Vaccine Hesitancy During the COVID-19 Pandemic: A Latent Class Analysis of Middle-Aged and Older US Adults.

It is important to distinguish between apprehensions that lead to vaccine rejection and those that do not. In this study, we (1) identifed latent classes of individuals by vaccination attitudes, and (2) compared classes of individuals by sociodemographic characteristics COVID-19 vaccination, and risk reduction behaviors. The COVID-19 Coping Study is a longitudinal cohort of US adults aged ≥ 55 years (n = 2358). We categorized individuals into three classes based on the adult Vaccine Hesitancy Scale using latent class analysis (LCA). The associations between class membership and sociodemographic characteristics, COVID-19 vaccination, and other behaviors were assessed using chi-square tests. In total, 88.9% were Vaccine Acceptors, 8.6% were Vaccine Ambivalent, and 2.5% Vaccine Rejectors. At the end, 90.7% of Acceptors, 62.4% of the Ambivalent, and 30.7% of the Rejectors had been vaccinated. The Ambivalent were more likely to be Black or Hispanic, and adopted social distancing and mask wearing behaviors intermediate to that of the Acceptors and Rejectors. Targeting the Vaccine Ambivalent may be an efficient way of increasing vaccination coverage. Controlling the spread of disease during a pandemic requires tailoring vaccine messaging to their concerns, e.g., through working with trusted community leaders, while promoting other risk reduction behaviors.

Childhood vaccination timeliness following maternal migration to an informal urban settlement in Kenya.

INTRODUCTION: Timely receipt of recommended vaccines is a proven strategy to reduce preventable under-five deaths. Kenya has experienced impressive declines in child mortality from 111 to 43 deaths per 1000 live births between 1980 and 2019. However, considerable inequities in timely vaccination remain, which unnecessarily increases risk for serious illness and death. Maternal migration is a potentially important driver of timeliness inequities, as the social and financial stressors of moving to a new community may require a woman to delay her child's immunizations. This analysis examined how maternal migration to informal urban settlements in Nairobi, Kenya influenced childhood vaccination timeliness. METHODS: Data came from the Nairobi Urban Health and Demographic Surveillance System, 2002-2018. Migration exposures were migrant status (migrant, non-migrant), migrant origin (rural, urban), and migrant type (first-time, circular [previously resided in settlement]). Age at vaccine receipt (vaccination timeliness) was calculated for all basic vaccinations. Accelerated failure time models were used to investigate relationships between migration exposures and vaccination timeliness. Confounding was addressed using propensity score weighting. RESULTS: Over one-third of the children of both migrants and non-migrants received at least one dose late or not at all. Unweighted models showed the children of migrants had shorter time to OPV1 and DPT1 vaccine receipt compared to the children of non-migrants. After accounting for confounding only differences in timeliness for DPT1 remained, with the children of migrants receiving DPT1 significantly earlier than the children of non-migrants. Timeliness was comparable among migrants with rural and urban origins and among first-time and circular migrants. CONCLUSION: Although a substantial proportion of children in Nairobi's informal urban settlements do not receive timely vaccination, this analysis found limited evidence that maternal migration and migration characteristics were associated with delays for most doses. Future research should seek to elucidate potential drivers of low vaccination timeliness in Kenya.

The influence of maternal migration on child vaccination in Kenya: An inverse probability of treatment-weighted analysis.

OBJECTIVES: Kenya has substantially improved child mortality between 1990 and 2019, with under-5 mortality decreasing from 104 to 43 deaths per 1000 live births. However, only two-thirds of Kenyan children receive all recommended vaccines by 1 year, making it essential to identify undervaccinated subpopulations. Internal migrants are a potentially vulnerable group at risk of decreased access to healthcare. This analysis explored how maternal migration within Kenya influences childhood vaccination. METHODS: Data were from the 2014 Kenya Demographic and Health Survey, a nationally representative cross-sectional survey. Logistic regressions assessed relationships between maternal migration and full and up-to-date child vaccination using inverse probability of treatment weighting. Two exposure variables were examined: migration status and stream (e.g. rural-urban). Multiple imputation was used to impute up-to-date status for children without vaccination cards to reduce selection bias. RESULTS: After accounting for selection and confounding biases, all relationships between migration status and migration stream and full and up-to-date vaccination became statistically insignificant. CONCLUSIONS: Null findings indicate that, in Kenya, characteristics enabling migration, rather than the process of migration itself, drive differential vaccination behavior between migrants and non-migrants. This finding is an important deviation from previous literature, which did not rigorously address important biases.

Inequities in On-Time Childhood Vaccination: Evidence From Sub-Saharan Africa.

INTRODUCTION: Vaccination coverage has improved in the past decade, but inequalities persist: the poorest, least educated, and rural communities are left behind. Programming has focused on increasing coverage and reaching the hardest-to-reach children, but vaccination timeliness is equally important because delays leave children vulnerable to infections. This study examines the levels and inequities of on-time vaccination in the Sub-Saharan African region. METHODS: The most recent Demographic and Health Surveys or Multiple Indicator Clusters Surveys since 2000 from Sub-Saharan Africa were used to assess on-time vaccination and inequalities by household wealth, maternal education, and place of residence. Inequalities were quantified using slope index of inequality and concentration index. RESULTS: The analysis included 153,632 children aged 12-36 months from 40 Sub-Saharan Africa countries. Median on-time vaccination coverage was <50% in all the 4 subregions. Differences in on-time vaccination were observed by place of residence in the Southern (20.8 percentage points, 95% CI=0.8, 40.8), West (17.5 percentage points, 95% CI=5.1, 29.9), and Eastern (20.9 percentage points, 95% CI=6.5, 35.2) regions. Wealth-related inequities were observed in the Southern (22.6 percentage points, 95% CI=4.0, 41.2), Western (30.6 percentage points, 95% CI=19.1, 42.1), and Eastern (26.1 percentage points, 95% CI=8.2, 44.0) regions. Significant education-related differences in on-time vaccination were observed in the Western (20.7 percentage points, 95% CI=10.9, 30.5) and Eastern (21.2 percentage points, 95% CI=7.0, 35.4) regions. CONCLUSIONS: On-time vaccination coverage was low in all subregions and nearly all countries. Inequalities in on-time immunization by household wealth, place of residence, and education existed in most countries. Concrete strategies to improve levels of timeliness are needed. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Women's Empowerment and Child Vaccination in Kenya: The Modifying Role of Wealth.

INTRODUCTION: Although vaccination coverage is high in Kenya relative to other African nations, undervaccinated children remain, making it important to identify characteristics of these children and their caregivers. Potentially relevant but understudied factors are women's empowerment and early marriage. Women who marry older and have more autonomous decision-making authority may be better able to ensure their children receive health services, including immunizations. This analysis examines the relationship between early marriage and multiple dimensions of women's empowerment and child vaccination status in Kenya and explores whether these relationships are modified by wealth. METHODS: Data were from the 2014 Kenya Demographic and Health Survey. The analysis was completed in 2020 using updated data made available to researchers in 2019. Logistic regressions assessed relationships among early marriage, 3 dimensions of women's empowerment (enabling conditions, intrinsic agency, and instrumental agency), and child vaccination. Analyses were stratified by wealth to explore potential effect modification. RESULTS: For women in the middle wealth tertile, the odds of having a fully vaccinated child were 3.45 (95% CI=1.51, 7.91) times higher for those with higher versus lower empowerment. Further, among the wealthiest women, those with middle empowerment were 5.99 (95% CI=2.06, 17.40) times more likely to have a fully vaccinated child than women with lower empowerment. CONCLUSIONS: Results suggest a threshold effect of wealth's role in the relationship between empowerment and vaccination. Enabling conditions may not influence immunization among the poorest women but exert a stronger positive influence on childhood vaccination among wealthier women. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

A Review of the Literature on the Global Epidemiology of Corneal Blindness.

PURPOSE: This study seeks to review published research on the global epidemiology of corneal blindness, with a specific focus on the available published estimates of incidence, prevalence, and trends in incidence or prevalence, as well as the contribution of corneal causes to overall burden of blindness. METHODS: A scoping review was conducted of the published literature on the global epidemiology of corneal blindness, with emphasis on prevalence and incidence studies. Four databases were searched using both epidemiological and corneal blindness keywords. This review was limited to studies with a primary aim of determining the incidence, prevalence, or trends in corneal blindness or the percentage of blindness due to corneal causes. Only conditions considered to signify current blindness were included, not diseases that eventually could lead to blindness if left untreated. RESULTS: A total of 185 articles met the selection criteria. Of these, 145 articles investigated all-cause blindness prevalence. Only 10 articles specifically aimed to determine estimates of corneal blindness prevalence, 7 articles provided results for all-cause blindness incidence, and no studies focused on obtaining corneal blindness incidence. Data on corneal blindness were most often present in studies investigating all-cause blindness and in trachoma studies. CONCLUSIONS: The results demonstrate the somewhat inconsistent and fragmented information regarding corneal causes of vision loss. A significant outcome of this research is the demonstration of a need for further research into global corneal blindness and the necessary steps to address the problem.

Childhood Immunization in Ethiopia: Accuracy of Maternal Recall Compared to Vaccination Cards.

Health surveys conducted in low- and middle-income countries typically estimate childhood vaccination status based on written vaccination cards, maternal recall (when cards are not available), or a combination of both. This analysis aimed to assess the accuracy of maternal recall of a child's vaccination status in Ethiopia. Data came from a 2016 cross-sectional study conducted in the Southern Nations, Nationalities, and Peoples' (SNNP) Region of Ethiopia. Vaccine doses received by a given 12-23-month-old child were recorded from both a vaccination card and based on maternal recall and then compared. Concordance, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen's Kappa were calculated. Estimates of full immunization coverage were similar when collected via vaccination card (75%) and maternal recall (74%). For fully vaccinated children, comparison of maternal recall versus vaccination card showed high concordance (96%), sensitivity (97%), specificity (93%), PPV (98%), NPV (92%), and Kappa (90%). Accuracy of maternal recall of a child's vaccination status is high in the SNNP region of Ethiopia. Although determination of vaccination status via vaccination card is preferred since it constitutes a written record, maternal recall can also be used with confidence when vaccination cards are not available.

Vaccine non-receipt and refusal in Ethiopia: The expanded program on immunization coverage survey, 2012.

INTRODUCTION: Rates of full childhood immunization in Ethiopia are well below the WHO global goal of 90% coverage by 2020. This study explores associations between sociodemographic characteristics and healthcare services utilization with experiences of not receiving a vaccine in Ethiopia. METHODS: This analysis uses data from Ethiopia's 2012 Expanded Program on Immunization Coverage Survey. The relationships between explanatory variables, including sociodemographic and healthcare utilization factors, and various reasons a child was not vaccinated were assessed with Rao-Scott chi-square tests. Multivariable logistic regression analyses examined significant predictors of these experiences. RESULTS: The sample includes the caregivers of 2,722 children. Experiences of not receiving a vaccine were characterized overall and by type of experience: whether a caregiver ever refused vaccination for their child (2.9%), ever decided to not take their child to a health center for vaccination (3.6%), and ever went to a health facility for vaccination but child was not vaccinated (12.0%). Region of residence, possession of a vaccination card, and the setting of the child's last routine vaccination were predictors of not receiving a vaccine. Caregivers reported negative perceptions of vaccines were among their reasons for refusing a vaccine or declining to take their child to a health facility for vaccination. CONCLUSION: Prior experiences with health facilities, such as where a child received their last routine vaccine, play a key role in future vaccination. Vaccine receipt at an outreach event is associated with not bringing a child to a health facility for vaccination, which may indicate an unwillingness to visit or difficulty accessing health centers. Further, negative perceptions of vaccines may result in vaccine refusal or delay. Findings of this study provide public health officials with a better understanding of factors related to vaccination experiences and can inform development of interventions that will improve childhood vaccination rates in Ethiopia.

Vaccination timeliness among newborns and infants in Ethiopia.

BACKGROUND: We characterize the risk factors for delayed polio dose 1, diphtheria-tetanus-pertussis (DTP) dose 1, pentavalent dose 1, and measles dose 1 in Ethiopian infants. We also examine the interaction between institutional delivery and demographic factors on the birth doses of the BCG and polio vaccines to better understand factors influencing vaccination. METHODS: Using the 2011 Ethiopia Demographic and Health Survey, we calculated the distribution of the study population across different demographic and vaccination characteristics. We computed acceleration factors using a multivariable accelerated failure time model with a Weibull distribution to account for left and right censoring. For the birth doses, we further specified an interaction term between institutional delivery and every other a priori specified independent variable to test whether institutional delivery modifies sociodemographic disparities in vaccination timeliness. RESULTS: Low wealth status, home delivery, and ethnicity are risk factors for delayed vaccination of polio 1, DPT 1, pentavalent 1, and measles 1. Religion is a risk factor for measles 1 vaccination delay and rural residence are risk factors for delayed DPT1 and polio 1 doses. For birth doses of polio and BCG, institutional delivery attenuated many sociodemographic disparities in vaccination delay, except for urbanicity, which showed rural dwellers with more delay than urban dwellers with an institutional vs home birth. CONCLUSIONS: Less delayed vaccination among children with institutional deliveries highlights the importance of perinatal care and the potential for promoting healthy behaviors to parents. Persistent disparities between urban and rural residents, even among those with institutional births, can be targeted for future interventions. Timely vaccination is key to prevention of unnecessary childhood mortality.

Have community health workers increased the delivery of maternal and child healthcare in India?

Background: Accredited Social Health Activists (ASHAs) are community health workers in rural India. This study estimates the proportion of villages with an ASHA and examines the impact of increased ASHA placement on changes in healthcare. Methods: Information about ASHA placement and maternal and child healthcare was obtained from the District-Level Household Surveys from 2007 to 2008 and 2012 to 2013. In this ecological analysis, the difference in district-level proportions of maternal and child healthcare outcomes between 2012-13 and 2007-08 was regressed onto the difference in ASHA placement between those years. Results: Within 218 districts from 21 states, the average proportion of villages with an ASHA increased from 39.1 to 76.2%, unmet need for family planning increased from 14.7 to 22.4%, institutional delivery increased from 61.6 to 82.5%, and full immunization coverage decreased from 71.2 to 65.1%. A 1% increase in ASHA placement resulted in 0.05% less unmet need for family planning and 0.22% more full immunization, but no changes in institutional delivery. Conclusions: ASHAs provide essential services to their community by acting as a conduit to healthcare services, but they may require more training about certain services like promoting institutional delivery to be effective in increasing access to these health services.

Trends of vaccine-preventable diseases in Afghanistan from the Disease Early Warning System, 2009-2015.

BACKGROUND: Afghanistan's public health system was neglected during decades of military and civil conflict, and trends in infectious disease occurrence remain poorly characterized. This study examines cyclical and long-term trends of six vaccine-preventable diseases: pneumonia, diarrhea, meningitis, typhoid, measles, and acute viral hepatitis. METHODS: Using weekly data collected between 2009 and 2015 through Afghanistan's Disease Early Warning System, we calculated monthly case counts, and fit a Poisson regression with a Fourier transformation for seasonal cycles and dummy variables for year. RESULTS: We found the greatest incidence of diarrhea and typhoid in the summer, pneumonia in the winter, and measles in the late spring. Meningitis and acute viral hepatitis did not demonstrate substantial seasonality. Rates of pneumonia and diarrhea were constant across years whereas rates of meningitis, typhoid, and acute viral hepatitis decreased. Measles incidence increased in 2015. CONCLUSIONS: Communicable disease reporting systems can guide public health operations-such as the implementation of new vaccines, and permit evaluation of health interventions. For example, measles supplementary immunization activities in Afghanistan have not slowed long-term transmission of the disease, but decreases in typhoid fever and acute viral hepatitis are probably tied to improvements in sanitation in the country.