A Scalar Approach to Vaccination Ethics.

Should people get vaccinated for the sake of others? What could ground-and limit-the normative claim that people ought to do so? In this paper, we propose a reasons-based consequentialist account of vaccination for the benefit of others. We outline eight harm-based and probabilistic factors that, we argue, give people moral reasons to get vaccinated. Instead of understanding other-directed vaccination in terms of binary moral duties (i.e., where people either have or do not have a moral duty to get vaccinated), we develop a scalar approach according to which people can have stronger or weaker moral reasons to get vaccinated in view of the moral good of vaccination. One advantage of our approach is that it can capture why a person might have strong moral reasons to get vaccinated with Vaccine A, but only weak moral reasons to get vaccinated with Vaccine B. We discuss theoretical strengths of our approach and provide a case study of vaccination against COVID-19 to demonstrate its practical significance.

The ethics of COVID-19 vaccine mandates for healthcare workers: Public health and clinical perspectives.

COVID-19 vaccine uptake among healthcare workers (HCWs) remains of significant public health concern due to the ongoing COVID-19 pandemic. As a result, many healthcare institutions are considering or have implemented COVID-19 vaccine mandates for HCWs. We assess defenses of COVID-19 vaccine mandates for HCWs from both public health and professional ethics perspectives. We consider public health values, professional obligations of HCWs, and the institutional failures in healthcare throughout the COVID-19 pandemic which have impacted the lived experiences of HCWs. We argue that, despite the compelling urgency of maximizing COVID-19 vaccine uptake among HCWs, the ethical case for COVID-19 vaccine mandates for HCWs in the United States is complex, and, under current circumstances, inconclusive. Nevertheless, we recognize that COVID-19 vaccine mandates for HCWs have already been and will continue to be implemented across many healthcare institutions. Given such context, we provide suggestions for implementing COVID-19 vaccine mandates for HCWs.

A socio-ecological exploration to identify factors influencing the COVID-19 vaccine decision-making process among pregnant and lactating women: Findings from Kenya.

The vaccine decision-making process of pregnant and lactating women is complex. Regarding COVID-19, pregnant women are at increased risk for severe disease and poor health outcomes. While pregnant and lactating women were excluded from COVID-19 vaccine trials, available evidence suggests that COVID-19 vaccines are safe and protective during pregnancy. In this study, we used a socio-ecological approach to explore factors influencing the decision-making process for COVID-19 vaccines in pregnant and lactating women in Kenya, for the purpose of informing demand generation strategies. As pregnant and lactating women are influenced by many factors, we conducted 84 in-depth interviews with a variety of stakeholders, including 31 pregnant or lactating women, 20 healthcare workers such as nurses, midwives, doctors, and frontline workers, 25 male family members of pregnant or lactating women, and 8 gatekeepers such as community leaders and faith-based leaders. These individuals were recruited from six communities in Kenya: three urban, and three rural. We applied a grounded theory approach to identify emerging themes and organized emerging themes using the SAGE Vaccine Hesitancy model, which includes three categories of determinants of vaccine acceptance, including contextual influences, individual and group influences, and vaccine and vaccination specific issues. Myths, interpersonal norms, and religion emerged as themes related to contextual influences. Safety, risk perception, and the role of the healthcare worker emerged as themes related to individual and group influences. For vaccine and vaccination specific issues, emerging themes included availability, accessibility, and eligibility. While maternal immunization can substantially reduce the effect of infectious diseases in mothers and infants, vaccine acceptance is critical. However, vaccines do not save lives; vaccination does. We hope the results of this study can be used to tailor communication efforts to increase vaccine demand among pregnant and lactating women.

Lack of clear national policy guidance on COVID-19 vaccines influences behaviors in pregnant and lactating women in Kenya.

SARS-CoV-2 infection in pregnancy is associated with a greater risk of maternal and newborn morbidity and maternal death. In Kenya, pregnant and lactating women (PLW) were ineligible to receive COVID-19 vaccines until August 2021. How shifts in policy influence vaccine behaviors, such as health worker recommendations and vaccine uptake, is not well documented. We conducted qualitative interviews with PLW, health workers, and policymakers in Kenya to understand how different stakeholders' perceptions of national policy regarding COVID-19 vaccination in pregnancy shaped vaccine behaviors and decision-making. Policymakers and health workers described pervasive uncertainty and lack of communication about the national policy, cited vaccine safety as their primary concern for administering COVID-19 vaccines to PLW, and expressed that PLW were inadequately prioritized in the COVID-19 vaccine program. PLW perceived the restrictive policy as indicative of a safety risk, resulting in vaccine hesitancy and potentially exacerbated inequities in vaccine access. These findings support the need for the development and dissemination of effective vaccine communication guidelines and the prioritization of PLW in COVID-19 vaccination policies and campaigns. To ensure PLW do not face the same inequities in future epidemics, data on infectious disease burdens and vaccine uptake should be collected systematically among pregnant women, and PLW should be included in future vaccine trials.

Conceptualizing the COVID-19 Pandemic: Perspectives of Pregnant and Lactating Women, Male Community Members, and Health Workers in Kenya.

Pregnant women are at greater risk of adverse outcomes from SARS-CoV-2 infection. There are several factors which can influence the ways in which pregnant women perceive COVID-19 disease and behaviorally respond to the pandemic. This study seeks to understand how three key audiences-pregnant and lactating women (PLW), male community members, and health workers-in Kenya conceptualize COVID-19 to better understand determinants of COVID-19 related behaviors. This study used qualitative methods to conduct 84 in-depth interviews in three counties in Kenya. Data were analyzed using a grounded theory approach. Emerging themes were organized based on common behavioral constructs thought to influence COVID-19 related behaviors and included myths, risk perception, economic implications, stigma, and self-efficacy. Results suggest that risk perception and behavioral attitudes substantially influence the experiences of PLW, male community members, and health workers in Kenya during the COVID-19 pandemic. Public health prevention and communication responses targeting these groups should address potential barriers to preventive health behaviors, such as the spread of misinformation, financial constraints, and fear of social ostracization.

The unintended consequences of COVID-19 vaccine policy: why mandates, passports and restrictions may cause more harm than good.

Vaccination policies have shifted dramatically during COVID-19 with the rapid emergence of population-wide vaccine mandates, domestic vaccine passports and differential restrictions based on vaccination status. While these policies have prompted ethical, scientific, practical, legal and political debate, there has been limited evaluation of their potential unintended consequences. Here, we outline a comprehensive set of hypotheses for why these policies may ultimately be counterproductive and harmful. Our framework considers four domains: (1) behavioural psychology, (2) politics and law, (3) socioeconomics, and (4) the integrity of science and public health. While current vaccines appear to have had a significant impact on decreasing COVID-19-related morbidity and mortality burdens, we argue that current mandatory vaccine policies are scientifically questionable and are likely to cause more societal harm than good. Restricting people's access to work, education, public transport and social life based on COVID-19 vaccination status impinges on human rights, promotes stigma and social polarisation, and adversely affects health and well-being. Current policies may lead to a widening of health and economic inequalities, detrimental long-term impacts on trust in government and scientific institutions, and reduce the uptake of future public health measures, including COVID-19 vaccines as well as routine immunisations. Mandating vaccination is one of the most powerful interventions in public health and should be used sparingly and carefully to uphold ethical norms and trust in institutions. We argue that current COVID-19 vaccine policies should be re-evaluated in light of the negative consequences that we outline. Leveraging empowering strategies based on trust and public consultation, and improving healthcare services and infrastructure, represent a more sustainable approach to optimising COVID-19 vaccination programmes and, more broadly, the health and well-being of the public.

Intervention hesitancy among healthcare personnel: conceptualizing beyond vaccine hesitancy.

We propose an emerging conceptualization of "intervention hesitancy" to address a broad spectrum of hesitancy to disease prevention interventions among healthcare personnel (HCP) beyond vaccine hesitancy. To demonstrate this concept and its analytical benefits, we used a qualitative case-study methodology, identifying a "spectrum" of disease prevention interventions based on (1) the intervention's effectiveness, (2) how the intervention is regulated among HCP in the Israeli healthcare system, and (3) uptake among HCP in the Israeli healthcare system. Our cases ultimately contribute to a more nuanced conceptualization of hesitancy that HCP express towards disease prevention interventions. Our case interventions included the seasonal influenza vaccine, the Mantoux test, and the hepatitis B (HBV) vaccine. Influenza and HBV are vaccine-preventable diseases, though their respective vaccines vary significantly in effectiveness and uptake among HCP. The Mantoux test is a tuberculin skin test which provides a prevention benchmark for tuberculosis (TB), a non-vaccine preventable disease. We conducted semi-structured interviews with relevant stakeholders and analyzed them within Israeli and international policy context between 2016 and 2019, a period just prior to the COVID-19 pandemic. We propose the conceptualization of "intervention hesitancy"-beyond "vaccine hesitancy"-as "hesitancy towards a wide range of public health interventions, including but not limited to vaccines". Results suggested that intervention hesitancy among HCP is rooted in weak trust in their employer, poor employment conditions, as well as mixed institutional guidelines and culture. Conceptualizing intervention hesitancy expands the ability of healthcare systems to understand the root of hesitancy and foster a supportive institutional culture and trust, cognizant of diverse disease prevention interventions beyond vaccination.

Against COVID-19 vaccination of healthy children.

COVID-19 vaccination of children has begun in a number of countries with provisional regulatory approval and public support. This article provides an ethical analysis of COVID-19 vaccination of healthy children. Specifically, we present three of the strongest arguments that might justify COVID-19 vaccination of children: (a) an argument from paternalism, (b) an argument from indirect protection and altruism, and (c) an argument from global eradication. We offer a series of objections to each of these arguments to show that none of them is currently tenable. Given the minimal direct benefit of COVID-19 vaccination for healthy children, the potential for rare risks to outweigh these benefits and to undermine vaccine confidence, the substantial evidence that COVID-19 vaccination confers adequate protection to risk groups whether or not healthy children are vaccinated and that current vaccines do not provide sterilizing immunity, and given that eradication of the virus is neither feasible nor a high priority for global health, we argue that routine COVID-19 vaccination of healthy children is currently ethically unjustified. Since mandates for children have already been implemented in some places (e.g., California) and may be considered elsewhere, we also present two additional arguments explicitly against making COVID-19 vaccination mandatory for children.

Conspiracy theories and misinformation about COVID-19 in Nigeria: Implications for vaccine demand generation communications.

INTRODUCTION: COVID-19 vaccine hesitancy is a worldwide phenomenon and a serious threat to pandemic control efforts. Until recently, COVID-19 vaccine hesitancy was not the cause of low vaccine coverage in Nigeria; vaccine scarcity was the problem. As the global supply of COVID-19 vaccines improves in the second half of 2021 and more doses are deployed in Nigeria, the supply/demand dynamic will switch. Vaccine acceptance will become a key driver of coverage; thus, amplifying the impact of vaccine hesitancy. Conspiracy theories and misinformation about COVID-19 are rampant and have been shown to drive vaccine hesitancy and refusal. This study systematically elicits the misinformation and conspiracy theories circulating about COVID-19 among the Nigerian public to understand relevant themes and potential message framing for communication efforts to improve vaccine uptake. METHODS: From February 1 to 8, 2021, we conducted 22 focus group discussions and 24 key informant interviews with 178 participants from six states representing the six geopolitical zones. Participants were purposively selected and included sub-national program managers, healthcare workers, and community members. All interviews were iteratively analyzed using a framework analysis approach. RESULTS: We elicited a total of 33 different conspiracy theories or misinformation that participants had heard about the COVID-19 virus, pandemic response, or vaccine. All participants had heard some misinformation. The leading claim was that COVID-19 was not real, and politicians took advantage of the situation and misused funds. People believed certain claims based on distrust of government, their understanding of Christian scripture, or their lack of personal experience with COVID-19. CONCLUSIONS: Our study is the first to report a thematic analysis of the range of circulating misinformation about COVID-19 in Nigeria. Our findings provide new insights into why people believe these theories, which could help the immunization program improve demand generation communication for COVID-19 vaccines by targeting unsubstantiated claims.

Global disparities in public health guidance for the use of COVID-19 vaccines in pregnancy.

INTRODUCTION: Gaps in information about the safety and efficacy of COVID-19 vaccines in pregnancy have led to substantial global variation in public health guidance regarding the use of COVID-19 vaccines in pregnancy over the course of the pandemic. METHODS: We conducted systematic screenings of public health authorities' websites across 224 countries and territories every 3 weeks to track the development of policies on COVID-19 vaccine use in pregnancy. Policies were categorised using a 1-5 permissiveness scale, with 1 indicating policies that recommended use, and 5 indicating policies that recommended against use. RESULTS: As of 30 September 2021, 176 countries/territories had issued explicit guidance on COVID-19 vaccine use in pregnancy, with 38% recommending use, 28% permitting use, 15% permitting use with qualifications, 2% not recommending but with exceptions, and 17% not recommending use whatsoever. This represented a significant shift from May 2021, when only 6% of countries/territories with such policies recommended the use of COVID-19 vaccines in pregnancy (p<0.001). However, no policy positions could be found for 21% of all countries and territories, the vast majority being low and middle income. Policy positions also varied widely by vaccine product, with Pfizer/BioNTech and Moderna vaccines being most commonly recommended or permitted. CONCLUSION: Our study highlights the evolution of policies regarding COVID-19 vaccine use in pregnancy over a 5-month period in 2021, the role of pregnancy-specific data in shaping these policies and how inequities in access for pregnant people persist, both within countries and globally.

COVID-19 vaccine acceptance among Bangladeshi adults: Understanding predictors of vaccine intention to inform vaccine policy.

OBJECTIVES: The purpose of this study was to identify predictors of COVID-19 vaccine intention among Bangladeshi adults. METHODS: Secondary data from the COVID-19 Beliefs, Behaviors & Norms Survey conducted by the Massachusetts Institute of Technology (MIT) and Facebook were analyzed. Data were collected from 2,669 adult Facebook users in Bangladesh and was collected between February 15 and February 28, 2021. Binomial logistic regression examined the relationship between COVID-19 vaccination intent and demographic variables, risk perception, preventive behaviors, COVID-19 knowledge, and likelihood of future actions. RESULTS: Seventy-nine percent of respondents reported intent to get the COVID-19 vaccine when it becomes available. Intent to get vaccinated was highest among females, adults aged 71-80, individuals with college or graduate-level degrees, city dwellers, and individuals who perceived that they were in excellent health. Results of the binomial logistic regression indicated that predictors of vaccination intent include age (OR = 1.39), high risk perception of COVID-19 (OR = 1.47), and intent to practice social distancing (OR = 1.22). DISCUSSION: Findings suggest that age, perceived COVID-19 risk, and non-pharmaceutical COVID-19 interventions may predict COVID-19 vaccination intent among Bangladeshi adults. Findings can be used to create targeted messaging to increase demand for and uptake of COVID-19 vaccines in Bangladesh.

Advancing child health and educational equity during the COVID-19 pandemic through science and advocacy.

The COVID-19 pandemic has underscored the changing role of scientists, clinicians, ethicists, and educators in advocacy as they rapidly translate their findings to inform practice and policy. Critical efforts have been directed towards understanding child well-being, especially with pandemic-related educational disruptions. While school closures were part of early widespread public health measures to curb the spread of COVID-19, they have not been without consequences for all children, and especially for children from disadvantaged backgrounds. In a recent Isr J Health Policy Res perspective, Paltiel and colleagues demonstrate the integral role of academic activism to promote child well-being during the pandemic by highlighting work of the multidisciplinary academic group on children and coronavirus (MACC). In this commentary, we explore parallels to MACC's work in an international context by describing the efforts of a multidisciplinary team at Johns Hopkins University in Baltimore, Maryland, United States, to aggregate data, conduct analyses, and offer training tools intended to minimize health and educational inequities for children throughout the COVID-19 pandemic. As both MACC and our work collectively demonstrates, multidisciplinary partnerships and public-facing data-driven initiatives are crucial to advocating for children's equitable access to quality health and education. This will likely not be the last pandemic that children experience in their lifetime. As such, efforts should be made to apply the lessons learned during the current pandemic to strengthen multidisciplinary academic-public partnerships which will continue to play a critical role in the future.

Assessing the Governance of Digital Contact Tracing in Response to COVID-19: Results of a Multi-National Study.

This paper describes the results of a multi-country survey of governance approaches for the use of digital contact tracing (DCT) in response to the COVID-19 pandemic. We argue that the countries in our survey represent two distinct models of DCT governance, both of which are flawed. The "data protection model" emphasizes privacy protections at the expense of public health benefit, while the "emergency response model" sacrifices transparency and accountability, prompting concerns about excessive governance surveillance. The ethical and effective use of DCT in the future requires a new governance approach that is better suited to this novel use of mobile phone data to promote public health."

COVID-19 Vaccine Uptake Through the Lived Experiences of Health Care Personnel: Policy and Legal Considerations.

Purpose: To investigate whether coronavirus disease 2019 (COVID-19) vaccination campaigns targeted at health care personnel (HCP) in the United States have addressed the lived experiences of HCP on the frontlines of the COVID-19 pandemic and to analyze policy and legal considerations for improving COVID-19 vaccine uptake among HCP. Methods: We conducted a literature and policy review to explore the lived experiences of different occupational groups of HCP on the frontlines of the COVID-19 pandemic-physicians, nurses, trainees, and nonclinical essential workers-in relation to ongoing COVID-19 vaccination campaigns. Finally, we discuss policy and legal considerations to improve the state of HCP COVID-19 vaccine uptake as the pandemic progresses. Results: COVID-19 vaccination campaigns have not achieved consistent high uptake among HCP for many reasons, including vaccine hesitancy, personal, professional considerations, and equity-rooted challenges. Conclusion: HCPs lived experiences during the COVID-19 pandemic reveal meaningful impediments to their COVID-19 vaccine uptake. We suggest that health care systems minimize inequity inherent in existing vaccination campaigns by providing financial and social support to HCP to raise HCP COVID-19 vaccine uptake.

"You Have to Die Not to Come to Work": A Mixed Methods Study of Attitudes and Behaviors regarding Presenteeism, Absenteeism and Influenza Vaccination among Healthcare Personnel with Respiratory Illness in Israel, 2016-2019.

INTRODUCTION: Healthcare personnel (HCP) have an increased risk of exposure to influenza and other respiratory pathogens. Increased presenteeism, decreased absenteeism, and low uptake of the influenza vaccine can contribute to the spread of influenza among HCP in healthcare settings. We used a mixed methods approach to investigate attitudes and behaviors of HCP in Israel towards influenza vaccination, presenteeism, and absenteeism. METHODS: The study took place over three influenza seasons (2016-2017, 2017-2018, 2018-2019) at the largest hospital in southern Israel. We administered a Knowledge, Attitudes and Practices (KAP) questionnaire and conducted semi-structured interviews with HCP who had been recently ill with respiratory symptoms. The KAP questionnaire included closed-ended questions about attitudes and behaviors regarding influenza, working while sick, and influenza vaccination. The interviews investigated HCP's perceptions of influenza infection and attitudes about absenteeism, presenteeism, and the influenza vaccine. RESULTS: We conducted 74 semi-structured interviews over three influenza seasons. Four HCP were interviewed twice, in separate seasons for different illness episodes. The 70 individuals interviewed included 16 physicians, 45 nurses or technicians, and 9 administrative staff. The median age was 42.5 years (range: 25-60), and most (79%) were female. Half (50%) got vaccinated against influenza before their illness episode. In interviews, most HCP said they come to work while sick (presenteeism) due to a strong personal work ethic and an institutional culture that discourages taking sick leave (absenteeism). HCP expressed skepticism about the effectiveness of the influenza vaccine as well as concern that the influenza vaccine causes severe illness. DISCUSSION: Over three influenza seasons in Israel, HCP cited a number of reasons for working while sick, and doubted the usefulness of influenza vaccine. Addressing reasons for presenteeism and vaccine hesitancy among HCP is crucial to protect HCP and patients from influenza virus infection and other viral respiratory illnesses, such as COVID-19.

An ethical analysis of vaccinating children against COVID-19: benefits, risks, and issues of global health equity.

COVID-19 vaccination of children has begun in various high-income countries with regulatory approval and general public support, but largely without careful ethical consideration. This trend is expected to extend to other COVID-19 vaccines and lower ages as clinical trials progress. This paper provides an ethical analysis of COVID-19 vaccination of healthy children. Specifically, we argue that it is currently unclear whether routine COVID-19 vaccination of healthy children is ethically justified in most contexts, given the minimal direct benefit that COVID-19 vaccination provides to children, the potential for rare risks to outweigh these benefits and undermine vaccine confidence, and substantial evidence that COVID-19 vaccination confers adequate protection to risk groups, such as older adults, without the need to vaccinate healthy children. We conclude that child COVID-19 vaccination in wealthy communities before adults in poor communities worldwide is ethically unacceptable and consider how policy deliberations might evolve in light of future developments.

Maximizing influenza vaccination uptake among healthcare personnel in Israel: lessons learned from mandatory vaccination policy in the United States.

BACKGROUND: Maximizing vaccination uptake is crucial in generating herd immunity and preventing infection incidence (Quach et al., Am J Infect Control 11:1017-23, 2013). Vaccination of healthcare personnel (HCP) against influenza is vital to influenza infection control in healthcare settings, given the consistent exposure of HCP to high-risk patients like: those with compromised immune systems, children, and the elderly (Johnson & Talbot, Curr Opin Infect Dis 24: 363-369, 2011). Influenza vaccination uptake among HCP remains suboptimal: in 2017-18, 47.6% of HCP who worked in settings where influenza vaccination was not mandatory were vaccinated against influenza in United States (Black et al., Morb Mortal Wkly Rep 67: 1050, 2018). Mandatory vaccination policies result in HCP influenza vaccination uptake rates substantially higher than opt-in influenza vaccination campaigns (94.8% vs. 47.6%) (Black et al., Morb Mortal Wkly Rep 67: 1050, 2018). GOALS: The Israel Journal of Health Policy Research has published articles focused on the issues of influenza vaccination (Yamin et al., Isr J Health Policy Res 3: 13, 2014), improving influenza vaccination coverage of HCP (Weber et al., Isr J Health Policy Res 5: 1-5, 2016), influenza vaccination motivators among HCP (Nutman and Yoeli, Isr J Health Policy Res 5: 52, 2016), legal imposition of vaccination (Kamin-Friedman, Isr J Health Policy Res 6:58, 2017), and mandatory vaccination (Gostin, Cell Biosci 8: 1-4, 2018). Each article explores factors influencing disease prevention from different angles within an Israeli context. This article attempts to fuse these topics by investigating how to apply aspects of American mandatory influenza vaccination policy targeted at HCP in an Israeli context. METHODS: Critical document analysis was conducted on relevant literature and policy discussing influenza prevention interventions among HCP within the United States. Mandatory vaccination policies were highlighted. A discussion of the professional responsibility of HCP to vaccinate against influenza serves as background. Case studies of hospitals in the United States that implemented mandatory vaccination policies for their employees are analyzed. The article concludes with analysis exploring how qualities of mandatory influenza vaccination policy of HCP could take shape in Israel, giving contextual limitations, urging Israeli health policy makers to reflect on lessons learned from the American case study. MAIN FINDINGS AND CONCLUSION: Mandatory HCP influenza vaccination policies in comparison to non-mandatory interventions are most effective in obtaining maximum influenza vaccination uptake among HCP (Black et al., Morb Mortal Wkly Rep 67: 1050, 2018). Many HCP cite individual objections to influenza vaccination rooted in personal doubts and ethical concerns. The ethical responsibility of HCP to their patients and work environments to prevent and lower influenza infection incidence arguably overrules such individual objections. Mandatory HCP influenza vaccination policies are an effective method of maximizing HCP influenza vaccine uptake and minimizing the spread of the influenza virus within healthcare settings. Still, cultural, social and political sensitivity must be taken into consideration when implementing both full-on mandatory HCP influenza vaccination policies and/or aspects of mandatory policies, especially within an Israeli context.

Vaccination uptake and income inequalities within a mass vaccination campaign.

BACKGROUND: In July 2013, Israel was swept with fear of a polio outbreak. In response to the importation of wild polio virus, the Ministry decided to take preventive action by administering oral poliovirus vaccine (OPV) to all children born after 1 January 2004 who had received at least one dose of inactivated poliovirus vaccine (IPV) in the past. This study analyzes the vaccination uptake rates resulting from the mass polio vaccination campaign on the basis of health inequality parameters of socioeconomic status (SES), principles of solidarity, and the Gini inequality index. The research explores understanding the value of the Gini inequality index within the context of SES and solidarity. METHODS: The study is based on data gathered from the Israeli Ministry of Health's administrative records from mother-and-child clinics across Israel. The research population is comprised of resident infants and children whom the Ministry of Health defined as eligible for the OPV between August and December 2013 (the "campaign period"). The analysis was carried out at the municipality level as well as the statistical area level. RESULTS: The higher the SES level of the municipality where the mother-and-child clinic is located, the lower the OPV vaccination uptake is. The greater the income inequality is in the municipality where the mother-and-child clinic is situated, the lower the vaccination uptake. CONCLUSIONS: Public health professionals promoting vaccine programs need to make specially-designed efforts both in localities with high average income and in localities with a high level of income diversity/inequality. Such practice will better utilize funds, resources, and manpower dedicated to increasing vaccination uptake across varying populations and communities.

Study of Healthcare Personnel with Influenza and other Respiratory Viruses in Israel (SHIRI): study protocol.

BACKGROUND: The Study of Healthcare Personnel with Influenza and other Respiratory Viruses in Israel (SHIRI) prospectively follows a cohort of healthcare personnel (HCP) in two hospitals in Israel. SHIRI will describe the frequency of influenza virus infections among HCP, identify predictors of vaccine acceptance, examine how repeated influenza vaccination may modify immunogenicity, and evaluate influenza vaccine effectiveness in preventing influenza illness and missed work. METHODS: Cohort enrollment began in October, 2016; a second year of the study and a second wave of cohort enrollment began in June 2017. The study will run for at least 3 years and will follow approximately 2000 HCP (who are both employees and members of Clalit Health Services [CHS]) with routine direct patient contact. Eligible HCP are recruited using a stratified sampling strategy. After informed consent, participants complete a brief enrollment survey with questions about occupational responsibilities and knowledge, attitudes, and practices about influenza vaccines. Blood samples are collected at enrollment and at the end of influenza season; HCP who choose to be vaccinated contribute additional blood one month after vaccination. During the influenza season, participants receive twice-weekly short message service (SMS) messages asking them if they have acute respiratory illness or febrile illness (ARFI) symptoms. Ill participants receive follow-up SMS messages to confirm illness symptoms and duration and are asked to self-collect a nasal swab. Information on socio-economic characteristics, current and past medical conditions, medical care utilization and vaccination history is extracted from the CHS database. Information about missed work due to illness is obtained by self-report and from employee records. Respiratory specimens from self-collected nasal swabs are tested for influenza A and B viruses, respiratory syncytial virus, human metapneumovirus, and coronaviruses using validated multiplex quantitative real-time reverse transcription polymerase chain reaction assays. The hemagglutination inhibition assay will be used to detect the presence of neutralizing influenza antibodies in serum. DISCUSSION: SHIRI will expand our knowledge of the burden of respiratory viral infections among HCP and the effectiveness of current and repeated annual influenza vaccination in preventing influenza illness, medical utilization, and missed workdays among HCP who are in direct contact with patients. TRIAL REGISTRATION: NCT03331991 . Registered on November 6, 2017.