy and media use, trust in health care workers and government, and country income and infrastructure. In Asia Pacific, social vulnerability was determined by literacy, country income and infrastructure, and population density. The index was associated with compliance with the WHO advice in both time points in African countries but only during the follow-up period in Asia Pacific countries. At baseline, the index values in African countries ranged from 0.00 to 0.31 in 13 countries, with 1 country having an index value of 1.00. The index values in Asia Pacific countries ranged from 0.00 to 0.23 in 12 countries, with 2 countries having index values of 0.79 and 1.00. During the follow-up phase, the index values decreased in 6 of 7 African countries and the 2 most vulnerable Asia Pacific countries. The index values of the least vulnerable countries remained unchanged in both regions. CONCLUSIONS: In both regions, significant inequalities in social vulnerability to compliance with WHO advice were observed at baseline, and the gaps became larger after the first Omicron wave. Understanding the dimensions that influence social vulnerability to protective behaviors against COVID-19 may underpin targeted interventions to enhance compliance with WHO recommendations and mitigate the impact of future pandemics among vulnerable groups.

A Prediction Model for Identifying Seasonal Influenza Vaccination Uptake Among Children in Wuxi, China: Prospective Observational Study.

BACKGROUND: Predicting vaccination behaviors accurately could provide insights for health care professionals to develop targeted interventions. OBJECTIVE: The aim of this study was to develop predictive models for influenza vaccination behavior among children in China. METHODS: We obtained data from a prospective observational study in Wuxi, eastern China. The predicted outcome was individual-level vaccine uptake and covariates included sociodemographics of the child and parent, parental vaccine hesitancy, perceptions of convenience to the clinic, satisfaction with clinic services, and willingness to vaccinate. Bayesian networks, logistic regression, least absolute shrinkage and selection operator (LASSO) regression, support vector machine (SVM), naive Bayes (NB), random forest (RF), and decision tree classifiers were used to construct prediction models. Various performance metrics, including area under the receiver operating characteristic curve (AUC), were used to evaluate the predictive performance of the different models. Receiver operating characteristic curves and calibration plots were used to assess model performance. RESULTS: A total of 2383 participants were included in the study; 83.2% of these children (n=1982) were <5 years old and 6.6% (n=158) had previously received an influenza vaccine. More than half (1356/2383, 56.9%) the parents indicated a willingness to vaccinate their child against influenza. Among the 2383 children, 26.3% (n=627) received influenza vaccination during the 2020-2021 season. Within the training set, the RF model showed the best performance across all metrics. In the validation set, the logistic regression model and NB model had the highest AUC values; the SVM model had the highest precision; the NB model had the highest recall; and the logistic regression model had the highest accuracy, F1 score, and Cohen κ value. The LASSO and logistic regression models were well-calibrated. CONCLUSIONS: The developed prediction model can be used to quantify the uptake of seasonal influenza vaccination for children in China. The stepwise logistic regression model may be better suited for prediction purposes.

Predictors of Global Disparities in COVID-19 Vaccination Coverage - 219 Countries and Territories, December 2020-July 2022.

What is already known about this topic?: The significant disparities in global coronavirus disease 2019 (COVID-19) vaccine coverage hamper the pace of epidemic control. There is a need to better understand the factors contributing to disparities in COVID-19 vaccination rates across countries. What is added by this report?: This report revealed significant associations between vaccination coverage and various country-level indicators. Better pandemic preparedness, higher levels of trust, and a lower proportion of young population aged 0-14 were strongly correlated with higher COVID-19 vaccination coverage. What are the implications for public health practices?: Our findings emphasize the need for enhanced pandemic preparedness and governance, coupled with building trust in government and healthcare systems. It also needs to address the hesitancy of vaccinating children and adolescents aged 0-14 as the vaccination campaign progresses.

COVID-19 vaccine acceptance and its associated factors in the Western Pacific Region.

Background: COVID-19 vaccines effectively reduced the severity of the pandemic, but the mass rollout was challenged by vaccine hesitancy, which was related to heterogenous factors-such as religiosity, mistrust, and a lack of scientific knowledge-around the globe. Distinguishing these potential influencers and quantifying their impacts would help authorities to tailor strategies that boost vaccine confidence and acceptance. Methods: We conducted a large-scale, data-driven analysis on vaccine acceptance and actual uptake in eight Western Pacific countries before (2021) and after (2022) the mass COVID-19 vaccine rollouts. We compared vaccine acceptance or uptake rates between different subpopulations using Bootstrap methods and further constructed a logistic model to investigate the relationship between vaccine endorsement and diverse socio-demographic or trust-related determinants at these two time points. Findings: Substantial between-country differences in vaccine acceptance and uptake were observed across the Western Pacific, with Mongolia, Vietnam, Laos, Cambodia, and Malaysia being more pro-vaccine than the other three countries (Japan, South Korea, and the Philippines). Actual vaccination rates in 2022 were all higher than predicted from the 2021 responses. Influencers for vaccine endorsement were country-specific, but generally, groups susceptible to vaccine hesitancy included females, the less-educated, and those distrusting vaccines or health care providers. Interpretation: Our findings demonstrate the successful translation of vaccine intent to actual uptake with the deployment of COVID-19 vaccination in the Western Pacific. Increasing vaccine confidence and supressing dissemination of misinformation may play an essential role in reducing vaccine hesitancy and ramping up immunisation. Funding: AIR@InnoHK.

Socio-sexual norms and young people's sexual health in urban Bangladesh, India, Nepal and Pakistan: A qualitative scoping review.

In South Asia, young people face myriad challenges and opportunities regarding their sexual lives relating to varied experiences of norms and restrictions; gender norms and socio-sexual taboos limit communication around sexual health which in turn can affect sexual health outcomes. In this article we focus on norms affecting young people's sexual health experiences in urban settings in Bangladesh, India, Nepal, and Pakistan. We conducted a scoping review of peer reviewed empirical studies based on qualitative data pertaining to young people's experiences of sexuality and sexual health in Bangladesh, India, Nepal, and Pakistan. We searched four electronic databases for articles published (2010-2022), using terms relating to sexual health, young people, and South Asia. Sixteen articles met the inclusion criteria with sample size ranging from 9 to 180. The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines for the design and analysis of this study. We synthesised the included articles using thematic analysis. The studies covered topics such as sexual health services and contraceptive use; sexuality education and communication; and gender and sexual violence. Recurring findings included: parental and societal expectations around premarital 'sexual purity' through abstinence; limited communication around sexuality between young people and parents/adults; gender norms limiting young women's sexual and reproductive decision making; and an absence of research on experiences of sexual and gender minorities. We identified common themes as well as prominent gaps which must be addressed if we are to capture diverse experiences and build a better evidence base to improve sexual health services for young people in the region. The body of research fails to include experiences of young people with diverse gender, sexual orientation, and sex characteristics.

Perceptions about respiratory syncytial virus (RSV) and attitudes toward the RSV vaccine among the general public in China: A cross-sectional survey.

Our study aims to assess the public's perceptions of respiratory syncytial virus (RSV) and attitudes toward the RSV vaccine and to identify associated factors in China. A nationwide cross-sectional survey conducted using an online platform between August 16 and September 14, 2023. Questions related to socio-demographics, awareness, knowledge, perceptions of susceptibility and severity of RSV, and attitudes toward the RSV vaccine were included in the questionnaire. We used the chi-square test and logistic regression model to explore the associated factors. Overall, 2133 individuals were included in this study. Nearly a quarter of participants (24.3%) indicated that they had never heard of RSV. The proportion of individuals aged over 50 years reporting never having heard of RSV (36.5%) and having a low knowledge level of RSV (55.3%) was significantly higher that of other younger age groups. More than half of individuals (55.7%) exhibited low level of perceptions of susceptibility concerning RSV infection. A total of 68.4% of the participants expressed willingness to receive the RSV vaccine. Younger age was positively associated with a higher willingness to be vaccinated. The most frequent reason for declining the vaccine was "Concern about vaccine's safety or side effects." About 60% of individuals considered a price of RSV vaccine below 200 CNY (28 USD) as acceptable. The awareness and perceived susceptibility to RSV infection were limited to the Chinese public. It is necessary to take measures to address the low awareness and knowledge of RSV and acceptability of the RSV vaccine among older adults.

Between now and later: a mixed methods study of HPV vaccination delay among Chinese caregivers in urban Chengdu, China.

BACKGROUND: Adolescent girls in China have a low HPV vaccination rate. Although vaccination is recommended by the Chinese health authorities, the cost is not covered by the national immunisation programme. Vaccination delay, among other reasons such as supply shortage and poor affordability, may contribute to low uptake. This sequential mixed methods study aimed to identify potential factors of delayed HPV vaccination among Chinese adolescent girls. METHODS: Quantitative data about the attitudes and perceptions of HPV vaccination were collected from 100 caregivers of 14-18-year-old girls using an online survey in Chengdu, China. The survey data informed a subsequent qualitative study using four focus group discussions. We conducted a descriptive analysis of the survey data and a thematic analysis of the qualitative data. The findings were interpreted using a health behaviour model adapted from the Health Belief Model and the Andersen's Behavioural Model for Health Services Use. RESULTS: A total of 100 caregivers - 85 were mothers and 15 were fathers - participated in the survey; 21 caregivers joined focus group discussions. When asked about their intended course of action if the 9vHPV vaccine was out-of-stock, 74% chose to delay until the 9vHPV vaccine is available while 26% would consider 2vHPV or 4vHPV vaccines or seek alternative ways to procure the vaccine. Qualitative results confirmed that caregivers preferred delaying HPV vaccination for adolescent girls. The intent to delay was influenced by systemic barriers such as supply shortage and individual-level factors such as a preference for the 9vHPV vaccine, safety concerns, inadequate health communication, and the belief that adolescents were unlikely to be sexually active. CONCLUSION: In urban areas, Chinese caregivers' intent to delay vaccination in favour of 9vHPV vaccine over receiving the more accessible options was influenced by a mix of individual and contextual factors. Focussed health communication strategies are needed to accelerate HPV vaccination among adolescents.

Spatiotemporal trends in COVID-19 vaccine sentiments on a social media platform and correlations with reported vaccine coverage.

Objective: To assess spatiotemporal trends in, and determinants of, the acceptance of coronavirus disease 2019 (COVID-19) vaccination globally, as expressed on the social media platform X (formerly Twitter). Methods: We collected over 13 million posts on the platform regarding COVID-19 vaccination made between November 2020 and March 2022 in 90 languages. Multilingual deep learning XLM-RoBERTa models annotated all posts using an annotation framework after being fine-tuned on 8125 manually annotated, English-language posts. The annotation results were used to assess spatiotemporal trends in COVID-19 vaccine acceptance and confidence as expressed by platform users in 135 countries and territories. We identified associations between spatiotemporal trends in vaccine acceptance and country-level characteristics and public policies by using univariate and multivariate regression analysis. Findings: A greater proportion of platform users in the World Health Organization's South-East Asia, Eastern Mediterranean and Western Pacific Regions expressed vaccine acceptance than users in the rest of the world. Countries in which a greater proportion of platform users expressed vaccine acceptance had higher COVID-19 vaccine coverage rates. Trust in government was also associated with greater vaccine acceptance. Internationally, vaccine acceptance and confidence declined among platform users as: (i) vaccination eligibility was extended to adolescents; (ii) vaccine supplies became sufficient; (iii) nonpharmaceutical interventions were relaxed; and (iv) global reports on adverse events following vaccination appeared. Conclusion: Social media listening could provide an effective and expeditious means of informing public health policies during pandemics, and could supplement existing public health surveillance approaches in addressing global health issues.

Vaccine confidence mediates the association between a pro-social pay-it-forward intervention and improved influenza vaccine uptake in China: A mediation analysis.

INTRODUCTION: A Chinese clinical trial has demonstrated that a prosocial pay-it-forward intervention that offered subsidized vaccination and postcard messages effectively increased influenza vaccine uptake and vaccine confidence. This secondary analysis explored the potential mediating role of vaccine confidence on the association between a pay-it-forward intervention and influenza vaccine uptake, and how this might vary by individual annual income levels. METHODS: Data from 300 participants (150 standard-of-care and 150 pay-it-forward participants) were included in the analysis. We conducted descriptive analysis of demographic and vaccine confidence variables. Multivariable regression and mediation analysis on interventions, vaccine confidence and vaccine uptake were conducted. A sub-group analysis was conducted to further understand whether associations between these variables vary by income levels (<=$1860 or >$1860). RESULTS: The pay-it-forward intervention was significantly associated with greater levels of perceived influenza vaccine importance (adjusted odds ratio (aOR) = 3.60, 95 %CI: 1.77-7.32), effectiveness (aOR = 3.37, 95 %CI: 1.75-6.52) and safety (aOR = 2.20, 95 %CI: 1.17-4.15). Greater perceived influenza vaccine importance was associated with increased vaccine uptake (aOR = 8.51, 95 %CI: 3.04-23.86). The indirect effect of the pay-it-forward intervention on vaccination was significant through improved perceived influenza vaccine importance (indirect effect1 = 0.07, 95 %CI: 0.02-0.11). This study further revealed that, irrespective of the individual income level, the pay-it-forward intervention was associated with increased vaccine uptake when compared to the standard-of-care approach. CONCLUSIONS: Pay-it-forward intervention may be a promising strategy to improve influenza vaccine uptake. Perceived confidence in vaccine importance appears to be a potential mediator of the association between pay-it-forward and vaccine uptake.

Substantial Disparities In COVID-19 Vaccine Uptake And Unmet Immunization Demand In Low- And Middle-Income Countries.

The two primary narratives that have emerged to explain low COVID-19 vaccine uptake in low- and middle-income countries are constrained accessibility and vaccine hesitancy. However, it is unclear how much each issue contributes to low uptake. This article examines these twin barriers to access. Using global survey data from 15,696 respondents across seventeen Western Pacific and African countries, collected between May 2022 and January 2023, we estimated the unmet demand for vaccines and examined its predictors. We found that among unvaccinated respondents, by the time of the survey, 50 percent had unmet demand-meaning they were still willing to get vaccinated. Rates of unmet demand were highest in African countries and lowest in Western Pacific countries. The perceived accessibility of vaccines and respondents' age and sex were identified as consistent predictors of unmet demand. These issues suggest that inequitable supply continues to play a substantial role in limiting vaccine access. Targeted efforts to increase vaccination rates are necessary, particularly in countries with low coverage and high unmet demand. Policy efforts should address barriers to vaccine access, ensure accessibility and distribution of mRNA vaccines, and aim to overcome vaccine hesitancy-all critical factors in reducing unmet immunization demand and achieving higher vaccination rates across regions.

Who gets COVID-19 booster vaccination? Trust in public health institutions and promotion strategies post-pandemic in the Republic of Korea.

INTRODUCTION: It is increasingly recognized that regular boosters will be necessary for the continued management of the COVID-19 pandemic. While vaccine hesitancy in the context of the initial COVID-19 vaccinations has been extensively studied, less is known about hesitancy around boosters in the post-pandemic era, where the immediate threat of COVID-19 has diminished. METHODS: Using 5,584 survey responses from people who had received at least one COVID-19 vaccine dose based on a four-round survey between May and November 2022, we examined various factors that affect booster vaccine uptake and the willingness to take an additional shot. Ordinary least squares regressions were conducted to confirm the statistical significance of the findings. RESULTS: Nearly 99% of vaccinated respondents reported having had two COVID-19 vaccine doses, while 69% of respondents reported having received a booster shot (three or more vaccine doses) and 48% reported being willing to get another shot. Booster uptake was strongly increased along with the degree of trust in the Korean Disease Control Agency (KDCA) and was also significantly associated with older age, gender, political propensity, and household income-level. When examining willingness to get an additional shot, the predictors were similar to booster vaccine uptake. However, the effect of trust in the KDCA became more salient. CONCLUSION: The factors associated with booster uptake and willingness to continue to boost are similar to those associated with initial vaccine acceptance in the ROK, namely trust in the public health authority and older age. Despite high initial uptake in the ROK, convincing the public of the continued necessity of routine immunization against COVID-19 may pose challenges in the post-pandemic era.

Conversational AI and Vaccine Communication: Systematic Review of the Evidence.

BACKGROUND: Since the mid-2010s, use of conversational artificial intelligence (AI; chatbots) in health care has expanded significantly, especially in the context of increased burdens on health systems and restrictions on in-person consultations with health care providers during the COVID-19 pandemic. One emerging use for conversational AI is to capture evolving questions and communicate information about vaccines and vaccination. OBJECTIVE: The objective of this systematic review was to examine documented uses and evidence on the effectiveness of conversational AI for vaccine communication. METHODS: This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Web of Science, PsycINFO, MEDLINE, Scopus, CINAHL Complete, Cochrane Library, Embase, Epistemonikos, Global Health, Global Index Medicus, Academic Search Complete, and the University of London library database were searched for papers on the use of conversational AI for vaccine communication. The inclusion criteria were studies that included (1) documented instances of conversational AI being used for the purpose of vaccine communication and (2) evaluation data on the impact and effectiveness of the intervention. RESULTS: After duplicates were removed, the review identified 496 unique records, which were then screened by title and abstract, of which 38 were identified for full-text review. Seven fit the inclusion criteria and were assessed and summarized in the findings of this review. Overall, vaccine chatbots deployed to date have been relatively simple in their design and have mainly been used to provide factual information to users in response to their questions about vaccines. Additionally, chatbots have been used for vaccination scheduling, appointment reminders, debunking misinformation, and, in some cases, for vaccine counseling and persuasion. Available evidence suggests that chatbots can have a positive effect on vaccine attitudes; however, studies were typically exploratory in nature, and some lacked a control group or had very small sample sizes. CONCLUSIONS: The review found evidence of potential benefits from conversational AI for vaccine communication. Factors that may contribute to the effectiveness of vaccine chatbots include their ability to provide credible and personalized information in real time, the familiarity and accessibility of the chatbot platform, and the extent to which interactions with the chatbot feel "natural" to users. However, evaluations have focused on the short-term, direct effects of chatbots on their users. The potential longer-term and societal impacts of conversational AI have yet to be analyzed. In addition, existing studies do not adequately address how ethics apply in the field of conversational AI around vaccines. In a context where further digitalization of vaccine communication can be anticipated, additional high-quality research will be required across all these areas.

Cost-effectiveness of seasonal influenza vaccination of children in China: a modeling analysis.

BACKGROUND: China has a high burden of influenza-associated illness among children. We aimed to evaluate the cost-effectiveness of introducing government-funded influenza vaccination to children in China (fully-funded policy) compared with the status quo (self-paid policy). METHODS: A decision tree model was developed to calculate the economic and health outcomes, from a societal perspective, using national- and provincial-level data. The incremental cost-effectiveness ratio (ICER) [incremental costs per quality-adjusted life year (QALY) gained] was used to compare the fully-funded policy with the self-paid policy under the willingness-to-pay threshold equivalent to national and provincial GDP per capita. Sensitivity analyses were performed and various scenarios were explored based on real-world conditions, including incorporating indirect effect into the analysis. RESULTS: Compared to the self-paid policy, implementation of a fully-funded policy could prevent 1,444,768 [95% uncertainty range (UR): 1,203,446-1,719,761] symptomatic cases, 92,110 (95% UR: 66,953-122,226) influenza-related hospitalizations, and 6494 (95% UR: 4590-8962) influenza-related death per season. The fully-funded policy was cost-effective nationally (7964 USD per QALY gained) and provincially for 13 of 31 provincial-level administrative divisions (PLADs). The probability of a funded vaccination policy being cost-effective was 56.5% nationally, and the probability in 9 of 31 PLADs was above 75%. The result was most sensitive to the symptomatic influenza rate among children under 5 years [ICER ranging from - 25,612 (cost-saving) to 14,532 USD per QALY gained]. The ICER of the fully-funded policy was substantially lower (becoming cost-saving) if the indirect effects of vaccination were considered. CONCLUSIONS: Introducing a government-funded influenza policy for children is cost-effective in China nationally and in many PLADs. PLADs with high symptomatic influenza rate and influenza-associated mortality would benefit the most from a government-funded influenza vaccination program.

Pay-it-forward to increase uptake among 15-18-year-old adolescent girls compared with user-paid vaccination: The pilot results of a two-arm randomized controlled trial in China.

Background: China has low human papillomavirus(HPV) vaccination rate due to lack of public funding and mistrust in domestic vaccines. This pilot study evaluated the feasibility and preliminary effectiveness of an innovative pay-it-forward strategy, which has a participant receive a subsidized vaccine and offers her an opportunity to donate to support other girls, in improving HPV vaccine uptake among 15-18-year-old adolescent girls. Methods: A two-arm randomized controlled pilot trial was performed in one vaccination clinic in Western China. Adolescent girls (via caregivers) were invited to participate the study via online dissemination of the pilot study. Eligible ones were then randomly allocated using a sealed envelope method into standard-of-care or pay-it-forward arm in a 1:1 ratio. Pay-it-forward participants received hand-written postcard messages, a subsidized vaccine, and an opportunity to donate and (or) write postcards for future recipient girls. Standard-of-care participants self-paid for vaccines. The primary outcome was the first-dose HPV vaccine uptake, which was calculated using multivariable logistic regression, presented as crude/adjusted odds ratios (cORs/aORs) and 95% con dence intervals (CIs). Standard scales were used to assess the feasibility of the program. Results: A total of 100 participants (50 in each arm) were recruited from Jan 4, 2022 to Feb 18, 2022. The HPV vaccine uptake rate was 98% (49/50) in the pay-it-forward arm and 82% (41/50) in the standard-of-care arm (cOR = 10.76, 95% CI: 1.31-88.47, P = 0.027; aOR = 12.12, 95% CI: 1.37-107.29, P = 0.025). The completion rate of full schedule of HPV vaccination in the two arms was 100% (49/49) and 95.1% (39/41), respectively. Of all 49 vaccinated girls in the pay-it-forward arm, 38 (77.6%) donated to support future participants, and the total donation accounted for 33.3% of prepaid subsidization. Among caregivers in the pay-it-forward arm, 97.6% (41/42) believed that this strategy was feasible. Conclusions: The pilot showed feasibility and preliminary effectiveness of a pay-it-forward strategy to increase HPV vaccination rate. The high uptake rate in the standard-of-care arm is likely caused by the selection bias associated with the online dissemination approach and secured vaccine supply through the program. Further adaption of the intervention package and a population-based recruitment pathway are needed to better reflect local contexts and enhance the generalizability of the subsequent formal trial. Trial registration: Chinese Clinical Trial Registry (ChiCTR), ChiCTR2200055542. Retrospectively registered on 11 January 2022, https://www.chictr.org.cn/showproj.html?proj=139738.

The impact of inpatient bloodstream infections caused by antibiotic-resistant bacteria in low- and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: Bloodstream infections (BSIs) produced by antibiotic-resistant bacteria (ARB) cause a substantial disease burden worldwide. However, most estimates come from high-income settings and thus are not globally representative. This study quantifies the excess mortality, length of hospital stay (LOS), intensive care unit (ICU) admission, and economic costs associated with ARB BSIs, compared to antibiotic-sensitive bacteria (ASB), among adult inpatients in low- and middle-income countries (LMICs). METHODS AND FINDINGS: We conducted a systematic review by searching 4 medical databases (PubMed, SCIELO, Scopus, and WHO's Global Index Medicus; initial search n = 13,012 from their inception to August 1, 2022). We only included quantitative studies. Our final sample consisted of n = 109 articles, excluding studies from high-income countries, without our outcomes of interest, or without a clear source of bloodstream infection. Crude mortality, ICU admission, and LOS were meta-analysed using the inverse variance heterogeneity model for the general and subgroup analyses including bacterial Gram type, family, and resistance type. For economic costs, direct medical costs per bed-day were sourced from WHO-CHOICE. Mortality costs were estimated based on productivity loss from years of potential life lost due to premature mortality. All costs were in 2020 USD. We assessed studies' quality and risk of publication bias using the MASTER framework. Multivariable meta-regressions were employed for the mortality and ICU admission outcomes only. Most included studies showed a significant increase in crude mortality (odds ratio (OR) 1.58, 95% CI [1.35 to 1.80], p < 0.001), total LOS (standardised mean difference "SMD" 0.49, 95% CI [0.20 to 0.78], p < 0.001), and ICU admission (OR 1.96, 95% CI [1.56 to 2.47], p < 0.001) for ARB versus ASB BSIs. Studies analysing Enterobacteriaceae, Acinetobacter baumanii, and Staphylococcus aureus in upper-middle-income countries from the African and Western Pacific regions showed the highest excess mortality, LOS, and ICU admission for ARB versus ASB BSIs per patient. Multivariable meta-regressions indicated that patients with resistant Acinetobacter baumanii BSIs had higher mortality odds when comparing ARB versus ASB BSI patients (OR 1.67, 95% CI [1.18 to 2.36], p 0.004). Excess direct medical costs were estimated at $12,442 (95% CI [$6,693 to $18,191]) for ARB versus ASB BSI per patient, with an average cost of $41,103 (95% CI [$30,931 to $51,274]) due to premature mortality. Limitations included the poor quality of some of the reviewed studies regarding the high risk of selective sampling or failure to adequately account for relevant confounders. CONCLUSIONS: We provide an overview of the impact ARB BSIs in limited resource settings derived from the existing literature. Drug resistance was associated with a substantial disease and economic burden in LMICs. Although, our results show wide heterogeneity between WHO regions, income groups, and pathogen-drug combinations. Overall, there is a paucity of BSI data from LMICs, which hinders implementation of country-specific policies and tracking of health progress.

Effectiveness of chatbots on COVID vaccine confidence and acceptance in Thailand, Hong Kong, and Singapore.

Chatbots have become an increasingly popular tool in the field of health services and communications. Despite chatbots' significance amid the COVID-19 pandemic, few studies have performed a rigorous evaluation of the effectiveness of chatbots in improving vaccine confidence and acceptance. In Thailand, Hong Kong, and Singapore, from February 11th to June 30th, 2022, we conducted multisite randomised controlled trials (RCT) on 2,045 adult guardians of children and seniors who were unvaccinated or had delayed vaccinations. After a week of using COVID-19 vaccine chatbots, the differences in vaccine confidence and acceptance were compared between the intervention and control groups. Compared to non-users, fewer chatbot users reported decreased confidence in vaccine effectiveness in the Thailand child group [Intervention: 4.3 % vs. Control: 17%, P = 0.023]. However, more chatbot users reported decreased vaccine acceptance [26% vs. 12%, P = 0.028] in Hong Kong child group and decreased vaccine confidence in safety [29% vs. 10%, P = 0.041] in Singapore child group. There was no statistically significant change in vaccine confidence or acceptance in the Hong Kong senior group. Employing the RE-AIM framework, process evaluation indicated strong acceptance and implementation support for vaccine chatbots from stakeholders, with high levels of sustainability and scalability. This multisite, parallel RCT study on vaccine chatbots found mixed success in improving vaccine confidence and acceptance among unvaccinated Asian subpopulations. Further studies that link chatbot usage and real-world vaccine uptake are needed to augment evidence for employing vaccine chatbots to advance vaccine confidence and acceptance.

Effect of a mobile app chatbot and an interactive small-group webinar on COVID-19 vaccine intention and confidence in Japan: a randomised controlled trial.

INTRODUCTION: We investigated the effect of social media-based interventions on COVID-19 vaccine intention (VI) and confidence in Japan. METHODS: We conducted a three-arm randomised controlled trial between 5 November 2021 and 9 January 2022 during a low incidence (<1000/day) of COVID-19 in Japan in the midst of the second and the third waves. Japanese citizens aged ≥20 who had not received any COVID-19 vaccine and did not intend to be vaccinated were randomly assigned to one of the following three groups: (1) a control group, (2) a group using a mobile app chatbot providing information on COVID-19 vaccines and (3) a group using interactive webinars with health professionals. VI and predefined Vaccine Confidence Index (VCI) measuring confidence in the importance, safety and effectiveness were compared before and after the interventions under intention-to-treat principle. Logistic regression models were used to investigate the effect of each intervention on postintervention VI and changes of VCI compared with control. RESULTS: Among 386 participants in each group, 359 (93.0%), 231 (59.8%) and 207 (53.6%) completed the postsurvey for the control, chatbot and webinar groups, respectively. The average duration between the intervention and the postsurvey was 32 days in chatbot group and 27 days in webinar group. VI increased from 0% to 18.5% (95% CI 14.5%, 22.5%) in control group, 15.4% (95% CI 10.8%, 20.1%) in chatbot group and 19.7% (95% CI 14.5%, 24.9%) in webinar group without significant difference (OR for improvement=0.8 (95% CI 0.5, 1.3), p=0.33 between chatbot and control, OR=1.1 (95% CI 0.7, 1.6), p=0.73 between webinar and control). VCI change tended to be larger in chatbot group compared with control group without significant difference (3.3% vs -2.5% in importance, OR for improvement=1.3 (95% CI 0.9, 2.0), p=0.18; 2.5% vs 1.9% in safety, OR=1.1 (95% CI 0.7, 1.9), p=0.62; -2.4% vs -7.6% in effectiveness, OR=1.4 (95% CI 0.9, 2.1), p=0.09). Improvement in VCI was larger in webinar group compared with control group for importance (7.8% vs -2.5%, OR=1.8 (95% CI 1.2, 2.8), p<0.01), effectiveness (6.4% vs -7.6%, OR=2.2 (95% CI 1.4, 3.4), p<0.01) and safety (6.0% vs 1.9%, OR=1.6 (95% CI 1.0, 2.6), p=0.08). CONCLUSION: This study demonstrated that neither the chatbot nor the webinar changed VI importantly compared with control. Interactive webinars could be an effective tool to change vaccine confidence. Further study is needed to identify risk factors associated with decreased vaccine confidence and investigate what intervention can increase VI and vaccine confidence for COVID-19 vaccines. TRIAL REGISTRATION NUMBER: UMIN000045747.

Global antimicrobial-resistance drivers: an ecological country-level study at the human-animal interface.

BACKGROUND: Antimicrobial resistance (AMR) is a pressing, holistic, and multisectoral challenge facing contemporary global health. In this study we assessed the associations between socioeconomic, anthropogenic, and environmental indicators and country-level rates of AMR in humans and food-producing animals. METHODS: In this modelling study, we obtained data on Carbapenem-resistant Acinetobacter baumanii and Pseudomonas aeruginosa, third generation cephalosporins-resistant Escherichia coli and Klebsiella pneumoniae, oxacillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecium AMR in humans and food-producing animals from publicly available sources, including WHO, World Bank, and Center for Disease Dynamics Economics and Policy. AMR in food-producing animals presented a combined prevalence of AMR exposure in cattle, pigs, and chickens. We used multivariable ß regression models to determine the adjusted association between human and food-producing animal AMR rates and an array of ecological country-level indicators. Human AMR rates were classified according to the WHO priority pathogens list and antibiotic-bacterium pairs. FINDINGS: Significant associations were identified between animal antimicrobial consumption and AMR in food-producing animals (OR 1·05 [95% CI 1·01-1·10]; p=0·013), and between human antimicrobial consumption and AMR specifically in WHO critical priority (1·06 [1·00-1·12]; p=0·035) and high priority (1·22 [1·09-1·37]; p<0·0001) pathogens. Bidirectional associations were also found: animal antibiotic consumption was positively linked with resistance in critical priority human pathogens (1·07 [1·01-1·13]; p=0·020) and human antibiotic consumption was positively linked with animal AMR (1·05 [1·01-1·09]; p=0·010). Carbapenem-resistant Acinetobacter baumanii, third generation cephalosporins-resistant Escherichia coli, and oxacillin-resistant Staphylococcus aureus all had significant associations with animal antibiotic consumption. Analyses also suggested significant roles of socioeconomics, including governance on AMR rates in humans and animals. INTERPRETATION: Reduced rates of antibiotic consumption alone will not be sufficient to combat the rising worldwide prevalence of AMR. Control methods should focus on poverty reduction and aim to prevent AMR transmission across different One Health domains while accounting for domain-specific risk factors. The levelling up of livestock surveillance systems to better match those reporting on human AMR, and, strengthening all surveillance efforts, particularly in low-income and middle-income countries, are pressing priorities. FUNDING: None.