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.

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.

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.

Influenza vaccine uptake among children and older adults in China: a secondary analysis of a quasi-experimental study.

BACKGROUND: Influenza vaccination is the key to prevent influenza-related disease, especially among high-risk populations. However, influenza vaccine uptake in China is low. This secondary analysis of a quasi-experimental trial aimed to understand factors associated with influenza vaccine uptake among children and older people stratified by funding context. METHODS: A total of 225 children (aged 0.5-8 years) and 225 older people (aged 60 years or above) were recruited from three clinics (rural, suburban and urban) in Guangdong Province. Participants were allocated into two groups based on funding contexts: a self-paid group (N = 150, 75 children and 75 older adults) in which participants paid full price for their vaccination; and a subsidized group (N = 300, 150 children and 150 older adults) in which varying levels of financial support was provided. Univariate and multivariable logistic regressions were conducted stratified by funding contexts. RESULTS: Overall, 75.0% (225/300) of participants in the subsidized group and 36.7% (55/150) in the self-paid group got vaccinated. Older adults had lower vaccination rates than children in both funding groups, while both age groups showed much higher uptake in the subsidized group than in the self-paid group (aOR = 5.96, 95% CI: 3.77-9.42, p = 0.001). In the self-paid group, having prior influenza vaccination history of children (aOR:2.61, 95%CI: 1.06-6.42) or older people (aOR:4.76, 95%CI: 1.08-20.90) was associated with increased influenza vaccine uptake compared to those who had no prior vaccination experiences in the family. While in the subsidized group, participants who got married or lived with partners (aOR = 0.32, 0.10-0.98) had lower vaccination uptake than single ones. Trust in providers' advice (aOR = 4.95, 95%CI:1.99, 12.43), perceived effectiveness of the vaccine (aOR: 12.18, 95%CI: 5.21-28.50), and experienced influenza-like illnesses in the family in the past year (aOR = 46.52, 4.10, 533.78) were associated with higher vaccine uptake. CONCLUSIONS: Older people had suboptimal vaccine uptake compared to children in both contexts and need more attention to enhance influenza vaccination. Tailoring interventions to different vaccine funding contexts may help improve influenza vaccination: In self-paid context, motivating people to accept their first ever influenza vaccination may be a promising strategy. In subsidized context, improving public confidence in vaccine effectiveness and providers' advice would be useful.

The effectiveness of pay-it-forward in addressing HPV vaccine delay and increasing uptake among 15-18-year-old adolescent girls compared to user-paid vaccination: a study protocol for a two-arm randomized controlled trial in China.

BACKGROUND: Human papillomavirus (HPV) vaccination could prevent cervical and other HPV-associated cancers attributable to vaccine-associated HPV types. However, HPV vaccination coverage among women aged 9-18 years old is low in China. Common barriers include poor financial affordability, minimal public engagement, and low confidence in domestically produced HPV vaccines. Pay-it-forward offers an individual a free or subsidized service then an opportunity to voluntarily donate and/or create a postcard message to support future people. This study aims to assess the effectiveness of pay-it-forward as compared to standard-of-care self-paid vaccination to improve HPV vaccine uptake among adolescent girls aged 15-18 years, who are left out in the current pilot free HPV vaccination task force in some parts of China. METHODS: This is a two-arm randomized controlled trial in Chengdu, China. Eligible adolescent girls (via caregivers) will be randomly selected and recruited through four community health centers (one in the most developed urban areas, one in higher middle-income and one in lower middle-income suburban areas, and one in the least developed rural areas) using the resident registration list. A total of 320 participants will be randomized into two study arms (user-paid versus pay-it-forward vaccination) in a 1:1 ratio. The intervention assignment will be blinded to recruiters and participants using envelop concealment until the research assistants open the envelop to determine which treatment to deliver to each individual. The primary outcome of the study will be HPV vaccine uptake by administrative data. Secondary outcomes include costs, vaccine hesitancy, and the completion rates of the 3-dose HPV vaccination series. DISCUSSION: This study will investigate an innovative pay-it-forward strategy's effectiveness and economic costs to improve HPV vaccination among 15-18-year-old adolescent girls. Study findings will have implications for increasing HPV vaccine uptake in places where HPV vaccines are provided for a fee. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR), ChiCTR2200055542. Registered on 11 January 2022.

Applications of Social Media and Digital Technologies in COVID-19 Vaccination: Scoping Review.

BACKGROUND: Social media and digital technologies have played essential roles in disseminating information and promoting vaccination during the COVID-19 pandemic. There is a need to summarize the applications and analytical techniques of social media and digital technologies in monitoring vaccine attitudes and administering COVID-19 vaccines. OBJECTIVE: We aimed to synthesize the global evidence on the applications of social media and digital technologies in COVID-19 vaccination and to explore their avenues to promote COVID-19 vaccination. METHODS: We searched 6 databases (PubMed, Scopus, Web of Science, Embase, EBSCO, and IEEE Xplore) for English-language articles from December 2019 to August 2022. The search terms covered keywords relating to social media, digital technology, and COVID-19 vaccines. Articles were included if they provided original descriptions of applications of social media or digital health technologies/solutions in COVID-19 vaccination. Conference abstracts, editorials, letters, commentaries, correspondence articles, study protocols, and reviews were excluded. A modified version of the Appraisal Tool for Cross-Sectional Studies (AXIS tool) was used to evaluate the quality of social media-related studies. The review was undertaken with the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. RESULTS: A total of 178 articles were included in our review, including 114 social media articles and 64 digital technology articles. Social media has been applied for sentiment/emotion analysis, topic analysis, behavioral analysis, dissemination and engagement analysis, and information quality analysis around COVID-19 vaccination. Of these, sentiment analysis and topic analysis were the most common, with social media data being primarily analyzed by lexicon-based and machine learning techniques. The accuracy and reliability of information on social media can seriously affect public attitudes toward COVID-19 vaccines, and misinformation often leads to vaccine hesitancy. Digital technologies have been applied to determine the COVID-19 vaccination strategy, predict the vaccination process, optimize vaccine distribution and delivery, provide safe and transparent vaccination certificates, and perform postvaccination surveillance. The applied digital technologies included algorithms, blockchain, mobile health, the Internet of Things, and other technologies, although with some barriers to their popularization. CONCLUSIONS: The applications of social media and digital technologies in addressing COVID-19 vaccination-related issues represent an irreversible trend. Attention should be paid to the ethical issues and health inequities arising from the digital divide while applying and promoting these technologies.

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.

Infectious diseases prevention and control using an integrated health big data system in China.

BACKGROUND: The Yinzhou Center for Disease Prevention and Control (CDC) in China implemented an integrated health big data platform (IHBDP) that pooled health data from healthcare providers to combat the spread of infectious diseases, such as dengue fever and pulmonary tuberculosis (TB), and to identify gaps in vaccination uptake among migrant children. METHODS: IHBDP is composed of medical data from clinics, electronic health records, residents' annual medical checkup and immunization records, as well as administrative data, such as student registries. We programmed IHBDP to automatically scan for and detect dengue and TB carriers, as well as identify migrant children with incomplete immunization according to a comprehensive set of screening criteria developed by public health and medical experts. We compared the effectiveness of the big data screening with existing traditional screening methods. RESULTS: IHBDP successfully identified six cases of dengue out of a pool of 3972 suspected cases, whereas the traditional method only identified four cases (which were also detected by IHBDP). For TB, IHBDP identified 288 suspected cases from a total of 43,521 university students, in which three cases were eventually confirmed to be TB carriers through subsequent follow up CT or T-SPOT.TB tests. As for immunization screenings, IHBDP identified 240 migrant children with incomplete immunization, but the traditional door-to-door screening method only identified 20 ones. CONCLUSIONS: Our study has demonstrated the effectiveness of using IHBDP to detect both acute and chronic infectious disease patients and identify children with incomplete immunization as compared to traditional screening methods.

Willingness and uptake of the COVID-19 testing and vaccination in urban China during the low-risk period: a cross-sectional study.

BACKGROUND: Regular testing and vaccination are effective measures to mitigate the ongoing COVID-19 pandemic. Evidence on the willingness and uptake of the COVID-19 testing is scarce, and the willingness and uptake of vaccination may change as the pandemic evolves. This study aims to examine willingness and uptake of COVID-19 testing and vaccination during a low-risk period of the COVID-19 pandemic in urban China. METHODS: A cross-sectional online survey was conducted among 2244 adults in urban China. Descriptive analyses were performed to compare the respondents' willingness and uptake of COVID-19 testing and vaccination. Multivariate logistic regressions were fitted to investigate factors associated with the willingness and uptake of the two measures. RESULTS: In early 2021, about half (52.45%) of the respondents had received or scheduled a COVID-19 test at least once, and a majority (95.63%) of the respondents were willing to receive testing. About two-thirds (63.28%) of the respondents had received/scheduled or were willing to receive a COVID-19 vaccine. Willingness and uptake of COVID-19 testing were not associated with socio-demographic characteristics, except for occupation. Being of older age, migrants, having higher educational attainment and secure employment were associated with a higher uptake of COVID-19 vaccination among the surveyed respondents, while willingness to vaccinate was consistent across socio-demographic characteristics among those who had not been vaccinated. CONCLUSIONS: By early 2021, Chinese adults expressed almost universal willingness of COVID-19 testing and over half of adults have been tested, while the willingness and uptake of COVID-19 vaccination were relatively low at the low-risk period of the COVID-19 pandemic. Maintaining willingness of COVID-19 vaccination is critical and necessary, especially when the pandemic evolved into a low-risk period.

Vaccines and the social amplification of risk.

In 2019, the World Health Organization (WHO) named "Vaccine Hesitancy" one of the top 10 threats to global health. Shortly afterward, the COVID-19 pandemic emerged as the world's predominant health concern. COVID-19 vaccines of several types have been developed, tested, and partially deployed with remarkable speed; vaccines are now the primary control measure and hope for a return to normalcy. However, hesitancy concerning these vaccines, along with resistance to masking and other control measures, remains a substantial obstacle. The previous waves of vaccine hesitancy that led to the WHO threat designation, together with recent COVID-19 experience, provide a window for viewing new forms of social amplification of risk (SAR). Not surprisingly, vaccines provide fertile ground for questions, anxieties, concerns, and rumors. These appear in new globalized hyperconnected communications landscapes and in the context of complex human (social, economic, and political) systems that exhibit evolving concerns about vaccines and authorities. We look at drivers, impacts, and implications for vaccine initiatives in several recent historical examples and in the current efforts with COVID-19 vaccination. Findings and insights were drawn from the Vaccine Confidence Project's decade long monitoring of media and social media and its related research efforts. The trends in vaccine confidence and resistance have implications for updating the social amplification of risk framework (SARF); in turn, SARF has practical implications for guiding efforts to alleviate vaccine hesitancy and to mitigate harms from intentional and unintentional vaccine scares.

Vaccination against COVID-19: A systematic review and meta-analysis of acceptability and its predictors.

We aimed to estimate the coronavirus disease 2019 (COVID-19) vaccine acceptance rate and identify predictors associated with acceptance. To this end, we searched PubMed, Web of Science, Cochrane Library, and Embase databases until November 4, 2020. Meta-analyses were performed to estimate the rate with 95% confidence intervals (CI). Predictors were identified to be associated with vaccination intention based on the health belief model framework. Thirty-eight articles, with 81,173 individuals, were included. The pooled COVID-19 vaccine acceptance rate was 73.31% (95%CI: 70.52, 76.01). Studies using representative samples reported a rate of 73.16%. The pooled acceptance rate among the general population (81.65%) was higher than that among healthcare workers (65.65%). Gender, educational level, influenza vaccination history, and trust in the government were strong predictors of COVID-19 vaccination willingness. People who received an influenza vaccination in the last year were more likely to accept COVID-19 vaccination (odds ratio: 3.165; 95%CI: 1.842, 5.464). Protecting oneself or others was the main reason for willingness, and concerns about side effects and safety were the main reasons for unwillingness. National- and individual-level interventions can be implemented to improve COVID-19 vaccine acceptance before large-scale vaccine rollout. Greater efforts could be put into addressing negative predictors associated with willingness.

Expectant parents' vaccine decisions influenced by the 2018 Chinese vaccine crisis: A cross-sectional study.

Immunization programs have been challenged by vaccine crises. Between 2013 and 2018, China has experienced three major vaccine scandals and crises, which has partly impaired Chinese public trust in domestically produced vaccines. This study aims to explore the associations between parental trust toward CDC-released crisis communication information, parents' critical understanding of crisis information, parental confidence in vaccine efficacy, and parental vaccine decisions. A cross-sectional survey was conducted among 1065 expectant parents two weeks after the 2018 vaccine crisis was revealed. The proportion of parental hesitancy toward domestically produced vaccines and overall vaccination increased from 30.6% to 82.7% and 8.3% to 52.1%, respectively, after the crisis. Parents with higher levels of trust toward crisis communication information were less likely to report vaccine hesitancy toward both domestically produced vaccines and vaccines overall after the crisis. Parents with better critical understanding of crisis information were less likely to report a vaccine hesitancy toward overall vaccine and more likely to maintain a vaccine intention. Additionally, parents with lower levels of confidence in vaccine efficacy were more likely to became vaccine hesitant but were also more likely to maintain their vaccine intentions after the crisis. It is crucial to guarantee the safety of vaccines, maintain parental confidence in vaccine efficacy, and eliminate the potential risks that result in parental vaccine hesitancy. Future crisis communication strategies are encouraged to ensure timely responses to sustain public confidence.

The Uncounted Casualties of a Hidden COVID-19 Epidemic in China: Cross-sectional Study on Deaths Related to Overwork.

BACKGROUND: During the COVID-19 response, nonclinical essential workers usually worked overtime and experienced significant work stress, which subsequently increased their risk of mortality due to cardiovascular diseases, stroke, and pre-existing conditions. Deaths on duty, including deaths due to overwork, during the COVID-19 response were usually reported on web-based platforms for public recognition and solidarity. Although no official statistics are available for these casualties, a list of on-duty deaths has been made publicly available on the web by crowdsourcing. OBJECTIVE: This study aims to understand the trends and characteristics of deaths related to overwork among the frontline nonclinical essential workers participating in nonpharmaceutical interventions during the first wave of COVID-19 in China. METHODS: Based on a web-based crowdsourced list of deaths on duty during the first wave of the COVID-19 response in China, we manually verified all overwork-related death records against the full-text web reports from credible sources. After excluding deaths caused by COVID-19 infection and accidents, a total of 340 deaths related to overwork among nonclinical essential workers were attributed to combatting the COVID-19 crisis. We coded the key characteristics of the deceased workers, including sex, age at death, location, causes of death, date of incidence, date of death, containment duties, working area, and occupation. The temporal and spatial correlations between deaths from overwork and COVID-19 cases in China were also examined using Pearson correlation coefficient. RESULTS: From January 20 to April 26, 2020, at least 340 nonclinical frontline workers in China were reported to have died as a result of overwork while combatting COVID-19. The weekly overwork mortality was positively correlated with weekly COVID-19 cases (r=0.79, P<.001). Two-thirds of deceased workers (230/340, 67.6%) were under 55 years old, and two major causes of deaths related to overwork were cardiovascular diseases (138/340, 40.6%) and cerebrovascular diseases (73/340, 21.5%). Outside of Hubei province, there were almost 2.5 times as many deaths caused by COVID-19-related overwork (308/340, 90.6%) than by COVID-19 itself (n=120). CONCLUSIONS: The high number of deaths related to overwork among nonclinical essential workers at the frontline of the COVID-19 epidemic is alarming. Policies for occupational health protection against work hazards should therefore be prioritized and enforced.

Assessing COVID-19 Vaccine Hesitancy, Confidence, and Public Engagement: A Global Social Listening Study.

BACKGROUND: Monitoring public confidence and hesitancy is crucial for the COVID-19 vaccine rollout. Social media listening (infoveillance) can not only monitor public attitudes on COVID-19 vaccines but also assess the dissemination of and public engagement with these opinions. OBJECTIVE: This study aims to assess global hesitancy, confidence, and public engagement toward COVID-19 vaccination. METHODS: We collected posts mentioning the COVID-19 vaccine between June and July 2020 on Twitter from New York (United States), London (United Kingdom), Mumbai (India), and Sao Paulo (Brazil), and Sina Weibo posts from Beijing (China). In total, we manually coded 12,886 posts from the five global metropolises with high COVID-19 burdens, and after assessment, 7032 posts were included in the analysis. We manually double-coded these posts using a coding framework developed according to the World Health Organization's Confidence, Complacency, and Convenience model of vaccine hesitancy, and conducted engagement analysis to investigate public communication about COVID-19 vaccines on social media. RESULTS: Among social media users, 36.4% (571/1568) in New York, 51.3% (738/1440) in London, 67.3% (144/214) in Sao Paulo, 69.8% (726/1040) in Mumbai, and 76.8% (2128/2770) in Beijing indicated that they intended to accept a COVID-19 vaccination. With a high perceived risk of getting COVID-19, more tweeters in New York and London expressed a lack of confidence in vaccine safety, distrust in governments and experts, and widespread misinformation or rumors. Tweeters from Mumbai, Sao Paulo, and Beijing worried more about vaccine production and supply, whereas tweeters from New York and London had more concerns about vaccine distribution and inequity. Negative tweets expressing lack of vaccine confidence and misinformation or rumors had more followers and attracted more public engagement online. CONCLUSIONS: COVID-19 vaccine hesitancy is prevalent worldwide, and negative tweets attract higher engagement on social media. It is urgent to develop an effective vaccine campaign that boosts public confidence and addresses hesitancy for COVID-19 vaccine rollouts.

Comparison of Public Responses to Containment Measures During the Initial Outbreak and Resurgence of COVID-19 in China: Infodemiology Study.

BACKGROUND: COVID-19 cases resurged worldwide in the second half of 2020. Not much is known about the changes in public responses to containment measures from the initial outbreak to resurgence. Monitoring public responses is crucial to inform policy measures to prepare for COVID-19 resurgence. OBJECTIVE: This study aimed to assess and compare public responses to containment measures during the initial outbreak and resurgence of COVID-19 in China. METHODS: We curated all COVID-19-related posts from Sina Weibo (China's version of Twitter) during the initial outbreak and resurgence of COVID-19 in Beijing, China. With a Python script, we constructed subsets of Weibo posts focusing on 3 containment measures: lockdown, the test-trace-isolate strategy, and suspension of gatherings. The Baidu open-source sentiment analysis model and latent Dirichlet allocation topic modeling, a widely used machine learning algorithm, were used to assess public engagement, sentiments, and frequently discussed topics on each containment measure. RESULTS: A total of 8,985,221 Weibo posts were curated. In China, the containment measures evolved from a complete lockdown for the general population during the initial outbreak to a more targeted response strategy for high-risk populations during COVID-19 resurgence. Between the initial outbreak and resurgence, the average daily proportion of Weibo posts with negative sentiments decreased from 57% to 47% for the lockdown, 56% to 51% for the test-trace-isolate strategy, and 55% to 48% for the suspension of gatherings. Among the top 3 frequently discussed topics on lockdown measures, discussions on containment measures accounted for approximately 32% in both periods, but those on the second-most frequently discussed topic shifted from the expression of negative emotions (11%) to its impacts on daily life or work (26%). The public expressed a high level of panic (21%) during the initial outbreak but almost no panic (1%) during resurgence. The more targeted test-trace-isolate measure received the most support (60%) among all 3 containment measures in the initial outbreak, and its support rate approached 90% during resurgence. CONCLUSIONS: Compared to the initial outbreak, the public expressed less engagement and less negative sentiments on containment measures and were more supportive toward containment measures during resurgence. Targeted test-trace-isolate strategies were more acceptable to the public. Our results indicate that when COVID-19 resurges, more targeted test-trace-isolate strategies for high-risk populations should be promoted to balance pandemic control and its impact on daily life and the economy.

Survey of Parental Use of Antimicrobial Drugs for Common Childhood Infections, China.

In a large-scale survey of 9,526 parents in China, we investigated antimicrobial drug use for common childhood infections. Of children with self-limiting conditions, formal care was sought for 69.2%; of those, 53.4% received drug prescriptions, including 11.2% from parental demands. Where drugs were taken without prescriptions, 70% were from community pharmacies.

Cross-Country Comparison of Public Awareness, Rumors, and Behavioral Responses to the COVID-19 Epidemic: Infodemiology Study.

BACKGROUND: Understanding public behavioral responses to the coronavirus disease (COVID-19) epidemic and the accompanying infodemic is crucial to controlling the epidemic. OBJECTIVE: The aim of this study was to assess real-time public awareness and behavioral responses to the COVID-19 epidemic across 12 selected countries. METHODS: Internet surveillance was used to collect real-time data from the general public to assess public awareness and rumors (China: Baidu; worldwide: Google Trends) and behavior responses (China: Ali Index; worldwide: Google Shopping). These indices measured the daily number of searches or purchases and were compared with the numbers of daily COVID-19 cases. The trend comparisons across selected countries were observed from December 1, 2019 (prepandemic baseline) to April 11, 2020 (at least one month after the governments of selected countries took actions for the pandemic). RESULTS: We identified missed windows of opportunity for early epidemic control in 12 countries, when public awareness was very low despite the emerging epidemic. China's epidemic and the declaration of a public health emergency of international concern did not prompt a worldwide public reaction to adopt health-protective measures; instead, most countries and regions only responded to the epidemic after their own case counts increased. Rumors and misinformation led to a surge of sales in herbal remedies in China and antimalarial drugs worldwide, and timely clarification of rumors mitigated the rush to purchase unproven remedies. CONCLUSIONS: Our comparative study highlights the urgent need for international coordination to promote mutual learning about epidemic characteristics and effective control measures as well as to trigger early and timely responses in individual countries. Early release of official guidelines and timely clarification of rumors led by governments are necessary to guide the public to take rational action.

The impacts of parent-child communication on left-behind children's mental health and suicidal ideation: A cross sectional study in Anhui.

This study aimed to investigate the impact of previous maternal migration experiences on left-behind children's (LBC) mental health status and suicidal ideation, and the possible mediating role of parent-child communication. A cross-sectional study among rural children was conducted in Anhui, China, in 2018. LBC who self-reported that (a) their fathers were migrants and (b) they were living with their mothers at the time of the survey were included in this study. The participants were then divided into two subgroups by previous maternal migration experience. Previous maternal migration was associated with worse mental health and a higher prevalence of suicidal ideation among LBC compared with their peers. Healthy communication between children and parents fully mediates the adverse effects caused by previous maternal migration experiences on mental health among LBC, and communication with mother partially mediates the association with suicidal ideation. Communication classes for returning parents offered jointly by governments and schools could be an effective way to mitigate the impacts of maternal migration on child mental health and should be studied.

Inequalities in the health survey using validation question to filter insufficient effort responding: reducing overestimated effects or creating selection bias?

BACKGROUND: The presence of insufficient effort responding participants (IERPs) in a survey can produce systematic bias. Validation questions are commonly used to exclude IERPs. Participants were defined as IERPs if responding inconsistently to two matched validation questions, and non-insufficient effort responding participants (non-IERPs) if responding consistently. However, it has not been tested whether validation questions themselves could result in selection bias. METHODS: This study was a cross-sectional survey conducted in Guangxi, China. Participants' intentions to use antibiotics for their children when they have self-limiting diseases, including sore throat, cold, diarrhea, and fever, were measured. The Chi-square tests were used to compare the socio-economic status (SES) between non-IERPs and IERPs. Logistic regression was adopted to test the association between intentions to misuse antibiotics and groups (non-IERPs, IERPs with high SES, and IERPs with low SES). RESULTS: Data with 3264 non-IERPs and 1543 IERPs were collected. The results showed IERPs had a lower education level (χ2 = 6.100, p = 0.047) and a higher proportion of rural residence (χ2 = 4.750, p = 0.030) compared with non-IERPs. Rural IERPs reported significantly higher rates of intentions to misuse antibiotics when their children have a sore throat (OR = 1.32; 95% CI = 1.11,1.56; p < 0.01), cold (OR = 1.33; 95%CI = 1.13,1.58; p < 0.01), diarrhea (OR = 1.46; 95%CI = 1.20,1.77; p < 0.001), and fever (OR = 1.22; 95% CI = 1.04,1.43; p < 0.05) compared with non-IERPs. IERPs living in urban areas reported significantly lower rates of intentions to use antibiotics when their children have a sore throat (OR = 0.76; 95%CI = 0.62,0.93; p < 0.01) compared with non-IERPs. IERPs with lower levels of education reported significantly higher rates of intentions to use antibiotics when their children have a sore throat (OR = 1.19; 95%CI = 1.02,1.39; p < 0.05), cold (OR = 1.43; 95% CI = 1.23,1.66; p < 0.001), diarrhea (OR = 1.38; 95%CI = 1.15,1.64; p < 0.01), and fever (OR = 1.25; 95% CI = 1.09,1.44; p < 0.01) compared with non-IERPs. IERPs with higher education levels reported significantly lower rates of intentions to use antibiotics when their children have a sore throat (OR = 0.72; 95% CI = 0.56,0.94; p < 0.05), cold (OR = 0.66; 95% CI = 0.51,0.86; p < 0.01), and fever (OR = 0.74; 95% CI = 0.60,0.92; p < 0.01) compared with non-IERPs. IERPs with low-income reported significantly higher rates of intentions to use antibiotics when their children have a cold (OR = 1.36; 95% CI = 1.13,1.64; p < 0.01) and diarrhea (OR = 1.30; 95% CI = 1.05,1.62; p < 0.05) compared with non-IERPs. CONCLUSIONS: Using validation questions to exclude IERPs can result in selection bias in which participants with lower socio-economic standing and poor antibiotic use intentions were disproportionately excluded.

The relative persuasiveness of narrative versus non-narrative health messages in public health emergency communication: Evidence from a field experiment.

Previous studies indicated that narrative health messages are more effective than non-narrative messages in influencing health outcomes. However, this body of evidence does not account for differences in health domain, and little is known about the effectiveness of this message execution strategy during public health emergencies. In this study, we examined the relative effectiveness of the two formats in influencing knowledge and perceived response efficacy related to prevention of pandemic influenza, and determined whether effects of message format vary across population sub-groups. Data for the study come from an experiment fielded in 2013 that involved a nationally representative sample of 627 American adults. Participants were randomly assigned to view either a narrative (n=322) or a non-narrative (n=305) video clip containing closely matched information about knowledge and preventive actions related to pandemic influenza, and completed pre- and post-viewing questions assessing knowledge and perceived response efficacy related to the prevention of pandemic influenza. Results indicated that participants in the non-narrative condition reported greater knowledge and rated pandemic influenza prevention measures as more effective compared with those in the narrative condition. Message format effects did not vary across population sub-groups; post-viewing scores of knowledge and perceptions related to pandemic influenza were consistently higher in the non-narrative condition compared with the narrative condition across five socio-demographic groups: age, gender, education, race/ethnicity and income. We concluded that didactic, non-narrative messages may be more effective than narrative messages to influence knowledge and perceptions during public health emergencies.