Design and implementation of tailored intervention to increase vaccine acceptance in a Somali community in Stockholm, Sweden - based on the Tailoring Immunization Programmes approach.

Objectives: Sweden has had a high and stable vaccination coverage for measles-mumps-rubella (MMR) vaccine (>96%) through the national immunization program (NIP), but coverage rates highlight local pockets of lower vaccination coverage. This project addressed low MMR vaccine acceptance among parents in a Somali community, in Stockholm. The objective of the intervention was to increase vaccine confidence and MMR-vaccine uptake and also to inform practices addressing vaccine acceptance. Study design: This paper describes the design and implementation of a multi-component intervention based on the Tailoring Immunization Programmes (TIP) approach, developed by the WHO European Regional Office. Methods: The theoretical underpinning of TIP is the Capability, Opportunity, and Motivation Model (COM-B model) and Behaviour Change Wheel framework (BCW), adapted for vaccination. The COM-model was used to identify barriers and drivers to vaccination and intervention types. The TIP-phases described in this paper are: pre-TIP (planning), three succeeding TIP phases (situational analysis, formative research, intervention design) and the post-TIP phase (implementation). Results: The situation analysis and formative research revealed that parents feared the MMR vaccine due to autism or that their child would stop talking following vaccination, despite lack of scientific evidence for an association between autism and MMR vaccines. Barriers were linked to their associated COM-B factors and mapped to appropriate intervention types for two target groups: Somali parents and nurses at the Child Health Centres (CHC). Selected intervention types targeting parents were education, persuasion and modelling whereas education and training were selected for CHC nurses. The intervention activities included community engagement for parents, while the activities for nurses focused on improving encounters and dialogue with parents having low vaccine acceptance. Following the intervention design the activities were developed, pilot tested and implemented. Conclusion: This study confirm that the TIP approach is valuable for guiding a stepwise working process for a thorough understanding of barriers and drivers for MMR vaccination among parents in this Somali community. It facilitated the design of a theory and evidence-informed intervention targeting parents and nurses.

TIPICO X: report of the 10th interactive infectious disease workshop on infectious diseases and vaccines.

TIPICO is an expert meeting and workshop that aims to provide the most recent evidence in the field of infectious diseases and vaccination. The 10th Interactive Infectious Disease TIPICO workshop took place in Santiago de Compostela, Spain, on November 21-22, 2019. Cutting-edge advances in vaccination against respiratory syncytial virus, Streptococcus pneumoniae, rotavirus, human papillomavirus, Neisseria meningitidis, influenza virus, and Salmonella Typhi were discussed. Furthermore, heterologous vaccine effects were updated, including the use of Bacillus Calmette-Guérin (BCG) vaccine as potential treatment for type 1 diabetes. Finally, the workshop also included presentations and discussion on emergent virus and zoonoses, vaccine resilience, building and sustaining confidence in vaccination, approaches to vaccine decision-making, pros and cons of compulsory vaccination, the latest advances in decoding infectious diseases by RNA gene signatures, and the application of big data approaches.

Ten considerations for effectively managing the COVID-19 transition.

Governments around the world have implemented measures to manage the transmission of coronavirus disease 2019 (COVID-19). While the majority of these measures are proving effective, they have a high social and economic cost, and response strategies are being adjusted. The World Health Organization (WHO) recommends that communities should have a voice, be informed and engaged, and participate in this transition phase. We propose ten considerations to support this principle: (1) implement a phased approach to a 'new normal'; (2) balance individual rights with the social good; (3) prioritise people at highest risk of negative consequences; (4) provide special support for healthcare workers and care staff; (5) build, strengthen and maintain trust; (6) enlist existing social norms and foster healthy new norms; (7) increase resilience and self-efficacy; (8) use clear and positive language; (9) anticipate and manage misinformation; and (10) engage with media outlets. The transition phase should also be informed by real-time data according to which governmental responses should be updated.

TIPICO IX: report of the 9th interactive infectious disease workshop on infectious diseases and vaccines.

The Ninth Interactive Infectious Disease workshop TIPICO was held on November 22-23, 2018, in Santiago de Compostela, Spain. This 2-day academic experience addressed current and topical issues in the field of infectious diseases and vaccination. Summary findings of the meeting include: cervical cancer elimination will be possible in the future, thanks to the implementation of global vaccination action plans in combination with appropriate screening interventions. The introduction of appropriate immunization programs is key to maintain the success of current effective vaccines such as those against meningococcal disease or rotavirus infection. Additionally, reduced dose schedules might improve the efficiency of some vaccines (i.e., PCV13). New vaccines to improve current preventive alternatives are under development (e.g., against tuberculosis or influenza virus), while others to protect against infectious diseases with no current available vaccines (e.g., enterovirus, parechovirus and flaviviruses) need to be developed. Vaccinomics will be fundamental in this process, while infectomics will allow the application of precision medicine. Further research is also required to understand the impact of heterologous vaccine effects. Finally, vaccination requires education at all levels (individuals, community, healthcare professionals) to ensure its success by helping to overcome major barriers such as vaccine hesitancy and false contraindications.

Towards equity in immunisation.

In the World Health Organization (WHO) European Region, differences in uptake rates of routine childhood immunisation persist within and among countries, with rates even falling in some areas. There has been a tendency among national programmes, policymakers and the media in recent years to attribute missed vaccinations to faltering demand or refusal among parents. However, evidence shows that the reasons for suboptimal coverage are multifactorial and include the social determinants of health. At the midpoint in the implementation of the European Vaccine Action Plan 2015-2020 (EVAP), national immunisation programmes should be aware that inequity may be a factor affecting their progress towards the EVAP immunisation targets. Social determinants of health, such as individual and household income and education, impact immunisation uptake as well as general health outcomes - even in high-income countries. One way to ensure optimal coverage is to make inequities in immunisation uptake visible by disaggregating immunisation coverage data and linking them with already available data sources of social determinants. This can serve as a starting point to identify and eliminate underlying structural causes of suboptimal uptake. The WHO Regional Office for Europe encourages countries to make the equitable delivery of vaccination a priority.

Nurses' Perceptions Of MMR Vaccine Hesitancy In An Area With Low Vaccination Coverage.

BACKGROUND AND AIM: Measles, mumps, and rubella vaccine (MMR) coverage is low in an area in the Northern part of Stockholm, Sweden. The overall aim of this study was to explore the perceptions, views, and experiences of child health clinic nurses related to vaccine hesitancy in Rinkeby and Tensta. METHODS: The study focused specifically on hesitancy towards measles-mumps-rubella (MMR) vaccination. Eleven in-depth interviews were conducted in Swedish with female nurses who were directly responsible for vaccination programmes. Their thoughts and experiences were sought using probing and question rephrasing techniques. Transcripts of the data were analysed using content analysis. RESULTS: Four themes emerged, namely hesitancy among Somali parents, lack of confidence in the MMR vaccine, loss of confidence in other vaccines due to mistrust of the MMR vaccine, and complacency regarding vaccination in general. CONCLUSION: There is a strong influence of fear of vaccine-induced autism among parents in the Somali community in areas of Stockholm, that requires continued attention by the health care providers.

Perspectives on the Measles, Mumps and Rubella Vaccination among Somali Mothers in Stockholm.

Background: Vaccination hesitancy and skepticism among parents hinders progress in achieving full vaccination coverage. Swedish measles, mumps and rubella (MMR) vaccine coverage is high however some areas with low vaccination coverage risk outbreaks. This study aimed to explore factors influencing the decision of Somali parents living in the Rinkeby and Tensta districts of Stockholm, Sweden, on whether or not to vaccinate their children with the measles, mumps and rubella (MMR) vaccine. Method: Participants were 13 mothers of at least one child aged 18 months to 5 years, who were recruited using snowball sampling. In-depth interviews were conducted in Somali and Swedish languages and the data generated was analysed using qualitative content analysis. Both written and verbal informed consent were obtained from participants. Results: Seven of the mothers had not vaccinated their youngest child at the time of the study and decided to postpone the vaccination until their child became older (delayers). The other six mothers had vaccinated their child for MMR at the appointed time (timely vaccinators). The analysis of the data revealed two main themes: (1) barriers to vaccinate on time, included issues surrounding fear of the child not speaking and unpleasant encounters with nurses and (2) facilitating factors to vaccinate on time, included heeding vaccinating parents' advice, trust in nurses and trust in God. The mothers who had vaccinated their children had a positive impact in influencing other mothers to also vaccinate. Conclusions: Fear, based on the perceived risk that vaccination will lead to autism, among Somali mothers in Tensta and Rinkeby is evident and influenced by the opinions of friends and relatives. Child Healthcare Center nurses are important in the decision-making process regarding acceptance of MMR vaccination. There is a need to address mothers' concerns regarding vaccine safety while improving the approach of nurses as they address these concerns.

Mandatory infant & childhood immunization: Rationales, issues and knowledge gaps.

Globally, infant and childhood vaccine uptake rates are not high enough to control vaccine preventable diseases, with outbreaks occurring even in high-income countries. This has led a number of high-, middle-and low income countries to enact, strengthen or contemplate mandatory infant and/or childhood immunization to try to address the gap. Mandatory immunization that reduces or eliminates individual choice is often controversial. There is no standard approach to mandatory immunization. What vaccines are included, age groups covered, program flexibility and rigidity e.g. opportunities for opting out, penalties or incentives, degree of enforcement, and whether a compensation program for causally associated serious adverse events following immunization exists vary widely. We present an overview of mandatory immunization with examples in two high- and one low-income countries to illustrate variations, summarize limited outcome data related to mandatory immunization, and suggest key elements to consider when contemplating mandatory infant and/or child immunization. Before moving forward with mandatory immunization, governments need to assure financial sustainability, uninterrupted supply and equitable access to all the population. Other interventions may be more effective and less intrusive than mandatory. If mandatory is implemented, this needs to be tailored to fit the context and the country's culture.

Tailoring immunisation programmes: Using behavioural insights to identify barriers and enablers to childhood immunisations in a Jewish community in London, UK.

INTRODUCTION: Due to regular vaccine preventable disease outbreaks and sub-optimal immunisation uptake in the London borough of Hackney, home to the largest Charedi Orthodox Jewish community in Europe, it was decided, in consultation with the community, to implement the WHO Tailoring Immunization Programmes approach (TIP). DESIGN: The WHO Tailoring Immunization Programmes (TIP) approach was used. TIP provides a framework based on behavioural insights methodology to identify populations susceptible to vaccine preventable diseases, diagnose supply and demand side barriers and enablers to vaccination and recommend evidence-informed responses to improve vaccination coverage. RESULTS: The results of the formative research and behavioural analysis challenged the assumption that a cultural or religious anti-vaccination sentiment existed within the community. Critical issues related to access to and convenience of immunisation services. Service providers in the area have challenges due to having to deliver immunisation services to the large numbers of children without additional resource. Where mothers were choosing to delay or refuse vaccinations their reasons were broadly similar to the wider population. The behavioural analysis identified potential categorisation of subgroups within the community enabling a more tailored approach to addressing concerns and meeting parents' needs. CONCLUSION: The TIP approach was an effective way of investigating factors linked to sub-optimal immunisation within the Charedi community. The use of behavioural insights enabled the categorisation of subgroups so that more targeted interventions could be developed. The comprehensive stakeholder engagement which is a key pillar of the TIP approach ensured a deeper understanding of the barriers and enablers to vaccination as well as increasing the level of ownership in the community. TIP should be considered as a useful approach to identify main facilitators and barriers to vaccination in communities with suboptimal immunisation uptake.

Tailoring immunisation service delivery in a disadvantaged community in Australia; views of health providers and parents.

In 2014 the Australian immunisation target was raised from 90% to 95% of children to be fully immunised. A national priority is to identify geographic areas of low coverage and implement strategies to improve immunisation rates. Using The World Health Organization's Tailoring Immunization Programmes (TIP) Guidelines, the aim of this study was to identify areas of low immunisation coverage for children in the Hunter New England Local Health District, New South Wales, and to gain a deeper understanding of the factors influencing immunisation in those areas in order to develop tailored strategies for increasing immunisation coverage. Data from the Australian Immunisation Register was used to identify geographic areas of low coverage. Data from interviews and focus groups with parents and service providers were used to gain a deeper understanding of the factors influencing immunisation in those areas. The regional city of Maitland in New South Wales was identified as having a persistently high number and relatively high proportion of children not fully immunised (n = 427, 15.4% in 2016). Themes from 59 stakeholder interviews and focus groups included; (i) limited engagement with health services unless the need is urgent, (ii) multi-dimensional access barriers to immunisation services in Maitland, (iii) a flexible, supportive family centred, primary health care approach, utilising strong partnerships, is most likely to be effective in increasing childhood immunisation rates in Maitland, (iv) data can be used more effectively to inform service providers about trends and individual children not fully immunised. TIP guidelines proved useful for identifying areas of low coverage and providing an understanding of determining factors and the strategies most likely to be effective. Understanding the complex problems many parents face and the access barriers that contribute to low immunisation coverage is essential in developing appropriate solutions. Finding ways to support parents and remove those barriers can contribute to higher coverage. In Maitland, targeted outreach and home visiting has been implemented in consultation with community and health service representatives to ensure that the children from socially disadvantaged populations identified do not miss out on vaccination.

Progress and challenges in measles and rubella elimination in the WHO European Region.

INTRODUCTION: Despite availability of safe and cost-effective vaccines to prevent it, measles remains one of the significant causes of death among children under five years of age globally. The World Health Organization (WHO) European Region has seen a drastic decline in measles and rubella cases in recent years, and a few of the once common measles genotypes are no longer detected. Buoyed by this success, all Member States of the Region reconfirmed their commitment in 2010 to eliminating measles and rubella, and made this a central objective of the European Vaccine Action Plan 2015-2020 (EVAP). Nevertheless, sporadic outbreaks continue, recently affecting primarily adolescents and young adults with no vaccination or an incomplete vaccination history. The European Regional Verification Commission for Measles and Rubella Elimination was established in 2011 to evaluate the status of measles and rubella elimination based on documentation submitted annually by each country's national verification committee. DISCUSSION: Each country's commitment to eliminate measles and rubella is influenced by competing health priorities, and in some cases lack of capacity and resources. All countries need to improve case-base surveillance for both measles and rubella, ensure documentation of each outbreak and strengthen the link between epidemiology and laboratory data. Achieving high coverage with measles- and rubella-containing vaccines will require a multisectoral approach to address the root causes of lower uptake in identified communities including service delivery challenges or vaccine safety concerns caused by circulating myths about vaccination. CONCLUSIONS: The WHO European Region has made steady progress towards eliminating measles and rubella and over half of the countries interrupted endemic transmission of both diseases by 2015. The programmatic challenges in disease surveillance, vaccination service delivery and communication in the remaining endemic countries should be addressed through periodic evaluation of the strategies by all stakeholders and exploring additional opportunities to accelerate the ongoing elimination activities.

Global polio eradication: Where are we in Europe and what next?

The world was never so close to reach the polio eradication: only 37 cases notified in 2016 in only three countries, but the game is not yet at the end. The risk of polio outbreaks in the EU is smaller than it has ever been in the past, but it is not so small that we can ignore it. The EU MS must remain alert and plan and prepare for managing polio events or outbreaks because of the possible dire consequences. The IPV only vaccination schedule universally applied in EU has achieved satisfactory coverage, but constantly leaving small accumulating pockets of susceptible individuals. Moreover the IPV only schedule is not an absolute barrier against poliovirus silent transmission as demonstrated in the recent Israel outbreak. The availability of annually revised S.O.P. from WHO GPEI on the identification and response of a polio event, without local poliovirus transmission or a polio outbreak with sustained transmission, helps and challenge EU countries to update their polio national preparedness plans. The EU/EEA area, in fact, is a peculiar area regarding the polio risk both for its vaccination policy, the large polio vaccines manufactures and the constant immigration from areas at polio high risk, but also EU include cultural and financial potentials crucial to sustain the polio end game strategy and reach the benefit of a world without polio risk. Poliovirus eradication will continue to be challenged as long as there is the worldwide presence of polioviruses in laboratories and vaccine production plants. Most of the world's OPV vaccines are produced in the EU and many laboratories and research centers store and handle polio viruses. EU Member States are engaged actively in implementing the poliovirus biocontainment plans that are part of the polio eradication strategy and to certify the destruction of poliovirus strains and potentially contaminated biological materials.

Addressing barriers to vaccine acceptance: an overview.

Addressing the drivers of vaccine hesitancy and the barriers to vaccine acceptance is a complex but important task. While the percentage of hesitant does vary from country to country and in time few, if any, countries are ever free from this problem. Overcoming hesitancy requires detection, diagnosis and tailored intervention as there is no simple strategy that can address all of the barriers to vaccine acceptance. Immunization program managers and health care workers need to become adept at recognizing and tackling hesitancy in all of its incarnations if high levels of vaccine acceptance are to be achieved but must also actively support immunization acceptors in order to build and support vaccine acceptance resiliency. This paper presents evidence-informed strategies to achieve these goals.

Slow Progress In Finalizing Measles And Rubella Elimination In The European Region.

All countries in the World Health Organization European Region committed to eliminating endemic transmission of measles and rubella by 2015, and disease incidence has decreased dramatically. However, there was little progress between 2012 and 2013, and the goal will likely not be achieved on time. Genuine political commitment, increased technical capacity, and greater public awareness are urgently needed, especially in Western Europe.

Improving Medical Decision Making and Health Promotion through Culture-Sensitive Health Communication: An Agenda for Science and Practice.

This review introduces the concept of culture-sensitive health communication. The basic premise is that congruency between the recipient's cultural characteristics and the respective message will increase the communication's effectiveness. Culture-sensitive health communication is therefore defined as the deliberate and evidence-informed adaptation of health communication to the recipients' cultural background in order to increase knowledge and improve preparation for medical decision making and to enhance the persuasiveness of messages in health promotion. To achieve effective health communication in varying cultural contexts, an empirically and theoretically based understanding of culture will be indispensable. We therefore define culture, discuss which evolutionary and structural factors contribute to the development of cultural diversity, and examine how differences are conceptualized as scientific constructs in current models of cultural differences. In addition, we will explicate the implications of cultural differences for psychological theorizing, because common constructs of health behavior theories and decision making, such as attitudes or risk perception, are subject to cultural variation. In terms of communication, we will review both communication strategies and channels that are used to disseminate health messages, and we will discuss the implications of cultural differences for their effectiveness. Finally, we propose an agenda both for science and for practice to advance and apply the evidence base for culture-sensitive health communication. This calls for more interdisciplinary research between science and practice but also between scientific disciplines and between basic and applied research.

[The State of Measles and Rubella in the WHO European region].

The long-standing and widespread use of vaccines against measles has resulted in a dramatic decline in cases and measles mortality worldwide compared with the pre-vaccination era.All regions of the World Health Organization (WHO) have measles elimination goals and the WHO regions of the Americas, Europe and Western Pacific also have rubella elimination goals. This article aims to report on progress toward elimination of measles and rubella in the WHO European Region based on the latest available data. We also discuss current challenges and actions needed to reach this goal in the Region. Despite substantial progress made towards controlling measles and rubella, the countries of the WHO European Region continue to face challenges in interrupting endemic transmission of these diseases. Widespread outbreaks and endemic transmission of measles and rubella persisted in some countries of the Region in 2014 and have continued in 2015. Interrupting endemic transmission in each and every country is necessary to declare elimination for the entire Region. High population immunity and high-quality surveillance are the cornerstones to eliminate measles and rubella. In the absence of sustained political commitment and implementation of the required strategies by all countries, the goal of eliminating these diseases in the WHO European Region is at stake.