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It is important to distinguish between apprehensions that lead to vaccine rejection and those that do not. In this study, we (1) identifed latent classes of individuals by vaccination attitudes, and (2) compared classes of individuals by sociodemographic characteristics COVID-19 vaccination, and risk reduction behaviors. The COVID-19 Coping Study is a longitudinal cohort of US adults aged ≥ 55 years (n = 2358). We categorized individuals into three classes based on the adult Vaccine Hesitancy Scale using latent class analysis (LCA). The associations between class membership and sociodemographic characteristics, COVID-19 vaccination, and other behaviors were assessed using chi-square tests. In total, 88.9% were Vaccine Acceptors, 8.6% were Vaccine Ambivalent, and 2.5% Vaccine Rejectors. At the end, 90.7% of Acceptors, 62.4% of the Ambivalent, and 30.7% of the Rejectors had been vaccinated. The Ambivalent were more likely to be Black or Hispanic, and adopted social distancing and mask wearing behaviors intermediate to that of the Acceptors and Rejectors. Targeting the Vaccine Ambivalent may be an efficient way of increasing vaccination coverage. Controlling the spread of disease during a pandemic requires tailoring vaccine messaging to their concerns, e.g., through working with trusted community leaders, while promoting other risk reduction behaviors. Supplementary Information The online version contains supplementary material available at 10.1007/s10900-022-01064-w.

Measles continues to result in focal outbreaks in India, despite over three decades of universal infant vaccination. The aims of this study were to examine measles immunity in the population of Chandigarh, India, and to compare immunity by vaccination vs. natural infection. In a cross-sectional study of individuals 1-60 years selected from 30 communities within Chandigarh during 2017-2018, measles immunity was assessed using serological surveys. Seropositivity was compared across demographic groups, and by prior history of vaccination and natural history of infection. Among those 1-20 years old, measles seropositivity, and histories of measles vaccination or prior measles diagnosis were separately assessed as outcomes in logistic regression models, with demographic factors as independent variables. Among 1690 participants, 94% were seropositive, and 6% had borderline or negative antibody levels. Of those positive, 30% had prior vaccination, 16% had a history of natural infection, and 54% had an unknown history. Over 50% of individuals among those20 years old, had unknown history of immunity. In the multivariable regression models, vaccination was more common in younger ages (P .0001), and in males compared to females (P = .0220), and in those with more education (P .0001). The majority of the population was seropositive, and seropositivity increased with age. Older age groups were more likely to be protected because of previous natural infection, whereas younger age groups were protected by vaccination. There was inequity in vaccination coverage by gender, and maternal education status.

Clinicians in intensive care units (ICUs) have been prioritized for COVID-19 vaccination. We aim to understand the reasons behind vaccination refusal, and assess preferences for COVID-19 vaccines among Chinese ICU clinicians.ICU clinicians throughout China's mainland were contacted to participate in an online survey. We compared concerns with vaccination status, and through a discrete choice experiment (DCE) assessed preferences for vaccines in terms of effectiveness, risk of adverse reactions, duration of immunity, and whether coworkers have been vaccinated.Among 11,951 ICU respondents from 252 prefecture-level regions, vaccination coverage was 75.4%, with an additional 9.2% not vaccinated but intending to, and 16.1% not vaccinated and not intending to. ICU clinicians not intending to be vaccinated significantly expressed more concerns about the speed of vaccine development (30.1%) and adverse reactions (65.9%). In the DCE, the only significant difference in preferences of a COVID-19 vaccine was for safety, with those not intending to have a stronger preference for a vaccine with fewer adverse reactions (OR = 4.49), compared to those already vaccinated (OR = 2.90) or those intending to vaccinate (OR = 3.46).Increasing vaccination coverage among Chinese ICU clinicians will require strong norms surrounding vaccination and transparency about safety information.

This study examined whether future COVID-19 vaccine acceptance differed based on an experimental manipulation of the vaccine safety and effectiveness profile. Data come from the Detroit Metro Area Community Study, a population-based study conducted July 15–20, 2020. Participants were asked whether they would get a new COVID-19 vaccine after being randomly assigned information about the vaccine’s effectiveness (50% or 95%) and chance of fever (5% or 20%). Among 1,117 Detroiters, 51.3% would accept a COVID-19 vaccine that is 50% effective and 77.1% would accept a vaccine that is 95% effective. Women and adults ≥65 were more accepting of a vaccine; Black Detroiters were less accepting. Believing vaccines to be important, effective, and safe was associated with higher acceptance. Uptake of a COVID-19 may be limited, depending on perceived vaccine effectiveness and general attitudes toward vaccines. Public health approaches to modifying these attitudes will be especially important in the Black community.

How countries, particularly low- and middle-income economies, should pay the coronavirus disease 2019 (COVID-19) vaccine is an important and understudied issue. We undertook an online survey to measure the willingness-to-pay (WTP) for a COVID-19 vaccine and its determinants in Indonesia. The WTP was assessed using a simple dichotomous contingent valuation approach and a linear regression model was used to assess its associated determinants. There were 1,359 respondents who completed the survey. In total, 78.3% (1,065) were willing to pay for the COVID-19 vaccine with a mean and median WTP of US$ 57.20 (95%CI: US$ 54.56, US$ 59.85) and US$ 30.94 (95%CI: US$ 30.94, US$ 30.94), respectively. Being a health-care worker, having a high income, and having high perceived risk were associated with higher WTP. These findings suggest that the WTP for a COVID-19 vaccine is relatively high in Indonesia. This WTP information can be used to construct a payment model for a COVID-19 vaccine in the country. Nevertheless, to attain higher vaccine coverage, it may be necessary to partially subsidize the vaccine for those who are less wealthy and to design health promotion materials to increase the perceived risk for COVID-19 in the country.

International travel may facilitate the spread of the novel coronavirus disease (COVID‐19). The study describes clusters of COVID‐19 cases within Chinese tour groups travelling in Europe January 16–28. We compared characteristics of cases and non‐cases to determine transmission dynamics. The index case travelled from Wuhan, China, to Europe on 16 January 2020, and to Shanghai, China, on 27 January 2020, within a tour group (group A). Tour groups with the same outbound flight (group B) or the same tourism venue (group D) and all Chinese passengers on the inbound flight (group C) were investigated. The outbreak involved 11 confirmed cases, 10 suspected cases and six tourists who remained healthy. Group A, involving seven confirmed cases and six suspected cases, consisted of familial transmission followed by propagative transmission. There was less pathogenicity with propagative transmission than with familial transmission. Disease was transmitted in shared outbound flights, shopping venues within Europe and inbound flight back to China. The novel coronavirus caused clustered cases of COVID‐19 in tour groups. When tourism and travel opens up, governments will need to improve screening at airports and consider increased surveillance of tour groups—particularly those with older tour members.

Background Hesitancy towards vaccination has been studied as a barrier to vaccination among children, as well as participation in vaccine trials. This study aimed to investigate hesitancy towards vaccination among parents in Indonesia, as a part of the Indonesia Zika Vaccine Study. Methods A cross-sectional study was conducted in eleven regencies and municipalities in Aceh and West Sumatra province, Indonesia. Parents were recruited from families at outpatient clinics of community health centers or hospitals. The survey included various questions about sociodemographic factors and the Parent Attitudes about Childhood Vaccination (PACV) scale. Linear regression was employed to assess the association between explanatory variables and vaccine hesitancy. Results A total of 956 parents were interviewed and 26.4% of participants had heard about Zika. Overall, 152 parents (15.9%) were vaccine hesitant, and this proportion was the highest in the safety and efficacy subdomain (61.6%). In the unadjusted analysis, having a diploma certificate, working in the health sector, and having heard about Zika were significantly associated with non-hesitancy towards children vaccination. Having heard about Zika was the only factor that was significantly associated with hesitancy towards vaccination in multivariate model (aOR: 0.43, 95% CI: 0.26–0.71). Mothers, younger parents (aged 20–29 years old), and those with only a primary school education were more concerned about vaccine safety and efficacy compared to fathers, older groups, and individuals with more education, respectively. Conclusions Hesitancy towards pediatric vaccination is observed in 15% of respondents and most of the hesitancy was expressed in terms of vaccine safety and efficacy. Therefore, continuous dissemination of vaccine information needs to be carried out to earn parents’ trust and increase vaccination coverage in Indonesia.

After the first, imported, laboratory-confirmed case of monkeypox in human was reported in Singapore on May 2019, countries in Asia started to strengthen disease surveillance systems. One challenge in preventing monkeypox is a lack of knowledge, particularly among healthcare workers. The aim of this study was to assess the knowledge of monkeypox among general practitioners (GPs) in Indonesia. A cross-sectional online survey was conducted. The survey collected participants’ knowledge on a 21-item scale and explanatory variables. A two-step logistic regression analysis was employed to assess the predictors of knowledge of monkeypox. A total of 432 GPs were included; 10.0% and 36.5% of them had a good knowledge using an 80% and 70% cutoff point for knowledge domain, respectively. No explanatory variables were associated with knowledge when using 80% cutoff point. Using the lower cutoff, there was lower knowledge among GPs who graduated from universities located in Sumatra or other islands versus Java (adjusted odds ratio (aOR): 0.53; 95%CI: 0.28–0.97, p = 0.041) and among those were older than 30 years compared to younger GPs (aOR: 0.61; 95%CI: 0.39–0.96, p = 0.033). GPs working in private clinics had less knowledge compared to GPs in community health centers (aOR: 0.55; 95%CI: 0.31–0.99, p = 0.047). In conclusion, knowledge of monkeypox among GPs in Indonesia is relatively low in all groups. Increasing knowledge of monkeypox will be key to improving the capacity of GPs to respond to human monkeypox cases and to report into a disease surveillance system.

Background:Streptococcus pneumoniae infection among adults, especially in adults over 60 years old in China results in a large number of hospitalizations and a substantial financial burden. This study assessed the vaccine effectiveness (VE) of 23-valent pneumococcal polysaccharide vaccine (PPV23) against pneumococcal diseases among the elderly aged 60 years or older in Shanghai, China.Methods: We conducted a test-negative case–control study among the elderly aged 60 years or older who sought care at hospitals in 13 districts of Shanghai from September 14, 2013 to August 31, 2019. A case was defined as pneumococcal disease and testing positive for Streptococcus pneumoniae. Controls had symptoms congruent with pneumococcal disease but were negative for Streptococcus pneumoniae. We conducted 1:2 matching by gender, age, hospital and admission date. Vaccination status was verified from the immunization system database. VE was calculated with conditional logistic regression according to the formula (1–OR) ×100%.Results: Overall, 603 adults aged 60 years or older with pneumococcal disease and positive for Streptococcus pneumoniae were included as cases, and 19.6% (118 persons) had a recorded PPV23 vaccination. The controls included 1,206 adults, whose vaccination rate was 23.8% (287 persons). The VE against pneumococcal diseases among the whole population was 24% (95% CI: 2%, 40%) and among women 44% (95% CI: 6%, 67%). After adjusting for multiple variables, the effectiveness of PPV23 against pneumococcal diseases was still statistically significant with VE for all of 25% (95% CI: 3%, 42%) and VE for women of 49% (95% CI: 11%, 71%).Conclusion: PPV23 was effective against pneumococcal diseases in adults aged 60 years or older in Shanghai, China. Its relatively high effectiveness among women warrants this group to be particularly targeted for vaccination, with further research on why vaccination effectiveness is less among men.

Hepatitis E virus (HEV) has been divided into eight genotypes and approximately thirty subtypes. Past studies of blood donors have revealed a substantial prevalence of HEV infection. We examined anti-HEV antibodies and HEV RNA in Chinese voluntary blood donors (VBDs). Blood specimens were collected during 2010-2011, 2014-2015, and 2018, and tested for anti-HEV IgG and IgM antibodies. HEV RNA was tested using real-time PCR and nested reverse transcription PCR (RT-PCR). Phylogenetic analysis determined the genotype using MEGA 7.0. Among 4044 VBDs, 2774 were men (68.6%). In total, 19.8% and 1.1% of the VBDs were reactive to anti-HEV IgG and IgM, respectively. The seroprevalence of anti-HEV IgG was significantly associated with age and time period (P 0.05), whereas anti-HEV IgM was associated with anti-Treponema pallidum and time period (P 0.05). A total of five specimens were positive for HEV RNA with normal ALT levels. Subtype 4f (n=1; in the specimens reactive to anti-HEV IgM) and 4d (n=3; 1 in the specimens reactive to anti-HEV IgM and 2 in the anti-HEV negative specimens) were found. The last specimen positive for HEV RNA was not genotyped due to failure in amplifying the partial sequence. In conclusion, our study identified HEV subtype 4f for the first time in China. Additionally, we confirmed the high prevalence of HEV in Chinese VBDs. These findings suggest a substantial risk of transfusion-transmitted HEV. Therefore, screening for HEV among Chinese VBDs might be warranted to prevent further transfusion-mediated spread of HEV.

Background Understanding people’s perceptions of the economic benefits of a potential Zika vaccine (ZV) is critical to accelerating its introduction into either public sector programs or private market. The aim of this study was to assess the acceptance and willingness-to-pay (WTP) for a hypothetical ZV and the associated explanatory variables in Indonesia. Methods We conducted a health facility-based cross-sectional study in Aceh and West Sumatra province from 1 February to 13 June 2018. Patients who visited outpatient departments, have had children or were expecting their first child, were approached and interviewed to collect information on acceptance, WTP, demographic and socio-economic variables and attitudes towards childhood vaccines. Associations of explanatory variables influencing acceptance and WTP were assessed using logistic regression and linear regression analysis, respectively. Results In total, 956 respondents were included in the final analysis of acceptance, of whom 338 (35.3%) expressed their WTP. We found that 757 (79.1%) of the respondents were likely to be vaccinated and to recommend their partner to be vaccinated. Higher educational attainment, having a job, having heard about Zika and a good attitude towards childhood vaccination were associated with ZV acceptance in the univariate analyses. In the multivariate analysis, attitude towards childhood vaccination was the strongest predictor for ZV vaccination. We found the geometric mean and median of WTP was US$ 13.1 (95% CI: 11.37–15.09) and US$ 7.0 (95% CI: 4.47–10.98), respectively. In the final model, having heard about Zika, having a job, and higher income were associated with a higher WTP. Conclusion Although the acceptance rate of the ZV is relatively high in Indonesia, less than 40% of respondents are willing to pay, underscoring the need for a low-cost, high-quality vaccine and public sector subsidies for Zika vaccinations in the country.

Background Achieving COVID-19 community protection (aka, herd immunity) in China may be challenging because many individuals remain unsure or are unwilling to be vaccinated. One potential means to increase COVID-19 vaccine uptake is to essentially mandate vaccination by using existing mobile technologies that can prohibit unvaccinated individuals from certain public spaces. The “Health Code” is a ubiquitous mobile phone app in China that regulates freedom of travel based on individuals’ predicted risk of exposure to SARS-CoV-2. Green-colored codes indicate ability to travel unrestricted in low-risk regions; yellow-colored codes indicate prohibition from major public spaces and modes of public transportation. We examined the effects of a “Health Code”-based vaccine mandate on willingness to vaccinate for COVID-19 in China. Methods In August 2020, an online discrete choice experiment (DCE) was conducted among adults living in China. Participants completed up to six DCE choice sets, each containing two hypothetical COVID-19 vaccination scenario choices and a “do not vaccinate” choice. Half of the choice sets had a “Health Code” attribute that associated the “do not vaccinate” choice with a yellow Health Code implying restricted travel. Weighted, mixed effects multinomial logit regression was used to estimate preference utilities and predicted choice probabilities. Results Overall, 873 participants completed 4317 choice sets. Most participants attained at least college-level education (90.9%). 29.8% of participants were identified as vaccine hesitators (defined as being unsure or unwilling to receive a COVID-19 vaccination). With and without the “Health Code”-based vaccine mandate, there was an 8.6% (85% CI: 6.4% − 10.92%) and 17.3% (85% CI:13.1% − 21.6%) respective predicted probability that vaccine hesitators would choose “do not vaccinate” over a common vaccination scenario currently in China (i.e., free, domestic vaccine, 80% effectiveness, 10% probability of fever side-effects, administered in a large hospital, two doses). Corresponding predicted probabilities for people who did not express vaccine hesitancy was 0.3% (93% CI: 0.0% − 14.3%) and 3.5% (93% CI:2.3% − 4.8%). The “Health Code”-based mandate significantly increased willingness to vaccinate when vaccine efficacy was greater than 60%. Conclusion Among vaccine hesitators with higher educational attainment, willingness to vaccinate for COVID-19 appears to increase if mobile technology-based vaccine mandates prohibit unvaccinated individuals from public spaces and public transportation. However, such mandates may not increase willingness if perceived vaccine efficacy is low.

The arrival of the COVID-19 vaccine has been accompanied by increased discussion of vaccine hesitancy. However, it is unclear if there are shared patterns between general vaccine hesitancy and COVID-19 vaccine rejection, or if these are two different concepts. This study characterized rejection of a hypothetical COVID-19 vaccine, and compared patterns of association between general vaccine hesitancy and COVID-19 vaccine rejection. The survey was conducted online March 20-22, 2020. Participants answered questions on vaccine hesitancy and responded if they would accept the vaccine given different safety and effectiveness profiles. We assessed differences in COVID-19 rejection and general vaccine hesitancy through logistic regressions. Among 713 participants, 33.0% were vaccine hesitant, and 18.4% would reject a COVID-19 vaccine. Acceptance varied by effectiveness profile: 10.2% would reject a 95% effective COVID-19 vaccine, but 32.4% would reject a 50% effective vaccine. Those vaccine hesitant were significantly more likely to reject COVID-19 vaccination [odds ratio (OR): 5.56, 95% confidence interval (CI): 3.39, 9.11]. In multivariable logistic regression models, there were similar patterns for vaccine hesitancy and COVID-19 vaccine rejection by gender, race/ethnicity, family income, and political affiliation. But the direction of association flipped by urbanicity (P=0.0146, with rural dwellers less likely to be COVID-19 vaccine rejecters but more likely to be vaccine hesitant in general), and age (P=0.0037, with fewer pronounced differences across age for COVID-19 vaccine rejection, but a gradient of stronger vaccine hesitancy in general among younger ages). During the COVID-19 epidemic’s early phase, patterns of vaccine hesitancy and COVID-19 vaccine rejection were relatively similar. A significant minority would reject a COVID-19 vaccine, especially one with less-than-ideal effectiveness. Preparations for introducing the COVID-19 vaccine should anticipate substantial hesitation and target concerns, especially among younger adults.

Most research on vaccine hesitancy has focused on parental attitudes toward childhood vaccination, but it will be important to understand dimensions of vaccine hesitancy in the adult population as more adult vaccines are introduced in the future. We modified the Vaccine Hesitancy Scale to target adult vaccines and provide measures of its reliability and validity relative to influenza vaccine uptake and COVID-19 vaccination acceptance in cross-sectional internet surveys in the United States and in China. We assessed the impact of vaccine hesitancy on influenza and COVID-19 vaccination using multivariable regression modeling, which informed concurrent validity of the adult Vaccine Hesitancy Scale (aVHS). Among 1103 participants in the March 2020 China survey, 5.4% would not accept a COVID-19 vaccine, whereas this figure was 18.8% for the March 2020 US survey and 27.3% for the June 2020 US survey. The aVHS exhibits good internal consistency in all three surveys. Models adjusted for age, gender and income level show that prevalence of COVID-19 vaccine acceptance was a fraction as high in those who scored higher on the VHS than those who scored lower on all three surveys. Prevalence of past and future flu vaccine acceptance was a fraction as high in those with higher aVHS scores than those with lower scores. Prevalence of COVID-19 vaccine acceptance is lower in those with higher vaccine hesitancy scores, which supports the scale's concurrent validity. The aVHS exhibits good internal consistency, making it a valid and reliable tool for measuring vaccination uptake.

Objectives:The aim of this study was to determine the level of coronavirus disease 2019 (COVID-19) risk perceptions in Indonesia and characterize predictors of perceptions.Methods:An online cross-sectional study was conducted. A questionnaire assessed perceived risk and collected independent variables, including sociodemographic data. A multivariable linear regression model was used to characterize the relationship between independent variables and perceived risk.Results:We included 1379 respondents in the final analysis with the mean and median of perceived risk score was 19.21% and 10.0%, respectively. Respondents aged between 21 and 30 years had the highest perceived risk, and those who were unmarried had 4.3% higher perceived risk compared with those who were married. Compared with the lowest monthly income group, those making Indonesian Rupiah (IDR) 6-10 million and more than IDR 10 million a month believed they had 4.2% and 8.8% higher risk, respectively. Citizens who lived in cities and health-care workers also had a higher perceived risk compared with those in the rural areas and non–health-care workers, respectively.Conclusions:Perceived risk of COVID-19 in Indonesia is relatively low, and this could hamper the adoption of preventive measures of COVID-19. Efforts to increase the awareness and perceived risk are important to prevent the pandemic from escalating.

Introduction: Several vaccine candidates are being clinically tested in response to the 2019 coronavirus disease (COVID-19) pandemic. This study was conducted to assess the acceptance of a 50 or 95% effective COVID-19 vaccine, when it becomes available in southeast Asia, among the general population in Indonesia. Methods: A cross-sectional online survey was conducted between March 25 and April 6, 2020. Participants were asked if they would accept a free vaccine which was 95 or 50% effective. Using a logistic regression model, we assessed the associations between sociodemographic characteristics, exposure to COVID-19 information, or perceived risk of infection with acceptance of a hypothetical COVID-19 vaccine. Results: Among 1,359 respondents, 93.3% of respondents (1,268/1,359) would like to be vaccinated for a 95% effective vaccine, but this acceptance decreased to 67.0% (911/1,359) for a vaccine with 50% effectiveness. For a 95% effective vaccine, being a healthcare worker and having a higher perceived risk of COVID-19 infection were associated with higher acceptance, adjusted odds ratio (aOR): 2.01; 95%CI: 1.01, 4.00 and aOR: 2.21; 95%CI: 1.07, 4.59, respectively; compared to civil servants, being retired was associated with less acceptance (aOR: 0.15; 95%CI: 0.04, 0.63). For a 50% effective vaccine, being a healthcare worker was also associated with greater acceptance, aOR: 1.57; 95%CI: 1.12, 2.20. Conclusion: Acceptance of a COVID-19 vaccine was highly influenced by the baseline effectiveness of the vaccine. Preparing the general population to accept a vaccine with relatively low effectiveness may be difficult.

Introduction Rapidly urbanizing communities in middle-income countries could be sources of vaccine hesitancy, and may create hot spots of low vaccination coverage. This study characterizes vaccine hesitancy in Shanghai and identifies disparities in vaccine safety and efficacy concerns by residency status—a marker for recent migration into the city. Methods Parents of children aged ≤18 years from immunization clinics in Shanghai were enrolled in summer 2019, with the data analyzed during winter 2019–2020. The paper questionnaire used the Parental Attitudes towards Childhood Vaccines scale, which included questions about vaccine safety and efficacy concerns. The primary independent variable was residency—whether an individual was a Shanghai local or a recent migrant (i.e., non-local). Linear regression models assessed the relationship between residency and vaccine safety and efficacy concerns. Results Among 1,021 participants, 65.4% had local residency, and the remainder were urban non-locals (13.1%) or rural non-locals (21.5%). A majority of parents expressed concerns about vaccine side effects (73.8%), vaccine safety (63.9%), and vaccine effectiveness (52.4%). Compared with locals, rural non-locals were more concerned about vaccine side effects (β=0.26, 95% CI=0.07, 0.46), vaccine safety (β=0.42, 95% CI=0.19, 0.65), and vaccine effectiveness (β=0.37, 95% CI=0.16, 0.58). Conclusions Differences in vaccine hesitancy by residency could lead to geographical and sociodemographic disparities in vaccination coverage and outbreaks of vaccine-preventable disease. Supplement information This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Background A clinical trial is ongoing to evaluate the safety and efficacy of a monkeypox vaccine among healthcare workers (HCWs). The critical question that needs to be addressed is whether HCWs are willing to accept and purchase this vaccine. The objective of this study was to evaluate the acceptance and willingness to pay (WTP) for the vaccine among HCWs. Methods From May to July 2019, a cross-sectional study was conducted among registered general practitioners (GPs) in Indonesia. A contingent valuation method was employed to evaluate the WTP. Besides acceptance and WTP, various explanatory variables were also collected and assessed. A logistic regression and a multivariable linear regression were used to explore the explanatory variables influencing acceptance and WTP, respectively. Results Among 407 respondents, 391 (96.0%) expressed acceptance of a free vaccination. The mean and median WTP was US$ 37.0 (95%CI: US$ 32.76–US$ 41.23) and US$ 17.90 (95%CI: US$ 17.90–US$ 17.90), respectively. In an unadjusted analysis, those 30 years old or younger had 2.94 times greater odds of vaccine acceptance compared to those who were older (95%CI: 1.07–8.08). Location of alma mater, type of workplace, length of individual medical experience, and monthly income of GPs were all significantly associated with WTP. Conclusion Although the vast majority of GPs would accept a freely provided vaccine, they were also somewhat price sensitive. This finding indicates that partial subsidy maybe required to achieve high vaccine coverage, particularly among GPs at community health centres or those with a shorter duration of medical practice.

Background Adults with chronic conditions such as heart disease, diabetes, or lung disease are more likely to develop complications from a number of vaccine-preventable diseases, including influenza and pneumonia. In this study, we use the data from a chronic disease management information system in Shanghai to estimate vaccination coverage and characterize predictors of seasonal influenza and 23-valent pneumococcal polysaccharide vaccine (PPSV23) vaccination among people with chronic disease in Shanghai. Methods The Shanghai Centers for Disease Control and Prevention have information systems related to chronic disease management, hospital records, and immunizations. Data from individuals with hypertension, diabetes and chronic obstructive pulmonary disease (COPD) were abstracted during July 2017. The main outcome was coverage of pneumococcal and influenza vaccination. Vaccination coverage was calculated across demographic groups. Significance in bivariate associations was assessed through Pearson’s chi-square tests, and in multivariable models through logistic regression models with a forward stepwise method to select variables. Results In the sample of 2,531,227 individuals ≥15 years, 22.8% were vaccinated for pneumonia from January 2013 to July 2017, and the vaccination coverage of influenza in the 2016/17 influenza season was 0.4%. Vaccination coverage was highest in those 70–79 and lowest in those younger than 60. Compared to urban areas, uptake in rural areas was higher for pneumonia vaccination (OR: 2.43, 95% CI: 2.41, 2.45), but lower for influenza vaccination (OR: 0.55, 95% CI: 0.51, 0.59). Having a greater number of chronic diseases was associated with higher likelihood of pneumonia vaccination (3 vs 1: OR: 1.68, 95% CI: 1.64, 1.71), but this relationship was not statistically significant for influenza vaccination. Conclusions We found low levels with of pneumococcal vaccination, and extremely low uptake of influenza vaccination among individuals with high risk conditions in Shanghai who should be priority groups targeted for vaccination. Interventions could be designed to target groups with low uptake – like younger adults, and individuals who have not yet retired.

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.

Introduction: Vaccines are vital to reducing childhood mortality, and prevent an estimated 2 to 3 million deaths annually which disproportionately occur in the developing world. Overall vaccine coverage is typically used as a metric to evaluate the adequacy of vaccine program performance, though it does not account for untimely administration, which may unnecessarily prolong children's susceptibility to disease. This study explored a hypothesized positive association between increasing vaccine hesitancy and untimeliness of immunizations administered under the Expanded Program on Immunization (EPI) in Addis Ababa, Ethiopia. Methods: This cross-sectional survey employed a multistage sampling design, randomly selecting one health center within five sub-cities of Addis Ababa. Caregivers of 3 to 12-month-old infants completed a questionnaire on vaccine hesitancy, and their infants' vaccination cards were examined to assess timeliness of received vaccinations. Results: The sample comprised 350 caregivers. Overall, 82.3% of the surveyed children received all recommended vaccines, although only 55.9% of these vaccinations were timely. Few caregivers (3.4%) reported ever hesitating and 3.7% reported ever refusing a vaccine for their child. Vaccine hesitancy significantly increased the odds of untimely vaccination (AOR 1.94, 95% CI: 1.02, 3.71) in the adjusted analysis. Conclusions: This study found high vaccine coverage among a sample of 350 young children in Addis Ababa, though only half received all recommended vaccines on time. High vaccine hesitancy was strongly associated with infants' untimely vaccination, indicating that increased efforts to educate community members and providers about vaccines may have a beneficial impact on vaccine timeliness in Addis Ababa.

Objectives This study measures the prevalence of risk factors among pregnant women and young children aged 12-24 months in a rural community in West Bengal, India. Methods Community health workers (CHWs) enrolled women and children into this 2015 cross-sectional study. Pregnant women were evaluated for underweight, anemia, and abnormal blood pressure. Children were evaluated for underweight, abnormal head and upper arm circumferences, and low scores from the Ages and Stages Questionnaire (ASQ). Data were collected on smartphones and tablets or by paper. Results More than half of the 279 women (59.9%) had a risk factor during pregnancy: 48.7% were anemic, 35.1% had low blood pressure, and 7.5% were underweight. Among the 366 children, 59.3% had a risk factor, including 24.0% with low ASQ scores and 49.7% who had abnormal anthropometric measures. Conclusions for Practice Vulnerable populations, such as pregnant women and young children, needed a greater connection to doctors in this rural community. This study demonstrated the feasibility of CHWs to listen to health concerns and connect underserved populations with health care services.

Background Many measles cases in Tianjin, China, occur in infants whose mothers were born after widespread vaccination programs. We assessed age-specific decreases in maternal measles antibodies in infants and examined maternal and infant characteristics in relation to infant antibody titers. Methods Infant and mother dyads were enrolled from a sample of immunization clinics in all Tianjin districts. Participants' antibody titers were measured from dried blood spots. A multivariable log-linear model regressed infant antibody titers onto infant and mother characteristics. Results Among 551 infants aged ≤8 months, protective levels of measles antibodies were observed in infants whose mothers had measles titers ≥800 IU/mL (mean antibody titer, 542.5 IU/mL) or 400 to

Teenagers have a high prevalence of ascariasis in low-income countries with endemic disease, and their hygienic behaviors and access to proper sanitation may be limited in rapidly urbanizing settings. We studied university students in Kabul to estimate the proportion with ascariasis and determine the prevalence of risk factors for infection. Ascariasis was assessed through microscopy for 520 students attending Kabul Medical University. Overall, 15.8% of students were infected. Living in a hostel (21.2% versus 10.4% in houses) using well water (27.7% versus 9.7% for piped water), eating street food (29.4% versus 3.0% for those who do not), and eating unwashed vegetables (63.6% versus 8.8% for those who do not) were risk factors for infection. Recent city migrants who live in group hostels, including students, are important targets for interventions to reduce ascariasis. Such interventions could include encouraging individuals to prepare their own food and use only potable water.

Several new vaccines have been introduced into China in recent years, but some parents in China have shown concerns about the scheduling of vaccinations for young infants. This study explores caregiver concerns about children receiving multiple vaccines during a single visit and about vaccine administration in infants6months, and assesses the degree to which these concerns are associated with ratings of the importance of different sources of vaccine information in Shanghai.Caregivers of children 8months to 7years presenting at immunization clinics in Shanghai completed a survey about vaccine co-administration and vaccine administration6months of age. Respondents provided ratings of information from different sources (Internet, family/friends, other parents) and trust in doctors. We analyzed vaccine concerns using linear regression analyses that included these information sources after adjusting for socioeconomic variables.Among 618 caregivers, 64% were concerned about vaccine co-administration and 31% were concerned about vaccine administration to infants6months of age. Higher ratings of Internet as an important source of information were associated with greater concern about co-administration (β=0.11, 95% CI: 0.00, 0.22) and concern about administration at6months of age (β=0.17, 95% CI: 0.05, 0.28). Higher ratings given to information from other parents corresponded to 0.24 points greater concern about vaccine co-administration (95% CI: 0.04, 0.44). More trust in doctors and ratings of information from friends and family were not associated with vaccine concerns.Caregiver concerns about vaccine scheduling may limit China's flexibility to add vaccines to its official immunization schedule. Reporting information about vaccine safety on the Internet and bringing groups of parents together to discuss vaccines might help to ameliorate concerns about vaccine scheduling.

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

Background In 2013, the World Health Organization (WHO) and CIOMS introduced a revised Causality Assessment Protocol (CAP) for Adverse Events following Immunization (AEFI). India is one of the first countries to adopt the revised CAP. This study describes the application of the revised CAP in India. Methods We describe use of CAP by India’s AEFI surveillance program to assess reported AEFIs. Using publicly available results of causality assessment for reported AEFIs, we describe the results by demographic characteristics and review the trends for the results of the causality assessment. Results A total of 771 reports of AEFI between January 2012 and January 2015, completed causality review by August 2016. The cases were reported as belonging to a cluster (54%; n = 302), hospitalized or requiring hospitalization (41%; n = 270), death (25%; n = 195), or resulting in disability (0.4%; n = 3). The most common combinations of vaccines leading to report of an AEFI were DTwP, Hepatitis B, and OPV (14%; n = 106), followed by Pentavalent and OPV (13%; n = 103), and JE vaccine (13%; n = 101). Using the WHO Algorithm, most AEFI reports (89%, n = 683) were classifiable. Classifiable AEFI reports included those with a consistent causal association (53%; n = 407), an inconsistent causal association (29%; n = 226) or were indeterminate causal association with implicated vaccine(s) or vaccination process (6.5%; n = 50) (Fig. 1); 88 reports remained unclassifiable. Conclusions The revised CAP was informative and useful in classifying most of the reviewed AEFIs in India. Unclassifiable reports could be minimized with more complete information from health records. Improvements in causality assessment, and standardization in reporting between countries, can improve public confidence in vaccine system performance and identify important vaccine safety signals.

Background The aim of this study was to assess the knowledge and attitudes towards pregnancy-related issues of Zika virus (ZIKV) infection among general practitioners (GPs), a frontline healthcare worker group, in Indonesia. Methods A cross-sectional, online survey assessing knowledge and attitudes towards ZIKV infection on multiple-item scales was sent to GPs in the Sumatra and Java islands of Indonesia. The associations between independent factors and either knowledge or attitude were assessed with logistic regressions. The correlation and association between knowledge and attitude were estimated. Results We included 457 (53.7%) out of 850 responses in the analysis. Among these, 304 (66.5%) and 111 (24.2%) respondents had a good knowledge and attitude, respectively. No demographic, workplace, professional development, or experiential characteristics related to ZIKV infection were associated with knowledge. In the multivariate analysis, only contact experience was associated with attitude. There was a significant, positive correlation between knowledge and attitude scores. Conclusions Although knowledge of pregnancy-related complications of ZIKV infection is relatively high among GPs in Indonesia, more than 75% of them had a poor attitude towards pregnancy-related issues of Zika. Strategies for enhancing the capacity of GPs to develop positive attitudes and respond to ZIKV infection are needed. Electronic supplementary material The online version of this article (10.1186/s12879-019-4297-4) contains supplementary material, which is available to authorized users.

Background: Some Ebola vaccines have been developed and tested in phase III clinical trials. However, assessment of whether public have willingness to purchase or not, especially in unaffected areas, is lacking. The aim of this study was to determine willingness to pay (WTP) for a hypothetical Ebola vaccine in Indonesia. Methods: A cross-sectional study was conducted from 1 August to 30 December 2015 in five cities in Aceh province of Indonesia. Patients’ family members who visited outpatient departments were approached and interviewed about their sociodemographic characteristics, knowledge of Ebola, attitude towards vaccination practice and their WTP for a hypothetical Ebola vaccine. A multivariable linear regression model assessed the relationship between these explanatory variables and WTP. Results: During the study, 500 participants were approached and interviewed. There were 424 (84.8%) respondents who completed the interview and 74% (311/424) expressed their acceptance for an Ebola vaccine. There were 288 participants who were willing to pay for an Ebola vaccine (92.6% out of 311). The mean of WTP was US$2.08 (95% CI: 1.75-2.42). The final multivariable model indicated that young age, high educational attainment, working as a private employee, entrepreneur or civil servant (compared to farmers), being unmarried, and residing in a suburb (compared to a city) were associated with higher WTP. Conclusions: Although the proportion of the participants who would accept the Ebola vaccine was relatively high, the amount they were willing to pay for Ebola vaccine was very low. This finding would indicate the need of subsidies for Ebola vaccine in the country.

Background Hepatitis B (HepB) is a major public health concern in Malaysia yet little is known about knowledge and awareness of this infection in the country. Such information is essential for designing effective intervention strategies for HepB prevention and control. The aim of this study was to characterize knowledge and awareness regarding HepB in Malaysia and to identify their associated sociodemographic determinants. Methods A community-based cross-sectional survey was conducted between January and May 2016 in Selangor state of Malaysia. A two-stage cluster random sampling design was used and one adult member of selected households was interviewed face-to-face. Logistic regression was used to estimate the differences in knowledge and awareness between groups. Results A total of 764 households completed the interviews and were included in the final analysis. Only 36.9 and 38.8% of the participants had good knowledge and awareness, respectively. The factors associated with good knowledge were being in the 35–44 year age group, Malay ethnicity, high educational attainment and high family income. Being Chinese, being older and having high educational attainment were determinants of having good awareness towards HepB. Participants who had good knowledge were 2.5 times more likely to also have good awareness (OR: 2.41, 95% CI: 1.78–3.26, p

Objectives: Due to reports of substandard influenza preparedness, the country of Georgia developed two influenza surveillance systems. This paper describes these surveillance systems in their capacity to detect influenza. Methods: Two surveillance systems for influenza operate in Georgia: an influenza-like illness (ILI) sentinel surveillance system for out-patient cases, based in the capital, Tbilisi, and a severe acute respiratory infection (SARI) sentinel surveillance system for in-patient cases with five sentinel sites â one in Tbilisi, and four in Kutaisi. Patients in these surveillance systems provide samples for laboratory testing, including influenza confirmation. Results: From 2015-2016, 825 cases were surveilled in the ILI surveillance system and 1367 cases were surveilled in the SARI surveillance system, with 222 (26.9%) and 451 (33.0%) positive for influenza, respectively. Influenza positivity varied by age with adults 30-64 years having highest proportion of influenza-positive cases at 42.2%. Conclusions: The sensitivity of the surveillance systems to influenza was relatively high compared to neighboring countries. These findings show the importance of influenza surveillance in the country of Georgia. Keywords: Surveillance, Influenza, Severe acute respiratory illness

The current re-emergence of human monkeypox (HMPX) is a global concern for endemic and non-endemic countries, but healthcare workers in some regions, like Asia, have less experience with identifying and treating HMPX cases. This study aimed to assess the confidence and its predictors in HMPX case management among general practitioners (GPs), the frontline doctors in Indonesia, and to explore their perspectives on HMPX. Between May and July 2019, GPs in Indonesia completed an online-based survey. The questionnaire collected information on GPs' confidence, perspective, sociodemographic, workplace and professional characteristics, exposure to HMPX information and knowledge on HMPX. A logistic regression analysis was employed to explore the explanatory variables influencing the confidence and the perspective. We included 395 GPs in our analysis (77.4% out of 510 responses received) of which 10.1% and 34.9% were classified having good confidence using an 80% and 70% cut-off for confidence score, respectively. In the adjusted analysis, receiving information about HMPX during medical training was the only variable significantly associated with good confidence (adjusted odds ratio 2.74, 95% confidence interval 1.57 to 4.78 and p 0.001). Approximately 73.6% and 77.9% of GPs agreed that HMPX is an important infectious disease and it has potential to detrimentally impact the Indonesian economy, respectively. In addition, 88.8% of GPs suggested that the disease should be incorporated into the National Medical Curriculum of Indonesia. In conclusion, in case of HMPX outbreak, majority of the GPs in Indonesia seem to be less confident in diagnosing and treating cases, using their current knowledge, skills and their workplace facilities. Therefore, a systematic strategy to improve their confidence in managing HMPX is required.

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 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 China has reduced incidence of vaccine-preventable diseases through its Expanded Program on Immunization (EPI). Vaccines outside of the EPI are not provided for free by the government, however. This study explored how the stated importance of different disease and vaccine-related attributes interacted with beliefs about the immune system of a child to affect Chinese parents’ decision to obtain a non-EPI vaccine. Methods Mothers and fathers of young children at immunization clinics in Shanghai, China, were interviewed about vaccine decision-making and what attributes of a disease were important when making this decision. An inductive thematic analysis explored their beliefs about disease attributes and how these related to vaccination decisions. Results Among the 34 interviews, severity of the disease—particularly in causing long-term disability—was the most commonly cited factor influencing a parent’s decision to get a vaccine for their child. Many parents believed that natural infection was preferable to vaccination, as long as disease was not severe, and many were concerned that imported vaccines were inadequate for Chinese children’s physical constitutions. All these beliefs could influence the decision to vaccinate. Conclusions Many parents do not appear to understand how and why vaccines can support development of a healthy immune system. Because severity emerged as parents’ overriding concern when making decisions about vaccines, marketing for a childhood vaccine could focus on the severe condition that a vaccine can protect against.

Background: Workplaces are a common location for infectious disease transmission among adults. To provide recommendations regarding appropriate health promotion programs, we evaluated the impact of three different interventions on factory workers. Methods: In a prospective intervention study carried out from October 2012 to June 2013, three factories were selected and each was assigned a different intervention method (i.e. self-study group, manager training group and interactional group discussion group). Participants were scored on their knowledge, behavior, and hygienic practices related to infectious disease prevention both before and after the intervention. Results: A total of 1154 participants completed the survey before the intervention and 1111 completed the survey after. The sum infectious disease knowledge score in the manager training group was higher after the intervention (9.09/12) than before (8.63/12, t = 4.47, p

Severe acute respiratory infection (SARI) presents a huge disease and economic burden worldwide. The present study described the frequency and types of different infectious etiologies among hospitalized patients with SARI in Tianjin, China, during 2015 and 2016. Basic information, in addition to a throat or serum sample, was collected from SARI patients. Nine viruses were detected using reverse transcription polymerase chain reaction, and Mycoplasma pneumoniae was detected using the Serodia Myco II gelatin particle agglutination test. A total of 585 specimens from 2,290 SARI cases were collected. The most common infection (19.66%, 115/585) was M. pneumoniae, followed by influenza virus A/B (6.15%, 36/585), and respiratory syncytial virus (4.96%, 29/585). Identification of viral or M. pneumoniae infections was the highest in the pediatric medicine ward (74.84%, 119/159), followed by the intensive care unit (37.04%, 80/216) and respiratory medicine ward (34.29%, 72/210). M. pneumoniae was highest (38.71%, 24/62) in the 5-14-year age group. Influenza was the main infection in January 2015 and March 2016. The correlation coefficient for the proportion of hospitalized cases of SARI and the positive detection rate within the same week was 0.25. M. pneumoniae and influenza were the leading pathogens among hospitalized SARI patients. A continued surveillance of hospitalized cases of SARI can detect emerging diseases, such as avian influenza A (H7N9) virus and other respiratory disease outbreaks.

Background: Measles incidence in China has declined over the last decade and elimination is targeted by 2020. Despite increases in routine immunization services and supplementary immunization activities (SIAs) periodic outbreaks continue to occur. In this paper we examine measles epidemiology during 2005-2014 in Tianjin China. Methods: Measles case data were extracted from a web-based communicable disease surveillance system. We examined the socio-demographic characteristics of measles case patients including age sex urbanicity residency status and vaccination history. Demographic characteristics of cases were compared with the general population. Results: From January 1 2005 to December 31 2014 12466 measles cases in Tianjin were reported. Among the cases 7179 (57.6%) were male and 5287 (42.4%) were female. Over time more cases occurred in adults and for the 2711 cases in 2014 the majority were either infants

Objectives India has more unvaccinated children than any other country despite provision of free vaccines through the government's Universal Immunization Program. In this study, we calculated the proportion of children aged 12-48 months who were fully vaccinated, under-vaccinated, or who had not received any vaccines. Childhood, household, and sociocultural factors associated with under-vaccination and non-vaccination were evaluated. Methods Using data from India's 4th District-level Health and Facility Survey, 2012-2013 (DLHS-4) and the 2012-2013 Annual Health Survey (AHS), we calculated the proportion of children who were non-vaccinated, under-vaccinated, or fully vaccinated with 1 dose of Bacillus Calmette-Guerin, 3 doses of oral polio vaccine, 3 doses of diphtheria-pertussis-tetanus, and 1 dose of measles-containing vaccine. The odds of full vaccination compared to non-vaccination and under-vaccination relative to various factors was assessed using a multivariable, multinomial logistic regression which accounted for survey design. Results Of 1,929,580 children aged 12-48 months, 59% were fully vaccinated, 34% were under-vaccinated, and 7% were non-vaccinated. Compared to children born in government institutions, children delivered in non-institutional settings with a skilled birth attendant present had higher odds of non-vaccination (OR 1.66) and those without a skilled attendant present had still greater odds of non-vaccination (OR 2.39) and under-vaccination (OR 1.11). Conclusions for Practice India's vaccination rates among children aged 12-48 months remains unacceptably low. The Indian government should encourage institutional delivery or birthing with a skilled attendant to ensure women receive adequate health education through antenatal care that includes the importance of childhood vaccination.

Background In China, the measles vaccine is offered for free whereas the pneumococcal vaccine is a for-fee vaccine. This difference has the potential to influence how caregivers evaluate whether a vaccine is important or necessary for their child, but it is unclear if models of health behavior, such as the Health Belief Model, reveal the same associations for different diseases. This study compares caregiver perceptions of different diseases (measles, pneumonia and meningitis); and characterizes associations between Health Belief Model constructs and both pneumococcal vaccine uptake and perceived vaccine necessity for pneumonia, measles, and meningitis. Methods Caregivers of infants and young children between 8 months and 7 years of age from Shanghai (n = 619) completed a written survey on their perceptions of measles, pneumonia, and meningitis. We used logistic regression models to assess predictors of pneumococcal vaccine uptake and vaccine necessity. Results Only 25.2% of children had received a pneumococcal vaccine, although most caregivers believed that pneumonia (80.8%) and meningitis (92.4%), as well as measles (93.2%), vaccines were serious enough to warrant a vaccine. Perceived safety was strongly associated with both pneumococcal vaccine uptake and perceived vaccine necessity, and non-locals had 1.70 times higher odds of pneumonia vaccine necessity than non-locals (95% CI: 1.01, 2.88). Conclusions Most factors had a similar relationship with vaccine necessity, regardless of disease, indicating a common mechanism for how Chinese caregivers decided which vaccines are necessary. Because more caregivers believed meningitis needed a vaccine than pneumonia, health care workers should emphasize pneumococcal vaccination’s ability to protect against meningitis. Electronic supplementary material The online version of this article (doi:10.1186/s12887-017-0900-2) contains supplementary material, which is available to authorized users.

BackgroundIn Malaysia, one million individuals are estimated to be infected with the hepatitis B virus. A vaccine for infants has been compulsory since 1989, whereas those born before 1989 need to spend their own money to be vaccinated in private clinics or hospitals. The aim of this study was to investigate and ascertain the determinants of willingness to pay (WTP) for adult hepatitis B vaccine in Selangor, Malaysia.MethodsIn 2016, 728 households were selected through a stratified, two stage cluster sample and interviewed. Willingness to pay for hepatitis B vaccine was estimated using the Contingent Valuation Method, and factors affecting WTP were modelled with logit regression.ResultsWe found that 273 (37.5%) of the households were willing to pay for hepatitis B vaccination. The mean and median of WTP was estimated at Ringgit Malaysia (RM)303 (approximately US$73) for the three dose series. The estimated WTP was significantly greater in those with higher levels of education, among Malays and Chinese (compared to others, predominantly Indians), and for those with greater perceived susceptibility to hepatitis B virus infection. Other factors-perceived severity, barriers, benefits and cues to action-were not significantly associated with WTP for adult hepatitis B vaccination.ConclusionAdditional resources are needed to cover the households that are not willing to pay for hepatitis B vaccination. More awareness (particularly in regards to hepatitis B virus susceptibility) could change the national perception towards self-paid hepatitis B virus vaccination and increase hepatitis B vaccine coverage.

Background The World Health Organization recommends the elderly and persons with certain chronic diseases to receive an annual influenza vaccine and to be prioritized for immunization against pandemic influenza, because they are at greater risk for health complications. This paper aims to compare influenza vaccination coverage between adults in China with and without high-risk health conditions. Methods Data were from the cross-sectional China General Social Survey, 2010. Adults were interviewed about their health, including whether they had been vaccinated against either seasonal or pandemic influenza within the past year. A multivariable logistic regression model estimated the adjusted odds of any influenza vaccination in high-risk groups compared with low-risk groups. Results Only 10.5% (372/3592) of Chinese adults were vaccinated against influenza. In a multivariable regression model, there was no significant difference in influenza vaccine uptake between those with and without high-risk health conditions. However, healthcare attitudes and behaviours were significantly associated with vaccine uptake. Conclusions Influenza vaccination coverage is extremely low in Chinese adults who are elderly and have chronic diseases. These two groups are at greatest risk for influenza-related morbidity and mortality and should be targets of programmes to increase positive attitudes towards vaccination and decrease barriers to uptake.

Background Measles is a highly infectious illness requiring herd immunity of 95% to interrupt transmission. Measles is targeted for elimination in China, which has not reached elimination goals despite high vaccination coverage. We developed a population profile of measles immunity among residents aged 0–49 years in Tianjin, China. Methods Participants were either from community population registers or community immunization records. Measles IgG antibody status was assessed using dried blood spots. We examined the association between measles IgG antibody status and independent variables including urbanicity, sex, vaccination, measles history, and age. Results 2818 people were enrolled. The proportion measles IgG negative increased from 50.7% for infants aged 1 month to 98.3% for those aged 7 months. After 8 months, the age of vaccination eligibility, the proportion of infants and children measles IgG negative decreased. Overall, 7.8% of participants 9 months of age or older lacked measles immunity including over 10% of those 20–39 years. Age and vaccination status were significantly associated with measles IgG status in the multivariable model. The odds of positive IgG status were 0.337 times as high for unvaccinated compared to vaccinated (95% CI: 0.217, 0.524). Conclusions The proportion of persons in Tianjin, China immune to measles was lower than herd immunity threshold with less than 90% of people aged 20–39 years demonstrating protection. Immunization programs in Tianjin have been successful in vaccinating younger age groups although high immunization coverage in infants and children alone would not provide protective herd immunity, given the large proportion of non-immune adults.

BackgroundMalaysia has a comprehensive, publicly-funded immunization program for hepatitis B (HepB) among infants, but adults must pay for the vaccine. The number of HepB carriers among adults is expected to increase in the future; therefore, we examined the impact of five constructs (cues to action, perceived barriers, perceived benefit, perceived severity, and perceived susceptibility) on adults' willingness to pay (WTP) for HepB vaccine; secondarily, we examined the association between perceived barriers and perceived benefits.MethodsAdults were selected through a stratified, two-stage cluster community sample in Selangor, Malaysia. The reliability, convergent validity, and discriminant validity of the measurement model were assessed before implementing a partial least squares structural equation model (PLS-SEM) to evaluate the significance of the structural paths.ResultsA total of 728 participants were enrolled. The five constructs all showed adequate internal reliability, convergent validity, and discriminant validity. There was a significant, positive relationship to WTP from constructs (perceived barriers [Path coefficient (β) = 0.082, P = 0.036], perceived susceptibility [β = 0.214, PConclusionsPolicy and programs should be targeted that can modify individuals' thoughts about disease risk, their obstacles in obtaining the preventive action, and their readiness to obtain a vaccine. Such programs include educational materials about disease risk and clinic visits that can pair HepB screening and vaccination.

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.

Summary Objectives China has repeatedly used supplemental immunization activities (SIAs) to work towards measles elimination, but it is unknown if the SIAs are reaching non-locals – migrants from rural to urban areas. This study characterized temporal trends in measles incidence by local and non-local residency and evaluated the impact of SIAs on measles incidence in Tianjin, China. Methods Daily measles case-counts were tabulated separately by residency. These two datasets were combined so that each day had two observations. Poisson regression was conducted using generalized estimating equations with an exchangeable working correlation structure to estimate rate ratios (RRs). Results There were 12465 measles cases in Tianjin over the 10-year period. The rate of measles was higher in non-locals than locals before the 2008 SIA (RR 3.60, 95% confidence interval (CI) 3.27–3.96), but this attenuated to a RR of 1.22 between the 2008 and 2010 SIAs (95% CI 1.02–1.45). Following the 2010 SIA, non-locals had a lower rate of measles (RR 0.78, 95% CI 0.69–0.87). Conclusions The disparity in measles incidence between locals and non-locals was reduced following two SIAs. Sustained public health interventions will be needed to maintain low measles incidence among non-locals given the ongoing migration of people throughout China.

Background 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. Methods 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. Results 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. Conclusions 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.

Background: Measles is a highly infectious disease, and timely administration of two doses of vaccine can ensure adequate protection against measles for all ages in a population. This study aims to estimate the proportion of children aged 8 months to 6 years vaccinated on time with measles-containing vaccines (MCV) and vaccinated during the 2008 and 2010 measles supplementary immunization activities. This study also characterizes differences in mean age at vaccination and vaccination timeliness by demographic characteristics, and describes maternal knowledge of measles vaccination. Methods: Immunization records were selected from a convenience sample of immunization clinics in Tianjin, China. From the records, overall vaccination coverage and timely vaccination coverage were calculated for different demographic groups. Mothers were also interviewed at these clinics to ascertain their knowledge of measles vaccination. Results: Within the 329 immunization clinic records, child’s birth year and district of residence were found to be significant predictors of different measures of vaccine timeliness. Children born in 2009 had a lower age at MCV dose 2 administration (17.96 months) than children born in 2005 (22.00 months). Children living in Hebei, a district in the urban center of Tianjin were less likely to be vaccinated late than children living in districts further from the urban core of Tianjin. From the 31 interviews with mothers, most women believed that timely vaccination was very important and more than one dose was very necessary; most did not know whether their child needed another dose. Conclusions: When reviewing MCV coverage in China, most studies do not consider timeliness. However, this study shows that overall vaccination coverage can greatly overestimate vaccination coverage within certain segments of the population, such as young infants.