Exploring the reasons for defaulting from childhood immunization: a qualitative study in Pakistan.

BACKGROUND: Childhood vaccination is widely recognized as the most effective means to prevent various diseases. However, a considerable amount of children still miss out on their vaccination schedules. Therefore, this study explores the reasons for defaulting from the expanded program on immunization in district Swat, Pakistan. METHODS: A qualitative phenomenological approach was used. Data collection took place from March to September 2022. Thirty-six in-depth interviews were conducted with participants who had defaulter children. The collected qualitative data were analysed thematically to identify key patterns and themes related to the reasons for defaulting from childhood vaccination schedules. RESULTS: Six themes emerged, i.e., illness of the defaulter child at the scheduled time, perceived side effects of the vaccination, factors related to caregivers, myths and misconceptions, vaccinators attitudes and crowed vaccination centres, as well as poor immunization service arrangements. Four subthemes arose related to caregivers, such as lack of clear understanding about completion of vaccination, least priority for child's vaccination, cultural restriction on mothers, and the loss of vaccination card. CONCLUSION: According to the study's findings, caregivers have their own perceptions regarding the non-completion of their children's vaccination schedule. The childhood immunization defaulting arises from various factors including child illness, Adverse Events Following Immunization (AEFIs) concerns, misconceptions, improper injection techniques, and negative vaccinator attitudes. The vaccination completion rate may be increased if the concerns of the caregivers are appropriately addressed.

The faces behind vaccination: unpacking the attitudes, knowledge, and practices of staff of Cameroon's Expanded program on Immunization.

BACKGROUND: Immunization is regarded as one of the most cost-effective public health interventions in global health. However, its cost-effectiveness depends greatly on the knowledge and skills of vaccinators. With the growing complexity of immunization programs, the need for a well-trained vaccination workforce cannot be overemphasized. In this study, we assessed the knowledge, attitudes, and practices among vaccination staff in Cameroon. METHODS: Through a descriptive cross-sectional design, we used structured questionnaires and observation guides to collect data from vaccination staff in health facilities that were selected by a multistage sampling method. Data were analyzed using STATA 13 software. RESULTS: Overall, we collected data from Expanded Program on Immunization focal staff in 265 health facilities across 68 health districts. Over half (53%) of the surveyed facilities were found in rural areas. Nearly two-thirds of health facilities had immunization focal staff with knowledge gaps for each of the four basic immunization indicators assessed. In other words, only 37% of staff knew how to estimate coverages, 36% knew how to inteprete the EPI monitoring curve, 35% knew how to prepare vaccine orders, and 37% knew how to estimate vaccine wastage. In terms of practices, staff waited for more than ten children to be present before opening a 20-dose vaccine vial in 63% of health facilities, and more than five children to be present before opening a 10-dose vaccine vial in 80% of surveyed facilities. Provision of vaccine-specific information (informing caregiver about vaccine received, explanation of benefits and potential side effects) during immunization sessions was suboptimal for the most part. CONCLUSION: This study suggests marked deficits in immunization knowledge among vaccination staff and exposes common attitudes and practices that could contribute to missed opportunities for vaccination and hinder vaccination coverage and equity in Cameroon. Our findings highlight the urgent need to invest in comprehensive capacity building of vaccination staff in Cameroon, especially now that the immunization program is becoming increasingly complex.

Vaccination Mandates-An Old Public Health Tool Faces New Challenges.

This Viewpoint discusses how federal vaccine requirements have helped thwart vaccine-preventable diseases as well as how growing public resistance to vaccines and judicial and legislative limits to vaccination mandates may change that.

Using geographic information system to track children and optimize immunization coverage and equity in Karachi, Pakistan.

BACKGROUND: Despite the potential of geospatial technologies to track and monitor coverage, they are underutilized for guiding immunization program strategy and implementation, especially in low-and-middle-income countries. We conducted geospatial analysis to explore the geographic and temporal trends of immunization coverage, and examined the pattern of immunization service access (outreach and facility based) by children. METHODOLOGY: We extracted data to analyze coverage rates across different dimensions (by enrolment year, birth year and vaccination year) from 2018 till 2020 in Karachi, Pakistan using the Sindh Electronic Immunization Registry (SEIR). We conducted geospatial analysis to assess variation in coverage rates of BCG, Pentavalent (Penta)-1, Penta-3, and Measles-1 vaccines using Government targets. We also analyzed the proportion of children receiving their routine vaccinations at fixed centers and outreach and examined whether children received vaccinations at the same or multiple immunization centers. RESULTS: A total of 1,298,555 children were born, enrolled or vaccinated from 2018 till 2020. At the district level, analysis by enrollment and birth year showed coverage increased between 2018 and 2019 and declined in 2020, while analysis by vaccination year showed consistent increase in coverage. However, micro-geographic analysis revealed pockets where coverage persistently declined. Notably 27/168, 39/168 and 3/156 Union councils showed consistently declining coverage when analyzing by enrollment, birth and vaccination year respectively. More than half (52.2%, 678,280/1,298,555) of the children received all their vaccinations exclusively through fixed centers and, 71.7% (499,391/696,701) received all vaccinations from the same centers. CONCLUSION: Despite overall improving vaccination coverage between 2018 and 2020, certain geographic areas have consistently declining coverage rates, which is detrimental for equity. Making immunization inequities visible through geospatial analysis is the first step to ensure resources are allocated optimally. Our study provides impetus for immunization programs to develop and invest in geospatial technologies, harnessing its potential for improved coverage and equity.

Parental preferences for rotavirus vaccination for their children under 5 years old in China: A discrete choice experiment.

Rotavirus vaccination is the most effective means to prevent rotavirus gastroenteritis, but its coverage in China is not ideal. We aimed to explore parental preferences for rotavirus vaccination for their children under 5years old to improve vaccination coverage. A Discrete Choice Experiment was conducted online on 415 parents with at least one child under 5years old in 3 cities. Five attributes including vaccine effectiveness, protection duration, risk of mild side-effects, out-of-pocket costs, and time required for vaccination were identified. Each attribute was set at three levels. Mixed-logit models were used to measure parental preferences and the relative importance of vaccine attributes. The optimal vaccination strategy was also explored. 359 samples were included in the analysis. The impacts of the vaccine attribute levels on vaccine choice were all statistically significant (p < .01), except for 1-hour vaccination time. The risk of mild side-effects was the most important factor influencing vaccination. The time required for vaccination was the least important attribute. The largest increase in vaccination uptake (74.45%) occurred with decreased the vaccine risk of mild side-effects from 1/10 to 1/50. The predicted vaccination uptake of the optimal vaccination scenario was 91.79%. When deciding about vaccination, parents preferred the rotavirus vaccination with lower risk of mild side-effects, higher effectiveness, longer protection duration, 2-hour vaccination time and lower cost. The authorities should support enterprises to develop vaccines with lower side-effects, higher effectiveness and longer protection duration in the future. We call for appropriate government subsidies for the rotavirus vaccine.

Increasing pneumococcal vaccine uptake in older adults: a scoping review of interventions in high-income countries.

BACKGROUND: There is low uptake of the pneumococcal vaccination in eligible older adults, even in high-income countries that offer routine and universal vaccination programs. OBJECTIVE: To systematically characterize interventions aimed at improving pneumococcal vaccine uptake in older adults. DESIGN: We conducted a scoping review following PRISMA-SCr guidelines of five interdisciplinary databases: Medline-Ovid, Embase, CINAHL, PsychInfo, and Cochrane Library. Databases were searched from January 2015 until April 2020. The interventions were summarized into three pillars according to the European Union Conceptional Framework for Action: information campaigns, prioritization of vaccination schemes, and primary care interventions. RESULTS: Our scoping review included 39 studies that summarized interventions related to pneumococcal vaccine uptake for older adults, encompassing 2,481,887 study participants (945 healthcare providers and 2,480,942 older adults) across seven countries. Examples of interventions that were associated with increased pneumococcal vaccination rate included periodic health examinations, reminders and decision-making tools built into electronic medical records, inpatient vaccination protocols, preventative health checklists, and multimodal educational interventions. When comparing the three pillars, prioiritization of vaccination schemes had the highest evidence for improved rates of vaccination (n = 14 studies), followed by primary care interventions (n = 8 studies), then information campaigns (n = 5 studies). CONCLUSION: Several promising interventions were associated with improved outcomes related to vaccine uptake, although controlled study designs are needed to determine which interventions are most effective.

Impact of disruptions to routine vaccination programs, quantifying burden of measles, and mapping targeted supplementary immunization activities.

Measles is a highly transmissible disease that requires high levels of vaccination coverage for control and elimination. Areas that are unable to achieve and maintain high coverage levels are at risk for measles outbreaks resulting in increased morbidity and mortality. Public health emergencies, such as the current COVID-19 pandemic, pose a threat to the functioning of health systems by disrupting immunization services which can derail measles vaccination efforts. Efforts to bridge coverage gaps in immunization include the rapid return to fully functioning services as well as deploying supplementary immunization activities (SIAs), which are additional vaccination campaigns intended to catch-up children who have missed routine services. However, SIAs, which to date tend to be national efforts, can be difficult to mobilize quickly, resource-intensive, and even more challenging to deploy during a public health crisis. By mapping expected burden of measles, more effective SIAs that are setting-specific and resource-efficient can be planned and mobilized. Using a spatial transmission model of measles dynamics, we projected and estimated the expected burden of national and local measles outbreaks in Zambia with the current COVID-19 pandemic as a framework to inform disruptions to routine vaccination. We characterize the impact of disruptions to routine immunization services on measles incidence, map expected case burden, and explore SIA strategies to mitigate measles outbreaks. We find that disruptions lasting six months or longer as well as having low MCV1 coverage prior to disruptions resulted in an observable increase of measles cases across provinces. Targeting provinces at higher risk of measles outbreaks for SIAs is an effective strategy to curb measles virus incidence following disruptions to routine immunization services.

A Survey Exploring Reasons behind Immunization Refusal among the Parents and Caregivers of Children under Two Years Living in Urban Slums of Karachi, Pakistan.

This study assesses the experiences of parents/caregivers regarding the refusal to childhood immunization. A cross-sectional study was conducted among the parents/caregivers of children under two years old from January 2019 to June 2019 who were residents of either Pathan Colony or Orangi Town, Karachi. In this study, the data collectors targeted parents/caregivers of 440 households who showed a refusal mark "R" in the Expanded Program of Immunization (EPI) H-chalking system. These households were approached using a 30 × 7 multistage-stratified-cluster random sampling technique and were interviewed using a structured questionnaire. The study sample produced two different types of refusals: true refusal (absence) and potential refusal (presence), based on the absence and presence of a vaccination card at the time of the survey. Multivariate logistic regression was used to analyze the data using Jamovi (V-1.6.13). A total of 230 households consented to participate in this study, of which 141 (61.3%) represented true refusals, while 89 (38.7%) represented potential refusals. More than half of the participants from both groups complained about fever and pain at the injection site following immunization. The use of alternative medicines and a history of adverse events following immunization (AEFI) were associated with increasing the odds of immunization refusals by four-to-five fold. However, advanced paternal age, a long distance to the clinic, a lack of trust in government, and the influence of community/religious leaders were associated with lower immunization refusal odds. Thus, an unawareness about self-limiting vaccine-related adverse events, the use of alternative medicines, and an increased concern about the safety and efficacy of vaccines were found to be barriers to immunization, which can be improved by increasing public awareness through media campaigns and policy reform.

Measles surveillance in Kashmir: A mixed methods study.

Background: Measles surveillance serves as the means of monitoring program success. The quintessential purpose of measles surveillance is to identify gaps and garner effective public health responses to achieve measles elimination. Objectives: There were two key objectives: (i) to conduct an in-depth review of the existing measles surveillance system in Kashmir and highlight its strengths and weaknesses and (ii) to assess the pattern of measles-containing vaccine (MCV1) coverage and MCV2 coverage among under-5 years children and describe the health-seeking patterns of suspected cases of measles. Methods: The mixed methods study was conducted in the Kashmir valley from March 2018 to March 2019. An explorative qualitative design was followed using individual face-to-face interviews with thirty-two (n = 32) different stakeholders from the state, district, medical block, and primary health center (PHC) levels. To complement the qualitative study, a quantitative survey was done in two districts, Srinagar and Ganderbal, which consist of 5 and 4 medical blocks, respectively. Results: Among the suspected cases of measles, 52% had visited PHCs. Sixty-four suspected cases of measles (64) were immunized with two doses of MCV. None of the clinically suspected cases of measles were further investigated. In the qualitative analysis, five themes were generated viz, "measles surveillance description of Kashmir valley;" "factors affecting measles surveillance, perceptions, and experiences of stakeholders;" "barriers to measles surveillance;" "measles surveillance activities need to be intensified;" and "respondent recommendations for building an effective and sensitive measles surveillance system." Conclusion: The current measles surveillance system in Kashmir was not effectively functioning; case-based measles surveillance is not being done as per the WHO guidelines. There is a lack of planning, advocacy, awareness, and communication of measles surveillance among the stakeholders. The visible barriers in measles surveillance included lack of training, logistics, incentives, and monitoring by internal and external agencies.

Factors affecting vaccination demand in Indonesia: a secondary analysis and multimethods national assessment.

OBJECTIVES: Vaccine hesitancy remains a major barrier to immunisation coverage worldwide. We explored influence of hesitancy on coverage and factors contributing to vaccine uptake during a national measles-rubella (MR) campaign in Indonesia. DESIGN: Secondary analyses of qualitative and quantitative data sets from existing cross-sectional studies conducted during and around the campaign. METHODS: Quantitative data used in this assessment included daily coverage reports generated by health workers, district risk profiles that indicate precampaign immunisation programme performance, and reports of campaign cessation due to vaccine hesitancy. We used t-test and χ2 tests for associations. The qualitative assessment employed three parallel national and regional studies. Deductive thematic analysis examined factors for acceptance among caregivers, health providers and programme managers. RESULTS: Coverage data were reported from 6462 health facilities across 395 districts from 1 August to 31 December 2018. The average district coverage was 73%, with wide variation between districts (2%-100%). One-third of districts fell below 70% coverage thresholds. Sixty-two of 395 (16%) districts paused the campaign due to hesitancy. Coverage among districts that never paused campaign activities due to hesitancy was significantly higher than rates for districts ever-pausing the campaign (81% vs 42%; p<0.001). Precampaign adequacy of district immunisation programmes did not explain coverage gaps (p=0.210). Qualitative analysis identified acceptance enablers including using digital health monitoring and feedback systems, increasing caregiver knowledge and awareness, making immunisation social norm, effective cross-sectoral collaboration, conducive service environment and positive experiences for mothers and children. Barriers included misinformation diffusion on social media, halal-haram issues, lack of healthcare provider knowledge, negative family influences and traditions, previous poor experiences and misinformation on adverse events. CONCLUSION: Barriers to vaccine uptake contributed to coverage gaps during national MR campaign in Indonesia. A range of supply-related and demand-related strategies were identified to address hesitancy contributors. Advancing a portfolio of tailored multilevel interventions will be critical to enhance vaccine acceptance.

Reasons and suggestions for improving low immunization uptake among children living in low socioeconomic status communities in Northern Alberta, Canada - A qualitative study.

OBJECTIVE: Under-immunization increases the risk of acquiring vaccine-preventable diseases in children and the community. The targeted coverage rate for routine childhood immunization in Alberta, especially in disadvantaged communities in rural and remote geographic areas, has not been achieved for many years. This study was conducted to identify reasons for under-immunization in children in low socioeconomic status (SES) communities and propose suggestions to address issues/concerns identified by low SES parents for improving immunization coverage in their communities. METHODS: Fourteen semi-structured phone interviews of low SES parents with under-immunized children living in rural and remote geographic areas in Northern Alberta were conducted. Transcripts were analyzed to identify relevant themes. RESULTS: Busy lifestyles of many parents prevented them from taking their children to clinics for immunization, which were exacerbated by long distances to clinics, transportation issues, operating hours of clinics, and lack of reminders. Many disadvantaged parents also exhibited varying levels of vaccine hesitancy due to safety concerns, especially about newer vaccines, thereby causing some parents to delay immunizing their child intentionally. CONCLUSION: Implementing procedures to alleviate access issues, such as offering extended operating hours, opening drop-in clinics/satellite clinics in distant areas, nurse visits to their homes, updating contact information of parents, frequent reminder options and addressing safety and effectiveness concerns about vaccines in plain language using evidence-based communication strategies can promote timely immunization among children of low SES parents.

COVID-19 vaccination, time for a second breath?

One year into the Covid-19 vaccination campaign, C. Gerke, B. Pulverer and P. Sansonetti discuss its results and redefine its objectives.

Learning from the COVID-19 pandemic to strengthen routine immunization systems.

Kate Causey and Jonathan F Mosser discuss what can be learnt from the observed impacts of the COVID-19 pandemic on routine immunisation systems.

Are vaccine shortages a relevant public health issue in Europe? Results from a survey conducted in the framework of the EU Joint Action on Vaccination.

National immunisation programmes require an adequate supply of vaccines to function properly but many countries, globally and in Europe, have reported vaccine shortages. A comprehensive view of vaccine shortages and stockouts in the EU/EEA is missing in the published literature. This study was conducted in the framework of the European Joint Action on Vaccination (EU-JAV). Twenty-eight countries, including 20 EU-JAV consortium member states and an additional 8 EU/EEA countries, were invited to participate in a survey aimed at collecting information on vaccine shortages and stock-outs experienced from 2016 to 2019, their main causes, actions taken, and other aspects of vaccine supply. Twenty-one countries completed the survey (response rate 75%), of which 19 reported at least one shortage/stock-out event. Overall, 115 events were reported, 28 of which led to a change in the national immunisation programme. The most frequently involved vaccines were DT- and dT-containing combination vaccines, hepatitis B, hepatitis A, and BCG vaccines. The median duration of shortages/stock-outs was five months (range <1 month-39 months). Interruption in supply and global shortage were the most frequently indicated causes. Only about half of countries reported having an immunization supply chain improvement plan. Similarly, only about half of countries had recommendations or procedures in place to address shortages/stockouts. The survey also identified the occurrence of shortages/stockouts of other biological products (e.g. diphtheria antitoxin in 12 countries). Public health strategies to assure a stable and adequate vaccine supply for immunization programmes require coordinated actions from all stakeholders, harmonized definitions, strengthening of reporting and monitoring systems, the presence of an immunization supply chain improvement plan in all countries, and procedures or recommendations in place regarding the use of alternative vaccines or vaccination schedules in case of shortages/stockouts.

Strategies for COVID-19 vaccination under a shortage scenario: a geo-stochastic modelling approach.

In a world being hit by waves of COVID-19, vaccination is a light on the horizon. However, the roll-out of vaccination strategies and their influence on the pandemic are still open questions. In order to compare the effect of various strategies proposed by the World Health Organization and other authorities, a previously developed SEIRS stochastic model of geographical spreading of the virus is extended by adding a compartment for vaccinated people. The parameters of the model were fitted to describe the pandemic evolution in Argentina, Mexico and Spain to analyze the effect of the proposed vaccination strategies. The mobility parameters allow to simulate different social behaviors (e.g. lock-down interventions). Schemes in which vaccines are applied homogeneously in all the country, or limited to the most densely-populated areas, are simulated and compared. The second strategy is found to be more effective. Moreover, under the current global shortage of vaccines, it should be remarked that immunization is enhanced when mobility is reduced. Additionally, repetition of vaccination campaigns should be timed considering the immunity lapse of the vaccinated (and recovered) people. Finally, the model is extended to include the effect of isolation of detected positive cases, shown to be important to reduce infections.

Taking a machine learning approach to optimize prediction of vaccine hesitancy in high income countries.

Understanding factors driving vaccine hesitancy is crucial to vaccination success. We surveyed adults (N = 2510) from February to March 2021 across five sites (Australia = 502, Germany = 516, Hong Kong = 445, UK = 512, USA = 535) using a cross-sectional design and stratified quota sampling for age, sex, and education. We assessed willingness to take a vaccine and a comprehensive set of putative predictors. Predictive power was analysed with a machine learning algorithm. Only 57.4% of the participants indicated that they would definitely or probably get vaccinated. A parsimonious machine learning model could identify vaccine hesitancy with high accuracy (i.e. 82% sensitivity and 79-82% specificity) using 12 variables only. The most relevant predictors were vaccination conspiracy beliefs, various paranoid concerns related to the pandemic, a general conspiracy mentality, COVID anxiety, high perceived risk of infection, low perceived social rank, lower age, lower income, and higher population density. Campaigns seeking to increase vaccine uptake need to take mistrust as the main driver of vaccine hesitancy into account.

Plano de ação: estratégia de vacinação nas fronteiras: agenda 2022 / Action Plan: Vaccination Strategy at the Borders: Agenda 2022

Este plano define as diretrizes para implementação da ação, com a finalidade de orientar as SES e SMS envolvidas, no intuito de subsidiar no planejamento, implementação e operacionalização da Estratégia.