Behavioral interventions for vaccination uptake: A systematic review and meta-analysis.

BACKGROUND: Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries. METHODS: We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately. FINDINGS: Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes. INTERPRETATION: Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Feasibility Study of a Powder-Based Supplement Intervention for a future Synbiotic Trial in Breastfed Children from South Africa.

Background: Children who are HIV-exposed uninfected (HEU), i.e., born to mothers living with HIV despite not acquiring HIV infection themselves, have increased morbidity and mortality. Data suggests that the breastmilk profile, and more specifically human milk oligosaccharide (HMO) composition, differ by maternal HIV status and may partly help explain this increased risk. We are currently conducting an HMO-based synbiotic randomized trial in breastfed children HEU, the MIGH-T MO study (ClinicalTrials.gov Identifier: NCT05282485), to assess the impact on health outcomes of children HEU. Here, we report our experience from a study of the feasibility and acceptability of a powder-based intervention given to breastfeeding children, conducted prior to the initiation of MIGH-T MO. Methods: 10 mothers living with HIV and their breastfeeding children HEU accessing care at Tygerberg Hospital, in Cape Town, South Africa were enrolled. A powder-based product, potato maltodextrin, was mixed with expressed breast milk and administered to the infants daily for 4 weeks. Data on feasibility, acceptability, adherence, and health outcomes were assessed at the enrollment visit and at the 4 week visit, along with weekly telephone calls. Results: 10 mother-infant pairs were enrolled in this study, with infant age ranging from 6-20 months of age. Among the mothers who met the eligibility criteria, all of them enrolled into the study suggesting high acceptability. While there was some Ioss-to-follow-up after the first visit, among the mothers who remained, there were no major feasibility concerns related to study procedures, product administration, adherence, tolerance, and health outcome assessment. Conclusion: Our pilot study demonstrated that a powder-based intervention for breastfeeding children HEU in South Africa is acceptable and feasible. This suggests potential feasibility and acceptability for other larger studies, including our ongoing MIGH-T MO study, that use similar powder-based interventions such as probiotics, prebiotics, or synbiotics, in breastfed infants from similar settings.

Association of Pregnancy and HIV Status With Molecular-Bacterial Vaginosis in Indian Women.

BACKGROUND: Bacterial vaginosis (BV) is a highly prevalent disorder of the cervicovaginal microbiota. Molecular-BV may put women at increased risk for adverse reproductive and obstetric outcomes. We investigated the association of HIV and pregnancy on the vaginal microbiota and associations with molecular-BV in women of reproductive age from Pune, India. SETTING: We studied vaginal samples from N = 170 women, including N = 44 nonpregnant HIV seronegative, N = 56 pregnant seronegative, N = 47 nonpregnant women with HIV (WWH), and N = 23 pregnant WWH, and collected data on clinical, behavioral, and demographic factors. METHODS: We used 16S rRNA gene amplicon sequencing to characterize the composition of the vaginal microbiota. We classified the vaginal microbiota of these women into community state types based on bacterial composition and relative abundance and further categorized them into molecular-BV versus Lactobacillus -dominated states. To determine associations between pregnancy and HIV status with outcome of molecular-BV, logistic regression models were used. RESULTS: There was a high prevalence of molecular-BV (30%) in this cohort. We found that pregnancy was associated with decreased odds of molecular-BV (adjusted OR = 0.35, 95% CI: 0.14 to 0.87), while HIV was associated with increased odds of molecular-BV (adjusted OR = 2.76, 95% CI: 1.33 to 5.73), even when controlling for multiple relevant factors such as age, number of sexual partners, condom use, and douching. CONCLUSION: Larger and longitudinal studies are needed to further characterize molecular-BV and the vaginal microbiota in pregnant women and WWH and relate these factors to infectious, reproductive, and obstetric outcomes. In the long term, these studies may lead to novel microbiota-based therapeutics to improve women's reproductive and obstetric health.

Mitigating Infectious morbidity and Growth deficits in HIV-exposed uninfected infanTs with human Milk Oligosaccharide (MIGH-T MO): a randomised trial protocol.

INTRODUCTION: Children who are HIV-exposed uninfected (HEU), that is, children who do not acquire HIV infection despite being born to mothers with HIV, have a higher risk of mortality, infectious morbidity and growth deficits than children who are HIV-unexposed uninfected (HUU). Prior research has focused on breast feeding and has pointed to changes in human milk oligosaccharides (HMOs) associated with maternal HIV that may influence the infant microbiome and thereby lead to these adverse outcomes. However, to our knowledge, no study has attempted to intervene along this pathway to reduce the occurrence of the adverse outcomes in children HEU. We will conduct a double-blind, randomised trial of a synbiotic intervention, which combines an HMO and probiotic, in breastfed infants HEU in South Africa to evaluate whether this intervention has promise to reduce excess infectious morbidity and growth faltering compared with controls. METHODS AND ANALYSIS: One hundred and forty-four breastfed infants HEU, aged 4 weeks, will be 1:1 randomised to receive either a daily synbiotic or an identical-looking placebo through age 24 weeks. Infants will be followed until age 48 weeks and outcomes of infectious morbidity, growth and biological measurements (eg, microbiota, inflammation and metabolome) will be assessed. Analyses will follow intention-to-treat principles comparing the cohorts as randomised. Infants HEU will be compared across arms with respect to the occurrence of infectious morbidity and growth outcomes through 4-24 weeks and 4-48 weeks using appropriate parametric and non-parametric statistical tests. Additionally, an observational cohort of 40 breastfed infants HUU will be recruited as a comparator group with no intervention. ETHICS AND DISSEMINATION: Ethical approval for this study has been obtained from the ethics committees at Columbia University and Stellenbosch University. The findings will be disseminated in publications. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT05282485. SANCTR ID number: DOH-27-122021-6543.

Prevalence of Chronic Diseases, Depression, and Stress Among US Childcare Professionals During the COVID-19 Pandemic.

INTRODUCTION: Given their central role in supporting children's development, childcare professionals' overall physical and mental health is important. We evaluated the prevalence of chronic diseases, depression, and stress levels during the COVID-19 pandemic among US childcare professionals. METHODS: Data were obtained from US childcare professionals (N = 81,682) through an online survey from May 22, 2020, through June 8, 2020. We used multivariable logistic and linear regression models to assess the association of sociodemographic characteristics with 4 physical health conditions (asthma, heart disease, diabetes, and obesity), depression, and stress weighted to national representativeness. RESULTS: For physical health conditions, 14.3% (n = 11,717) reported moderate to severe asthma, 6.5% (n = 5,317) diabetes, 4.9% (n = 3,971) heart disease, and 19.8% (n = 16,207) obesity. For mental health, 45.7% (n = 37,376) screened positive for depression and 66.5% (n = 54,381) reported moderate to high stress levels. Race, ethnicity, and sex/gender disparities were found for physical health conditions but not mental health of childcare professionals during the COVID-19 pandemic. CONCLUSION: Our findings highlighted that childcare professionals' depression rates during the pandemic were higher than before the pandemic, and depression, stress, and asthma rates were higher than rates among US adults overall during the pandemic. Given the essential work childcare professionals provided during the pandemic, policy makers and public health officials should consider what can be done to support their physical and mental health.

Relationship between the use of nonpharmaceutical interventions and COVID-19 vaccination among U.S. child care providers: A prospective cohort study.

BACKGROUND: The relationship between the use of nonpharmaceutical interventions and COVID-19 vaccination among U.S. child care providers remains unknown. If unvaccinated child care providers are also less likely to employ nonpharmaceutical interventions, then a vaccine mandate across child care programs may have larger health and safety benefits. METHODS: To assess and quantify the relationship between the use of nonpharmaceutical interventions and COVID-19 vaccination among U.S. child care providers, we conducted a prospective cohort study of child care providers (N = 20,013) from all 50 states, the District of Columbia, and Puerto Rico. Child care providers were asked to complete a self-administered email survey in May-June 2020 assessing the use of nonpharmaceutical interventions (predictors) and a follow-up survey in May-June 2021 assessing COVID-19 vaccination (outcome). Nonpharmaceutical interventions were dichotomized as personal mitigation measures (e.g., masking, social distancing, handwashing) and classroom mitigation measures (e.g., temperature checks of staff/children, symptom screening for staff/children, cohorting). RESULTS: For each unendorsed personal mitigation measure during 2020, the likelihood of vaccination in 2021 decreased by 7% (Risk Ratio = 0.93 [95% CI 0.93 - 0.95]). No significant association was found between classroom mitigation measures and child care provider vaccination (Risk Ratio = 1.01 [95% CI 1.00-1.01]). CONCLUSIONS: Child care providers who used fewer personal mitigation measures were also less likely to get vaccinated for COVID-19 as an alternative form of protection. The combined nonadherence to multiple types of preventative health behaviors, that is, both nonpharmaceutical interventions and vaccination, among some child care providers may support a role for mandatory vaccination to achieve pandemic control.

Association of Child Masking With COVID-19-Related Closures in US Childcare Programs.

Importance: It is not known how effective child masking is in childcare settings in preventing the transmission of SARS-CoV-2. This question is critical to inform health policy and safe childcare practices. Objective: To assess the association between masking children 2 years and older and subsequent childcare closure because of COVID-19. Design, Setting, and Participants: A prospective, 1-year, longitudinal electronic survey study of 6654 childcare professionals at home- and center-based childcare programs in all 50 states was conducted at baseline (May 22 to June 8, 2020) and follow-up (May 26 to June 23, 2021). Using a generalized linear model (log-binomial model) with robust SEs, this study evaluated the association between childcare program closure because of a confirmed or suspected COVID-19 case in either children or staff during the study period and child masking in both early adoption (endorsed at baseline) and continued masking (endorsed at baseline and follow-up), while controlling for physical distancing, other risk mitigation strategies, and program and community characteristics. Exposures: Child masking in childcare programs as reported by childcare professionals at baseline and both baseline and follow-up. Main Outcomes and Measures: Childcare program closure because of a suspected or confirmed COVID-19 case in either children or staff as reported in the May 26 to June 23, 2021, end survey. Results: This survey study of 6654 childcare professionals (mean [SD] age, 46.9 [11.3] years; 750 [11.3%] were African American, 57 [0.9%] American Indian/Alaska Native, 158 [2.4%] Asian, 860 [12.9%] Hispanic, 135 [2.0%] multiracial [anyone who selected >1 race on the survey], 18 [0.3%] Native Hawaiian/Pacific Islander, and 5020 [75.4%] White) found that early adoption (baseline) of child masking was associated with a 13% lower risk of childcare program closure because of a COVID-19 case (adjusted relative risk, 0.87; 95% CI, 0.77-0.99), and continued masking for 1 year was associated with a 14% lower risk (adjusted relative risk, 0.86; 95% CI, 0.74-1.00). Conclusions and Relevance: This survey study of childcare professionals suggests that masking young children is associated with fewer childcare program closures, enabling in-person education. This finding has important public health policy implications for families that rely on childcare to sustain employment.

The Association of Coronavirus Disease 2019 Risk Perception, County Death Rates, and Voluntary Health Behaviors Among United States Adult Population.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic continues to adversely impact the United States socially, culturally, and economically. The purpose of this study was to understand the relationship between COVID-19 county death rates, risk perception, and US adults' voluntary behaviors-particularly physical distancing. METHODS: Data were collected from CloudResearch/Qualtrics, Johns Hopkins University, the American Community Survey, and SafeGraph. RESULTS: Our results indicated that higher COVID-19 county death rates were associated with higher risk perceptions, leading to greater time spent at home. CONCLUSIONS: These findings will help public health officials identify strategies that best encourage voluntary health behaviors to help curb the spread of COVID-19.

Association of Maternal Inflammation During Pregnancy With Birth Outcomes and Infant Growth Among Women With or Without HIV in India.

Importance: The association of elevated levels of specific inflammatory markers during pregnancy with adverse birth outcomes and infant growth could indicate pathways for potential interventions. Objective: To evaluate whether higher levels of certain inflammatory markers during pregnancy are associated with preterm birth (PTB), low birth weight (LBW), and infant growth deficits. Design, Setting, and Participants: In this cohort study of pregnant women with or without HIV, 218 mother-infant pairs were followed up from pregnancy through 12 months post partum from June 27, 2016, to December 9, 2019. Pregnant women aged 18 to 40 years and between 13 and 34 weeks of gestation who were receiving antenatal care were enrolled in a cohort stratified by HIV status; sampling was based on convenience sampling from women receiving antenatal care at Byramjee Jeejeebhoy Government Medical College. Exposures: Levels of multiple circulating inflammation markers during the third trimester of pregnancy. Main Outcomes and Measures: The primary study outcome was PTB (<37 weeks' gestation). Secondary outcomes were LBW (<2500 g) and repeated measures (delivery; 6 weeks post partum; and 3, 6, and 12 months post partum using multivariable generalized linear models) of infant growth outcomes (length-for-age, weight-for-age, and weight-for-length z scores). Results: The median age of the 218 women at enrollment was 23 years (IQR, 21-27 years). In multivariable models, higher pregnancy levels of interleukin 17A were associated with increased odds of both PTB (adjusted odds ratio [aOR], 2.62; 95% CI, 1.11-6.17) and LBW (aOR, 1.81; 95% CI, 1.04-3.15). Higher levels of interleukin 1ß were associated with increased PTB (aOR, 1.47; 95% CI, 1.15-1.89) and infant growth deficits (lower length-for-age z score: adjusted ß = -0.10; 95% CI, -0.18 to -0.01; lower weight-for-age z score: adjusted ß = -0.07; 95% CI, -0.14 to 0.001). Conclusions and Relevance: This study suggests that increased levels of certain systemic inflammatory markers, including interleukin 1ß and interleukin 17A, during pregnancy were associated with adverse birth outcomes and infant growth deficits. Future studies should evaluate whether potential interventions to modulate specific inflammatory pathways during pregnancy could improve birth outcomes and infant growth.

COVID-19 Vaccine Uptake Among US Child Care Providers.

OBJECTIVES: Ensuring high coronavirus disease-2019 (COVID-19) vaccine uptake among US child care providers is crucial to mitigating the public health implications of child-staff and staff-child transmission of severe acute respiratory syndrome coronavirus 2; however, the vaccination rate among this group was previously unknown. METHODS: To characterize vaccine uptake among US child care providers, we conducted a multistate cross-sectional survey of the child care workforce. Providers were identified through various national databases and state registries. A link to the survey was sent via e-mail between May 26 and June 23, 2021. A 37.8% response yielded 21 663 respondents, with 20 013 satisfying inclusion criteria. RESULTS: Overall COVID-19 vaccine uptake among US child care providers (78.2%, 90% confidence interval: 77.5% to 78.9%) was higher than the US general adult population (65%). Vaccination rates varied between states from 53.5% to 89.4%. Vaccine uptake among respondents differed significantly (P < .01) based on respondent age (70.0% for ages 25-34, 91.6% for ages 75-84), race (70.0% for Black or African Americans, 92.5% for Asian Americans), annual household income (70.8% for <$35 000, 85.1% for >$75 000), and child care setting (73.0% for home-based, 79.7% for center-based). CONCLUSIONS: COVID-19 vaccine uptake among US child care providers was higher than the general US adult population. Those who were younger, lower income, Black or African American, resided in states either in the Mountain West or the South, and/or worked in home-based child care programs reported the lowest rates of vaccination. State public health leaders and lawmakers should prioritize these subgroups to realize the largest gains in vaccine uptake among providers.

COVID-19 Sources of Information, Knowledge, and Preventive Behaviors Among the US Adult Population.

CONTEXT: The COVID-19 pandemic has resulted in more than 20 million cases and 350 000 deaths in the United States. With the ongoing media coverage and spread of misinformation, public health authorities need to identify effective strategies and create culturally appropriate and evidence-based messaging that best encourage preventive health behaviors to control the spread of COVID-19. OBJECTIVE: The purpose of this study was to understand the relationship between COVID-19 sources of information and knowledge, and how US adults' knowledge may be associated with preventive health behaviors to help mitigate COVID-19 cases and deaths. DESIGN AND SETTING: For this cross-sectional study, survey data pertaining to COVID-19 were collected via online platform, Qualtrics, in February and May 2020. PARTICIPANTS: Data responses included 718 US adults from the February survey and 672 US adults from the May survey-both representative of the US adult population. MAIN OUTCOME MEASURES: Sociodemographic characteristics, COVID-19 knowledge score, COVID-19 reliable sources of information, and adherence to COVID-19 preventive health behaviors. RESULTS AND CONCLUSIONS: The main findings showed that disseminating COVID-19 information across various sources, particularly television, health care providers, and health officials, to increase people's COVID-19 knowledge contributes to greater adherence to infection prevention behaviors. Across February and May 2020 survey data, participants 55 years and older and those with higher educational background reported a higher average COVID-19 knowledge score. In addition, among the racial and ethnic categories, Black/African American and Native American/Alaska Native participants reported a lower average COVID-19 knowledge score than white participants-signaling the need to establish COVID-19 communication that is culturally-tailored and community-based. Overall, health care authorities must deliver clear and concise messaging about the importance of adhering to preventive health behaviors, even as COVID-19 vaccines become widely available to the general public. Health officials must also focus on increasing COVID-19 knowledge and dispelling misinformation.

COVID-19 Transmission in US Child Care Programs.

OBJECTIVES: Central to the debate over school and child care reopening is whether children are efficient coronavirus disease 2019 (COVID-19) transmitters and are likely to increase community spread when programs reopen. We compared COVID-19 outcomes in child care providers who continued to provide direct in-person child care during the first 3 months of the US COVID-19 pandemic with outcomes in those who did not. METHODS: Data were obtained from US child care providers (N = 57 335) reporting whether they had ever tested positive or been hospitalized for COVID-19 (n = 427 cases) along with their degree of exposure to child care. Background transmission rates were controlled statistically, and other demographic, programmatic, and community variables were explored as potential confounders. Logistic regression analysis was used in both unmatched and propensity score-matched case-control analyses. RESULTS: No association was found between exposure to child care and COVID-19 in both unmatched (odds ratio [OR], 1.06; 95% confidence interval [CI], 0.82-1.38) and matched (OR, 0.94; 95% CI, 0.73-1.21) analyses. In matched analysis, being a home-based provider (as opposed to a center-based provider) was associated with COVID-19 (OR, 1.59; 95% CI, 1.14-2.23) but revealed no interaction with exposure. CONCLUSIONS: Within the context of considerable infection mitigation efforts in US child care programs, exposure to child care during the early months of the US pandemic was not associated with an elevated risk for COVID-19 transmission to providers. These findings must be interpreted only within the context of background transmission rates and the considerable infection mitigation efforts implemented in child care programs.