Nonlethal deleterious mutation-induced stress accelerates bacterial aging.

Random mutagenesis, including when it leads to loss of gene function, is a key mechanism enabling microorganisms' long-term adaptation to new environments. However, loss-of-function mutations are often deleterious, triggering, in turn, cellular stress and complex homeostatic stress responses, called "allostasis," to promote cell survival. Here, we characterize the differential impacts of 65 nonlethal, deleterious single-gene deletions on Escherichia coli growth in three different growth environments. Further assessments of select mutants, namely, those bearing single adenosine triphosphate (ATP) synthase subunit deletions, reveal that mutants display reorganized transcriptome profiles that reflect both the environment and the specific gene deletion. We also find that ATP synthase α-subunit deleted (ΔatpA) cells exhibit elevated metabolic rates while having slower growth compared to wild-type (wt) E. coli cells. At the single-cell level, compared to wt cells, individual ΔatpA cells display near normal proliferation profiles but enter a postreplicative state earlier and exhibit a distinct senescence phenotype. These results highlight the complex interplay between genomic diversity, adaptation, and stress response and uncover an "aging cost" to individual bacterial cells for maintaining population-level resilience to environmental and genetic stress; they also suggest potential bacteriostatic antibiotic targets and -as select human genetic diseases display highly similar phenotypes, - a bacterial origin of some human diseases.

Now is the Time to Scale Up Birth-Dose Hepatitis B Vaccine in Low- and Middle-Income Countries.

Fewer than half of the world's infants have access to the birth dose of hepatitis B vaccine (HBV), which prevents mother-to-child transmission of HBV and subsequent liver cancer. Now is the time to expand access for infants born in low-resource settings.

Transporting monovalent rotavirus vaccine efficacy estimates to an external target population: a secondary analysis of data from a randomised controlled trial in Malawi.

Oral rotavirus vaccine efficacy estimates from randomised controlled trials are highly variable across settings. Although the randomised study design increases the likelihood of internal validity of findings, results from trials may not always apply outside the context of the study due to differences between trial participants and the target population. Here, we used a weight-based method to transport results from a monovalent rotavirus vaccine clinical trial conducted in Malawi between 2005 and 2008 to a target population of all trial-eligible children in Malawi, represented by data from the 2015-2016 Malawi Demographic and Health Survey (DHS). We reweighted trial participants to reflect the population characteristics described by the Malawi DHS. Vaccine efficacy was estimated for 1008 trial participants after applying these weights such that they represented trial-eligible children in Malawi. We also conducted subgroup analyses to examine the heterogeneous treatment effects by stunting and tuberculosis vaccination status at enrolment. In the original trial, the estimates of one-year vaccine efficacy against severe rotavirus gastroenteritis and any-severity rotavirus gastroenteritis in Malawi were 49.2% (95% CI 15.6%-70.3%) and 32.1% (95% CI 2.5%-53.1%), respectively. After weighting trial participants to represent all trial-eligible children in Malawi, vaccine efficacy increased to 62.2% (95% CI 35.5%-79.0%) against severe rotavirus gastroenteritis and 38.9% (95% CI 11.4%-58.5%) against any-severity rotavirus gastroenteritis. Rotavirus vaccine efficacy may differ between trial participants and target populations when these two populations differ. Differences in tuberculosis vaccination status between the trial sample and DHS population contributed to varying trial and target population vaccine efficacy estimates.

Recommending COVID-19 vaccination for adolescents in primary care.

BACKGROUND: COVID-19 vaccines are available for adolescents in the United States, but many parents are hesitant to have their children vaccinated. The advice of primary care professionals strongly influences vaccine uptake. OBJECTIVE: We examined the willingness of primary care professionals (PCPs) to recommend COVID-19 vaccination for adolescents. METHODS: Participants were a national sample of 1,047 US adolescent primary care professionals. They participated in an online survey in early 2021, after a COVID-19 vaccine had been approved for adults but before approval for adolescents. Respondents included physicians (71%), advanced practice providers (17%), and nurses (12%). We identified correlates of willingness to recommend COVID-19 vaccination for adolescents using logistic regression. RESULTS: The majority (89%) of respondents were willing to recommend COVID-19 vaccination for adolescents, with advanced practice providers and nurses being less likely than paediatricians to recommend vaccination (84% vs. 94%, aOR 0.47, 95% CI 0.23-0.92). Respondents who had received at least one dose of a COVID-19 vaccine were more likely to recommend adolescent vaccination (92% vs. 69%, aOR 4.20, 95% CI 2.56-6.87) as were those with more years in practice (94% vs. 88%, aOR 2.93, 95% CI 1.79-4.99). Most respondents (96%) said they would need some measure of support in order to provide COVID-19 vaccination to adolescents, with vaccine safety and efficacy information being the most commonly cited need (80%). CONCLUSION: Adolescent primary care professionals were generally willing to recommend COVID-19 vaccination. However, most indicated a need for additional resources to be able to administer COVID-19 vaccines at their clinic.

Diagnostic Accuracy of the World Health Organization Pediatric Emergency Triage, Assessment and Treatment Tool Plus Among Patients Seeking Care in Nairobi, Kenya: A Cross-sectional Study.

INTRODUCTION: The World Health Organization developed Emergency Triage Assessment and Treatment Plus (ETAT+) guidelines to facilitate pediatric care in resource-limited settings. ETAT+ triages patients as nonurgent, priority, or emergency cases, but there is limited research on the performance of ETAT+ regarding patient-oriented outcomes. This study assessed the diagnostic accuracy of ETAT+ in predicting the need for hospital admission in a pediatric emergency unit at Kenyatta National Hospital in Nairobi, Kenya. METHODS: This was a secondary analysis of a cross-sectional study of pediatric emergency unit patients enrolled over a 4-week period using fixed random sampling. Diagnostic accuracy of ETAT+ was evaluated using receiver operating curves (ROCs) and respective 95% confidence intervals (CIs) with associated sensitivity and specificity (reference category: nonurgent). The ROC analysis was performed for the overall population and stratified by age group. RESULTS: A total of 323 patients were studied. The most common reasons for presentation were upper respiratory tract disease (32.8%), gastrointestinal disease (15.5%), and lower respiratory tract disease (12.4%). Two hundred twelve participants were triaged as nonurgent (65.6%), 60 as priority (18.6%), and 51 as emergency (15.8%). In the overall study population, the area under the ROC curve was 0.97 (95% CI, 0.95-0.99). The ETAT+ sensitivity was 93.8% (95% CI, 87.0%-99.0%), and the specificity was 82.0% (95% CI, 77.0%-87.0%) for admission of priority group patients. The sensitivity and specificity for the emergency patients were 66.0% (95% CI, 55.0%-77.0%) and 98.0% (95% CI, 97.0%-100.0%), respectively. CONCLUSIONS: ETAT+ demonstrated diagnostic accuracy for predicting patient need for hospital admission. This finding supports the utility of ETAT+ to inform emergency care practice. Further research on ETAT+ performance in larger populations and additional patient-oriented outcomes would enhance its generalizability and application in resource-limited settings.

Pediatric Medical Emergencies and Injury Prevention Practices in the Pediatric Emergency Unit of Kenyatta National Hospital, Nairobi, Kenya.

INTRODUCTION: The epidemiology and presence of pediatric medical emergencies and injury prevention practices in Kenya and resource-limited settings are not well understood. This is a barrier to planning and providing quality emergency care within the local health systems. We performed a prospective, cross-sectional study to describe the epidemiology of case encounters to the pediatric emergency unit (PEU) at Kenyatta National Hospital in Nairobi, Kenya; and to explore injury prevention measures used in the population. METHODS: Patients were enrolled prospectively using systematic sampling over four weeks in the Kenyatta National Hospital PEU. Demographic data, PEU visit data and lifestyle practices associated with pediatric injury prevention were collected directly from patients or guardians and through chart review. Data were analyzed with descriptive statistics with stratification based on pediatric age groups. RESULTS: Of the 332 patients included, the majority were female (56%) and 76% were under 5 years of age. The most common presenting complaints were cough (40%) fever (34%), and nausea/vomiting (19%). The most common PEU diagnoses were upper respiratory tract infections (27%), gastroenteritis (11%), and pneumonia (8%). The majority of patients (77%) were discharged from the PEU, while 22% were admitted. Regarding injury prevention practices, the majority (68%) of guardians reported their child never used seatbelts or car seats. Of 68 patients that rode bicycles/motorbikes, one reported helmet use. More than half of caregivers cook at potentially dangerous heights; 59% use ground/low level stoves. CONCLUSIONS: Chief complaints and diagnoses in the PEU population were congruent with communicable disease burdens seen globally. Measures for primary injury prevention were reported as rarely used in the sample studied. The epidemiology described by this study provides a framework for improving public health education and provider training in resource-limited settings.

Measles outbreak in Western Uganda: a case-control study.

BACKGROUND: Measles outbreaks are prevalent throughout sub-Saharan Africa despite the preventive measures like vaccination that target under five-year-old children and health systems strengthening efforts like prioritizing the supply chain for supplies. Measles immunization coverage for Kasese district and Bugoye HC III in 2018 was 72 and 69%, respectively. This coverage has been very low and always marked red in the Red categorization (below the national target/poor performing) on the national league table indicators. The aim of this study was to assess the scope of the 2018-2019 measles outbreak and the associated risk factors among children aged 0-60 months in Bugoye sub-county, Kasese district, western Uganda. METHODS: We conducted a retrospective unmatched case-control study among children aged 0-60 months with measles (cases) who had either a clinical presentation or a laboratory confirmation (IgM positivity) presenting at Bugoye Health Centre III (BHC) or in the surrounding communities between December 2018 and October 2019.. Caregivers of the controls (whose children did not have measles) were selected at the time of data collection in July 2020. A modified CDC case investigation form was used in data collection. Quantitative data was collected and analyzed using Microsoft excel and STATA version 13. The children's immunization cards and health registers at BHC were reviewed to ascertain the immunization status of the children before the outbreak. RESULTS: An extended measles outbreak occurred in Bugoye, Uganda occured between December 2018 and October 2019. All 34 facility-based measles cases were documented to have had maculopapular rash, conjunctivitis, and cough. Also, the majority had fever (97%), coryza (94.1%), lymphadenopathy (76.5%), arthralgias (73.5%) and Koplik Spots (91.2%) as documented in the clinical registers. Similar symptoms were reported among 36 community-based cases. Getting infected even after immunized, low measles vaccination coverage were identified as the principal risk factors for this outbreak. CONCLUSION: Measles is still a significant problem. This study showed that this outbreak was associated with under-vaccination. Implementing a second routine dose of measles-rubella vaccine would not only increase the number of children with at least one dose but also boost the immunity of those who had the first dose.

Using Telehealth to Deliver Primary Care to Adolescents During and After the COVID-19 Pandemic: National Survey Study of US Primary Care Professionals.

BACKGROUND: The COVID-19 pandemic has led to unprecedented use of telehealth, including by primary care professionals (PCPs) who serve adolescents. OBJECTIVE: To inform future practice and policies, we sought to characterize PCPs' recent experience using adolescent telehealth as well as their support for it after the COVID-19 pandemic is over. METHODS: From February to March 2021, we conducted a web-based survey of 1047 PCPs in the United States. Our national sample included physicians (747/1047, 71%), advanced practice providers (177/1047, 17%), and nurses (123/1047, 12%) who provided primary care to adolescents aged 11-17 years. RESULTS: Most PCPs reported using telehealth for a low, moderate, or high proportion of their adolescent patients in the three months prior to the survey (424/1047, 40%, 286/1047, 27%, and 219/1047, 21%, respectively); only 11% (118/1047) reported no use. A majority of respondents agreed that adolescent telehealth increases access to care (720/1047, 69%) and enables them to provide high-quality care (560/1047, 53%). Few believed that adolescent telehealth takes too much time (142/1047, 14%) or encourages health care overuse (157/1047, 15%). Most supported giving families the option of adolescent telehealth for primary care after the pandemic is over (683/1047, 65%) and believed that health insurance plans should continue to reimburse for telehealth visits (863/1047, 82%). Approximately two-thirds (702/1047, 67%) wanted to offer adolescent telehealth visits after the pandemic, with intentions being higher among those with recent telehealth experience (P<.001). CONCLUSIONS: PCPs in our national sample reported widespread use of and predominantly positive attitudes toward adolescent telehealth. Our findings also suggest broad support among PCPs for continuing to offer adolescent telehealth after the COVID-19 pandemic ends.

Hepatitis B Elimination Globally-The Answer May Not Be the Same for Everyone.

While progress has been made towards global elimination of hepatitis B virus, many countries lag behind. A one-size-fits-all approach is not practical to address HBV. Rather, the approach should be tailored to local prevalence, risk factors and available resources.

Using intervention mapping to develop an implementation strategy to improve timely uptake of streamlined birth-dose vaccines in the Democratic Republic of the Congo.

Despite the policy recommendation and effectiveness of administering the hepatitis B birth-dose vaccine (HepB-BD) to newborns to prevent mother-to-child hepatitis B transmission, timely uptake remains an issue. Countries adopting the HepB-BD to their national immunization schedule report programmatic challenges to administering the vaccine within the recommended 24-hour window after delivery. Further, while the World Health Organization recommends streamlining three birth-dose vaccines (HepB-BD, BCG, and OPV0), scarce Sub-Saharan(SSA)-based literature reports on a streamlined and timely approach to birth-dose vaccines. As more SSA countries adopt the new birth-dose vaccine to their immunization schedules, a systematically developed implementation strategy-Vaccination of Newborns-Innovative Strategies to Hasten Birth-Dose vaccines' delivery (VANISH-BD)-will facilitate the adoption and implementation of timely birth-dose vaccine uptake. In this paper, we describe the development of the implementation strategy using intervention mapping, an evidence-based and theory-driven approach. We report on the development of our intervention, beginning with the needs assessment based in Kinshasa Province, Democratic Republic of the Congo (DRC), informing step 1 of intervention mapping. The intervention is contextually relevant, locally produced, sustainable, and designed to improve timely birth-dose vaccine uptake in the DRC. We intend to inform future implementers about improving timely and streamlined birth-dose vaccine uptake and for VANISH-BD to be adapted for similar contexts.

Hepatitis B Virus Prevalence and Transmission in the Households of Pregnant Women in Kinshasa, Democratic Republic of Congo.

Background: The World Health Organization Africa region has high regional hepatitis B virus (HBV) prevalence, and evidence suggests more frequent horizontal HBV transmission than other regions. Context-specific epidemiological studies are needed to inform additional HBV prevention measures. Methods: In the cross-sectional Horizontal and Vertical Transmission of Hepatitis B (HOVER-HBV) study, we introduced HBV surface antigen (HBsAg) screening alongside existing HIV screening as part of routine antenatal care in high-volume maternity clinics in Kinshasa, Democratic Republic of Congo. We recruited households of pregnant women ("index mothers") who were HBsAg-positive and HBsAg-negative, defining households as index-positive and index-negative, respectively. Household members underwent HBsAg testing and an epidemiological survey. We evaluated HBsAg prevalence and potential transmission correlates. Results: We enrolled 1006 participants from 200 households (100 index-positive, 100 index-negative) across Kinshasa. HBsAg-positivity prevalence was more than twice as high in index-positive households (5.0% [95% confidence interval {CI}, 2.8%-7.1%]) as in index-negative households (1.9% [95% CI, .6%-3.2%]). HBsAg-positivity prevalence was 3.3 (95% CI, .9-11.8) times as high among direct offspring in index-positive versus index-negative households. Factors associated with HBsAg positivity included older age, marriage, and having multiple recent partners or any new sexual partners among index mothers; and older age, lower household wealth, sharing nail clippers, and using street salons among offspring in index-positive households. Conclusions: Vertical and horizontal HBV transmission within households is ongoing in Kinshasa. Factors associated with infection reveal opportunities for HBV prevention efforts, including perinatal prevention, protection during sexual contact, and sanitation of shared personal items.

Implementation of Hepatitis B Screening Into Routine Antenatal Care to Prevent Mother-to-Child Transmission in Rural Western Uganda.

In rural Uganda where birth dose vaccination for hepatitis B is not routine, we implemented a pilot program for preventing mother-to-child transmission that effectively identified women with high-risk hepatitis B virus (HBV) infection and started antiviral treatment during pregnancy. Further work is required to enhance antiviral adherence through delivery to ensure effective prevention of vertical HBV transmission.

Getting Human Papillomavirus Vaccination Back on Track: A National Survey.

PURPOSE: Adolescent human papillomavirus (HPV) vaccine uptake in the United States dropped during the COVID-19 pandemic due to a decrease in well visits. This study sought to identify opportunities for primary care professionals (PCPs) to get adolescent vaccination back on track. METHODS: In early 2021, we recruited 1,047 PCPs (71% physicians) who provided adolescent vaccines in the United States from an existing panel. Participants completed an online survey about changes in adolescent HPV vaccine uptake and actions taken to promote vaccination during the pandemic, as well as intentions to engage in activities to increase adolescent vaccination in the next 3 months. RESULTS: A substantial proportion of PCPs (43%) reported that HPV vaccine uptake decreased in the first year of the pandemic; few (7%) PCPs reported an increase in uptake. PCPs reporting increased uptake were more likely to have used nurse-only vaccination visits, held drop-in and drive-through vaccination clinics, and used telehealth visits to recommend vaccination (all p < .05). Nearly two-thirds (62%) of all PCPs planned to promote adolescent vaccine uptake in the next 3 months. Planning was more common among PCPs who believed HPV vaccine uptake at their clinics increased during the pandemic, who saw more than 10 adolescent patients per week, who had ever reviewed their clinic's vaccination rates, and were nurses (all p < .05). DISCUSSION: Many PCPs saw HPV vaccination drop during the pandemic. Several interventions could help clinics get HPV vaccination back on track, including increasing the availability of nurse-only vaccination visits and vaccination-only clinics.

Changes in hepatitis B vaccine perception in response to the COVID-19 pandemic: Development of the Shift in vaccine confidence (SVC) survey tool.

The COVID-19 pandemic has disrupted access to, adherence to, and perceptions of routine vaccinations. We developed the Shift in Vaccine Confidence (SVC) survey tool to assess the impact of the pandemic on routine vaccinations, with a focus on the HBV vaccine, in Kinshasa, Democratic Republic of Congo (DRC). This study describes the content validation steps we conducted to ensure the survey tool is meaningful to measure changes in vaccine confidence to regular immunization (HBV vaccine) due to the pandemic. Three rounds of stakeholder feedback from a DRC-based study team, content and measurement experts, and study participants allowed us to produce a measure with improved readability and clarity.

Participant perspectives to improve tenofovir adherence in the prevention of mother-to-child transmission of hepatitis B virus in Kinshasa, DRC.

Prevention of mother-to-child transmission (PMTCT) programs for hepatitis B virus (HBV) are critical to reach the World Health Organization's 2030 HBV elimination goals. Despite demonstrated feasibility utilizing HIV infrastructure, HBV PMTCT programs are not implemented in many African settings, including in the Democratic Republic of Congo (DRC). In a previous pilot of HBV PMTCT implementation in DRC's capital, Kinshasa, we observed low TDF metabolite levels at delivery among women with high-risk HBV who were given tenofovir disoproxil fumarate (TDF) antiviral therapy. As such, we conducted qualitative interviews with women who received TDF to understand facilitators and barriers of medication adherence. We used a modified Information-Motivation-Behavioral Skills model (IMB+) as a framework for thematic content analysis. We found that trust in healthcare workers, familial support, and improved awareness of the disease and treatment options were important facilitators of TDF adherence; pill size, social stigma, and low HBV knowledge were barriers to adherence. While overall acceptance of TDF was high in this pilot, improved TDF adherence is needed in order to reach efficacious levels for preventing transmission from mothers to newborns. We suggest ongoing HBV sensitization within existing maternity and HIV care infrastructure would address gaps in knowledge and stigma identified here. Additionally, given the trust women have towards maternity center staff and volunteers, scaled HBV PMTCT interventions should include specific sensitization and education for healthcare affiliates, who currently receive no HBV prevention or information in DRC. This study is timely as TDF, particularly future long-acting formulations, could be considered as an alternate rather than adjuvant to birth-dose vaccination for HBV PMTCT in sub-Saharan Africa.

Childhood immunization uptake determinants in Kinshasa, Democratic Republic of the Congo: ordered regressions to assess timely infant vaccines administered at birth and 6-weeks.

BACKGROUND: Despite global efforts to reduce preventable childhood illness by distributing infant vaccines, immunization coverage in sub-Saharan African settings remains low. Further, timely administration of vaccines at birth-tuberculosis (Bacille Calmette-Guérin [BCG]) and polio (OPV0)-remains inconsistent. As countries such as Democratic Republic of the Congo (DRC) prepare to add yet another birth-dose vaccine to their immunization schedule, this study aims to improve current and future birth-dose immunization coverage by understanding the determinants of infants receiving vaccinations within the national timeframe. METHODS: The study used two ordered regression models to assess barriers to timely BCG and first round of the hepatitis B (HepB3) immunization series across multiple time points using the Andersen Behavioral Model to conceptualize determinants at various levels. The assessment leveraged survey data collected during a continuous quality improvement study (NCT03048669) conducted in 105 maternity centers throughout Kinshasa Province, DRC. The final sample included 2398 (BCG analysis) and 2268 (HepB3 analysis) women-infant dyads living with HIV. RESULTS: Between 2016 and 2020, 1981 infants (82.6%) received the BCG vaccine, and 1551 (68.4%) received the first dose of HepB3 vaccine. Of those who received the BCG vaccine, 26.3%, 43.5%, and 12.8% received BCG within 24 h, between one and seven days, and between one and 14 weeks, respectively. Of infants who received the HepB3 vaccine, 22.4% received it within six weeks, and 46% between six and 14 weeks of life. Many factors were positively associated with BCG uptake, including higher maternal education, household wealth, higher facility general readiness score, and religious-affiliated facility ownership. The factors influencing HepB3 uptake included older maternal age, higher education level, household wealth, transport by taxi to a facility, higher facility general and immunization readiness scores, and religious-affiliated facility ownership. CONCLUSIONS: This study demonstrated that the study participants' uptake of vaccines was consistent with the country average, but not in a timely manner. Various factors were associated with timely uptake of BCG and HepB3 vaccines. These findings suggest that investment to strengthen the vaccine delivery system might improve timely vaccine uptake and equity in vaccine coverage.

Hepatitis B virus prevalence and transmission in the households of pregnant women in Kinshasa, Democratic Republic of Congo.

Background: Despite routine infant vaccination and blood donor screening, the Democratic Republic of Congo (DRC) has high hepatitis B virus (HBV) prevalence compared to the United States and Europe. Through the cross-sectional Horizontal and Vertical Transmission of Hepatitis B (HOVER-HBV) study, we characterized household prevalence in DRC's capital, Kinshasa, to inform additional prevention efforts. Methods: We introduced HBV surface antigen (HBsAg) screening alongside existing HIV screening as part of routine antenatal care (ANC) in high-volume maternity clinics in Kinshasa. We recruited households of pregnant women who were HBsAg-positive and HBsAg-negative, defining households as "exposed" and "unexposed," respectively. Household members underwent HBsAg testing and an epidemiological survey. We evaluated HBsAg prevalence and potential transmission correlates. Results: We enrolled 1,006 participants from 200 households (100 exposed, 100 unexposed) across Kinshasa. HBsAg prevalence was more than twice as high in exposed households (5.0%; 95% CI: 2.8%-7.1%) as in unexposed households (1.9%; 0.6%-3.2%). Exposed direct offspring had 3.3 (0.9, 11.8) times the prevalence of unexposed direct offspring. Factors associated with HBsAg-positivity included older age, marriage, and having multiple recent partners or any new sexual partners among index mothers; and older age, lower household wealth, sharing nail clippers, and using street salons among exposed offspring. Conclusions: Vertical and horizontal HBV transmission within households is ongoing in Kinshasa. Factors associated with infection reveal opportunities for HBV prevention efforts, including perinatal prevention, protection during sexual contact, and sanitation of shared personal items.

Primary care professionals' support for Covid-19 vaccination mandates: Findings from a US national survey.

Healthcare organizations have been early adopters of Covid-19 vaccine mandates as a strategy to end the pandemic. We sought to evaluate support for such mandates among pediatric primary care professionals (PCPs) in the United States. In February-March 2021, we conducted a national online survey of 1,047 PCPs (71% physicians). We used multivariable logistic regression to assess correlates of PCPs' support for Covid-19 vaccine mandates for health care workers. Most PCPs supported Covid-19 vaccine mandates for health care workers (83%). PCPs were more likely to support mandates if they perceived health care workers to be at highest risk of getting Covid-19 compared to other worker types (8 percentage points, p < 0.01). PCPs were also more likely to support mandates if their clinic recommended or required vaccination (11 percentage points and 20 percentage points respectively, both p < 0.01). However, PCPs were less likely to support mandates if their clinic offered incentives to vaccinate (10 percentage points, p < 0.05). Clinic recommendations and requirements for Covid-19 vaccination may increase support for mandates. Incentives may decrease support, perhaps by creating the perception that viable alternatives to mandates exist.

Explaining higher Covid-19 vaccination among some US primary care professionals.

BACKGROUND AND OBJECTIVE: Research in several countries shows higher Covid-19 vaccination willingness and uptake among physicians than nurses. Our paper aims to characterize and explain this difference. METHODS: In early 2021, we surveyed 1047 U.S. primary care professionals who served adolescents, ages 11-17. The national sample included physicians (71%) as well as nurses and advanced practice providers. The survey assessed the three domains of the Increasing Vaccination Model: thinking and feeling, social processes, and direct behavior change. RESULTS: Covid-19 vaccine uptake was higher among physicians than among nurses and advanced practice providers (91% vs. 76%, p < .05). Overall, in the thinking and feeling domain, higher confidence in Covid-19 vaccination, higher perceived susceptibility to the disease, and stronger anticipated regret were associated with higher vaccine uptake (all p < .05). In the social processes domain, perceiving more positive social norms for Covid-19 vaccination, receiving recommendations to get the vaccine, and wanting to help others were associated with higher vaccine uptake (all p < .05). In the direct behavior change domain, receiving an invitation to get the vaccine and better access to vaccination were associated with higher uptake (both p < .05). Of these variables, most of the thinking and feeling and social processes variables mediated the association of training with vaccine uptake. CONCLUSIONS: Physicians had higher Covid-19 vaccine uptake than nurses and advanced practice providers, corresponding with their more supportive vaccine beliefs and social experiences. Efforts to reach the remaining unvaccinated cohort can build on these findings.

Implementation Approaches for Introducing and Overcoming Barriers to Hepatitis B Birth-Dose Vaccine in sub-Saharan Africa.

In sub-Saharan Africa (SSA), chronic viral hepatitis B (HBV) affects more than 60 million people. Mother-to-child transmission is a major contributor to the ongoing HBV epidemic and yet only 11 of 54 (20.3%) SSA countries have introduced the birth dose of HBV vaccine (HepB-BD) into their regular immunization schedule. As more African countries adopt HepB-BD, implementation approaches must be targeted to ensure effective and timely HepB-BD delivery, especially in rural and under-resourced settings. We conducted a systematic literature review of published literature using PubMed. We included 39 articles published from January 2010 to August 2020, as well as gray literature, case studies, and research performed in SSA. We describe barriers to the uptake of HepB-BD in SSA at the policy, facility, and community levels and propose solutions that are relevant to stakeholders wishing to introduce HepB-BD. We highlight the importance and challenge of reaching infants who are born outside of health care facilities (i.e., home deliveries) with HepB-BD in partnership with community health workers. We also discuss the critical role of maternal education and community engagement in future HepB-BD scale-up efforts in SSA.