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The COVID-19 pandemic presents an opportunity to assess the relationship between personal experiences and vaccine decision-making. The aim of this study was to examine the associations between experiences with COVID-19 and COVID-19 vaccination status. We administered 28 repeated cross-sectional, online surveys between June 2020 and June 2021 in the US and Asia. The main exposure was media showing COVID-19 cases, and we distinguished those with no such experience, those seeing a not severe case of disease, and those seeing a severe case of disease. Logistic regression models estimated the association between experience and acceptance of a hypothetical COVID-19 vaccine (pre-rollout) or actual vaccination (post-rollout). We explored perceived susceptibility as a potential mediator. Intent to vaccinate was lowest in the US and Taiwan, and highest in India, Indonesia, and China. Across all countries, seeing a severe case of COVID-19 in the media was associated with 1.72 times higher odds of vaccination intent in 2020 (95% CI: 1.46, 2.02) and 2.13 times higher odds of vaccination in 2021 (95% CI: 1.70, 2.67), compared to those not seeing a case or a less severe case. Perceived susceptibility was estimated to mediate 25% of the relationship with hypothetical vaccination (95% CI: 18%, 31%, P

In order to reduce the spread of SARS-CoV-2, much of the US was placed under social distancing guidelines during March 2020. We characterized risk perceptions and adherence to social distancing recommendations in March 2020 among US adults aged 18+ in an online survey with age and gender quotas to match the general US population (N = 713). We used multivariable logistic and linear regression to estimate associations between age (by generational cohort) and these outcomes. The median perceived risk of infection with COVID-19 within the next month was 32%, and 65% of individuals were practicing more social distancing than before the outbreak. Baby Boomers had lower perceived risk than Millennials (-10.6%, 95% CI: -16.2%, -5.0%), yet were more frequently social distancing (OR = 1.64; 95% CI: 1.05, 2.56). Public health outreach should focus on raising compliance with social distancing recommendations, especially among high risk groups. Efforts to address risk perceptions alone may be inadequate.

COVID-19 vaccination rates for children globally are relatively low. This study aimed to investigate parental vaccine hesitancy and parents' acceptance of a COVID-19 for their children for their children in the United States, China, Taiwan, India, Indonesia, and Malaysia.We analyzed data from an opt-in, internet-based cross-sectional study (n = 23,940). Parents were asked about their acceptance of a COVID-19 vaccine for their children, and if they would accept the vaccine with different risk and effectiveness profiles for themselves. Poisson regression was used to generate prevalence ratios (PR) of the relationship between vaccine acceptance for a child and vaccine profile, by country and waves and overall. Between August 2020 and June 2021, COVID-19 vaccine acceptance for children decreased in the United States (89% to 72%) and Taiwan (79% to 71%), increased in India (91% to 96%) and Malaysia (81% to 91%), and was stable in Indonesia (86%) and China (at 87%-90%). Vaccine risk and effectiveness profiles did not consistently affect parent's acceptance of a COVID-19 vaccine for their children. Instead, being not hesitant was a large driver of vaccine acceptance (PR: 1.24, 95% CI: 1.14, 1.36). Adolescent COVID-19 vaccination have already been established in many high and middle-income countries, but our study suggests that there is a movement of vaccine hesitancy which could impede the success of future pediatric and adolescent COVID-19 vaccination programs.

BackgroundWe 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.MethodsUsing 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.ResultsLow 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.ConclusionsLess 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.

BACKGROUND:Vaccine hesitancy has been little studied in low- and middle-income countries but is a potential concern because vaccine refusal may increase the burden of infectious diseases and impede control efforts. The aim of this study was to compare vaccine hesitancy between locals, long-time city residents, and non-locals, who have more recently moved to the city from either other urban or rural areas, in Shanghai, China. METHODS:Parents of infants ≤3 months of age were surveyed at immunization clinics in Shanghai, China. Participants completed a paper questionnaire utilizing the 10-item Vaccine Hesitancy Scale, which was developed by the World Health Organization Strategic Advisory Group of Experts on Immunization. Items were grouped based on internal consistency, and regressed onto demographic variables using a negative binomial model. RESULTS:In total, 1,188 (92.5%) individuals participated. For most items on the scale, parents expressed positive beliefs about vaccines. However, about half of parents somewhat or strongly agreed that new vaccines carried more risks than older vaccines, and 71.6% somewhat or strongly agreed that they were concerned about serious adverse effects. Seven items from the Vaccine Hesitancy Scale were highly correlated and mapped onto "lack of confidence"; the other three items were analysed separately. Compared to mothers, fathers had less lack of confidence (β: -0.06, 95% CI: -0.12, -0.01), and individuals living in the outer suburbs (β: 0.13, 95% CI: 0.01, 0.25) and rural non-locals (β: 0.10, 95% CI: 0.02, 0.18) had greater lack of confidence in vaccines compared to their urban or local counterparts, respectively. DISCUSSION:Shanghai parents professed confidence in certain vaccine benefits, but vaccine messaging could focus on addressing misconceptions about vaccines for diseases no longer common, newer vaccines, and adverse effects associated with vaccination. These messages may need to be separately tailored to locals and non-locals, who have differing concerns.

BACKGROUND:Community health workers (CHWs) have been placed in many rural areas in India to increase villagers' connections to basic preventive health care. In this study, we describe how pregnant women and mothers of young children react when CHWs inform them that they, or their child, are at high risk of pregnancy-related complications or early childhood developmental delays, and further screening and health care from a physician is recommended. METHODS:In this longitudinal study in rural villages in West Bengal, India, pregnant mothers, as well as mothers of children aged 12-24 months, were screened for high risk complications. They were re-contacted and asked questions regarding how and to what extent did visits by the CHWs improve their household's overall health behavior, along with details about what additional care, if any, they sought. These responses are presented by different demographic and medical characteristics. RESULTS:Of the 231 pregnant women, all said they had sought additional care in response to the CHW visit, and all stated that feedback from the CHW resulted in improvement to their health behaviors. Most (90%) pregnant women gave birth at an institution. Among the 213 mothers of young children who were followed up, all sought additional care in response to the CHW's visit. Most (67%) mentioned that they had a significant improvement in their health behaviors following feedback from the CHW, and the rest stated that they had some improvement. CONCLUSIONS:With the proper training, CHWs can be partners in health care to improve the health of vulnerable populations, not only in rural areas of India, but also in other developing countries. CHWs can promote positive health outcomes in their villages of residence.

BACKGROUND:Severe Acute Respiratory Infection (SARI) causes substantial mortality and morbidity worldwide. The country of Georgia conducts sentinel surveillance to monitor SARI activity and changes in its infectious etiology. This study characterizes the epidemiology of SARI in Georgia over the 2015/16 and 2016/17 influenza seasons, compares clinical presentations by etiology, and estimates influenza vaccine effectiveness using a test-negative design. METHODS:SARI cases were selected through alternate day systematic sampling between September 2015 and March 2017 at five sentinel surveillance inpatient sites. Nasopharyngeal swabs were tested for respiratory viruses and Mycoplasma pneumoniae using a multiplex diagnostic system. We present SARI case frequencies by demographic characteristics, co-morbidities, and clinical presentation, and used logistic regression to estimate influenza A vaccine effectiveness. RESULTS:1,624 patients with SARI were identified. More cases occurred in February (28.7%; 466/1624) than other months. Influenza was the dominant pathogen in December-February, respiratory syncytial virus in March-May, and rhinovirus in June-November. Serious clinical symptoms including breathing difficulties, ICU hospitalization, and artificial ventilation were common among influenza A and human metapneumovirus cases. For influenza A/H3, a protective association between vaccination and disease status was observed when cases with unknown vaccination status were combined with those who were unvaccinated (OR: 0.53, 95% CI: 0.30, 0.97). CONCLUSIONS:Multi-pathogen diagnostic testing through Georgia's sentinel surveillance provides useful information on etiology, seasonality, and demographic associations. Influenza A and B were associated with more severe outcomes, although the majority of the population studied was unvaccinated. Findings from sentinel surveillance can assist in prevention planning.

BACKGROUND:Chinese parents have access to domestic and foreign vaccines for their children. Their vaccine preferences are unclear, especially given recent pharmaceutical quality scandals and widely held beliefs deriving from Traditional Chinese Medicine (TCM). This study characterized parental beliefs about the safety and effectiveness of Chinese and foreign vaccines. METHODS:In May 2014, caregivers of young children at public immunization clinics in Shanghai, China, responded to a survey on vaccine perceptions. The two outcomes (differential belief in the effectiveness and safety of foreign vs domestic vaccines) were separately regressed onto demographic predictors in multinomial logistic regression models. RESULTS:Among 618 caregivers, 56% thought the effectiveness of domestic and foreign vaccines were comparable; 33% thought domestic were more effective and 11% foreign. Two-thirds thought foreign and domestic vaccines had similar safety; 11% thought domestic were safer and 21% thought foreign were safer. Compared to college graduates, those with a high school education or less had greater odds of believing domestic vaccines were more effective, and also had greater odds of believing imported vaccines were safer. Greater trust in TCM was not associated with differential beliefs in the effectiveness or safety of domestic vs foreign vaccines. CONCLUSIONS:Although there is no evidence that foreign and domestic vaccines differ in either effectiveness or safety, less educated caregivers in China (but not those with greater trust in TCM) appear to believe such differences exist. Further exploration of the causes of these beliefs may be necessary in order to optimize vaccine communications in China.

Control groups in previous case-control studies of vaccine-preventable diseases have included people immune to disease. This study examines risk factors for measles acquisition among adults 20 to 49 years of age in Tianjin, China, and compares findings using measles IgG antibody-negative controls to all controls, both IgG-negative and IgG-positive.Measles cases were sampled from a disease registry, and controls were enrolled from community registries in Tianjin, China, 2011-2015. Through a best subsets selection procedure, we compared which variables were selected at different model sizes when using IgG-negative controls or all controls. We entered risk factors for measles in two separate logistic regression models: one with measles IgG-negative controls and the other with all controls.The study included 384 measles cases and 1,596 community controls (194 IgG-negative). Visiting a hospital was an important risk factor. For specialty hospitals, the odds ratio (OR) was 4.53 (95% confidence interval (CI): 1.28, 16.03) using IgG-negative controls, and OR = 5.27 (95% CI: 2.73, 10.18) using all controls. Variables, such as age or length of time in Tianjin, were differentially selected depending on the control group. Individuals living in Tianjin ≤3 years had 2.87 (95% CI: 1.46, 5.66) times greater odds of measles case status compared to all controls, but this relationship was not apparent for IgG-negative controls.We recommend that case-control studies examining risk factors for infectious diseases, particularly in the context of transmission dynamics, consider antibody-negative controls as the gold standard.

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.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.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.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.

BACKGROUND:Haemophilus influenzae type b (Hib) vaccine and pneumococcal conjugate vaccine (PCV) are relatively expensive, newly introduced vaccines in China. This study evaluates the impact of residency and urbanicity on Hib vaccine and PCV coverage for children aged 2 to 7 years living in Shanghai, China, in August 2012. METHODS:In this exploratory cohort study, a sample of children aged 2 to 7 years, all of whom were eligible to have received the complete series of Hib vaccine and PCV, was obtained from the Shanghai Immunization Program Information System. Three measures of vaccination coverage for Hib vaccine and PCV were examined: dose 1 coverage, series completion, and timeliness of dose 1 vaccination. Multivariable binomial regression was used to estimate the difference in vaccination coverage between locals and the floating population. RESULTS:Dose 1 coverage was 50.9% for Hib vaccine and 11.4% for PCV for the 28,141 abstracted pediatric records. For both vaccines, dose 1 coverage was higher in locals than in the floating population. The disparity in coverage between locals and the floating population was greater in suburban areas than urban areas. Of all children who received dose 1, 79.7% completed the Hib vaccine series, and 91.3% completed the PCV series. Timely dose 1 coverage was 8.2% for Hib vaccine and 0.5% for PCV. CONCLUSION:Low vaccination coverage and extremely low levels of timely dose 1 vaccination indicate that current vaccination efforts are inadequate to reduce the burden of Hib and pneumococcal disease among Chinese children, especially infants. Government funding of the Hib vaccine and PCV through the Expanded Program on Immunization would increase uptake and could also ensure that improvement in the timeliness of administration and series completion is targeted for all demographic groups.