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Vaccine hesitancy—the delay or refusal of vaccines despite their availability—has been linked to lower vaccination rates and outbreaks of vaccine-preventable diseases. Using cross-sectional surveys of 78,725 parents and other family members in the United States, Nguyen et al. (Am J Epidemiol. 2022;191(9):1626-1635) calculated the population attributable fraction (PAF) of vaccine hesitancy on nonreceipt of recommended childhood vaccines, including influenza vaccine. The PAF is readily calculated: p(rr − 1)/rr, where p is the proportion of those hesitant among nonvaccinated individuals, and rr is the risk ratio of nonvaccination between those hesitant over those nonhesitant. By vaccine, the PAF ranged from 6.5% for nonreceipt of the hepatitis B vaccine birth dose to 31.3% for nonreceipt of the diphtheria-tetanus-pertussis vaccine dose 3. For nonreceipt of influenza vaccine, the PAF varied geographically, with relatively high values in some Northeast (e.g., New York at 22.6%) and Northwest (e.g., Oregon at 23.0%) states and lower values in certain Southern (e.g., Louisiana at 7.5%) and Mountain West (e.g., Utah at 8.8%) states. The PAF can elucidate the contribution of vaccine hesitancy on nonvaccination in different circumstances. Future studies can apply this technique in different populations and incorporate different measures of vaccine hesitancy.

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.

It is not clear what kind of preferences parents in China would have for vaccines that could be added to a future immunization schedule. This study’s aim was to assess Chinese parents’ preferences for attributes of vaccines. We surveyed parents of young infants ≤3 months of age at immunization clinics in Shanghai, China, in 2017. We used a discrete choice experiment (DCE) to present parents with choices between two hypothetical profiles of vaccines which were described using the following attributes: cost, risk of side effect, location of vaccine manufacturer, vaccine testing, vaccine effectiveness, severity of disease, disease prevalence. A logistic regression output estimates of preference utilities. In total, 599 caregivers completed the DCE. Parents expressed lower preference for vaccines with a 30% chance of fever as an adverse event vs a 10% chance (OR: 0.53, 95% CI: 0.44, 0.64), for vaccines only 85% effective vs those 95% effective (OR: 0.55, 95% CI: 0.48, 0.62), and for imported vaccines (OR: 0.74, 95% CI: 0.60, 0.92) and those not tested in Chinese children (OR: 0.45, 95% CI: 0.37, 0.53) compared to domestic vaccines. More affluent groups preferred more expensive vaccines whereas less affluent groups did not express cost-based preferences. Promotion of vaccines in China should focus on parents’ stated preferences, which include past testing done in Chinese children – which is, in fact, required of all licensed vaccines in China. Information about these trials could emphasize low risk of adverse events and high effectiveness.

Introduction:measures of vaccine timing require data on vaccination dates, which may be unavailable. This study compares estimates of vaccine coverage and timing; and compares regression techniques that model these measures in the presence of incomplete data. Methods:this cross-sectional study used the 2016 Ethiopian Demographic and Health Survey (DHS), and a 2016 survey from Worabe, Ethiopia. Three measures of vaccine uptake were calculated: coverage (regardless of timing), timeliness (within 1 week of recommended administration), and delay (the number of days between the recommended and actual date of vaccination). Vaccine coverage and timeliness were modeled with logistic regressions. After excluding those without dates, vaccine delay was estimated using linear regression or survival analysis. Vaccine delay was also estimated using accelerated failure time (AFT) models. Results:the DHS survey included 3819 children aged 12-60 months and the Worabe survey included 484 children aged 12-23 months. In the Worabe survey, vaccine coverage for pentavalent vaccine dose 3 was 87.4%, with 8.6% receiving it within 1 week, and 71.7% within 4 weeks; the median delay was 19 days. Predictors of outcomes were similar in both the Worabe survey and Ethiopian DHS, with the largest numbers of significant associations seen in models with vaccine coverage or delays (with AFT models) as the outcomes. Conclusion:estimates of coverage may miss a substantial proportion of infants who have delayed vaccination. accelerated failure time (AFT) models are useful to estimate vaccine delay because they include information from all respondents (those with full and partial data on vaccination dates) and are agnostic about an age limit for timely vaccination.

Background: Traditional measurements of vaccine coverage at specific ages can mask poor vaccine timeliness. However, optimal measurement of timing is unclear due to variations in countries’ recommended vaccination schedules and lack of a commonly accepted standard for “timeliness”. We conducted a systematic review of literature on vaccine timeliness and delay in low- and middle-income countries from 2007 to 2017. Methods: A search of articles published between January 1 2007 and December 31 2017, was performed in PubMed, EBSCOhost, and Embase. Results: 67 papers were included, of which 83% used a categorical measure of delay and 41% evaluated continuous delay. The most common age at assessment was 1 month, with earlier age benchmarks typically used with birth doses. Conclusions: Categorical definitions of vaccination timing vary widely, with benchmarks of delay varying from days to weeks to months. Use of a continuous measure of vaccine delay may be more informative and comparable.

Introduction Rates of full childhood immunization in Ethiopia are well below the WHO global goal of 90% coverage by 2020. This study explores associations between sociodemographic characteristics and healthcare services utilization with experiences of not receiving a vaccine in Ethiopia. Methods This analysis uses data from Ethiopia’s 2012 Expanded Program on Immunization Coverage Survey. The relationships between explanatory variables, including sociodemographic and healthcare utilization factors, and various reasons a child was not vaccinated were assessed with Rao-Scott chi-square tests. Multivariable logistic regression analyses examined significant predictors of these experiences. Results The sample includes the caregivers of 2,722 children. Experiences of not receiving a vaccine were characterized overall and by type of experience: whether a caregiver ever refused vaccination for their child (2.9%), ever decided to not take their child to a health center for vaccination (3.6%), and ever went to a health facility for vaccination but child was not vaccinated (12.0%). Region of residence, possession of a vaccination card, and the setting of the child’s last routine vaccination were predictors of not receiving a vaccine. Caregivers reported negative perceptions of vaccines were among their reasons for refusing a vaccine or declining to take their child to a health facility for vaccination. Conclusion Prior experiences with health facilities, such as where a child received their last routine vaccine, play a key role in future vaccination. Vaccine receipt at an outreach event is associated with not bringing a child to a health facility for vaccination, which may indicate an unwillingness to visit or difficulty accessing health centers. Further, negative perceptions of vaccines may result in vaccine refusal or delay. Findings of this study provide public health officials with a better understanding of factors related to vaccination experiences and can inform development of interventions that will improve childhood vaccination rates in Ethiopia.

Morbidity from vaccine-preventable diseases is high in India, but precise estimates of vaccination timeliness are difficult to compute because many children lack records of vaccination dates. This study assessed vaccination timeliness after accounting for right and left censoring of data. This cross-sectional study used the 2012–2013 District Level Household and Facility Survey in India. The outcome was vaccination timeliness for 9 vaccine doses: 1 dose Bacillus Calmette-Guerin (BCG), 4 doses oral polio vaccine, 3 doses diphtheria-pertussis-tetanus vaccine (DPT), and 1 dose measles-containing vaccine. Age-specific probabilities of vaccination were calculated using Turnbull estimators: children not yet vaccinated were right censored, and children vaccinated but without a recorded date were left censored. Data from 108,783 children under 5 years were available. For children 25–60 months, maternal recall was a more common source of information than a vaccination record with dates. At one month past the recommended vaccination age, estimated coverage ranged from 35% for DPT-3 to 55% for BCG. Accounting for censored data improved vaccination timeliness measures, and demonstrated little increase in vaccination coverage after age one. Efforts to reduce morbidity from vaccine-preventable diseases in India should focus on eliminating missed opportunities for vaccination and instituting special vaccination programs for older children.

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.

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.

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.

Introduction Delays in vaccination can stymie the development of herd immunity, and a large proportion of children in the U.S. are known not to receive vaccines on time. This study quantifies delays in vaccination, compares vaccination timeliness to the proportion of children vaccinated, and evaluates the impact of combination vaccine use and timely administration of hepatitis B vaccine birth dose on vaccine timeliness among Michigan children. Methods This retrospective cohort study used data from the Michigan Care Improvement Registry—the state immunization information system—for children born 2006–2010. Children aged 24 months as of December 31, 2012, were included. The proportion of children with timely administration of vaccine doses was calculated, and the mean days of vaccination delay with SD were reported. Results Among 620,592 Michigan children, 42.2% had received all vaccines, but only 13.2% were vaccinated on time by age 24 months. Children’s vaccinations were delayed an average of 59.2 (SD=91.2) days by age 24 months for all recommended vaccine doses. Children who received a timely hepatitis B vaccine birth dose or who received a combination vaccine had less delay in vaccination. Conclusions Michigan children have high vaccination coverage based on standard measures but few receive these vaccines on time. Promoting use of combination vaccines may improve parental compliance with timely vaccination of children.

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.

Low- and middle-income countries receive limited guidance from external entities about how to introduce vaccines. This is especially true for the Hepatitis E (HepE) vaccine, which is currently only commercially available in China. The aims of this qualitative study are to identify which attributes of the HepE disease and vaccine are considered important, and to compare desired promotion methods between different stakeholders. Stakeholders included experts (Centers for Disease Control and Prevention staff, health care providers, and researchers), and nonexperts included members of high-risk populations, HepE cases, and vaccinees. Participants’ thoughts were coded and broadly summarized. We contacted 63 persons—35 experts and 28 nonexperts. Safety and effectiveness (but not price) of the vaccine, along with severity of disease and transmission route of infection, were all listed as important attributes. Emphasizing the importance of sharing stories from cases, relying on personal experiences, staying away from statistical explanations, and using the government as a source of promotion were other points repeatedly raised by the participants. Qualitative interviews with experts and nonexperts has revealed that focusing on attributes of disease severity and susceptibility to infection, as well as vaccine safety and effectiveness within stories of cases, are preferred ways to promote the vaccine.

Objectives: China has made remarkable achievements in the field of immunization. However, several widespread vaccine safety-related events have recently received worldwide attention and reflect flaws in vaccine management. This study aimed to summarize vaccine safety-related events between 1985 and 2018 in China and analyze the profit motives of these events.Methods. Literature and media reviews were conducted to discover vaccine safety-related events. We developed a conceptual model with profit-related variables, and using information available from each event, we identified which profit-related variable was implicated, and how it related to the pursuit of higher profits.Results: A total of 39 vaccine safety-related events were found in vaccine production, procurement, transportation, and daily management, along with adverse events following immunization (AEFIs). Overall, 90% (35/39) of the events could be classified as profit-driven. The motives of most events could be tied to one or more reasons, including decreasing costs among vaccine producers (67%, 26/39), reducing actual procurement price (67%, 26/39), and reducing costs of transportation and/or cold chain (24/39, 62%).Conclusions: In order to deal with vaccine-related challenges, a more restrictive supervision system on vaccine production and more emergency preparedness, including health and risk communication strategies, for vaccine safety should be implemented.

Vaccine hesitancy is a continuum of behaviors ranging from delay in receipt to vaccination refusal. Prior studies have typically focused on high-income countries, where vaccine hesitancy is particularly prevalent in more affluent groups, but the relationship between socioeconomic status and vaccine hesitancy in Low- and Middle-Income Countries (LMICs) is less clear. The aim of this study was to describe vaccine hesitancy in five LMICs. Mothers of children in Sirajganj, Bangladesh (n = 60), Shanghai, China (n = 788), Addis Ababa, Ethiopia (n = 341), Guatemala City and Quetzaltenango, Guatemala (n = 767), and Chandigarh, India (n = 309), completed a survey between 2016 and 2018 using the WHO&rsquo, s 10-item Vaccine Hesitancy Scale. The scores of different constructs were compared across countries and by the mother&rsquo, s education level using linear regression models with generalized estimating equations. Compared to mothers in China, mothers in Bangladesh perceived less vaccination benefit (&beta, 0.56, P = 0.0001), however, mothers in Ethiopia (&beta, &minus, 0.54, P &lt, 0.0001) and Guatemala (&beta, 0.74, P = 0.0004) perceived greater benefit. Education level was not significantly linked with vaccine hesitancy. Local circumstances are important to consider when developing programs to promote vaccines. We did not find consistent associations between education and vaccine hesitancy. More research is needed to understand socio-cultural influences on vaccine decision-making.

China approved a human papillomavirus (HPV) vaccine in 2018. Recommendations from health care providers can positively impact vaccine receipt. This study characterized vaccine providers’ attitudes toward the HPV vaccine and contrasted attitudes by the providers’ demographic characteristics. In total, 120 vaccine providers in Shanghai, China, completed a questionnaire. Associations between essential characteristics of the HPV vaccine and providers’ urbanicity and working length were explored using the Kruskal-Wallis test. Doctors with ≤5 years’ work experience were more likely to think it important to emphasize that HPV is a sexually transmitted disease compared to doctors with longer work experiences ( P = .0231). More suburban than urban providers thought that China should include the HPV vaccine into the publicly funded Expanded Program on Immunization ( P = .0315). Differences in attitudes toward HPV could lead to variation in how providers talk to parents and adolescents about the HPV vaccine, with disparities in vaccine uptake as a result.

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.

India has implemented the World Health Organization's revised Causality Assessment Protocol for adverse events following immunization (AEFI). We describe the number and types of serious/severe AEFIs, including deaths.Analysis of causality classification of reported serious/severe AEFIs from 1 January 2012 to 7 January 2016 was done. Classification includes (A) consistent with causal association to immunization; (B) indeterminate; (C) coincidental association; or (D) unclassifiable. We present descriptive statistics across each category.Analysis of causality assessment completed for 1037 reports of serious AEFIs: 499 (48%) were causally associated, 84 (8%) were indeterminate, 323 (31%) were coincidental, and 131 (13%) were unclassifiable. Of the 499 reports in the A category, the events were causally linked to vaccine product for 189 (18%), to immunization error for 135 (13%), and to immunization anxiety for 175 (17%). Among 279 reported deaths, more than half (55%; n = 153) were coincidental events and 37% were unclassifiable.Causality assessment of AEFI cases is an important component of vaccination programs and post-marketing surveillance of vaccines. Field reporting and investigation of AEFIs can be improved for many severe or serious reports, most of which are not causally linked to the vaccination program.

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.

Background 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. Methods 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. Results 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. Conclusions 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.

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 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.