Embracing context: Lessons from designing a dialogue-based intervention to address vaccine hesitancy.

Dialogue with people who are vaccine hesitant has been recommended as a method to increase vaccination uptake. The process of cultivating dialogue is shaped by the context in which it occurs, yet the development of interventions addressing vaccine hesitancy with dialogue often overlooks the role of context and favors relatively fixed solutions. This reflexive paper shares three key lessons related to context for dialogue-based interventions. These lessons emerged during a participatory research project to develop a pilot intervention to create open dialogue among healthcare workers in Belgium about COVID-19 vaccination concerns. Through a mixed methods study consisting of in-depth interviews, focus group discussions, and surveys, we engaged healthcare workers in the design, testing, and evaluation of a digital platform featuring text-based and video-based (face-to-face) interactions. The lessons are: (1) what dialogue means, entails, and requires can vary for a population and context, (2) inherent tension exists between helping participants voice (and overcome) their concerns and exposing them to others' ideas that may exacerbate those concerns, and (3) interactional exchanges (e.g., with peers or experts) that matter to participants may shape the dialogue in terms of its content and form. We suggest that having a discovery-orientation-meaning to work not only inductively and iteratively but also reflexively-is a necessary part of the development of dialogue-based interventions. Our case also sheds light on the influences between: dialogue topic/content, socio-political landscape, population, intervention aim, dialogue form, ethics, researcher position, and types of interactional exchanges.

Strategic silences, eroded trust: The impact of divergent COVID-19 vaccine sentiments on healthcare workers' relations with peers and patients.

BACKGROUND: Polarized debates about Covid-19 vaccination and vaccine mandates for healthcare workers (HCWs) challenge Belgian HCWs ability to discuss Covid-19 vaccine sentiments with peers and patients.Although studies have identified drivers of HCWs vaccine hesitancy, they do not include effects of workplace interactions and have not addressed consequences beyond vaccine coverage. METHODS: Interviews and focus group discussions with 74 HCWs practicing in Belgium addressed Covid-19 vaccine sentiments and experiences of discussing vaccination with peers and patients. RESULTS: Most participating HCWs reported difficulties discussing Covid-19 vaccination with peers and patients. Unvaccinated HCWs often feared that expressing their vaccine sentiments might upset patients or peers and that they would be suspended. Consequently, they used social cues to evaluate others' openness to vaccine-skeptical discourses and avoided discussing vaccines. Surprisingly, some vaccine-confident HCWs hid their vaccine sentiments to avoid peer and patient conflicts. Both vaccinated and unvaccinated HCWs observed that unvaccinated patients occasionally received suboptimal care. Suboptimal care was central in unvaccinated HCW unwillingness to express their vaccine sentiments to peers. Both vaccinated and unvaccinated HCWs described loss of trust and ruptured social relations with peers and patients holding divergent vaccine sentiments. DISCUSSION: Belgian HCW perceived Covid-19 vaccines as a risky discussion topic and engaged in "strategic silences" around vaccination to maintain functional work relationships and employment in health institutions. Loss of trust between HCW and peers or patients, along with suboptimal patient care based on vaccination status, threaten to weaken Belgium's, and by implication, other health systems, and to catalyze preventable disease outbreaks.

How Can Authorities Support Distributed Improvisation During Major Crises? A Study of Decision Bottlenecks Arising During Local COVID-19 Vaccine Roll-Out.

Despite the increased importance attributed to distributed improvisation in major crises, few studies investigate how central authorities can promote a harmonic, coordinated national response while allowing for distributed autonomy and improvisation. One idea implicit in the literature is that central authorities could help track and tackle common decision bottlenecks as they emerge across "improvising" local authorities as a result of shared, dynamic external constraints. To explore this idea we map central functions needed to roll-out vaccines to local populations and identify and classify bottlenecks to decision-making by local authorities managing COVID-19 vaccine roll-out in Norway. We found five bottlenecks which emerged as vaccine roll-out progressed, three of which could feasibly have been addressed by changing the local authorities' external constraints as the crisis developed. While the national crisis response strategy clearly allowed for distributed improvisation, our overall findings suggest that there is potential for central authorities to address external constraints in order to ease common bottlenecks as they emerge across local authorities responding to the crisis. More research is to explore alternative centralized response strategies and assess how well they effectively balance centralized and distributed control. The study contributes to the growing literature examining the interaction between local and centralized response in crisis management.

Age-dependent seroprevalence of SARS-CoV-2 antibodies in school-aged children from areas with low and high community transmission.

It is not yet clear to what extent SARS-CoV-2 infection rates in children reflect community transmission, nor whether infection rates differ between primary schoolchildren and young teenagers. A cross-sectional serosurvey compared the SARS-CoV2 attack-rate in a sample of 362 children recruited from September 21 to October 6, 2020, in primary (ages 6-12) or lower secondary school (ages 12-15) in a municipality with low community transmission (Pelt) to a municipality with high community transmission (Alken) in Belgium. Children were equally distributed over grades and regions. Blood samples were tested for the presence of antibodies to SARS-CoV-2 with an enzyme-linked immunosorbent assay. We found anti-SARS-CoV-2 antibodies in 4.4% of children in the low transmission region and in 14.4% of children in the high transmission region. None of the primary schoolchildren were seropositive in the low transmission region, whereas the seroprevalence among primary and secondary schoolchildren did not differ significantly in the high transmission region. None of the seropositive children suffered from severe disease. Children who were in contact with a confirmed case (RR 2.9; 95%CI 1.6-4.5), who participated in extracurricular activities (RR 5.6; 95%CI 1.2-25.3), or whose caregiver is a healthcare worker who had contact with COVID-19 patients (RR 2.2; 95%CI 1.0-4.6) were at higher risk of seropositivity. If SARS-CoV2 circulation in the community is high, this will be reflected in the pediatric population with similar infection rates in children aged 6-12 years and 12-15 years. What is Known: •Children are generally less affected by COVID-19 than adults but SARS-CoV2 infection rates among children are not well known. •There were large regional differences in infection rates during the first wave of the SARS-CoV2 pandemic. What is New: •None of the primary schoolchildren (6-12 years) were seropositive for SARS-CoV2 in an area with a low community transmission, but infection rates were higher in adolescents (12-15 years). •In an area with high community transmission, seroprevalence rates in younger children were more comparable to those in adolescents.

Seroprevalence of Antibodies against Diphtheria, Tetanus and Pertussis in Adult At-Risk Patients.

Patients with chronic diseases are at increased risk of complications following infection. It remains, however, unknown to what extend they are protected against vaccine-preventable diseases. We assessed seroprevalence of antibodies against diphtheria, tetanus and pertussis to evaluate whether current vaccination programs in Belgium are adequate. Antibody titers were assessed with a bead-based multiplex assay in serum of 1052 adults with chronic diseases. We included patients with diabetes mellitus type 1 (DM1) (n = 172), DM2 (n = 77), chronic kidney disease (n = 130), chronic obstructive pulmonary disease (COPD) (n = 170), heart failure (n = 77), HIV (n = 196) and solid organ transplant (SOT) recipients (n = 230). Factors associated with seroprevalence were analysed with multiple logistic regression. We found seroprotective titers in 29% for diphtheria (≥0.1 IU/mL), in 83% for tetanus (≥0.1 IU/mL) and 22% had antibodies against pertussis (≥5 IU/mL). Seroprotection rates were higher (p < 0.001) when vaccinated within the last ten years. Furthermore, diphtheria seroprotection decreased with age (p < 0.001). Tetanus seroprotection was less reached in women (p < 0.001) and older age groups (p < 0.001). For pertussis, women had more often a titer suggestive of a recent infection or vaccination (≥100 IU/mL, p < 0.01). We conclude that except for tetanus, the vast majority of at-risk patients remains susceptible to vaccine-preventable diseases such as diphtheria and pertussis.

Immunogenicity and Safety of the 9-Valent Human Papillomavirus Vaccine in Solid Organ Transplant Recipients and Adults Infected With Human Immunodeficiency Virus (HIV).

BACKGROUND: The burden of human papillomavirus (HPV) in human immunodeficiency virus (HIV)-infected persons and solid organ transplant (SOT) recipients is high. Clinical trials on HPV vaccines in persons living with HIV and particularly in SOT recipients have been sparse to date, included low numbers of participants, and none of them assessed the 9-valent HPV (9vHPV) vaccine. We investigated the immunogenicity with respect to HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 and the safety of the 9vHPV vaccine in persons living with HIV and recipients of a kidney, lung, or heart transplant. METHODS: This is a phase III investigator-initiated study in 100 persons living with HIV (age 18-45 years) and 171 SOT recipients (age 18-55 years). The 9vHPV vaccine was administered at day 1, month 2, and month 6. Primary outcome was seroconversion rates to the 9vHPV types at month 7. Secondary outcomes were geometric mean titers (GMTs) and frequency of adverse events (AEs). RESULTS: All HIV-infected participants seroconverted for all HPV types, but seroconversion ranged from 46% for HPV45 to 72% for HPV58 in SOT recipients. GMTs ranged from 180 to 2985 mMU/mL in HIV-positive participants and from 17 to 170 mMU/mL in SOT recipients, depending on the HPV type. Injection-site AEs occurred in 62% of participants but were mostly mild or moderate in intensity. None of the reported serious adverse events were deemed vaccine related. No patients died during the study. CONCLUSIONS: Immunogenicity of the 9vHPV vaccine is high in persons living with HIV but suboptimal in SOT recipients. The vaccine is safe and well tolerated in both groups.

Increased vaccine uptake and less perceived barriers toward vaccination in long-term care facilities that use multi-intervention manual for influenza campaigns.

Seasonal influenza is an annually recurring threat to residents of long-term care facilities (LTCFs) since high age and chronic disease diminish immune response following vaccination. Although immunization of healthcare workers (HCWs) has proven to be an added value, coverage rates remain low. A ready-to-use instruction manual was designed to facilitate the implementation of interventions known to increase vaccination coverage in healthcare institutions. It includes easy-access vaccination, role model involvement, personalized promotional material, education and extensive communication. We evaluated this manual during the 2017-vaccination campaign in 11 LTCFs in Belgium. Vaccination coverage before and after the campaign was recorded by the LTCFs and the usefulness of the manual was assessed by interviewing the organizers of the local campaigns. Attitudes toward vaccination and reasons for vaccination were evaluated with a quantitative survey in HCWs before and after the campaign. The mean vaccination coverage reported by the LTCFs was 54% (range: 35-72%) in 2016 and 68% (range: 45-81%) in 2017. After the campaign, HCWs were less likely to expect side effects after influenza vaccination (OR (95%CI): 0.4 (0.2-0.9)) or to oppose vaccination (OR (95%CI): 0.3 (0.1-0.9)). The majority (>60%) indicated to be well informed about the risks of influenza and the efficacy of the vaccine. The main reason for vaccination in those who previously refused it was resident protection. The manual was found useful by the organizers of the campaigns. We conclude that the use of an intervention manual may support vaccination uptake and decrease perceived barriers toward influenza vaccination in countries without mandatory vaccination in HCWs.

Vaccination coverage of recommended vaccines and determinants of vaccination in at-risk groups.

Upon exposure to vaccine-preventable diseases, certain individuals are at increased risk for complications due to preexisting diseases, age or immunosuppressive treatment. Vaccination against influenza, pneumococcal disease and hepatitis B (for some groups) is advised in addition to standard vaccination against diphtheria, tetanus and pertussis. We estimated the vaccination coverage and determinants of recommended vaccinations in patients with diabetes mellitus type 1 (n = 173) and type 2 (n = 177), chronic kidney disease (CKD) (n = 138), heart failure (n = 200), chronic obstructive pulmonary disease (COPD) (n = 187), HIV (n = 201) or solid organ transplantation (SOT) (n = 201) in a monocentric study. Vaccination data were retrieved from documents provided by patients and general practitioners, and from the Flemish vaccination register. Less than 10% had received all recommended vaccines. Overall, 29% of subjects were vaccinated against diphtheria-tetanus, 10% against pertussis, 44% against influenza, 32% against pneumococcal disease and 24% of HIV patients and 31% of CKD patients against hepatitis B. Age was positively associated with vaccination against influenza (OR:2.0, p < .01) and pneumococcal disease (OR:2.6, p < .001). Patients with COPD, HIV and SOT were more likely to be vaccinated against influenza (OR:2.8, p < .001, OR:1.8, p < .05; OR:2.0, p < .001, respectively) and pneumococcal disease (OR:2.9, p < .001, OR:25.0, p < .001; OR:2.6, p < .001, respectively) than patients with heart failure. Reason for non-vaccination were concerns about effectiveness, necessity and side effects of influenza vaccines, and not being aware of the recommendation for pneumococcal disease. Initiatives to monitor the vaccination status of vulnerable patients are needed, which is why we advocate systematic vaccination registration and frequent communication about vaccination.

Influence of subliminal intragastric fatty acid infusion on subjective and physiological responses to positive emotion induction in healthy women: A randomized trial.

BACKGROUND: Subliminal intragastric fatty acid infusion attenuates subjective and brain responses to negative emotion induction. However, the underlying gut-brain signaling mechanisms remain unclear, and it is unknown whether such effect equally applies to positive emotion. OBJECTIVE: We aimed to investigate the interaction between fatty acid-induced gut-brain signaling and subjective responses to positive emotion, and the potential mediational role of gastrointestinal (GI) hormones. DESIGN: Twelve fasting healthy women underwent intragastric infusion of 2.5 g lauric acid or saline, after which either positive or neutral emotion was induced for 30 min, in 4 separate visits. Appetite-related sensations, subjective emotional state, and GI hormones were measured at baseline and every 10 min after infusion. Heart rate variability was measured at baseline and at t = 20-30 min to quantify vagal tone (root mean square of successive differences, RMSSD), and sympathovagal balance (low frequency to high frequency ratio, LF/HF). RESULTS: Fatty acid infusion did not influence appetite-related sensations (as expected), nor emotional state ratings (contrary to expectations). As anticipated, fatty acid stimulated release of CCK at t = 20-40 min (p < 0.001), and GLP1 at t = 30-40 min (p < 0.001), but not PYY. Interestingly, positive emotion induction suppressed plasma octanoylated ghrelin at t = 20-40 min (p = 0.020). Further, both positive emotion and fatty acid attenuated RMSSD (p = 0.012 & 0.0073, respectively). Positive emotion attenuated LF/HF after fatty acid (p = 0.0006), but raised LF/HF after saline (p = 0.004). CONCLUSIONS: Subliminal fatty acid did not influence subjective responses to positive emotion induction. However, positive emotion induction suppressed octanoylated ghrelin release. Moreover, both positive emotion and subliminal fatty acid decreased cardiac vagal tone. Further, the fatty acid reversed the effect of positive emotion on sympathovagal balance.

Attitudes, believes, determinants and organisational barriers behind the low seasonal influenza vaccination uptake in healthcare workers - A cross-sectional survey.

BACKGROUND: Seasonal influenza threatens hospitalised patients and residents of nursing homes annually. Due to age and chronic disease their protection following immunisation is diminished. Additional immunisation of direct contacts and in particular healthcare workers (HCWs) has proven added value. As vaccination coverage in HCWs remains low, we aimed to gain insight in the factors behind the demotivation for influenza vaccination. METHODS: Attitudes and believes towards influenza vaccination and socio-demographic and professional determinants were surveyed in 5141 Belgian HCWs from 13 hospitals and 14 nursing homes. Additionally, influenza campaign coordinators of the participating healthcare institutions were interviewed about the factors of success/failure in their campaigns. RESULTS: The mean vaccination coverage registered by the participating healthcare institutions was 40.4% in the hospitals and 45.3% in the nursing homes. Overall, up to 90% of HCWs found it important not to infect their patients. However, only 20% of non-vaccinated HCWs considered influenza vaccination a duty to not harm their patients. Up to 40% of unvaccinated staff believed they could get influenza after vaccination and that vaccination weakens their immune system. Also, only about 20% of unvaccinated staff thought to have a high chance of getting influenza. Reasons for unvaccinated staff to get vaccinated in the future are self-protection and protection of family members. Factors that positively influenced vaccination coverage are encouragement by supervisors (OR, hospitals: 7.1, p < 0.001; nursing homes: 7.5, p < 0.001) and well-organized vaccination campaigns with on-site vaccination. Factors that negatively affected vaccination coverage are misconceptions about influenza and its vaccine (OR, range 0.1-0.7, p < 0.001 for most misconceptions) and underestimation of the risk of contracting influenza by patients or HCWs (OR of perceived susceptibility, range 2.1-5.1, p < 0.001 for most factors). CONCLUSION: There is a need for guidance for the organization of seasonal influenza campaigns, in which education, communication and easy accessible vaccination are promoted.